A non-government entity
Fallon Medicare Plus Green (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Fallon Medicare Plus Green (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Fallon Medicare Plus Green (HMO) in 2025, please refer to our full plan details page.
Fallon Medicare Plus Green (HMO) is a HMO 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 4 out of 5 stars in 2025.
It's important to know that Fallon Medicare Plus Green (HMO) 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 Fallon Medicare Plus Green (HMO).
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 Fallon Medicare Plus Green (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $90.00. 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 $175.00 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 $5200.00 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 Fallon Medicare Plus Green (HMO) plan has a $175 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $7 copay at standard and mail order pharmacies. For standard generic drugs, you will pay a $42 copay, and for preferred brand drugs you will pay a $95 copay. Non-preferred drugs have a 31% coinsurance, and there is no copay for specialty tier drugs.
Additional Benefits
The Fallon Medicare Plus Green (HMO) plan offers a range of benefits, including inpatient hospital stays with a $300 copay for the first five days, and outpatient services with varying copays. Emergency services have a $110 copay, and primary care visits cost $5. Preventive, hearing, vision, and dental services are covered, with copays ranging from $20 to $40 for some services. The plan also includes coverage for home health services with no copay, and offers benefits for medical equipment and home infusion services.
Inpatient Hospital See details
The Fallon Medicare Plus Green (HMO) plan covers Inpatient Hospital-Acute services with a $300 copay for days 1-5, and no copay for days 6-90, with no coinsurance. Inpatient Hospital Psychiatric services are covered with a $300 copay for days 1-5, and no copay for days 6-90, with no coinsurance.
Outpatient Services See details
Outpatient services are covered by the Fallon Medicare Plus Green (HMO) plan, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services and Ambulatory Surgical Center Services have a $275 copay, while individual and group outpatient substance abuse sessions have a copay between $40 and $40.
Partial Hospitalization See details
Partial Hospitalization is covered under the Fallon Medicare Plus Green (HMO) plan, but requires prior authorization and a doctor referral. There is no information about the cost of this benefit.
Ambulance and Transportation Services See details
The Fallon Medicare Plus Green (HMO) plan covers ambulance and transportation services. Ground and air ambulance services have a $225 copay with a service-specific out-of-pocket maximum of $900, and transportation services have a $35 copay. Transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Fallon Medicare Plus Green (HMO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $5 copay, and Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $225 copay.
Primary Care See details
The Fallon Medicare Plus Green (HMO) plan covers primary care physician services with a $5 copay. Chiropractic services, occupational therapy services, and physical and speech therapy all require a referral, with a $20 copay for chiropractic and occupational therapy, and a $20 copay for physical and speech therapy. Physician specialist services require prior authorization and a referral with a $20-$40 copay. Mental health and psychiatric services, and other health care professional services, have varying copays. Additional telehealth benefits have a $0-$40 copay, and Opioid Treatment Program Services are covered. Podiatry services are not covered.
Preventive Services See details
The Fallon Medicare Plus Green (HMO) plan covers various preventive services, including annual physical exams and additional preventive services, with specific costs depending on the service. Health education has a copay of $25, while wigs for hair loss related to chemotherapy have a 20% coinsurance up to a maximum of $350 per year. Some services like in-home safety assessments, personal emergency response systems, alternative therapies, therapeutic massage, adult day health services, home-based palliative care, in-home support services, and support for caregivers of enrollees are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $40 copay, with one exam covered per year, and prescription hearing aids with a copay between $695 and $2645 for all types, with two aids covered per year. The plan does not cover fitting/evaluation for hearing aids, prescription hearing aids for inner, outer, or over the ear, or OTC hearing aids.
Vision Services See details
Vision services are covered, including routine eye exams with a $40 copay. The plan also covers eyewear, including contact lenses, eyeglasses, eyeglass lenses, and eyeglass frames, with a combined maximum benefit of $150 per year.
Dental Services See details
The Fallon Medicare Plus Green (HMO) plan covers Medicare dental services with a $40 copay, and other diagnostic dental services with a copay of $20-$40. Oral exams are covered with a limit of 2 per year, and dental x-rays are covered, with a limit of 1. The plan also covers prophylaxis (cleaning) and fluoride treatments, with a limit of 2 visits per year, as well as restorative services with a copay of $31-$856, and adjunctive general services with a copay of $39-$157. Endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with copays ranging from $37 to $990. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Fallon Medicare Plus Green (HMO) plan. Insulin drugs have a copay of $0-$35, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered under the Fallon Medicare Plus Green (HMO) plan. You will pay a 20% coinsurance for this service.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance with no copay, while Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered, and Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Fallon Medicare Plus Green (HMO) plan. Diagnostic procedures/tests, lab services, outpatient X-Ray services, and therapeutic radiological services are not covered, but diagnostic radiological services have a copay of at most $250.
Home Health Services See details
Home Health Services are covered by the Fallon Medicare Plus Green (HMO) 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 technically covered, but not in practice, as Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. A doctor referral is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Fallon Medicare Plus Green (HMO) plan, but require prior authorization and a doctor's referral. For days 1-20, there is no copay, for days 21-44, the copay is $150, and for days 45-100, there is no copay. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items with a maximum benefit of $255 per year, but acupuncture, meal benefits, and dual eligible SNPs with highly integrated services are not covered. Also, 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.
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