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Plan Details

Network Health Cares (PPO D-SNP)

Medical and pharmacy coverage for people who have both Medicare and Medicaid benefits.

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Premium

$0 a month

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  • You pay the same in- and out-of-network for medical benefits (unless specified)
  • $0 copayment for an annual routine hearing exam
  • $50 HRA reward
  • $225 quarterly over-the-counter benefit
  • $400 allowance for glasses and contacts
  • One Pass™ fitness
  • Transportation benefit
  • $0 monthly premium
  • 100% coverage for preventive care
  • Comprehensive and preventive dental
  • Meal delivery after an inpatient or skilled nursing facility stay
  • Regular contact from specialized care coordinators
  • Must qualify for Medicaid to enroll in this plan

Additional Benefits

Over-the-Counter Allowance

To keep you healthy and well, our Network Health Cares members receive a $225 per quarter over-the-counter allowance. Hundreds of useful items can be mailed directly to your home at no cost to you.

Meals

Recovering after an inpatient stay can be difficult. That’s why Network Health partners with Mom’s Meals to provide Network Health Cares members with 28 delicious meals delivered right to your door after a qualifying inpatient hospital stay, a hospital observation or a skilled nursing facility stay.

Additionally, Network Health Cares members that have been diagnosed with diabetes, congestive heart failure or obesity may be eligible to receive fresh produce or pantry boxes for delivery, up to six boxes per calendar year. Contact your care manager to arrange delivery of the food boxes.

In-Home Support

Network Health offers you access to a network of friendly helpers that provide you support with daily activities such as household tasks, technology help, transportation, shopping, meal preparation and more. You receive 60 hours of in-home support services per year. 

Transportation

Need a ride to the dentist or to the doctor? We can help. Our partnership with Aryv helps you get to where you need to be, safely. The transportation benefit includes 36 one-way trips within the Network Health service area. Also includes 24 one-way trips for all members diagnosed with ESRD to get to and from dialysis for treatment.3

HRA Reward

You can receive $50, once per year, for completing your health risk assessment (HRA).

Dental

Protecting your teeth and gums should be as routine as your annual wellness visit. Network Health partners with Say Cheese Dental Network to offer Network Health Cares members preventive and comprehensive dental care. For a summary of what's included and frequently asked questions, click here. Visit the Say Cheese Dental Network website to Find a Dental Provider.

Vision

Annual vision exams are an important part of your health care, so we partner with EyeMed® to offer our Network Health Cares members an annual routine vision exam for a $0 copayment and up to $400 for eyewear. For a summary of what’s included and frequently asked questions, click here. Visit EyeMed's website to Find a Vision Provider.

Hearing

We partner with TruHearing® to offer you a hearing benefit, so you can enjoy the world around you. Your hearing benefit includes an annual routine hearing exam at a local TruHearing provider for $0 if you see an in-network provider or $40 if you see an out-of-network provider. You also have access to select high-quality hearing aids, hearing aid fittings and follow-up care for $495-$1,695 per device when purchased through TruHearing. We recommend checking your Medicaid hearing benefit prior to using this benefit. Medicaid may cover a hearing exam and hearing aids for you.

Part B Premium Giveback

If you pay a Medicare Part B premium, we may pay part of that monthly premium for you. We call this a Part B premium giveback, and it is included with the Network Health Cares plan.

To qualify for the monthly $2.50 Part B premium giveback, you must be enrolled in Medicare Parts A and B, pay your own premiums and live in a service area that offers the Part B giveback.

