Fallon Health NaviCare (D-SNP HMO), Franklin County, MA
Fallon Health NaviCare (HMO D-SNP), plan H8928-001-0, is a Medicare Advantage Special Needs Plan from Fallon Health. Delivery of healthcare services and costs are significantly different than in Original Medicare, and the plan offers additional benefits that are not included with Medicare Part A and Part B.
This plan has not been rated by CMS. See MedicareWire's review below. You must meet all qualification requirements to join this D-SNP plan.
GET NOTIFIED: 2024 Medicare Special Needs Plan Notification.
What You Need to Know
- Fallon Health NaviCare is a HMO health plan for dual-eligible (Medicare and Medicaid) beneficiaries.
- This is a zero-dollar D-SNP cost-sharing plan. Members have no copays when they use Medicare-approved healthcare services.
- To qualify, you must have both Medicare Part A and Part B, you must live in the plan's service area (Franklin County), and you must qualify for full Medicaid.
- It includes prescription drug coverage (Medicare Part D).
- The annual Part D deductible is $505.00. You pay this amount before cost-sharing begins.
- People who qualify for Medicare "Extra Help," can get additional assistance to help pay their Medicare Part D monthly premium, deductible, and copayments.
- The plan offers the same health insurance benefits as Original Medicare and some additional benefits that Original Medicare does not cover.
- If you don't qualify to join Fallon Health NaviCare, you might want to compare Medicare Advantage plans available in Franklin County, Massachusetts. Another popular option is to add one of the many Medicare supplements available in Massachusetts and a stand-alone prescription drug plan.
- 2024 costs and benefits for Fallon Health NaviCare will be available in early October. Get Notification.
| H8928-001-0 Plan Basics | |
|---|---|
| Plan ID: | H8928-001-0 |
| Plan Type: | D-SNP |
| Network Type: | HMO |
| Plan Year: | 2023 |
| Premium: | $36.30/mo Plus your Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | $7,550 In-network |
| Drug Plan Benefit: | Basic $505.00 deductible |
| Rx Gap Coverage: | No |
| Supplemental Benefits: | Dental |
| Availability: | Franklin County, MA |
| Insured By: | Fallon Health |
Health Plan Costs & Benefits
Fallon Health NaviCare is a Health Maintenance Organization (HMO) plan. HMO plan members usually receive health care services through the plan’s local network of providers. Referrals are almost always required to see a specialist and other providers. However, Fallon Health NaviCare does allow out-of-network care for emergencies and out-of-area dialysis.
Premiums, deductibles, and copays vary widely from plan to plan. It is very important to compare costs and apply them to your personal financial and healthcare needs.
Monthly Premium
Fallon Health NaviCare's total monthly premium in Franklin County is $36.30. This includes your prescription coverage, as well. Plus, you must continue to pay your monthly Medicare Part B premium.
Annual Deductible
Fallon Health NaviCare's annual health plan deductible is $0.00. This does not include the deductible for the prescription drug plan (if any), which is detailed below.
Maximum Out-of-Pocket Limit
The Maximum Out-of-Pocket (MOOP) with this Fallon Health plan is $7,550 in-network. Unlike Original Medicare, Medicare Advantage plans must set an annual Maximum Out-of-Pocket (MOOP) limit on inpatient and outpatient healthcare services. Once you reach this amount of spending on your copayments, all of your Medicare Part A and Part B services will be covered at no additional charge for the remainder of the year. MOOP does not include monthly premiums, prescriptions, or other extra benefits.
Health Plan Out-of-Pocket Costs
The following table is a summary of the most common out-of-pocket costs you will incur if you join this Fallon Health plan:
| Healthcare Service | Member Cost |
|---|---|
| Health plan deductible | $0 |
| Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | $7,550 In-network |
| Doctor Visits | |
| Primary | $0 copay |
| Wellness programs (e.g., fitness, nursing hotline) | Covered |
| Preventive care | $0 copay |
| Mental Health Services | |
| Outpatient group therapy visit with a psychiatrist | $0 copay (authorization required) |
| Inpatient hospital - psychiatric | $0 copay (authorization required) |
| Outpatient group therapy visit | $0 copay |
| Outpatient individual therapy visit with a psychiatrist | $0 copay (authorization required) |
| Rehabilitation Services | |
| Physical therapy and speech and language therapy visit | $0 copay (authorization required) |
| Medical Equipment / Supplies | |
| Prosthetics (e.g., braces, artificial limbs) | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (authorization required) |
| Diagnostic Procedures / Lab Services / Imaging | |
| Diagnostic tests and procedures | $0 copay |
| Outpatient x-rays | $0 copay (referral required, authorization required) |
| Lab services | $0 copay |
| Medicare Part B Drugs | |
| Other Part B drugs | $0 copay (authorization required) |
| Foot Care (podiatry Services) | |
| Routine foot care | Not covered |
| Hearing | |
| Hearing aids - outer ear | Not covered |
| Hearing aids - over the ear | Not covered |
| Hearing exam | $0 copay (referral required) |
| Fitting/evaluation | Not covered |
| Preventive Dental | |
| Oral exam | Not covered |
| Cleaning | Not covered |
| Fluoride treatment | Not covered |
| Comprehensive Dental | |
| Extractions | Not covered |
| Non-routine services | Not covered |
| Endodontics | $0 copay (limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (limits may apply) |
| Diagnostic services | Not covered |
| Periodontics | $0 copay (limits may apply) |
| Vision | |
| Other | Not covered |
| Eyeglasses (frames and lenses) | $0 copay (limits may apply) |
| Eyeglass lenses | $0 copay (limits may apply) |
| Contact lenses | $0 copay (limits may apply) |
| Upgrades | $0 copay (limits may apply) |
| Eyeglass frames | $0 copay (limits may apply) |
| Emergency Care / Urgent Care | |
| Emergency | $0 copay |
| Ground ambulance | $0 copay |
| Inpatient hospital coverage | $0 copay |
| Outpatient hospital coverage | $0 copay |
| Skilled Nursing Facility | $0 copay |
| Optional supplemental benefits | No |
Feel free to download our Fallon Health NaviCare Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Fallon Health NaviCare includes an basic benefit Medicare Part D plan (PDP). This simply means that the plan covers the minimum amount required by the Centers for Medicare & Medicaid Services, whereas enhanced benefit plans cover more.
