2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (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 · Medically-necessary medical or surgical services See “Outpatient surgery” earlier furnished in a certified ambulatory surgical center or in this chart for any applicable hospital outpatient department. copayments or coinsurance amounts for ambulatory surgical center visits or in a hospital outpatient setting. · Consultation, diagnosis, and treatment by a specialist. $0 copayment for services from a specialist or under 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).†† · Basic hearing and balance exams performed by your $0 copayment for each specialist, if your doctor orders it to see if you need Medicare-covered exam.†† medical treatment. · Some telehealth services including consultation, $0 copayment for each diagnosis, and treatment by a physician or practitioner, Medicare-covered visit.†† for patients in certain rural areas or other places approved by Medicare. · Telehealth services for monthly end-stage renal disease- 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.