NaviCare (HMO D-SNP) H8928 001 0 is a 2023 Medicare Advantage Special Needs Plan plan by Fallon Health. This plan from Fallon Health works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Fallon Health and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage.
NaviCare (HMO D-SNP) H8928-001 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.
The NaviCare (HMO D-SNP) H8928-001 is available to residents to
Medicare eligible seniors in Massachusetts.
All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage.
NaviCare (HMO D-SNP) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.
How much does NaviCare (HMO D-SNP) cost?
Part-C Premium
A monthly premium is the fee you pay to the plan in exchange for coverage. Fallon Health charges a $0 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. NaviCare (HMO D-SNP) has a monthly drug premium of $36.30 and a $505.00 drug deductible. This Fallon Health plan offers a $36.30 Part-D Basic Premium that is below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by Fallon Health above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $36.30. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.
Fallon Health Gap Coverage
In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Fallon Health plan does not offer additional coverage through the gap.
Extra Help Premium Assistance
The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The NaviCare (HMO D-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $9.10 for 75% low-income subsidy $18.20 for 50% and $27.20 for 25%.
Full Assistance Premium:
$0
75% Assistance Premium:
$9.10
50% Assistance Premium:
$18.20
25% Assistance Premium:
$27.20
H8928-001 Formulary and Drug Coverage
NaviCare (HMO D-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.
By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
The benefit information provided is a summary of what NaviCare (HMO D-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Fallon Health helps
get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.
Physical therapy and speech and language therapy visit
Rehabilitation services
$0 copay
Cleaning
Preventive dental
Not covered
Dental x-ray(s)
Preventive dental
$0 copay
Fluoride treatment
Preventive dental
Not covered
Oral exam
Preventive dental
Not covered
Preventive care
$0 copay
Outpatient hospital coverage
$0 copay
In-Network Other health plan deductibles?
No
Optional supplemental benefits
No
Inpatient hospital - psychiatric
Mental health services
$0 copay
Outpatient group therapy visit
Mental health services
$0 copay
Outpatient group therapy visit with a psychiatrist
Mental health services
$0 copay
Outpatient individual therapy visit
Mental health services
$0 copay
Outpatient individual therapy visit with a psychiatrist
Mental health services
$0 copay
Chemotherapy
Medicare Part B drugs
$0 copay
Other Part B drugs
Medicare Part B drugs
$0 copay
Diabetes supplies
Medical equipment/supplies
$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)
Medical equipment/supplies
$0 copay
Prosthetics (e.g., braces, artificial limbs)
Medical equipment/supplies
$0 copay
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$7,550 In-network
Inpatient hospital coverage
$0 copay
Fitting/evaluation
Hearing
Not covered
Hearing aids - inner ear
Hearing
Not covered
Hearing aids - outer ear
Hearing
Not covered
Hearing aids - over the ear
Hearing
Not covered
Hearing exam
Hearing
$0 copay
Health plan deductible
$0
Ground ambulance
$0 copay
Foot exams and treatment
Foot care (podiatry services)
$0 copay
Routine foot care
Foot care (podiatry services)
Not covered
Emergency
Emergency care/Urgent care
$0 copay
Urgent care
Emergency care/Urgent care
$0 copay
Primary
Doctor visits
$0 copay
Specialist
Doctor visits
$0 copay
Diagnostic radiology services (e.g., MRI)
Diagnostic procedures/lab services/imaging
$0 copay
Diagnostic tests and procedures
Diagnostic procedures/lab services/imaging
$0 copay
Lab services
Diagnostic procedures/lab services/imaging
$0 copay
Outpatient x-rays
Diagnostic procedures/lab services/imaging
$0 copay
Diagnostic services
Comprehensive dental
Not covered
Endodontics
Comprehensive dental
$0 copay
Extractions
Comprehensive dental
Not covered
Non-routine services
Comprehensive dental
Not covered
Periodontics
Comprehensive dental
$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services
Comprehensive dental
$0 copay
Restorative services
Comprehensive dental
$0 copay
In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
No
Coverage Area
(Click county or state to compare all available Advantage plans)
The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for NaviCare (HMO D-SNP) requires you to live in that plan’s service area. The service area is listed below:
Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.
Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.
Site Search:
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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
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