Dual-Eligible Special Needs Plan PPO Benefits

Network Health Cares (PPO D-SNP)

Monthly Premium
$0
Monthly Part B Premium Giveback2

Must be enrolled in Medicare Parts A and B, pay own premium and live in a service area that offers this benefit

$2.50 per month
Annual Medical Deductible
In 2024 the amounts were:
$0-$240 depending on your level of Medicaid eligibility.
These amounts may change for 2025.
Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

$8,300 for services you receive from in-network
providers
$12,450 for services you receive from any provider,
your limit for services received from in-network providers will count toward this limit
Primary Care Provider Visit
0%-20% of the cost
Specialist Visit
0%-20% of the cost
Preventive Care*
$0 in-network
0%-20% of the cost out-of-network
Annual Medicare Wellness Visit
Covered
Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

$0 in-network
0%-20% of the cost out-of-network
Medicare-Covered Vaccines

Hepatitis B, all other Part B vaccines

$0 in-network
0%-20% of the cost out-of-network
Inpatient Hospital Services 1

Per admission

In 2024 the amounts for each admission were
Days 1-60 $0-$1,632 deductible
Days 61-90 $0-$408 per day
Days 91 and beyond $0-$816 per day
(This plan covers 60 lifetime reserve days)
These amounts may change for 2025.
Outpatient Hospital Services1
0%-20% of the cost
Labs
0%-20% of the cost
Diagnostic Tests1

Such as ultrasound, EKG, stress test

0%-20% of the cost
X-rays
0%-20% of the cost
Diagnostic Radiology Services– Advanced Imaging1
0%-20% of the cost
Urgent Care Visit
0%-20% of the cost, up to $45
Emergency Room Visit
0%-20% of the cost, up to $110
Air and Ground Ambulance Services
0%-20% of the cost
Durable Medical Equipment

Such as insulin pumps1, CPAP machines1, prosthetic devices1

0%-20% of the cost
Physician Telehealth Services
Virtual primary care and urgent care services cost the same as an in-person visit
Virtual Visit with MDLIVE ® 2

For medical services

$0
Medicare Part B Drugs 1

Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act.

0-20% of the cost
Travel within the United States
Receive in-network coverage when you see a provider outside Wisconsin, anywhere in the United States
International Emergency Coverage

View the Evidence of Coverage at networkhealth.com/medicare/plan-materials for details

$125 per incident
$100,000
Maximum benefit
Preventive and Comprehensive Dental Coverage2
$0 Cleaning (twice a year)
$0 Dental X-ray(s) (bitewing 1 per year, full mouth 1 every 5 years)
$0 Oral exam (twice a year)
$0 Basic restorative services
$0 of the cost for major services received at in-network providers (endodontics/periodontics/extractions, prosthodontics, other oral/maxillofacial surgery, other services), member pays 50% coverage of the allowed amount out-of-network
$3,000 annual maximum
Medicare-Covered Dental Services

Does not include services in connection with care, treatment, filling, removal or replacement of teeth

0%-20% of the cost
Annual Routine Vision Exam 2
$0 in-network, or
$40 reimbursement out-of-network
Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

0%-20% of the cost
Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

0%-20% of the cost
Additional Eyewear2
$400 allowance in-network at EyeMed providers
$400 reimbursement out-of-network
Over-the-Counter Coverage 2
Two order per quarter
$225 per quarter. No rollover on quarterly allowance.
Fitness with One Pass™ 2
Included
Routine Hearing Exam 2
$0 in-network, or
$40 out-of-network
Diagnostic Hearing Exam
0%-20% of the cost
Hearing Aids 2

Maximum of two hearing aids per year
Hearing aid evaluation with TruHearing and fitting included

$495-$1,695 per device
Hearing aids must be purchased through TruHearing
No coverage out-of-network
Non-Emergency Transportation2
36 one-way trips, anywhere within the Network Health Medicare Advantage Plan service area. Additionally includes 24 one-way trips for members with end-stage renal disease (ESRD) to get to and from dialysis.3
Meal Delivery

Following a qualified hospital observation stay, inpatient hospital stay or skilled nursing facility stay

28 meals
Food Box Delivery

For those diagnosed with diabetes, congestive heart failure or obesity

Up to 6 pantry or produce boxes per year
HRA Reward
Earn a $50 health reward, per year, by completing your annual health risk assessment
Outpatient Mental Health

