2015 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Network Prime (MSA) | ||||
Location: | St. Croix, Wisconsin Click to see other locations | ||||
Plan ID: | H1181 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-800-378-5234 TTY users 1-800-947-3529 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Network Prime (MSA) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | MSAs do not have a monthly premium. (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | MSA * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $0 | ||||
Number of Members enrolled in this plan in St. Croix, Wisconsin: | less than 10 members | ||||
Number of Members enrolled in this plan in Wisconsin: | 891 members | ||||
Number of Members enrolled in this plan in (H1181 - 001): | 1,054 members | ||||
Plan’s Summary Star Rating: | Not Applicable. | ||||
• Customer Service Rating: | Plan not required to report measure. | ||||
• Member Experience Rating: | Plan not required to report measure. | ||||
• Drug Cost Accuracy Rating: | Plan not required to report measure. | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||
You pay nothing for your Medicare monthly plan premium. Medicare pays this monthly plan premium. You must keep paying your Medicare Part B premium. | |||||
$3 500 per year. | |||||
Medicare will deposit $1 500 into your account. | |||||
** Doctor and Hospital Choice ** | |||||
Acupuncture and Other Alternative Therapies | |||||
Not covered | |||||
** Extra Benefits ** | |||||
Inpatient Mental Health Care | |||||
For inpatient mental health care see the "Mental Health Care" section. | |||||
Outpatient Prescription Drugs | |||||
For Part B drugs such as chemotherapy drugs: You pay nothing after you pay your deductible | |||||
Other Part B drugs: You pay nothing after you pay your deductible | |||||
** Important Information ** | |||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||
You pay nothing for your Medicare monthly plan premium. Medicare pays this monthly plan premium. You must keep paying your Medicare Part B premium. | |||||
$3 500 per year. | |||||
Medicare will deposit $1 500 into your account. | |||||
** Outpatient Care and Services ** | |||||
Acupuncture and Other Alternative Therapies | |||||
Not covered | |||||
Ambulance Services | |||||
You pay nothing after you pay your deductible. | |||||
Chiropractic Care | |||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing after you pay your deductible | |||||
Dental Services | |||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing after you pay your deductible | |||||
Diabetes Supplies and Services | |||||
Diabetes monitoring supplies: You pay nothing after you pay your deductible Diabetes self-management training: You pay nothing after you pay your deductible Therapeutic shoes or inserts: You pay nothing after you pay your deductible | |||||
Diagnostic Tests, Lab and Radiology Services, and X-Rays | |||||
Diagnostic radiology services (such as MRIs CT scans): You pay nothing after you pay your deductible Diagnostic tests and procedures: You pay nothing after you pay your deductible Lab services: You pay nothing after you pay your deductible Outpatient x-rays: You pay nothing after you pay your deductible Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing after you pay your deductible | |||||
Doctor’s Office Visits | |||||
Primary care physician visit: You pay nothing after you pay your deductible | |||||
Specialist visit: You pay nothing after you pay your deductible | |||||
Durable Medical Equipment (wheelchairs, oxygen, etc.) | |||||
You pay nothing after you pay your deductible | |||||
Emergency Care | |||||
You pay nothing after you pay your deductible | |||||
Foot Care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing after you pay your deductible | |||||
Hearing Services | |||||
Exam to diagnose and treat hearing and balance issues: You pay nothing after you pay your deductible | |||||
Home Health Care | |||||
You pay nothing after you pay your deductible | |||||
Mental Health Care | |||||
Inpatient visit: | |||||
Our plan covers 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 services provided in a general hospital. You pay nothing after you pay your deductible. Outpatient group therapy visit: You pay nothing after you pay your deductible Outpatient individual therapy visit: You pay nothing after you pay your deductible | |||||
Outpatient Rehabilitation Services | |||||
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing after you pay your deductible Occupational therapy visit: You pay nothing after you pay your deductible Physical therapy and speech and language therapy visit: You pay nothing after you pay your deductible | |||||
Outpatient Substance Abuse | |||||
Group therapy visit: You pay nothing after you pay your deductible Individual therapy visit: You pay nothing after you pay your deductible | |||||
Outpatient Surgery | |||||
Ambulatory surgical center: You pay nothing after you pay your deductible | |||||
Outpatient hospital: You pay nothing after you pay your deductible | |||||
Over-the-Counter Items | |||||
Not Covered | |||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices: You pay nothing after you pay your deductible Related medical supplies: You pay nothing after you pay your deductible | |||||
Renal Dialysis | |||||
You pay nothing after you pay your deductible | |||||
Transportation | |||||
Not covered | |||||
Urgently Needed Care | |||||
You pay nothing after you pay your deductible | |||||
Vision Services | |||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing after you pay your deductible. Eyeglasses or contact lenses after cataract surgery: You pay nothing after you pay your deductible | |||||
** Hospice ** | |||||
Hospice | |||||
You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. | |||||
** Preventive Care ** | |||||
Preventive Care | |||||
You pay nothing | |||||
Our plan covers many preventive services including:
| |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
The copays 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 pay your deductible. | |||||
Inpatient Mental Health Care | |||||
For inpatient mental health care see the "Mental Health Care" section. | |||||
Skilled Nursing Facility (SNF) | |||||
Our plan covers up to 100 days in a SNF as long as you previously stayed in a hospital for 3 days. You pay nothing after you pay your deductible. | |||||
Outpatient Prescription Drugs | |||||
For Part B drugs such as chemotherapy drugs: You pay nothing after you pay your deductible | |||||
Other Part B drugs: You pay nothing after you pay your deductible | |||||
** Outpatient Care ** | |||||
Diabetes Supplies and Services | |||||
Diabetes monitoring supplies: You pay nothing after you pay your deductible Diabetes self-management training: You pay nothing after you pay your deductible Therapeutic shoes or inserts: You pay nothing after you pay your deductible | |||||
Foot Care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing after you pay your deductible | |||||
Hearing Services | |||||
Exam to diagnose and treat hearing and balance issues: You pay nothing after you pay your deductible | |||||
** Outpatient Medical Services and Supplies ** | |||||
Outpatient Substance Abuse | |||||
Group therapy visit: You pay nothing after you pay your deductible Individual therapy visit: You pay nothing after you pay your deductible | |||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices: You pay nothing after you pay your deductible Related medical supplies: You pay nothing after you pay your deductible | |||||
** Additional Benefits ** | |||||
Inpatient Mental Health Care | |||||
For inpatient mental health care see the "Mental Health Care" section. | |||||
** Cost ** | |||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||
Package 1: Wellness Benefit | |||||
Benefits include:
| |||||
Additional $6.20 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. | |||||
This package does not have a deductible. | |||||
Our plan pays up to $123 every year. | |||||
** Important Information ** | |||||
Package 1: Wellness Benefit | |||||
Benefits include:
| |||||
Additional $6.20 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. | |||||
This package does not have a deductible. | |||||
Our plan pays up to $123 every year. |