2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 112 Services that are covered for you What you must pay when you get these services in-network and out-of-network surgery. Even if you stay in the hospital overnight, you might Outpatient surgical services that still be considered an “outpatient.” This is called an can be delivered in an available “Outpatient Observation” stay. If you are not sure if you are ambulatory surgery center must an outpatient, you should ask your doctor or the hospital be delivered in an ambulatory staff. surgery center unless a hospital If you receive any services or items other than surgery, outpatient department is including but not limited to diagnostic tests, therapeutic medically necessary. services, prosthetics, orthotics, supplies or Part B drugs, there may be additional cost-sharing for those services or $0 copayment for Medicare- items. Please refer to the appropriate section in this chart for covered observation at an the additional service or item you received for the specific outpatient hospital or cost-sharing required. ambulatory surgical center.†† See “Colorectal cancer screening” earlier in this chart for screening and diagnostic colonoscopy benefit information. Partial hospitalization services and Intensive outpatient $0 copayment each day for services Medicare-covered benefits.†† “Partial hospitalization” is a structured program of active psychiatric treatment provided as a hospital outpatient service, or by a community mental health center, that is 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.