Individual or group therapy

0%-20% of the cost
Inpatient Mental Health 1

Per admission

In 2024 the amounts for each admission were
Days 1-60 $0-$1,632 deductible
Days 61-90 $0-$408 per day
Days 91 and beyond $0-$816 per day
(This plan covers 60 lifetime reserve days)
These amounts may change for 2025.
Opioid Treatment Services
0%-20% of the cost
Substance Abuse Services

Outpatient individual or group therapy

0%-20% of the cost
Skilled Nursing Facility 1

Per admission

In 2024 the amounts were
$0 per day, days 1-20
$0-$204 per day, days 21-100
These amounts may change for 2025.
Outpatient Physical 1, Occupational 1, Speech Therapy
0%-20% of the cost
Chiropractic Services

Manipulation of the spine to correct misalignment of one or more of the bones of your spine

0%-20% of the cost
Medicare-Covered Acupuncture

For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year

0%-20% of the cost
Medicare-Covered Home Health Care Visits 1
$0
Chemotherapy 1
0%-20% of the cost
Radiation Therapy 1

Per service

0%-20% of the cost
Acupuncture3

Up to 12 visits per year are covered for members who are undergoing chemotherapy and have severe nausea and/or vomiting

$0
Diabetes Monitoring Supplies and Test Strips

OneTouch ™ and FreeStyle™ test strips
Continuous glucose monitoring supplies1 limited to eligible FreeStyle Libre ® and Dexcom ® obtained through your pharmacy. All other brands are not covered.1

0%-20% of the cost
Diabetic Shoe Inserts

Coinsurance per pair

0%-20% of the cost
Part B Insulin

One month supply

0%-20% of the cost, up to $35
Diabetes Management

Diabetes self-management training teaches you to cope with and manage your diabetes

0-20% of the cost
Dialysis

Per treatment

0%-20% of the cost
1 Service may require prior authorization.
2 Visit networkhealth.com/medicare/extra-benefits-snp for more information.
3This is a Special Supplemental Benefit for the Chronically Ill (SSBCI) benefit. In addition to an eligible chronic condition, members must also meet additional eligibility requirements to receive the SSBCI benefit.
*Includes abdominal aortic aneurysm screening, alcohol misuse screening and counseling, annual wellness visit, bone mass measurement, breast cancer screening, cardiovascular disease screening, cardiovascular disease risk reduction visit, cervical and vaginal cancer screening, colorectal cancer screening (screening colonoscopy, fecal occult blood test, flexible sigmoidoscopy), depression screening, diabetes screening, glaucoma screening, HIV screening, lung cancer screening, medical nutrition therapy services, Medicare Diabetes Prevention Program, obesity screening and therapy, prostate cancer screening, screening for sexually transmitted infections and counseling, smoking and tobacco use cessation counseling, one time Welcome to Medicare preventive visit.
Because covered services and copayments could change, you should ask your provider what your copayment amount will be. If you get more than one service during the same appointment, you may be asked for more than one copayment.

 Your Drug Costs

Network Health Cares (PPO D-SNP)

After you reach your yearly deductible of $0-$590 for your Tier 1 drugs (all drugs), you pay the following coinsurance for your drugs. If you receive Extra Help, depending on your income level, your actual cost share may be less. You will need to fill your prescriptions at in-network retail pharmacies or the plan’s mail order pharmacy.
How much do I pay? 
For Part B drugs such as chemotherapy drugs1:
• In- and out-of-network: 0%-20% of the cost
Other Part B drugs1:
• In- and out-of-network: 0%-20% of the cost
Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act
Part D Prescription Drug Deductible
Tier 1 (all drugs): $590
30-Day Supply Pharmacy or Mail Order Pharmacy
25% of the total cost
3-Month Supply Pharmacy
25% of the total cost
Part D Insulin
One-month supply
25% of the total cost, up to $35
Part D Vaccines
Shingrix, Tdap, all other ACIP recommended vaccines
$0

 

CATASTROPHIC COVERAGE
You enter catastrophic coverage when your total out-of-pocket costs reach $2,000. You pay $0.

Out-of-network/non-contracted providers are under no obligation to treat Network Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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