Individual and Family Plans

Member Resources

At Network Health, we know you have many choices when it comes to health insurance. You probably have a lot of questions, too. Selecting health insurance can be overwhelming. We’re here to walk you through your options and help you choose the health insurance plan that is right for you.

For more than 35 years, Network Health has offered health insurance that puts members first. We provide high quality plan options and we’re here to help choose the right plan for you and your family.

Our individual and family plans are available on the health insurance exchange (known as the Marketplace) and outside of the Marketplace. 

Open enrollment begins November 1 and ends on December 15. If you miss open enrollment, you can only change plans or enroll under a qualifying life event. 

Questions?

Call our local customer service team at 855-275-1400, Monday, Wednesday, Thursday and Friday from 8 a.m. to 5 p.m and Tuesday from 8 a.m. to 4 p.m.

For details about nondiscrimination or getting assistance in another language, view this multi-language and nondiscrimination document.  

 Frequently Asked Questions

It’s a good idea to have health insurance because it helps protect you and your family financially in the event of an unexpected illness or injury. Medical care can be expensive and if you don’t have health insurance, you may easily find yourself crippled with medical debt. One emergency surgery can cost you thousands of dollars in medical bills. If complications arise during surgery, costs can add up quickly. Signing up for a Network Health Prestige plan can give you peace of mind knowing you're protecting your health and your wallet. Our insurance coverage allows you focus on life and avoid financial stress.

A subsidy is financial assistance provided by the government to help people afford health insurance. 

  • Premium Tax Credit – This is the amount of money provided by the government that goes toward your health insurance premium. It can help make your monthly payment lower. You can choose to apply the entire amount toward your premium each month (called Advanced Premium Tax Credit, or APTC), or wait until the end of the year and get the money back at tax time. You may qualify for this credit if you purchase a plan on the Marketplace and have an income below a certain level. The government pays a portion of your health insurance directly to your insurance company every month.

When you purchase your health plan, make sure you check to see if you qualify for a subsidy. To get a subsidy, you must enroll in a plan that’s on the Marketplace.            

Consider these two questions as you apply for a premium tax credit:

If you end up making more money than you estimated on your Marketplace application, you could wind up having to pay back some or all the tax credit you received. This payment will be due with your next tax return.

If you end up making less money than you estimated on your Marketplace application, you could qualify for a higher tax credit. This money would be refunded with your next tax return.

To avoid owing money at tax time or to receive a larger refund, you'll want to make sure to report any income changes to the Marketplace during your coverage year.

If you are receiving a Premium Tax Credit, please note the following as you file your taxes:

  • You must file a federal income tax return the year after you receive coverage through the Marketplace.
  • If you're married at the end of the coverage year, you must file jointly with a spouse.
  • You can’t be claimed as a dependent on another person’s tax return for the coverage year.
  • You must claim a personal exemption deduction on the coverage year federal income tax return for any dependent listed on your application whose premium is paid with a tax credit.

Learn more about the tax credit from the Internal Revenue Service. 

Eligibility is determined by factors such as your income, family size and where you live. When you get a quote for coverage, we will take you to HealthCare.gov to get your subsidy verified. 

The Marketplace (also known as the health insurance exchange) is a website for those who want to shop, compare and enroll in individual and family health plans. Network Health Prestige plans are available on the Marketplace. These plans are separated into three categories for different coverage levels: Bronze, Silver and Gold. Each category is based on the plan’s monthly cost, benefit level and amount you’ll pay over time.

Your agent can help you determine which category is a good fit and help you enroll. If you don’t have an agent, call us at 844-635-1322 and we can help.

Group, individual and self-insured health plans sold on or after September 23, 2010, must cover specified preventive services when provided by in-network doctors and facilities.

  • Alcohol misuse screening and counseling
  • Aspirin use to prevent cardiovascular disease for men and women of certain ages
  • Blood pressure screening for all adults
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal cancer screening for adults over 50
  • Depression screening for adults
  • Diabetes (Type 2) screening for adults with high blood pressure
  • Immunization vaccines for adults — doses, recommended ages and recommended populations vary:
    • Hepatitis A
    • Hepatitis B
    • Human Papillomavirus
    • Influenza (Flu Shot)
    • Measles, Mumps, Rubella
    • Meningococcal
    • Pneumococcal
    • Tetanus, Diphtheria, Pertussis
    • Varicella
  • Obesity screening and counseling for all adults
  • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  • Tobacco use screening for all adults and cessation interventions for tobacco users

View a detailed list of ACA preventive care services for adults.

