A non-government entity
HealthPartners Birch (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HealthPartners Birch (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HealthPartners Birch (PPO) in 2025, please refer to our full plan details page.
HealthPartners Birch (PPO) is a PPO plan offered by HealthPartners, Inc. available for enrollment in 2025 to people living in Northeastern Wisconsin including Door County. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that HealthPartners Birch (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about HealthPartners Birch (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For HealthPartners Birch (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $200.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6500.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6500.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for HealthPartners Birch (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The HealthPartners Birch (PPO) plan has a $200 deductible for prescription drugs. In the initial coverage phase, after you meet your deductible, you'll pay varying costs depending on the drug tier and pharmacy type. For example, you'll have no copay for preferred generic drugs at standard and mail-order pharmacies. Standard generic drugs have a $47 copay at all pharmacy types, while preferred brand drugs have 50% coinsurance at all pharmacies. After your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The HealthPartners Birch (PPO) plan offers a wide range of benefits with varying cost-sharing. Hospital stays have a copay, with outpatient services and emergency services also having copays. This plan covers primary care, vision, and dental services. It also includes coverage for hearing aids, ambulance services, and home health services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, the plan has a $350 copay for days 1-5 and no copay for days 6-90; additional days are covered with no copay. For Inpatient Hospital Psychiatric, the plan has a $350 copay for days 1-5 and no copay for days 6-90; additional days are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered under the HealthPartners Birch (PPO) plan. Outpatient Hospital Services and Observation Services have a $350 copay, while Ambulatory Surgical Center (ASC) Services have a $325 copay. Outpatient Substance Abuse Services have a $30 copay for both individual and group sessions, and Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial hospitalization is covered with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HealthPartners Birch (PPO). Ground and air ambulance services have a $300 copay, with no coinsurance, while transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services has a $125 copay, and Urgently Needed Services has a $45 copay, while Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $300 copay, all with no coinsurance.
Primary Care See details
The HealthPartners Birch (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $45 copay, and mental health specialty services with a $40 copay for individual and group sessions. The plan also covers physical therapy and speech-language pathology services with a $40 copay, and additional telehealth benefits with a copay ranging from $0 to $45. Podiatry services are not covered.
Preventive Services See details
Preventive services are covered, including Medicare-covered services, annual physical exams, and additional preventive services. Some preventive services are not covered, including Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services.
Hearing Services See details
Hearing services include routine hearing exams with a $45 copay, fitting/evaluation for hearing aids with no copay, and prescription hearing aids with a copay between $499 and $999. Prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with a $45 copay, as well as coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are limited to one visit per year.
Dental Services See details
The HealthPartners Birch (PPO) plan covers Medicare dental services with a $45 copay, and other dental services with a maximum benefit of $1,000 per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatments are covered, and each have limitations on the number of visits per year. Restorative services and periodontics are also covered, while adjunctive general services, endodontics, prosthodontics (removable, fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay, and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HealthPartners Birch (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the HealthPartners Birch (PPO) plan. Durable Medical Equipment (DME) is covered with a 20% coinsurance, and Prosthetic Devices, and Medical Supplies are covered with a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures with a $40 copay, lab services with at most 10% coinsurance, diagnostic radiological services with a $250 copay, therapeutic radiological services with at most 20% coinsurance, and outpatient X-ray services with a $75 copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the HealthPartners Birch (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HealthPartners Birch (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HealthPartners Birch (PPO) plan. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The HealthPartners Birch (PPO) plan covers acupuncture with a $45 copay for up to 20 treatments per year, and also covers over-the-counter items with a maximum benefit of $50 every three months, including nicotine replacement therapy and naloxone. The plan also covers a meal benefit for chronic illness and other services including US Emergency Travel Logistics, Travel Counseling, and Treatment at the Scene with a $300 copay. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved