2022 Network PlatinumPlus (PPO)

Network PlatinumPlus (PPO) H5215-001 is a 2022 Medicare Advantage Plan or Part-C by Network Health Medicare Advantage Plans available to residents in Wisconsin. This plan does not provide additional prescription drug (Part-D) coverage. The Network PlatinumPlus (PPO) has a monthly premium of $51.00 and has an in-network maximum out-of-pocket limit of $3,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,400 out-of-pocket. This can be a extremely nice safety net.

Network PlatinumPlus (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Network Health Medicare Advantage Plans works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Network PlatinumPlus (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Network Health Medicare Advantage Plans and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Network Health Medicare Advantage Plans except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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Sat 8am-8pm EST

2022 Network Health Medicare Advantage Plans Medicare Advantage Plan Costs

2021 Network PlatinumPlus (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$25-100 copay (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$25-100 copay
Diagnostic tests and procedures	$5-25 copay (Out-of-Network)
Diagnostic tests and procedures	$5-25 copay
Lab services	$0-5 copay
Lab services	$0-10 copay (Out-of-Network)
Outpatient x-rays	$25 copay (Out-of-Network)
Outpatient x-rays	$25 copay

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Doctor Visits

Primary	$15 copay per visit (Out-of-Network)
Primary	$15 copay per visit
Specialist	$40 copay per visit
Specialist	$40 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$120 copay per visit (always covered)
Urgent care	$15-40 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$40 copay
Foot exams and treatment	$40 copay (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$250 copay
$250 copay (Out-of-Network)

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Hearing

Fitting/evaluation	Not covered
Hearing aids	$795-2,370 copay
Hearing aids	$795-2,370 copay (Out-of-Network)
Hearing exam	$25 copay
Hearing exam	$25 copay (Out-of-Network)

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Inpatient Hospital Coverage

$175 per day for days 1 through 5 $0 per day for days 6 and beyond (Out-of-Network)
$175 per day for days 1 through 5 $0 per day for days 6 through 90

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Medical Equipment/Supplies

Diabetes supplies	$0-10 copay per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$150 per day for days 1 through 10 $0 per day for days 11 through 190 (Out-of-Network)
Inpatient hospital - psychiatric	$150 per day for days 1 through 10 $0 per day for days 11 through 90
Outpatient group therapy visit	$35 copay
Outpatient group therapy visit	$35 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$35 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$35 copay
Outpatient individual therapy visit	$35 copay
Outpatient individual therapy visit	$35 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$35 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$35 copay

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MOOP

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

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$350 copay per visit (Out-of-Network)
$350 copay per visit

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Package #1

Deductible	$100.00
Monthly Premium	$38.00

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Preventive Care

$0 copay (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	Covered under office visit
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Office visit	$0 copay (Out-of-Network)
Office visit	$30.00
Oral exam	Covered under office visit

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Rehabilitation Services

Occupational therapy visit	$40 copay
Occupational therapy visit	$40 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay (Out-of-Network)

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Skilled Nursing Facility

$20 per day for days 1 through 20 $184 per day for days 21 through 54 $0 per day for days 55 through 100
$20 per day for days 1 through 20 $184 per day for days 21 through 54 $0 per day for days 55 through 100 (Out-of-Network)

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Transportation

Not covered

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Vision

Contact lenses	Not covered
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	Not covered
Other	Not covered
Routine eye exam	$0 copay (Out-of-Network)
Routine eye exam	$10 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Network PlatinumPlus (PPO) H5215

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Network PlatinumPlus (PPO) Plans Performance

Health Plan Customer Service Rating for Network PlatinumPlus (PPO)

Network PlatinumPlus (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Network PlatinumPlus (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.