  • Breast Cancer mammography screenings every one to two years for women over 40
  • Breastfeeding support and counseling and access to breastfeeding supplies, for pregnant and nursing women
  • Cervical cancer screening for sexually active women
  • Chlamydia screening for women at higher risk
  • Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
  • Domestic and interpersonal violence screening and counseling for all women
  • Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
  • Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older
  • Osteoporosis screening for women over age 60 depending on risk factors
  • Sexually Transmitted Infections counseling
  • Well-woman visits

View a detailed list of ACA preventive care services for women.

  • Autism screening
  • Behavioral assessments
  • Blood pressure screening
  • Developmental screening
  • Hearing screening for all newborns
  • Height, weight and body mass index measurements
  • Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary.
  • Obesity screening and counseling
  • Oral health risk assessment for young children
  • Vision screening for all children

View a detailed list of ACA preventive care services for children.

Specific preventive services are covered without a copayment or coinsurance when services are provided by an in-network doctor or facility. That means you pay $0. This includes flu shots, blood pressure screenings, mammogram screenings and many more services that can help with early detection and prevention of illness. Below is a list of preventive services; you can find a complete list of these services at HealthCare.gov by searching for preventive care.

Open Enrollment Period
For individuals and families, open enrollment begins on November 1, 2018 and ends on December 15, 2018. If you miss open enrollment, you may still be able to enroll under a qualifying life event.

Special Enrollment Period
Special circumstances (called qualifying events) allow you to enroll in a health insurance plan outside of the open enrollment period. A Special Enrollment Period may be available to you if one or more of the following applies.

  • You had a baby or adopted a child
  • You got married
  • You moved to a new state
  • You lost coverage under a previous plan

For a complete list of qualifying events, go to HealthCare.gov and search qualifying life event.

Premium – The monthly payment you make for your health plan.

Deductible – The amount you must pay for covered health care services before Network Health begins to pay

Copayment – A set fee you might pay for a type of health care or a prescription drug. For example, your copayment for a doctor visit could be $20. Once your deductible is met, Network Health pays the rest.

Coinsurance – A set percentage you might pay for a type of health care or a prescription drug. For example, 10 percent coinsurance means you pay 10 percent of the cost. Network Health pays the rest.

Key Information About How to Use Your Plan

IFP service map

New – Redesigned Member Portal

For plan information that’s specific to your plan, log in to your member portal account at My Login. See our How to Register cheat sheet for first time login instructions.

We’ve gathered and incorporated customer feedback to deliver a new member portal that’s centered around you. The new portal is easier to navigate to find information regarding your plan, benefits, claims and more. Plus, it's mobile responsive and viewable from any device at any time. The first time you access the new portal, you will need to create a new account.

Once you are logged in, you'll find all this and more.

  • Benefits and coverage overview
  • Out-of-pocket expenses tracker
  • Claims detail and status
  • Your mobile ID card
  • Find a Doctor search and ability to select your personal doctor
  • Secure messaging with our local customer service team

Your Personal Doctor (also referred to as a Primary Care Practitioner or PCP) 

There are two ways to choose or verify a primary care practitioner or personal doctor.

  1. Go to My Login to sign in to your account. Once logged in, click your name in the upper right corner to bring up your profile. Select Change My Personal Doctor and follow the steps that appear to choose or change your personal doctor.
  2. Contact our Network Health customer service department by calling the number on the back of your Network Health ID card.

If you haven’t or don’t wish to choose a personal doctor, the Network Health system will automatically assign a personal doctor based on primary care doctors you have seen recently who are part of your plan and accepting new patients. For those who haven’t seen a personal doctor in two years, Network Health will work with our provider partners to assign you a personal doctor in your area who is accepting new patients. Whether your personal doctor is selected or assigned, you’ll receive the same high-quality care you’ve come to expect.

No Referrals 

You are not required to have a referral to see an in-network specialist. Simply make an appointment with the provider. Some specialty offices may require that you first seek care and evaluation at a personal doctor (also referred to as a primary care practitioner or PCP) before the office will see you. Emergency care is covered 24 hours a day from any emergency facility.

Services that Require Prior Approval

In some cases, Network Health will need to give approval for you to receive coverage for certain services provided by a specialist or other provider. This is called a prior authorization. Once approved, the service is subject to the terms of your policy and summary of responsibility table.

Your Network Health participating provider or his or her office staff will submit a request on your behalf for authorization. Network Health’s Care Management Department will review the request and make the decision to approve or deny the service. You will receive a letter from Network Health notifying you of the approval or denial of the service or visit. If you need non-emergent, non-urgent care services from an out-of-network provider, you are responsible for confirming that the service has been approved by Network Health’s Care Management Department prior to receiving the service. Please contact the care management department at least 14 days prior to receiving care. For pre-service urgent requests, Network Health will make a decision within 72 hours. For concurrent urgent requests (e.g. for a continued stay at a hospital), Network Health will make a decision within 24 hours. 

