2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 123 Services that are covered for you What you must pay when you get these services in-network and out-of-network Skilled nursing facility (SNF) care $0 copayment each day for (For a definition of “skilled nursing facility care,” see Chapter Medicare-covered SNF care.†† 12 of this document. Skilled nursing facilities are sometimes You are covered for inpatient called “SNFs.”) services in a SNF, in Covered services include, but are not limited to: accordance with Medicare · Semiprivate room (or a private room if medically guidelines. Original Medicare necessary) benefit periods do not apply. · Meals, including special diets · Skilled nursing services · Physical therapy, occupational therapy, and speech language therapy · Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) · Blood - including storage and administration. Coverage begins with the first pint of blood that you need. · Medical and surgical supplies ordinarily provided by SNFs · Laboratory tests ordinarily provided by SNFs · X-rays and other radiology services ordinarily provided by SNFs · Use of appliances such as wheelchairs ordinarily provided by SNFs · Physician/practitioner services A 3-day prior hospital stay is not required. There is no coinsurance, Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) copayment, or deductible for If you use tobacco, we cover two counseling quit attempts the Medicare-covered smoking within a 12-month period as a preventive service. Each and tobacco use cessation counseling attempt includes up to four face-to-face visits. preventive benefits.