2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 73 provider charges for a service and even if there is a dispute and we don’t pay certain provider charges. Here is how this protection works. · If your cost-sharing is a copayment (a set amount of dollars, for example, $15.00) then you pay only that amount for any covered services from a network provider. · If your cost-sharing is a coinsurance (a percentage of the total charges), then you never pay more than that percentage. However, your cost depends on which type of provider you see: - If you receive the covered services from a network provider, you pay the coinsurance percentage multiplied by the plan’s reimbursement rate (as determined in the contract between the provider and the plan). - If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers. - If you receive the covered services from an out-of-network provider who does not participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers. · If you believe a provider has “balance billed” you, call Customer Service. Section 2 Use the medical benefits chart to find out what is covered and how much you will pay Section 2.1 Your medical benefits and costs as a member of the plan The medical benefits chart on the following pages lists the services UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) covers and what you pay out-of-pocket for each service. Part D prescription drug coverage is covered in Chapter 5. The services listed in the medical benefits chart are covered only when the following coverage requirements are met: · Your Medicare-covered services must be provided according to the coverage guidelines established by Medicare. · Your services (including medical care, services, supplies, equipment, and Part B prescription drugs) must be medically necessary. “Medically necessary” means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. · Some of the in-network services listed in the medical benefits chart are covered only if your doctor or other network provider gets approval in advance (sometimes called “prior authorization”) from us. - Covered services that may need approval in advance to be covered as in-network services †† are marked by a double dagger ( ) in the medical benefits chart. - Network providers agree by contract to obtain prior authorization from the plan and agree to not balance bill you. - You never need approval in advance for out-of-network services from out-of-network providers.