Your plan provides coverage without authorization, with in-network providers for medically necessary urgent care at a hospital and for emergency health services during an emergency room stay.

If you are admitted to an out-of-network facility after receiving emergency care, or if you receive urgent care from an out-of-network facility, you must notify Network Health within 48 hours or on the next business day of the admission or service. If you are physically or mentally incapable of providing notice within that time, you must provide notice within 48 hours or the next business day of regaining capability. If you are a minor, your parent or guardian must provide notice within 48 hours or the next business day of your admission to an out-of-network facility after receiving emergency care services. If a parent or guardian is not aware of your admission, he or she must notify Network Health within 48 hours or the next business day of becoming aware of the admission. In any case, Network Health must be notified within two business days of discharge from the out-of-network facility or you may be financially responsible for the costs of the services.


If you have questions about which services require authorization, or the status of your authorization request, log in to the member portal at My Login. You can view a list of services that require authorization under My Materials. To see the status of an authorization request, select My Benefits and then My Authorizations.

If you have an authorization request or questions about the prior authorization process, call our care management department at 800-236-0208 or TTY 800-947-3529. For mental health and substance abuse services, please contact Network Health’s Care Management Behavioral Health Department at 800-555-3616. You may leave a message 24 hours a day, seven days a week. Calls about routine (non-urgent) authorization requests received after business hours will be returned the next business day. See the Inpatient Hospital Care section below for more information on urgent hospital stay requests received after business hours.

Requesting Prior Approval for Inpatient Hospital Care 

All non-emergency hospitalizations require prior authorization from Network Health. If you are admitted to a non-participating hospital for observation or as an inpatient after a stay in the emergency room, you or your physician must obtain approval from Network Health within 48 hours of the admission or the next business day to receive coverage. If this notification requirement is met, Network Health’s Care Management Department can approve hospital days following that emergency visit up to the time of the notification. Network Health will review any additional days to be sure the stay continues to be medically necessary.

Please call the care management department at 800-236-0208 for all prior authorizations and notifications. For mental health and substance abuse services contact Network Health’s Care Management Behavioral Health Department at 800-555-3616. Bilingual language assistance or translation services are available for members. Network Health also offers services for deaf, hard-of-hearing or speech-impaired members (TTY 800-947-3529).

Requesting an Independent Review 

We work hard to ensure member satisfaction, but you have the right to have an independent organization examine certain final decisions made by Network Health. Network Health contracts with three nationally-accredited independent review organizations (IRO) to conduct reviews, and the decisions are binding for both Network Health and the member.

Decisions made by Network Health that are eligible for review are those where we determined the requested care or services did not meet our requirements for medical necessity, appropriateness, health-care setting, level of care, effectiveness, experimental treatment, rescission of a policy or a certificate or coverage denial determination based on pre-existing condition exclusion. Requests for services that are not included in your benefits package are ineligible for independent review (including, but not limited to, benefits limitations and direct exclusions).

Typically, you must complete Network Health’s internal complaint process (called a grievance) prior to starting an independent review. However, you do not need to complete the process if you need immediate medical treatment and a delay could jeopardize your life or health, or if we agree with you that it is in everyone’s best interest to proceed with your concern directly to independent review.

For more information on the independent review organization process, call the number on the back of your Network Health ID card.

Evaluating New Technologies 

Network Health evaluates new technologies and new applications of existing technologies on a regular basis. This includes the evaluation of medical procedures, drugs and devices.

New technologies are reviewed by a group of participating physicians and health plan staff who make recommendations for inclusion as a covered benefit. The review process also includes evaluation of information from government regulatory bodies and published scientific evidence.

Forms

Coordination of Benefits (COB)
Fill out this form if you and other members of your household are covered by more than one health insurance plan. Network Health will communicate with the other health insurance company to determine which company pays for each claim.

Personal Health Information Form - When completed and signed by both parties, the Personal or Protected Health Information Consent form allows the specified person (a spouse, relative, friend, advocate, attorney, doctor or someone else) to call and discuss your coverage and plan information if it’s ever needed. Completed forms can be mailed to Network Health, P.O. Box 120, Menasha, WI 54952.

Advance Care Planning/Power of Attorney for Health Care Form 
Use this resource to find for you to give someone permission to make health care decisions on your behalf. For questions about advance directives, contact the Wisconsin Department of Health Services at 608-266-1251 or contact Network Health at 800-378-5234 (TTY 800-947-3529).

Authorized Representative Form
This form names a relative, friend, advocate, doctor or someone else to act on your behalf for an appeal or complaint. Send the completed form to Network Health, Attn: Appeals and Grievance Department, 1570 Midway Pl., Menasha, WI 54952.

