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NaviCare (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for NaviCare (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on NaviCare (HMO D-SNP) in 2025, please refer to our full plan details page.
NaviCare (HMO D-SNP) is a HMO D-SNP plan offered by Fallon Community Health Plan, Inc. available for enrollment in 2025 to people living in Massachusetts except Dukes and Nantucket counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that NaviCare (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
NaviCare (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about NaviCare (HMO D-SNP).
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 NaviCare (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $38.40. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.10. You must continue to pay paying your reduced 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 $590.00 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 Maximum Out-Of-Pocket cost of $7550.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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:
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Drug Coverage
The NaviCare (HMO D-SNP) plan has a $590.00 deductible for prescription drugs. Once you meet the deductible, you will pay the costs for drugs in each tier. After your yearly out-of-pocket drug costs reach $2000.00, you pay nothing for Medicare Part D covered drugs. If you qualify for the low-income subsidy (LIS), your monthly premium for Part D is $38.40. The plan's formulary will provide specific details on the drugs covered and their associated costs.
Additional Benefits
The NaviCare (HMO D-SNP) plan offers a variety of benefits with a focus on inpatient and outpatient care. Many services, including hospital stays, outpatient services, and primary care, require a 20% coinsurance. The plan also covers ambulance services, emergency services, vision, dental, and home health services, with some requiring prior authorization or a doctor's referral. Additional benefits include coverage for hearing exams, medical equipment, and home infusion services, each with varying coinsurance amounts. The plan also provides coverage for preventive services like health education and fitness benefits. The plan has a $35 copay for Medicare Part B Insulin Drugs, and covers over-the-counter items up to $275 every three months.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but additional days, non-Medicare covered stays, and upgrades for Inpatient Hospital-Acute and additional days and non-Medicare covered stays for Inpatient Hospital Psychiatric are not covered. Prior authorization is required for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services are covered, including all outpatient hospital services, observation services, individual sessions for outpatient substance abuse, and group sessions for outpatient substance abuse. Outpatient hospital and observation services have a 20% coinsurance, while individual and group substance abuse sessions have a coinsurance between 20% and 20%. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the NaviCare (HMO D-SNP) plan, but requires prior authorization and a doctor's referral. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the NaviCare (HMO D-SNP) plan. Ground and Air Ambulance Services have a 20% coinsurance, and there is no copay. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the NaviCare (HMO D-SNP) plan. Emergency Services and Urgently Needed Services have a 20% coinsurance, and Worldwide Emergency Services has no coinsurance.
Primary Care See details
The NaviCare (HMO D-SNP) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, chiropractic services, physician specialist services, physical therapy and speech-language pathology services, individual and group sessions for mental health and psychiatric services, and other health care professional services have a 20% coinsurance. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
NaviCare (HMO D-SNP) covers preventive services including Health Education, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy (up to $400 per year), Nutritional/Dietary Benefit, In-Home Support Services, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit (up to $400 per year), Remote Access Technologies, Kidney Disease Education Services (20% coinsurance), Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit; however, Annual Physical Exams, In-Home Safety Assessment, Personal Emergency Response System (PERS), Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, Support for Caregivers of Enrollees, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services are partially covered by the NaviCare (HMO D-SNP) plan, with a coinsurance of at most 20% for hearing exams, but routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids (all types, inner ear, outer ear, and over the ear), and OTC hearing aids are not covered. A doctor referral is required for hearing exams.
Vision Services See details
Vision services include coverage for eye exams with 20% coinsurance, while routine eye exams are not covered. Eyewear is covered with 20% coinsurance, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, with a combined maximum benefit of $403 per year.
Dental Services See details
The NaviCare (HMO D-SNP) plan covers some dental services, but not all. Medicare Dental Services are covered with 20% coinsurance after prior authorization, while oral exams and fluoride treatments are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the NaviCare (HMO D-SNP) plan, and require prior authorization. The plan covers Medicare Part B Insulin Drugs with a $35 copay, and has coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, with a minimum of 0% and a maximum of 20%.
Dialysis Services See details
Dialysis Services are covered by the NaviCare (HMO D-SNP) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by the NaviCare (HMO D-SNP) plan. Durable Medical Equipment (DME), Prosthetic Devices, and Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance, and Medical Supplies are covered with a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the NaviCare (HMO D-SNP) plan. Diagnostic procedures and tests, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services each have a coinsurance of at most 20%, with a minimum coinsurance of 20%.
Home Health Services See details
Home Health Services are covered by the NaviCare (HMO D-SNP) plan with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the NaviCare (HMO D-SNP) plan. A doctor referral is required for coverage, but the plan does not cover any of the listed services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but the plan does not provide Skilled Nursing Facility Services as a supplemental benefit under Part C and does not cover additional days beyond Medicare-covered for SNF or non-Medicare-covered stays for SNF. Prior authorization and a doctor referral are required.
Other Services See details
The NaviCare (HMO D-SNP) plan covers acupuncture with prior authorization, and over-the-counter (OTC) items up to $275 every three months, and other services like seat lift chairs with a maximum amount of $900. Meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, private duty nursing services, case management, and other services are not covered.
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