2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 94 Services that are covered for you What you must pay when you get these services in-network and out-of-network See "Medicare Part B prescription drugs" later in this chart for any applicable cost- sharing for drugs related to home infusion therapy.†† Hospice care When you enroll in a Medicare- You are eligible for the hospice benefit when your doctor certified hospice program, your and the hospice medical director have given you a terminal hospice services and your Part prognosis certifying that you’re terminally ill and have 6 A and Part B services related to months or less to live if your illness runs its normal course. your terminal prognosis are You may receive care from any Medicare-certified hospice paid for by Original Medicare, program. Your plan is obligated to help you find Medicare- not UnitedHealthcare® Group certified hospice programs in the plan’s service area, Medicare Advantage PEBB including those the MA organization owns, controls, or has a Balance (PPO). financial interest in. Your hospice doctor can be a network Note: If you are not entitled to provider or an out-of-network provider. Medicare Part A coverage, Covered services include: hospice services are not · Drugs for symptom control and pain relief covered by the plan or by Medicare. · Short-term respite care Note: If you need non-hospice · Home care care (care that is not related to When you are admitted to a hospice you have the right to your terminal prognosis), you remain in your plan; if you chose to remain in your plan you should contact us to arrange must continue to pay plan premiums. the services. For hospice services and for services that are covered by Medicare Part A or B and are related to your terminal prognosis: Original Medicare (rather than our plan) will pay your hospice provider for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the services that Original Medicare pays for. You will be billed Original Medicare cost- sharing.