Well-Child Resources 

Your personal doctor (also referred to as a primary care practitioner or PCP) is a key resource in managing the health and wellness of yourself and your family. Your doctor may have resources to help you track your child’s next appointment date(s) and upcoming care needs. Your doctor may also be able to provide you with a list containing completed immunizations and medications. Network Health cares about your child’s health and encourages you to work in close partnership with your chosen doctor to meet the physical, social and emotional health needs of your family. For assistance selecting a doctor, contact Network Health at the number on the back of your ID card.

The milestone tracker from the Centers for Disease Control and Prevention (CDC) is a tracking document for recommended immunizations, milestones and growth from birth to six years of age.

Healthychildren.org, a website sponsored by the American Academy of Pediatrics, has apps for families that are available for download; these apps give you the ability to track your children’s health information, needs and providers and give guidance on when well-child visits and immunizations are due. They also have apps available for tracking children’s needs with attention deficit hyperactivity disorder (ADHD), car seat safety and safety with physical activity and exercise. Some apps are available for a small fee.

The pre-visit questionnaires from healthychildren.org can help you organize and prioritize the topics you should to discuss with your provider during well-child visits from ages two days to 21 years old.

Immunization Resources 

Immunizations help keep us free from various diseases throughout our lifetimes, from infancy to teen years, through adulthood and into our elderly years. Network Health supports member choice when it comes to immunizations. We collected some resources to help you prepare and make the best decision for the health of yourself and your family.

The CDC has a library of information that relates to the health and wellness of you and your family.

A guide for parents on vaccinating your child

Making the vaccine decision

Recommended immunizations for children (birth to 6 years)

Recommended immunizations for children and teens (7 through 18 years)

Recommended immunizations for adults

Pregnancy Resources

If you’re pregnant or have a baby under 1 year, Network Health recommends Text4baby, a free service that helps you feel more prepared for motherhood. Text4baby will send you doctor appointment reminders and personalized information on prenatal care, baby’s development, signs of labor, breastfeeding, nutrition and more, directly to your cell phone. It’s easy to sign up and the text messages are FREE, regardless of how many text messages you have in your cellphone plan or even if you don’t have texting in your cellphone plan. To sign up, text BABY (or BEBE for Spanish) to 511411. You can cancel the service at any time by texting STOP (ALTO for Spanish) to 511411. There is also an app, available for download in the Google Play and iTunes stores, which provides additional information about baby’s development, pregnancy, childcare tips and more. You can also sign up and find more information at www.text4baby.org or on Text4baby’s Facebook page.

Parenting Resources 

The CDC offers Positive Parenting Tips for children from newborn to 17 years old.

  • Violence prevention. Thorough understanding of adverse childhood experiences is becoming more important in today’s society. The CDC shares resources about various issues and strategies for helping our children grow up happier and healthier.
  • Youth bullying prevention. Resources are available to help understand bullying, identify children at risk for bullying, explain types of bullying and provide strategies for parents, schools and community professionals to come together to stop bullying and its harmful effects on our children.
  • Coping with Stress. Resources to help the whole family, including children, teens and adults as we cope with normal life stressors such as finances, social acceptance and self-care. You can also find information to assist with threatening situations that cause traumatic physical or emotional tension, such as car accidents, domestic violence and alcohol and drug abuse.

Attention-Deficit/Hyperactivity Disorder (ADHD)
ADHD is a disorder that makes it difficult to pay attention and control impulsive behaviors. While symptoms generally begin in childhood, ADHD can continue through adolescence and into adulthood. Although the exact cause is unknown, research suggests ADHD may be caused by interactions between genetic and environmental factors. While there is not a cure for ADHD, treatments are available and may help reduce symptoms and improve function. Medications, behavioral therapy, counseling and practical support can help those with ADHD and their families cope with everyday problems.

Your personal doctor, pediatrician or behavioral health specialist are key resources for managing health and wellness for yourself and your family. It is important to schedule follow up visits as recommended to achieve the best outcomes.

Visit Centers for Disease Control and Prevention (CDC) ADHD website to learn more about symptoms of ADHD.

Additional Resources

Preventive Physical vs. Office Visit
Learn the difference between a preventive physical and an office visit.

Find a Pediatric Vision Provider

Your pediatric vision benefit is available through EyeMed.

How Health Plans Make Their Decisions
Find out how decisions are made about your care.

Confidentiality
Network Health ensures that everyone who handles protected health information within the organization maintains confidentiality at all times.

Notice of Privacy Practices
Our policies to ensure that your privacy and information is protected.

Member Rights and Responsibilities 
As a member, you have certain rights and responsibilities.

Appeals and Grievances
Learn more about how to file a complaint (called a grievance) or an appeal.

Women's Health and Cancer Rights Act of 1998

The Newborns' and Mothers' Health Protection Act of 1996 (NMHPA)

Clinical Practice Guidelines


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.