2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 72 Section 1 Understanding your out-of-pocket costs for covered services This chapter provides a medical benefits chart that lists your covered services and shows how much you will pay for each covered service as a member of UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO). Later in this chapter, you can find information about medical services that are not covered. It also explains limits on certain services. Section 1.1 Types of out-of-pocket costs you may pay for your covered services To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. · A “copayment” is the fixed amount you pay each time you receive certain medical services. You pay a copayment at the time you get the medical service. (The medical benefits chart in Section 2 tells you more about your copayments.) · “Coinsurance” is the percentage you pay of the total cost of certain medical services. You pay a coinsurance at the time you get the medical service. (The medical benefits chart in Section 2 tells you more about your coinsurance.) Most people who qualify for Medicaid or for the Qualified Medicare Beneficiary (QMB) program should never pay deductibles, copayments or coinsurance for Medicare-covered services. Be sure to show your proof of Medicaid or QMB eligibility to your provider, if applicable. Section 1.2 What is the most you will pay for Medicare Part A and Part B covered medical services? · Your combined maximum out-of-pocket amount is $500. This is the most you pay during the plan year for covered Medicare Part A and Part B services received from both in-network and out-of-network providers. The amounts you pay for copayments and coinsurance for covered services count toward this combined maximum out-of-pocket amount. The amounts your plan sponsor pays for your plan premiums and the amounts you pay for your Part D prescription drugs do not count toward your combined maximum out-of-pocket amount. In addition, amounts you pay for some services do not count toward your combined maximum out-of- pocket amount. These services are marked with an asterisk in the medical benefits chart. If you have paid $500 for covered services, you will have 100% coverage and will not have any out-of- pocket costs for the rest of the plan year for Part A and Part B services. However, you must continue to pay the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). Section 1.3 Our plan does not allow providers to “balance bill” you As a member of UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO), an important protection for you is that you only have to pay your cost-sharing amount when you get services covered by our plan and Original Medicare. Providers may not add additional separate charges, called “balance billing.” This protection applies even if we pay the provider less than the