2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 91 Services that are covered for you What you must pay when you get these services in-network and out-of-network Receive 6 hours of non-medical personal care through a professional caregiver to perform tasks such as companionship, meal prep, medication reminders and more. Call the customer service number on your UnitedHealthcare member ID card for more information and to receive non- medical personal care. · No referral required. · Unused hours do not roll over. · Caregiver hours must be scheduled in 2-hour increments. · You will typically be paired with a caregiver within 5 business days. · Some restrictions and limitations apply. You are not required to use all 3 services. New referrals for meals and transportation benefits are required after each discharge. Unused benefits do not roll over. Some restrictions and limitations may apply. Hearing services $30 copayment for each Medicare-covered exam.†† Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment You pay these amounts until are covered as outpatient care when furnished by a you reach the out-of-pocket physician, audiologist, or other qualified provider. maximum. Routine hearing services Hearing exam Please turn to Section 4 Routine Hearing Services of this $0 copayment for 1 exam per chapter for more detailed information about this benefit. plan year. Hearing aids You pay any amount over $2,500 for hearing aids (combined for both ears) every 3 years years.