Basic plans typically have less cost-sharing by the plan than plans with an enhanced benefit. But, close to a third of all enhanced plans charge more than the average for preferred brand name drugs, and over 50% charge more for non-preferred brand drugs. For most people, a basic plan is their best bet, due to lower premiums and lower cost-sharing, even if the plan has a deductible.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. The following table outlines the prescription drug plan premium details of this plan.
| Basic Part D Premium: | $36.30 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $36.30 |
| Part D Premium with Full LIS Assistance: | $0.00 |
| Part D Premium with 75% LIS Assistance: | $9.10 |
| Part D Premium with 50% LIS Assistance: | $18.20 |
| Part D Premium with 25% LIS Assistance: | $27.20 |
For more information about the Low-Income Subsidy (aka, "Extra Help") program, refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $505.00. This is the amount you must pay at the pharmacy before Fallon Health begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Fallon Health NaviCare has copayments (a fixed dollar amount) and/or coinsurances (a percentage amount) that you must pay when you pick up your prescriptions. The following table shows you those costs.
| Tier | Preferred | Standard |
|---|---|---|
| $0 copay on all covered generic and brand-name prescriptions. | ||
A Brief Review and CMS 5-Star Rating Marks
Each year Medicare rates D-SNP plans, like this one, in nine major categories. These ratings are designed to help you understand the quality of care and service you can expect if you qualify and choose to join Fallon Health NaviCare.
This plan too new to have a star rating from Medicare. But we can give you our take on Fallon Health NaviCare's value.
| CMS Measure | Star Rating |
|---|---|
| 2023 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
How to Qualify to Enroll in
Fallon Health NaviCare
To qualify for enrollment in Fallon Health NaviCare in Franklin County, you must be eligible for both Medicare and Medicaid. To be eligible for Medicare, you must be age 65 or older, or have Social Security Disability Insurance for 24 months. To be eligible for Medicaid, your income and assets must be at or below Massachusetts's state thresholds.
Before enrolling in Fallon Health NaviCare, or any other dual-eligible SNP, be sure to ask the following questions:
- What costs should I expect to pay out-of-pocket (premiums, deductibles, copayments)?
- Will I be able to use my doctors? Are they in the plan's network?
- Are the plan's in-network providers and facilities in convenient locations?
- Does the plan provide coverage for services I receive from out-of-network providers?
- Do I need a referral to see a specialist?
- Are my medications on the Part D plan's formulary? What if I can't afford my medications?
- What special accommodations does the plan make for persons with disabilities?
- Does the plan offer free meal delivery after a stay in the hospital?
- What help is offered for caregivers? Is adult day care covered?
- Does the plan offer a prepaid card for over the counter medications and covered groceries?
Additional D-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
Contact Fallon Health
Call 1-855-728-0510 (TTY 711) to speak with a licensed insurance agent (Mon-Fri, 8am-9pm , Sat 8am-8pm EST) and learn more about this Special Needs Plan and other plans on this site. You may also Enroll Online using our safe and secure online enrollment website or take advantage of the following plan resources:
| Plan Website: | http://fallonhealth.org/navicare |
|---|---|
| Formulay Information: | http://fallonhealth.org/navicare-pharmacy |
| Pharmacy Information: | Fallon Health Pharmacy Page |
| Prospective Members: | (877)255-7108 |
| TTY Users: | (711)- |
If you qualify for Medicare but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Centene Corporation, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna-HealthSpring, Humana, Molina Healthcare, Mutual of Omaha, Oscar Health Insurance, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, and UnitedHealthcare.
Citations & References
- Fallon Health, http://fallonhealth.org/navicare, Last Accessed October 13, 2022
- Medicaid.gov, "Medicaid & CHIP in Massachusetts", Last Accessed January 20, 2023
- CMS.gov, "Dual Eligible Special Needs Plans (D-SNPs)", Last Accessed January 20, 2023
- CMS.gov, Landscape Source Files, Last Accessed January 21, 2023
- CMS.gov, Medicare Part C & D Performance, Last Accessed January 21, 2023
- CMS.gov, Plan Benefits Package, Last Accessed January 21, 2023