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Medicare Plans

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

How much does Medicare deposit into my MSA bank account?

Medicare will deposit $1,500 into your account

Inpatient Hospital Coverage

The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period.

 

There’s no limit to the number of benefit periods.

 

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. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

 

You pay nothing after you meet your deductible.

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. Our plan covers many preventive services, including:

• Abdominal aortic aneurysm screening

• Alcohol misuse counseling

• Bone mass measurement

• Breast cancer screening (mammogram)

• Cardiovascular disease (behavioral therapy)

• Cardiovascular screenings

• Cervical and vaginal cancer screening

• Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmiodoscopy)

• Depression screening

• Diabetes screenings

• HIV screening

• Medical nutrition therapy services

• Obesity screening and counseling

• Prostate cancer screenings (PSA)

• Sexually transmitted infections screening and counseling

• Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

• Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

• “Welcome to Medicare” preventive visit (one-time)

• Yearly “Wellness” visit

 

Any additional preventive services approved by Medicare during the contract year will be covered.

 

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

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

In-network: $10 copayment

Out-of-network: maximum $30 reimbursement

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

Outpatient Rehabilitation

You pay nothing after you meet your deductible.

 

Covered services include:

• Cardiac (heart) rehab services (for a maximum of two one-hour sessions per day for up to 36 sessions up to 36 weeks)

• 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 Supplies and Services

You pay nothing after you meet your deductible Covered expenses include:

•Diabetes monitoring supplies

•Diabetes self-management training

•Therapeutic shoes or inserts

Durable Medical Equipment

You pay nothing after you meet your deductible

Prosthetic Devices

You pay nothing after you meet your deductible

Covered services include:

• Prosthetic devices

• Related medical supplies

Related Medical Supplies

In-network: 20% of the cost

Out-of-network: 25%

Home Health Care

You pay nothing after you meet your deductible


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.