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 $57.00. 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. Once the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, the copay is $7.00, while standard generic drugs have a $42.00 copay. Preferred brand drugs have a $95.00 copay. Non-preferred drugs have a 31% coinsurance, and specialty tier drugs have no copay.
Additional Benefits
The Fallon Medicare Plus Green (HMO) plan offers a variety of benefits with varying costs. It covers inpatient hospital stays with a $300 copay for the first five days, and then no copay after that. The plan also covers outpatient services, primary care, emergency services, and transportation services with copays ranging from $5 to $275. This plan includes coverage for preventive, hearing, vision, and dental services, with specific copays for each. It also covers home health, skilled nursing, and dialysis services. Additionally, the plan offers medical equipment coverage and home infusion services.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute, you will pay a $300 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will also pay a $300 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional days for Inpatient Hospital Psychiatric are not covered, but Non-Medicare-covered Stay is covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered. Outpatient Hospital Services and Ambulatory Surgical Center (ASC) Services have a $275 copay, while Individual and Group Sessions for Outpatient Substance Abuse 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.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including services not typically covered by Medicare, are covered by the Fallon Medicare Plus Green (HMO) plan. Ground and air ambulance services have a $225 copay, while transportation services to a plan-approved health-related location have a $35 copay.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $110 copay and no coinsurance, Urgently Needed Services have a $5 copay and no coinsurance, and Worldwide Emergency Services have a $110 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, a $225 copay for Worldwide Emergency Transportation, and a service-specific out-of-pocket maximum of $900.
Primary Care See details
The Fallon Medicare Plus Green (HMO) plan covers primary care physician services with a $5 copay. Chiropractic services have a $20 copay, but routine care is not covered, and a doctor referral is required. Occupational Therapy Services have a $20 copay, but require a referral and authorization. Physician Specialist Services have a $20-$40 copay, and require prior authorization and a doctor referral. Mental Health Specialty Services and Psychiatric Services have a $40 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $20 copay and require both a referral and authorization. Additional Telehealth Benefits range from no copay to a $40 copay, with a doctor referral. Opioid Treatment Program Services are covered.
Preventive Services See details
Preventive services, including Medicare-covered preventive services, are covered by the Fallon Medicare Plus Green (HMO) plan. Additional preventive services, such as Health Education, have a $25 copay, while other services like In-Home Safety Assessment, Alternative Therapies, and Counseling Services are not covered.
Hearing Services See details
Hearing services are covered, including routine hearing exams with a $40 copay per visit, limited to one visit per year, and prescription hearing aids with a copay between $695 and $2645 for all types of hearing aids, limited to two per year; however, fitting/evaluation, inner ear, outer ear, over-the-ear, and OTC hearing aids are not covered. A referral is required for hearing exams.
Vision Services See details
The Fallon Medicare Plus Green (HMO) plan covers vision services, including eye exams with a $40 copay, eyewear with a combined maximum benefit of $150 per year, and contact lenses. The plan also covers one pair of eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames per year.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $40 copay. Other diagnostic services have a copay of $20-$40, and other services like Oral Exams and Prophylaxis (Cleaning) are covered. Restorative Services have a copay of $31-$856, while Adjunctive General Services have a copay of $39-$157, Endodontics has a copay of $107-$990, Periodontics has a copay of $80-$953, Prosthodontics (removable) has a copay of $37-$865, Prosthodontics (fixed) has a copay of $76-$860, and Oral and Maxillofacial Surgery has a copay of $77-$667. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Part B insulin drugs with a copay between $0 and $35. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Fallon Medicare Plus Green (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical equipment coverage includes durable medical equipment (DME) with a 20% coinsurance and requires authorization, while durable medical equipment for use outside the home is not covered. Prosthetics/medical supplies have a 20% coinsurance, and diabetic equipment is covered, though diabetic supplies and therapeutic shoes/inserts are not.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Fallon Medicare Plus Green (HMO) plan. Diagnostic services, including diagnostic procedures/tests and lab services, are not covered, while diagnostic radiological services have a copay of up to $250.00.
Home Health Services See details
Home Health Services are covered by the Fallon Medicare Plus Green (HMO) plan with no copay and no coinsurance; however, additional hours of care and personal care services are not covered. This benefit requires both authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but some services are not covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. A doctor referral is required for these services.
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. There is no copay for days 1-20 and days 45-100, but there is a $150 copay for days 21-44. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items, with a maximum plan benefit coverage amount of $255.00 per year. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, 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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