Fallon Medicare Plus Blue HMO (HMO)

Fallon Medicare Plus Blue HMO (HMO) H9001-031 Plan Details
4.5 out of 5 stars

Fallon Medicare Plus Blue HMO (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Fallon Community Health Plan.
Plan ID: H9001-031.

$228.00
Monthly Premium

Fallon Medicare Plus Blue HMO (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Fallon Community Health Plan.
Plan ID: H9001-031.

Fallon Medicare Plus Blue HMO (HMO) H9001-031 Plan Details
4.5 out of 5 stars

Fallon Medicare Plus Blue HMO (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Fallon Community Health Plan.
Plan ID: H9001-031.

$228.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3400
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$10 copayment for in-office visits with primary care providers; $0 for telehealth visits including with an approved telehealth vendor.
Specialty Doctor Visit
$20 copayment for in-office or telehealth visits with most specialists. $0 copayment for telehealth visits with mental health or substance abuse providers.

Referral required for specialist visits.
Inpatient Hospital Care
$200 copayment for each inpatient acute or rehabilitation admission.

Your plan covers an unlimited number of days for inpatient acute or substance abuse stays and 90 days for an inpatient rehabilitation stay.

There are separate $400 out-of-pocket limits every year for inpatient acute and inpatient rehabilitation hospital care.

Referral and prior authorization required for inpatient hospital services.
Prior authorization required
Urgent Care
$10 copayment for each Medicare-covered urgently-needed-care visit inside the United States and its territories.

$120 copayment for each urgently-needed-care visit outside of the United States and its territories.
Emergency Room Visit
$120 copayment for each Medicare-covered emergency room visit.

Copayment for Medicare-covered emergency care waived if you are admitted to the hospital within 72 hours.

Coverage is worldwide.

$125 copayment for Medicare-covered emergency transportation anywhere in the world.

There is a $500 maximum out-of-pocket limit every year for emergency transportation.
Ambulance Transportation
$125 copayment for Medicare-covered ambulance services (one way).

There is a $500 maximum out-of-pocket limit every year.

Ambulance services covered worldwide. The maximum out-of-pocket limit is for all covered ambulance services.

Prior authorization required for non-emergency ambulance services.
Prior authorization required

Health Care Services and Medical Supplies

Fallon Medicare Plus Blue HMO (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
$15 copayment for each Medicare-covered office visit for chiropractic services.

Referral required for chiropractic services.
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
$0 copayment for Medicare-covered diabetic supplies, diabetic therapeutic shoes or inserts.

Prior authorization required for diabetic supplies and services.

Diabetic supplies and services limited to those from specified manufacturers. (Please see Evidence of Coverage.)
Prior authorization required
Durable Medical Eqipment (DME)
10% coinsurance for Medicare-covered durable medical equipment.

Prior authorization required for durable medical equipment.
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
$0 copayment for Medicare-covered diagnostic procedures, tests, labs, therapeutic radiology services and X-rays.

$150 copay for Medicare-covered diagnostic radiology services (not including X-rays).

There is a $600 maximum out-of-pocket limit every year.

Referral and prior authorization required for outpatient diagnostic/therapeutic radiology services.
Prior authorization required
Home Health Care
$0 copayment for Medicare-covered home health services.

Referral and prior authorization required for home health services.
Prior authorization required
Mental Health Inpatient Care
$200 copayment for each inpatient admission at a psychiatric hospital.

There is a $400 out-of-pocket limit every year for inpatient mental health care.

Prior authorization required for inpatient psychiatric hospital services.
Prior authorization required
Mental Health Outpatient Care
$20 copayment for each Medicare-covered individual or group in-office session; $0 for each Medicare-covered individual or group telehealth session.

Prior authorization required for certain outpatient mental health services. Refer to Evidence of Coverage for details.
Prior authorization required
Outpatient Services / Surgery
$120 copayment for each Medicare-covered outpatient surgery in a hospital outpatient facility.

Referral and prior authorization required for outpatient hospital services.

$0 copayment for Medicare-covered observation services.
Prior authorization required
Outpatient Substance Abuse Care
$20 copayment for each Medicare-covered individual or group in-office session; $0 for each Medicare-covered individual or group telehealth session.
Podiatry Services
$20 copayment for each Medicare-covered office visit for podiatry services.

Referral required for podiatry services.
Skilled Nursing Facility Care
$15 copayment per day for days 1-20,
$75 copayment per day for days 21-44,
$0 copayment per day for days 45-100.

Referral and prior authorization required for skilled nursing facility services.
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
Preventive dental: $25 copayment.

Office visits include: Oral exams, prophylaxis (cleaning), fluoride treatment, and dental X-rays.

Maximum two visits every year.

Comprehensive dental:
Medicare-covered benefits: $20 copayment.
Diagnostic services: $6 to $40
Restorative services: $31 to $856
Endodontics: $34 to $990
Periodontics: $80 to $953
Extractions: $37 to $506
Prosthodontics, other oral/maxillofacial surgery, other services: $0 to $865

Visit maximums apply - please see Dental Addenda for details.

You can also use your Benefit Bank to pay for these services, or to pay for dental care that you receive out-of-network.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
$20 copayment for Medicare-covered vision services.

$20 copayment for one routine eye exam every year.

$0 copayment for Medicare-covered eyewear after cataract surgery.

$0 copayment for contact lenses or eyeglasses (lenses and frames).

Maximum one pair every year.

You get $150 every year for eyewear that is not covered by Medicare.

You can also use your Benefit Bank to pay for eyewear. For example, if you buy a pair of $200 eyeglasses, your eyewear allowance covers the first $150. You can use your Benefit Bank card to pay the remaining $50.

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
$20 copayment for Medicare-covered diagnostic hearing exams.

$0 copayment for one routine hearing exam every year.

Referral required for hearing exams.

Hearing aids: $695 to $995 copayment per hearing aid.

Maximum two hearing aids every year.

Copayments apply only to hearing aid devices purchased through Amplifon. The minimum and maximum copayment amounts represent different technology available in hearing aids, such as the number of programmable channels, sound quality, microphone directionality and convenience features (such as Bluetooth and remote control). The hearing aids included in the minimum copayment category include less technology options than those in the maximum copayment category. This benefit includes one year of free care, a 3-year warranty and loss and damage protection.

You can also use your Benefit Bank to cover the cost of Amplifon copays or to pay for hearing aids purchased through another provider.

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
$0 copayment for Medicare-covered preventive services: Abdominal aortic aneurysm screening, Alcohol misuse screenings & counseling, Bone mass measurements (bone density), Cardiovascular disease screenings, Cardiovascular disease behavioral therapy, Cervical & vaginal cancer screenings, Colorectal cancer screenings, Depression screenings, Diabetes screenings, Diabetes self-management training, Glaucoma tests, Hepatitis B (HBV) infection screening, Hepatitis C screening test, HIV screening, Lung cancer screening, Mammograms (screening), Nutrition therapy services, Obesity screenings & counseling, One-time Welcome to Medicare preventive visit, Prostate cancer screenings (PSA), Sexually transmitted infections screening & counseling, COVID-19 vaccine, Flu shots, Hepatitis B shots, Pneumococcal shots, Tobacco use cessation, Yearly "Wellness" visit.

Prior authorization required for certain preventive services.

You may pay a $10 copayment for health/wellness education classes.
Prior authorization required