2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 112 Services that are covered for you What you must pay when you get these services in-network and out-of-network Please refer to virtual behavioral visits section in this chart for more information. Outpatient rehabilitation services $15 copayment for each Covered services include: physical therapy, occupational Medicare-covered physical therapy, and speech language therapy. therapy and speech-language therapy visit.†† Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, You pay these amounts until independent therapist offices, physician offices, and you reach the out-of-pocket Comprehensive Outpatient Rehabilitation Facilities (CORFs). maximum. $15 copayment for each Medicare-covered occupational therapy visit.†† You pay these amounts until you reach the out-of-pocket maximum. $15 copayment for each Medicare-covered comprehensive outpatient rehabilitation facility (CORF) visit.†† You pay these amounts until you reach the out-of-pocket maximum.