Mass Advantage Basic (HMO) Benefit Highlights 2025
At zero premium, our Basic HMO plan gives you full access to Mass Advantage’s network of pre-qualified providers who will work with you for any care you might need.
Our most affordable plan/$0 monthly premium
With Mass Advantage Basic (HMO), you pay no premium and choose your own Primary Care Provider (PCP). Your PCP oversees your overall care and makes sure any additional services you need are well-coordinated. You’re also saving money by sticking with Mass Advantage’s network providers--medical providers who have been carefully pre-screened and meet our high standards of care and service excellence. Part D prescription drug coverage is also included, so all of your healthcare services are easy to access.
Mass Advantage Basic (HMO)
Download or print your Summary of Benefits.
Mass Advantage Basic (HMO) Evidence of Coverage
Download or print your Evidence of Coverage.
Monthly Premium, Deductible, and Limits on how much you pay for covered services
Monthly Plan Premium | $0 You must continue to pay your Medicare Part B premium. |
Medical Deductible | This plan does not have a deductible. |
Maximum Out-of Pocket Responsibility | Your yearly limit(s) in this plan:
This is the most you will pay in copays and coinsurance for covered medical services for the year. Please note that you will still need to pay your monthly premiums and cost-sharing for Part D prescription drugs. Not all services apply to the Maximum Out-of-Pocket. Please refer to the Evidence of Coverage for more information. |
Covered Medical and Hospital Benefits
Inpatient Hospital Coverage* | Days 1 – 5: $300 copay per day Days 6+: $0 copay per day |
Outpatient Hospital Coverage* | Outpatient Hospital: $175 copay per visit Observation Services: $200 copay per stay |
Ambulatory Surgical Center* | $175 copay per visit |
Skilled Nursing Facility (SNF)* | Days 1-20: $0 copay per day Days 21-51: $188 copay per day Days 52-100: $0 copay per day |
Preventive Care | There is no coinsurance, copayment, or deductible for Medicare-covered preventive services. |
Doctor Visits* | Primary Care: $0 copay per visit Specialist: $25 copay per visit |
Telehealth Services | Primary Care Physician Services: $0 copay per visit Physician Specialist Services: $20 copay per visit Individual Sessions for Mental Health Specialty Services: $0 Individual Sessions for Outpatient Substance Abuse: $0 |
Diagnostic Services/ Labs/Imaging* | Lab services: $0 copay Diagnostic tests and procedures: $15 copay Outpatient X-ray services: $0 copay Diagnostic Radiology services (such as, MRI, MRA, CT, PET): |
Chiropractic Care | Chiropractic Care (Medicare-covered): $15 copay per visit |
Outpatient Rehabilitation* | Occupational therapy: $0 copay per visit Speech and language therapy: $0 copay per visit Physical therapy: $0 copay per visit |
Mental Health Services* | Outpatient group therapy: $25 copay per session Outpatient individual therapy: $25 copay per session Inpatient Mental Health Care:
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Emergency Care | $100 copay per visit If you are admitted to the hospital within 24 hours, you do not have to pay your emergency care copay. Worldwide Emergency Coverage: $90 copay per visit |
Urgently Needed Services | $10 copay per visit |
Ambulance* | Ground Ambulance: $295 copay (per ride) Air Ambulance: $295 copay (per ride) If you are admitted to the hospital, you do not have to pay your ambulance services copay. |
Medicare Part B Drugs* | Chemotherapy drugs: 20% coinsurance Other Part B drugs: 20% coinsurance |
Medical Equipment/ Supplies* | Durable Medical Equipment (e.g., wheelchairs, oxygen): 20% coinsurance Prosthetics (e.g., braces, artificial limbs): 20% coinsurance Diabetic supplies:
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Services with an * (asterisk) may require prior authorization from your doctor.
Additional Benefits
Dental Services | Dental services (Medicare-covered): $25 copay per visit Preventive and comprehensive dental services outlined below
Mass Advantage contracts with the Dominion PPO network. Your 2025 dental benefit coverage is based on using in-network Dominion PPO providers. If you choose to receive treatment from a licensed dentist outside of the Dominion PPO network, the procedures covered under our plan will be reimbursed up to the 2025 maximum benefit limit for your dental coverage (see your Evidence of Coverage for more information). You are responsible for any amounts that exceed your maximum benefit limit for both in-network and out-of-network dental services. |
Hearing Services | Hearing exam (Medicare-covered): $25 copay Routine and Hearing Aids services outlined below must be received from a NationsBenefits Hearing Health Care provider. Routine hearing exam: $0 copay (1 every calendar year) Entry Hearing Aids: $600 per hearing aid Basic Hearing Aids: $775 per hearing aid Prime Hearing Aids: $1,075 per hearing aid Preferred Hearing Aids: $1,375 per hearing aid Advanced Hearing Aids: $1,675 per hearing aid Premium Hearing Aids: $2,075 per hearing aid Limit of two hearing aids per calendar year (one per ear). |
Vision Services | You pay a $25 copay for each Medicare-covered eye exam related to the diagnosis and treatment of diseases and conditions of the eye. Routine exams and Eyewear allowances outlined below must be received from an EyeMed provider. Routine eye exam: $0 copay per visit (1 every calendar year) $200 allowance every calendar year to use towards the one-time purchase of contact lenses, eyeglass lenses, and eyeglass frames. |
Prepaid Benefit Card | The Prepaid Benefit Card consist of 3 separate benefit allowances:
** The parking benefits are part of a special supplemental program designed for qualified individuals with chronic illnesses. Eligible conditions include chronic alcohol and other drug dependence, autoimmune disorders, cancer, cardiovascular disorders, chronic heart failure, dementia, diabetes, end-stage liver disease, end-stage renal disease (ESRD), severe hematologic disorders, HIV/AIDS, chronic lung disorders, chronic and disabling mental health conditions, neurologic disorders, and stroke. Please note that eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For details, please contact us. |
Non-Emergent Transportation* | $0 copay for 12 one-way rides per year for plan approved health-related locations. Members can use taxi, rideshare, medical sedan, or wheelchair vans under this benefit. |
Over-the-Counter (OTC) Items | You have $125 every quarter to spend on plan approved OTC items. OTC items must be ordered through NationsBenefits. Any unused money will carry over to the next quarter but will not carry over to the next benefit year. |
Services with an * (asterisk) may require prior authorization from your doctor.
Part D Prescription Drugs
Deductible Stage | $0 Annual Prescription Drug Deductible | ||||||||||||||||||
Initial Coverage Stage | Mass Advantage members pay no more than $35 for a one-month supply of each insulin product, no matter which cost-sharing tier it’s on. Initial Coverage - Retail & Mail Order 1-30 /31 - 100 Day Supply You pay the following until your total out of pocket drug costs reach $2,000
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Catastrophic Coverage | You pay $0 for all covered Part D drugs for the remainder of the calendar year |