Network Health Plus (PPO)

H5215 - 001 - 0
5 out of 5 stars (5 / 5)

Network Health Plus (PPO) is a Medicare Advantage Plan by Network Health Medicare Advantage Plans.

This page features plan details for 2024 Network Health Plus (PPO) H5215 – 001 – 0 available in East Central Wisconsin.

IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:

No 2025 version found. You can use the location links below to find 2025 plans in your area.

Locations

Network Health Plus (PPO) is offered in the following locations.

Plan Overview

Network Health Plus (PPO) offers the following coverage and cost-sharing.

Insurer:Network Health Medicare Advantage Plans
Health Plan Deductible:$0.00
MOOP:$3,400 In and Out-of-network
$3,400 In-network
Drugs Covered:No

Ready to sign up for Network Health Plus (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Network Health Plus (PPO) has a monthly premium of $42.00. This amount includes your Part C premium but does not include your Part B premium.
Part B Part C Part B Give Back Total
$174.70 $42.00 $0.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

Network Health Plus (PPO) also provides the following benefits.

Health plan deductible

$0

Other health plan deductibles?

In-network No

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$3,400 In and Out-of-network
$3,400 In-network

Optional supplemental benefits

Yes

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-network No

Outpatient hospital coverage

In-network $350 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network $350 copay per visit (Authorization is required.) (Referral is not required.)

Doctor visits

In-network Primary$15 copay per visit (Not applicable.) (Not applicable.)
out-of-network Primary$15 copay per visit (Not applicable.) (Not applicable.)
In-network Specialist$40 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network Specialist$40 copay per visit (Authorization is required.) (Referral is not required.)

Preventive care

In-network $0 copay (Authorization is not required.) (Referral is not required.)
out-of-network $0 copay (Authorization is not required.) (Referral is not required.)

Emergency care/Urgent care

Emergency$110 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$40 copay per visit (always covered) (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

In-network Diagnostic tests and procedures$5-25 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic tests and procedures$5-25 copay (Authorization is required.) (Referral is not required.)
In-network Lab services$0-5 copay (Authorization is required.) (Referral is not required.)
out-of-network Lab services$0-5 copay (Authorization is required.) (Referral is not required.)
In-network Diagnostic radiology services (e.g., MRI)$25-100 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic radiology services (e.g., MRI)$25-100 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient x-rays$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient x-rays$25 copay (Authorization is required.) (Referral is not required.)

Hearing

In-network Hearing exam$25 copay (Authorization is not required.) (Referral is not required.)
out-of-network Hearing exam$25 copay (Authorization is not required.) (Referral is not required.)
In-network Fitting/evaluation$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Fitting/evaluation$40 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Hearing aids$495-1,695 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Hearing aids$495-1,695 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Preventive dental

In-network Office visit$30.00 (Authorization is not required.) (Referral is not required.)
out-of-network Office visit$0 copay (Authorization is not required.) (Referral is not required.)
Oral examCovered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.)
CleaningCovered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Fluoride treatmentNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Dental x-ray(s)Not covered (There are no limits.) (Not applicable.) (Not applicable.)

Comprehensive dental

Non-routine servicesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Diagnostic servicesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Restorative servicesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
EndodonticsNot covered (There are no limits.) (Not applicable.) (Not applicable.)
PeriodonticsNot covered (There are no limits.) (Not applicable.) (Not applicable.)
ExtractionsNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Prosthodontics, other oral/maxillofacial surgery, other servicesNot covered (There are no limits.) (Not applicable.) (Not applicable.)

Vision

In-network Routine eye exam$10 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Routine eye exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
OtherNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Contact lensesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Eyeglasses (frames and lenses)Not covered (There are no limits.) (Not applicable.) (Not applicable.)
Eyeglass framesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Eyeglass lensesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
UpgradesNot covered (Not applicable.) (Not applicable.)

Rehabilitation services

In-network Occupational therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Occupational therapy visit$40 copay (Authorization is required.) (Referral is not required.)
In-network Physical therapy and speech and language therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Physical therapy and speech and language therapy visit$40 copay (Authorization is required.) (Referral is not required.)

Ground ambulance

In-network $250 copay (Not applicable.) (Not applicable.)
out-of-network $250 copay (Not applicable.) (Not applicable.)

Transportation

Not covered (Not applicable.) (Not applicable.)

Foot care (podiatry services)

In-network Foot exams and treatment$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Foot exams and treatment$40 copay (Authorization is required.) (Referral is not required.)
Routine foot careNot covered (Not applicable.) (Not applicable.)

Medical equipment/supplies

In-network Durable medical equipment (e.g., wheelchairs, oxygen)0-20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Durable medical equipment (e.g., wheelchairs, oxygen)0-20% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Prosthetics (e.g., braces, artificial limbs)0-20% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Diabetes supplies$0 copay (Authorization is required.) (Not applicable.)
out-of-network Diabetes supplies$0-10 copay per item (Authorization is required.) (Not applicable.)

Wellness programs (e.g., fitness, nursing hotline)

Covered (Authorization is not required.) (Referral is not required.)

Medicare Part B drugs

In-network Chemotherapy0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Chemotherapy20% coinsurance (Authorization is required.) (Not applicable.)
In-network Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Other Part B drugs20% coinsurance (Authorization is required.) (Not applicable.)
In-network Part B Insulin drugs0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.)
out-of-network Part B Insulin drugs20% coinsurance (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

In-network $175 per day for days 1 through 5
$0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.)
out-of-network $175 per day for days 1 through 5
$0 per day for days 6 and beyond (Authorization is required.) (Referral is not required.)

Mental health services

In-network Inpatient hospital – psychiatric$150 per day for days 1 through 10
$0 per day for days 11 through 90 (Authorization is required.) (Referral is not required.)
out-of-network Inpatient hospital – psychiatric$150 per day for days 1 through 10
$0 per day for days 11 through 190 (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit with a psychiatrist$35 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit with a psychiatrist$35 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit with a psychiatrist$35 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit with a psychiatrist$35 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit$35 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit$35 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit$35 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit$35 copay (Authorization is required.) (Referral is not required.)

Skilled Nursing Facility

In-network $20 per day for days 1 through 20
$203 per day for days 21 through 40
$0 per day for days 41 through 100 (Authorization is required.) (Referral is not required.)
out-of-network $20 per day for days 1 through 20
$203 per day for days 21 through 40
$0 per day for days 41 through 100 (Authorization is required.) (Referral is not required.)

Package #1

Monthly Premium$42.00
Deductible$100.00

Ready to sign up for Network Health Plus (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

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