2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 111 Services that are covered for you What you must pay when you get these services in-network and out-of-network Please refer to virtual behavioral visits section in this chart for more information. Outpatient rehabilitation services $0 copayment for each Covered services include: physical therapy, occupational Medicare-covered physical therapy, and speech language therapy. therapy and speech-language therapy visit.†† Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, $0 copayment for each independent therapist offices, physician offices, and Medicare-covered occupational therapy visit.†† Comprehensive Outpatient Rehabilitation Facilities (CORFs). $0 copayment for each Medicare-covered comprehensive outpatient rehabilitation facility (CORF) visit.†† Outpatient substance abuse services $0 copayment for each Outpatient treatment and counseling for substance abuse. Medicare-covered individual therapy session.†† $0 copayment for each Medicare-covered group therapy session.†† Outpatient surgery and other medical services provided $0 copayment for Medicare- at hospital outpatient facilities and ambulatory surgical covered surgery or other centers services at an outpatient Note: If you are having surgery in a hospital facility, you hospital or ambulatory surgical should check with your provider about whether you will be center, including but not limited an inpatient or outpatient. Unless the provider writes an to hospital or other facility order to admit you as an inpatient to the hospital, you are an charges and physician or surgical charges.†† outpatient and pay the cost-sharing amounts for outpatient