2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 98 Services that are covered for you What you must pay when you get these services in-network and out-of-network for a covered organ transplant may also be covered. You can be reimbursed for eligible costs up to $125 per day total. Transportation services are not subject to the daily limit amount. · Blood - including storage and administration. Coverage begins with the first pint of blood that you need. · Physician services Note: To be an inpatient, your provider must write an order Outpatient observation cost- to admit you formally as an inpatient of the hospital. Even if sharing is explained in you stay in the hospital overnight, you might still be Outpatient surgery and other considered an “outpatient.” This is called an “outpatient medical services provided at observation” stay. If you are not sure if you are an inpatient hospital outpatient facilities and or an outpatient, you should ask the hospital staff. ambulatory surgical centers. You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web at medicare.gov/sites/default/files/2021-10/11435- Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.