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 so much more—at no cost
  • Access to primary care providers, medical specialists and behavioral health specialists

    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 but not much income.

    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 service coordinator (for members who live at home)
    • Facility liaison (for members who live in an assisted-living, long-term care or rest-home setting)
    • Behavioral health case manager (as needed)

    Benefits that go beyond what MassHealth Standard and Medicare provide

    In addition to having a Navigator and a Care Team, NaviCare members receive a wide range of benefits and services, such as:

    • Doctor visits
    • Preventive services
    • Coordinated care, such as medication management and support during care transitions
    • Rides to medical appointments and other locations
    • Vision, hearing and dental services—including glasses, hearing aids (with batteries) and dentures
    • Covered prescription drugs
    • Certain over-the-counter drugs, when prescribed by your doctor (such as vitamins)
    • NEW FOR 2017 Savings card that you can use to buy certain over-the-counter items at no cost
    • NEW FOR 2017 24 hour/7 day-a-week access to a doctor by phone or internet
    • 24/7 access to a nurse by phone
    • SilverSneakers® Fitness program, up to $200 toward another qualified fitness facility or classes—and up to 80 free rides there and back
    • Weight Watchers®
    • Tobacco cessation program
    • Enrollee Services Team available Monday–Friday, 8 a.m.–8 p.m.

    What to expect after your loved one joins NaviCare

    Once we receive your loved one's application for NaviCare, here's what happens next:

    • An enrollee services representative will send your loved one 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 will call the member and schedule a home visit.
    • During the home visit, the Navigator and nurse case manager work with the member to develop a unique care plan. The member will be asked about 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 to see them for up to six months. After that time, the Navigator will help your loved one choose new providers from the NaviCare provider network.

    With your loved one's permission, you are welcome to participate in the home visit. 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 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–Feb. 14, seven days a week). We'll be glad to talk with you.

     

    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. NaviCare SCO is available to anyone age 65 and older who has MassHealth Standard and lives in the service area. Individuals who also have Medicare Parts A and B may enroll in NaviCare HMO SNP. This information is not a complete description of benefits. Contact the plan for more information. Limitations and restrictions may apply. Benefits may change on January 1 of each year. The Formulary and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium unless the Commonwealth of Massachusetts pays this premium for you. SilverSneakers® is a registered trademark of Healthways. Weight Watchers® is a registered trademark of Weight Watchers International, Inc.

    H9001_N_2017_16 Approved 10142016
    The information on this page was last updated on 10/1/2016.