How NaviCare works

Information for caregivers and authorized personal representatives

When you provide care—or serve as an authorized personal representative—for an older friend or relative, you show your love and commitment every day. At Fallon Health, we want to make it easier for you to help your loved one.

As a member of the NaviCare program, your loved one receives complete coordinated health care and insurance coverage, including:

  • No copays, no coinsurance, no deductibles and no premiums
  • All covered MassHealth Standard and Medicare benefits, including prescription drug coverage—and much more—at no cost
  • Access to primary care providers, medical specialists and behavioral health specialists—in person or by telehealth
  • Rides to medical appointments and other approved locations like the grocery store and pharmacy

Some or all of your loved one's current medical providers may already be part of our provider network. If it is necessary to identify new providers, we will help with this process to ensure a smooth transition.

NaviCare is for people who are 65 or older and qualify for MassHealth Standard (with or without Medicare Parts A and B). In other words, older adults who may have complex health care needs with limited incomes.

Personalized care from a team of medical professionals

As a NaviCare member, your loved one has a Care Team, which coordinates individualized, complete care. The Care Team reviews members' care plans regularly and helps members and their caregivers—or authorized personal representatives—make better decisions about care.

The Care Team includes:

  • Navigator, who coordinates all benefits and services
  • Primary Care Provider
  • Nurse Case Manager (or Advanced Practitioner)
  • Geriatric Support Services Coordinator (if needed)
  • Behavioral Health Case Manager (as needed)
  • Clinical Pharmacist (if needed)

Benefits that go beyond what MassHealth Standard and Medicare provide

In addition to having a Navigator and a Care Team, NaviCare members have access to all benefits and services offered through MassHealth Standard and Medicare. Plus they receive additional benefits, items and services at no cost. Our program includes:

  • Doctor visits—in person or through telehealth services
  • Preventive services
  • Coordinated care, such as medication management and support during care transitions
  • Unlimited rides to medical appointments
  • Vision, hearing and dental services—including glasses, hearing aids (with batteries) and dentures
  • Covered prescription drugs
  • Certain over-the-counter drugs and items, when prescribed by your doctor (such as vitamins)
  • Up to $480 per year ($500 in 2020) on the Save Now card to help pay for certain health-related, over-the-counter items like cold/allergy medications, aspirin, toothbrushes/toothpaste, fish oil, probiotics and more
  • Telehealth, a service that provides 24 hour/7 day-a-week access to a doctor by phone, mobile app or online—at no extra cost
  • 24/7 access to a nurse by phone
  • Silver Sneakers® fitness program that offers free online fitness classes and on-demand workout videos, a free gym membership, and more 
  • Rides to the pharmacy, grocery store or other approved locations (up to 140 one-way rides per year, limit of one round-trip ride per day)
  • WW® (formerly Weight Watchers) membership
  • Tobacco cessation program
  • Up to $100 per year to buy healthy food, which can be earned by completing healthy activities like getting a flu shot or an annual physical exam

What to expect after your loved one joins NaviCare

Once your loved one joins NaviCare, here's what happens next:

  • A member of Fallon Health’s Enrollment Team will call you/your loved one to make sure you/your loved one understands how the plan works and to answer any questions.
  • During the call, you/your loved one will receive information about your/your loved one’s Navigator and/or Nurse Case Manager. Navigators are the main points of contact for our members, helping them set up doctor appointments, answer questions about the plan, and helping members get the care and services they need.
  • An Enrollee Services Representative will send the member a letter to confirm their enrollment in NaviCare.
  • The member will receive a letter of introduction from the Navigator, who will be the member's personal contact for the program. This letter will also introduce the Nurse Case Manager. If you are an authorized personal representative, you will also receive a letter from the Navigator.
  • The Navigator and Nurse Case Manager will develop a unique care plan based on your loved one’s needs including services that are currently being received, as well as any additional services that may be necessary—such as home care, delivered meals, physical therapy and more.
  • The Navigator will also ask about the medical providers your loved one currently sees. Some may accept NaviCare. If any of them do not, your loved one will be able to continue seeing them for up to 90 days or until your loved one is assessed by the Care Team and the plan of care is implemented, whichever is sooner. After that time, the Navigator will help your loved one choose new providers from the NaviCare provider network.

With the member's permission, you are welcome to participate in the assessment. This could be an opportunity to voice any questions or concerns you may have and help us better understand your loved one's circumstances.

If you have questions or concerns

Although we only answer specific questions about members when we have their authorization, you can always ask us questions about the program. If your loved one has already completed a Personal Representative Authorization form - SCO only or an Appointment of Representative form and returned it to us, we can explain their Individualized Plan of Care when you call. Call us at
1-866-368-6245 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (Oct. 1–March 31, seven days a week). We'll be glad to talk with you.

 

NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS. Fallon Health is an HMO plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Health depends on contract renewal. NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS. WW® is a registered trademark of Weight Watchers International, Inc.

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The information on this page was last updated on 10/1/2020.