2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 108 Services that are covered for you What you must pay when you get these services in-network and out-of-network Outpatient hospital observation Outpatient observation cost- Observation services are hospital outpatient services given sharing is explained in to determine if you need to be admitted as an inpatient or Outpatient surgery and other can be discharged. For outpatient hospital observation medical services provided at services to be covered, they must meet the Medicare criteria hospital outpatient facilities and and be considered reasonable and necessary. Observation ambulatory surgical centers. services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or order outpatient tests. Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” If you are not sure if you are an outpatient, you should ask the hospital staff. 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, 7days a week. Outpatient hospital services We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include, but are not limited to: · Services in an emergency department Please refer to Emergency Care.