Mass Advantage Basic HMO Summary of Benefits (2024)

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 Summary of Benefits

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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:

  • $6,500 for services you receive from in-network providers

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: $390 copay per day

Days 6 – beyond: $0 copay per day
Outpatient Hospital Coverage*

Outpatient Hospital: $300 copay per stay

Observation Services: $325 copay per stay
Ambulatory Surgical
Center*

$295 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: $40 copay per visit
Telehealth Services

Primary Care Physician Services: $0 copay per visit

Physician Specialist Services: $40 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: $20 copay

Outpatient X-ray services: $0 copay

Diagnostic Radiology services (such as, MRI, MRA, CT, PET):
$250 copay
Chiropractic Care Chiropractic Care (Medicare-covered): $15 copay per visit
Outpatient Rehabilitation*

Occupational therapy: $10 copay per visit

Speech and language therapy: $10 copay per visit

Physical therapy: $10 copay per visit
Mental Health Services*

Outpatient group therapy: $25 copay per visit

Outpatient individual therapy: $25 copay per visit

Inpatient Mental Health Care:

  • Days 1-5: $370 per day
  • Days 6-90: $0 per day
Emergency Care

$90 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 one-way trip)

Air Ambulance: $295 copay (per one-way trip)

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:

  • 0% coinsurance for Medicare-covered diabetic glucometer and supplies from a preferred manufacturer
  • 0% coinsurance for Medicare-covered therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease

Services with an * (asterisk) may require prior authorization from your doctor.

 

Additional Benefits

Dental Services*

Dental services (Medicare-covered): $40 copay per visit

Preventive and comprehensive dental services outlined below
must be received from a DentaQuest provider.

Preventive dental services include the following: $0 copay

  • Oral exam (2 per calendar year)
  • Cleaning (2 per calendar year)
  • Fluoride treatment (2 per calendar year)
  • Dental X-rays (1 set per calendar year)
    • One vertical bitewing imaging, and one panoramic imaging is covered once every 36 months
    • Intraoral occlusal imaging is covered twice every 24 months
    • Intraoral-complete series is covered once every 36 months
  • Comprehensive Oral exam is covered once every 36 months

Comprehensive dental services including restorative services,
periodontics, and extractions*: $0 copay

There is a maximum allowance of $1,500 each calendar year for
comprehensive dental services. You are responsible for amounts
beyond the benefit limit.

The Flex Card can be used for preventive and comprehensive
services not covered by DentaQuest

*You should review your EOC for additional details and coverage
limits.
Hearing Services

Hearing exam (Medicare-covered): $40 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: $500 per hearing aid

Basic Hearing Aids: $675 per hearing aid

Prime Hearing Aids: $975 per hearing aid

Preferred Hearing Aids: $1,275 per hearing aid

Advanced Hearing Aids: $1,575 per hearing aid

Premium Hearing Aids: $1,975 per hearing aid

Limit of two hearing aids per calendar year (one per ear).
Vision Services

You pay a $40 copay for each Medicare-covered eye exam related to the diagnosis and treatment of diseases and conditions of the eye.

Routine and vision services outlined below must be received by an in-network provider.

Routine eye exam: $0 copay per visit (1 every calendar year)

$200 allowance every calendar year to use towards the purchase of contact lenses, eyeglass lenses, and eyeglass frames. 
Flex Card

The Flex Card consists of 3 separate benefit wallets:

  • Wallet 1: $650– Dental**, fitness, weight management, nutritional/dietary, eyewear, mindfulness programs
  • Wallet 2: $500 – In-home support and companion care for assistance with independent daily living activities, such as helping with light chores, errands, and tech-support
  • Wallet 3: $50 – Parking for qualified members with certain Chronic Conditions (SSBCI)

The flex card is preloaded with the full benefit amount and members choose where to use it. Members may pay a portion or the full cost of an item or buy a combination of items up to the allotted limit.

Flex card is not eligible for cost sharing for covered benefits.

**Dental services not covered through DentaQuest
Transportation*

$0 copay for 12 one-way rides per year for plan approved health-related locations.

Members can use taxi, ridesharing, and medical transportation services under this benefit.
Over-the-Counter (OTC) Items

You have $90 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

$200 deductible for Tiers 3, 4 and 5
Initial Coverage Stage

You pay the following until your total yearly drug costs reach $5,030. Total yearly drug costs are the drug costs paid by both you and our Part D plan. 

Standard Retail Cost-Sharing

Tier One-month supply Three-month supply
Tier 1 (Preferred Generic) $0 copay $0 copay
Tier 2 (Generic) $4 copay $8 copay
Tier 3 (Preferred Brand)

$47 copay

$94 copay
Tier 4 (Non-Preferred Drug) $100 copay $200 copay
Tier 5 (Specialty Tier) 30% coinsurance 30% coinsurance

Standard Mail Order

Tier One-month supply Three-month supply
Tier 1 (Preferred Generic) $0 copay $0 copay
Tier 2 (Generic) $4 copay $8 copay
Tier 3 (Preferred Brand)

$47 copay

$94 copay
Tier 4 (Non-Preferred Drug) $100 copay $200 copay
Tier 5 (Specialty Tier) 30% coinsurance 30% coinsurance

Your cost-sharing may be different if you use a Long-Term Care pharmacy, or an out-of-network pharmacy.

Insulin: Although all of the insulins covered by our plan are on Tier 3, what you pay is lower than our plan’s Tier 3 copay. You pay $35 for a one-month supply of insulin. You pay this amount all year long until the Catastrophic Coverage stage.

Vaccines: You pay $0 for your vaccines that are covered under Part B (e.g. flu vaccine, COVID vaccine) and Part D (e.g. Shingrix) all year long.
Coverage Gap Stage

Tiers 1 and 2 drugs: You continue to pay the copay amounts that apply during the Initial Coverage Stage.

Tiers 3, 4, and 5 drugs: After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs (plus a portion of the dispensing fee) and 25% of the plan’s cost for covered generic drugs until your costs total $8,000 which is the end of the coverage gap. 
Catastrophic Stage

After your yearly out-of-pocket drug costs reach $8,000, you pay $0 for all covered Part D drugs for the remainder of the calendar year.