Medicare Plans

NetworkPrime (MSA)

$0 per month

Medical coverage for people who want control over their health care dollars with a medical savings account and high deductible health plan

  • No monthly premium
  • $1,500 deposited by Medicare in your Medicare Medical Savings Account
  • $5,100 medical deductible
  • You pay nothing for Medicare-covered services after you meet your deductible

Our service estimate guide helps you plan ahead by providing a range of cost estimates for common services. 

NetworkPrime MSA Benefits NetworkPrime (MSA)
Premium

You pay nothing for your Medicare monthly plan premium. Medicare pays this monthly plan premium. You must keep paying your Medicare Part B premium.

Deductible

$5,100 per year - you will pay nothing for Medicare-covered services after you meet your deductible

Inpatient Hospital Coverage

You pay nothing after you meet your deductible

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. Once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

Once you meet your deductible, the plan pays 100% of Medicare-approved costs.

Outpatient Surgery Services

You pay nothing after you meet your deductible.

Covered services include:
• Ambulatory surgical center
• Outpatient hospital

Primary Care Provider

You pay nothing after you meet your deductible.

Specialist

You pay nothing after you meet your deductible.

Preventive Care

You pay nothing after you meet your deductible. 

Until you meet your yearly deductible, you pay up to 100% for the Medicare-approved amount.

Emergency Room

You pay nothing after you meet your deductible

Urgent Care

You pay nothing after you meet your deductible

Low Cost Labs

You pay nothing after you meet your deductible

Lab and Clinical Diagnostic Tests

You pay nothing after you meet your deductible

Outpatient X-rays

You pay nothing after you meet your deductible

Ultrasound, EKGs, EEGs, Stress Test

You pay nothing after you meet your deductible

Radiation Therapy

You pay nothing after you meet your deductible

Diagnostic Radiology Services
(Such
as MRIs, CT Scans)

You pay nothing after you meet your deductible

Medicare Covered Hearing Exams

You pay nothing after you meet your deductible

Medicare Covered Dental

You pay nothing after you meet your deductible

Limited to Medicare-covered dental services only. Medicare does not cover services in connection with care, treatment, filling, removal, or replacement of teeth.

Supplemental Dental

The dental optional supplemental benefit package is available for a monthly premium of $35

Annual Maximum: $1,000
Comprehensive Deductible: $100

In-Network
0% of the cost for non-Medicare covered preventive and diagnostic dental services. Deductible does not apply.

50% of the cost for non-Medicare covered basic and major dental services after the deductible.

Out-of-Network
20% of the cost for non-Medicare covered preventive and diagnostic dental services. Deductible does not apply.

50% of the cost for non-Medicare covered basic and major dental services after the deductible.

Medicare Covered Eye Exam

You pay nothing after you meet your deductible

Covered services include:
• Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)
• Eyeglasses or contact lenses after cataract surgery

Supplemental Vision

Not included

Inpatient Mental Health Care

You pay nothing after you meet your deductible

Covered services include:
• Inpatient visit - Up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient   

   hospital care limit applies to inpatient mental health services provided in a general hospital.

Outpatient Mental Health Care

You pay nothing after you meet your deductible

Covered services include:
• Outpatient group therapy visit
• Outpatient individual therapy visit

Skilled Nursing Facility

You pay nothing after you meet your deductible

Covered services include up to 100 days in a skilled nursing facility

Physical Therapy

You pay nothing after you meet your deductible.

Covered services include:
• Occupational therapy visit
• Physical therapy and speech and language therapy visit

Ambulance

You pay nothing after you meet your deductible

Transportation

Not covered

Medicare Part B Drugs and Chemotherapy

You pay nothing after you meet your deductible

• For Part B drugs such as chemotherapy drugs
• Other Part B drugs

Medicare Part D Drugs

Not included

Chiropractic Care

You pay nothing after you meet your deductible

Chiropractic Care is limited to Manual Manipulation of the spine to correct a subluxation when 1 or more of the bones of your spine move out of position

Diabetes Monitoring Supplies and Test Strips1

You pay nothing after you meet your deductible

Diabete Self-Monitoring Training

You pay nothing after you meet your deductible

Theraputic Shoes/Inserts

 You pay nothing after you meet your deductible

Durable Medical Equipment

You pay nothing after you meet your deductible

Prosthetic Devices

You pay nothing after you meet your deductible

Related Medical Supplies

You pay nothing after you meet your deductible

Home Health Care1

You pay nothing after you meet your deductible

 

This plan does not include prescription drug coverage. However, you can combine it with a Stand Alone Prescription Drug Plan. You can also use your savings account to help pay for prescription drug coverage.This information is not a complete description of benefits. Call 800-378-5237 (TTY 800-947-3529) for more information. 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. You must file Form 1040, ‘US Individual Income Tax Return,’ along with Form 8853, Archer MSA and Long-Term Care Insurance Contracts’ with the Internal Revenue Service (IRS) for any distributions made from your Medicare MSA account to ensure you aren’t taxed on your MSA account withdrawals. You must file these tax forms for any year in which an MSA account withdrawal is made, even if you have no taxable income or other reason for filing a Form 1040. MSA account withdrawals for qualified medical expenses are tax free, while account withdrawals for non-medical expenses are subject to both income tax and a fifty (50) percent tax penalty. Tax publications are available on the IRS website at http://www.irs.gov or from 1-800-TAX-FORM (1-800-829-3676). 


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.