2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 116 Services that are covered for you What you must pay when you get these services in-network and out-of-network certain circumstances, treatment by a nurse practitioner, physician’s assistant or other non-physician health care professional in a specialist’s office (as allowed by Medicare).†† You pay these amounts until you reach the out-of-pocket maximum. · Basic hearing and balance exams performed by your $30 copayment for each specialist, if your doctor orders it to see if you need Medicare-covered exam.†† medical treatment. You pay these amounts until you reach the out-of-pocket maximum. · Some telehealth services including consultation, $15 copayment for each diagnosis, and treatment by a physician or practitioner, Medicare-covered visit.†† for patients in certain rural areas or other places You pay these amounts until approved by Medicare. you reach the out-of-pocket · Telehealth services for monthly end-stage renal disease- maximum. related visits for home dialysis members in a hospital- based or critical access hospital-based renal dialysis center, renal dialysis facility, or the member's home. · Telehealth services to diagnose, evaluate, or treat symptoms of a stroke regardless of their location. · Telehealth services for members with a substance use disorder or co-occurring mental health disorder, regardless of their location. · Telehealth services for diagnosis, evaluation, and treatment of mental health disorders. · Telehealth services for mental health visits provided by rural health clinics and federally qualified health centers · Medicare-covered remote patient monitoring services