2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 74 - While you don’t need approval in advance for out-of-network services, you or your doctor can ask us to make a coverage decision in advance. Other important things to know about our coverage: · For benefits where your cost-sharing is a coinsurance percentage, the amount you pay depends on what type of provider you receive the services from: If you receive the covered services from a network provider, you pay the coinsurance - percentage multiplied by the plan’s reimbursement rate (as determined in the contract between the provider and the plan). - If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers. - If you receive the covered services from an out-of-network provider who does not participate with Medicare, you pay the coinsurance percentage multiplied by the Original Medicare Limiting Charge. · Like all Medicare health plans, we cover everything that Original Medicare covers. For some of these benefits, you pay more in our plan than you would in Original Medicare. For others, you pay less. (If you want to know more about the coverage and costs of Original Medicare, look in your Medicare & You 2024 handbook. View it online at medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.) · For all Preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you. However, if you also are treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care received for the existing medical condition. See the medical benefits chart for information about your share of the out-of-network costs for these services. · If Medicare adds coverage for any new services during 2024, either Medicare or our plan will cover those services. You will see this apple next to the Preventive services in the benefits chart. Medically Necessary - means health care services, supplies, or drugs needed for the prevention, diagnosis, or treatment of your sickness, injury or illness that are all of the following as determined by us or our designee, within our sole discretion: · In accordance with Generally accepted standards of medical practice. · Most appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, or illness. · Not mainly for your convenience or that of your doctor or other health care provider. · Meet, but do not exceed your medical need, are at least as beneficial as an existing and available medically appropriate alternative, and are furnished in the most cost-effective manner that may be provided safely and effectively. Generally accepted standards of medical practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the