2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 114 Services that are covered for you What you must pay when you get these services in-network and out-of-network You pay these amounts until you reach the out-of-pocket maximum. Partial hospitalization services and Intensive outpatient $55 copayment each day for services Medicare-covered benefits.†† “Partial hospitalization” is a structured program of active You pay these amounts until psychiatric treatment provided as a hospital outpatient you reach the out-of-pocket service, or by a community mental health center, that is maximum. more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization. Intensive outpatient service is a structured program of active behavioral (mental) health therapy treatment provided in a hospital outpatient department, a community mental health center, a Federally qualified health center, or a rural health clinic that is more intense than the care received in your doctor’s or therapist’s office but less intense than partial hospitalization. Personal emergency response system (PERS) Lifeline $0 copayment; Benefit is A personal emergency response system (PERS) benefit is available through provider available to you through the provider, Lifeline. Lifeline. With a PERS, help is only a button press away. A PERS can quickly connect you to the help you need, 24 hours a day in any situation. It's a lightweight, water-resistant button that can be worn on your wrist or as a pendant. Depending on the model you choose, it may even automatically detect falls. You must have a working landline or live in an area that has cellular coverage. The cellular device works nationwide with