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 |