Mass Advantage Basic (HMO) Benefit Highlights 2025

$0

You must continue to pay your Medicare Part B premium. 

Your yearly limit(s) in this plan:

• $5,000 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.

Days 1 – 5: $300 copay per day

Days 6+: $0 copay per day

Outpatient Hospital: $175 copay per visit

Observation Services: $200 copay per stay

Days 1-20: $0 copay per day

Days 21-51: $188 copay per day

Days 52-100: $0 copay per day

Primary Care: $0 copay per visit

Specialist: $25 copay per visit

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

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):
$100 copay

Occupational therapy: $0 copay per visit

Speech and language therapy: $0 copay per visit

Physical therapy: $0 copay per visit

Outpatient group therapy: $25 copay per session

Outpatient individual therapy: $25 copay per session

Inpatient Mental Health Care:

• Days 1-5: $300 per day
• Days 6-90: $0 per day

$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

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.

Chemotherapy drugs: 20% coinsurance

Other Part B drugs: 20% coinsurance

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

Dental services (Medicare-covered): $25 copay per visit

Preventive and comprehensive dental services outlined below
must be received from a Dominion PPO network provider.

• $0 copay for preventive dental services including routine dental exams, cleanings, and X-rays (bitewing, intraoral, and panoramic)
• $0 copay for comprehensive services including restorative services, periodontics, and extractions
• $1,500 annual allowance for comprehensive dental services. You are responsible for amounts beyond the benefit limit.

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 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).

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.

The Prepaid Benefit Card consist of 3 separate benefit allowances:

• Wellness Allowance $600 – Fees required at fitness facilities, fees required at online fitness vendors, fitness-related items purchased through NationsBenefits, weight management support, mental health and mindfulness applications such as Calm and Headspace, eyewear, and hearing aids purchased through NationsBenefits hearing providers.
• Homemaking Allowance $500 – Support and assistance with independent daily living activities, such as helping with light chores, through plan approved vendors.
• Parking Allowance** $50 – Parking for members with certain chronic health conditions (SSBCI)

** 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.

$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.

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. 

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