2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 3: Using the plan for your medical services 62 Section 1 Things to know about getting your medical care as a member of our plan This chapter explains what you need to know about using the plan to get your medical care covered. It gives definitions of terms and explains the rules you will need to follow to get the medical treatments, services, equipment, prescription drugs, and other medical care that are covered by the plan. Because you are a member of the UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) plan, you can see any provider (network or out-of-network) at the same cost share, as long as they accept the plan and have not opted out of or been excluded or precluded from the Medicare Program. For the details on what medical care is covered by our plan and how much you pay when you get this care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what is covered and what you pay). Section 1.1 What are “network providers” and “covered services”? · “Providers” are doctors and other health care professionals licensed by the state to provide medical services and care. The term “providers” also includes hospitals and other health care facilities. · “Network providers” are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and your cost-sharing amount as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The providers in our network bill us directly for care they give you. When you see a network provider, you pay only your share of the cost for their services. · “Covered services” include all the medical care, health care services, supplies, equipment, and prescription drugs that are covered by our plan. Your covered services for medical care are listed in the benefits chart in Chapter 4. Your covered services for prescription drugs are discussed in Chapter 5. Section 1.2 Basic rules for getting your medical care covered by the plan As a Medicare health plan, UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) must cover all services covered by Original Medicare and must follow Original Medicare’s coverage rules. The plan will generally cover your medical care as long as: · The care you receive is included in the plan’s Medical Benefits Chart (this chart is in Chapter 4 of this document). · The care you receive is considered medically necessary. “Medically necessary” means that the services, supplies, equipment, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.