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).

Medicare Plans

NetworkPrime (MSA)