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
  • Free rides to and from medical appointments, plus up to 140 non-medical rides per year.     

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

NaviCare is for people who live in the service area, are 65 or older, qualify for MassHealth Standard (with or without Medicare Parts A and B), and don’t have any other comprehensive health insurance except Medicare. 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

  • Educates member about benefits and services
  • Helps member get care and services
  • Helps member make medical appointments

Primary Care Provider

  • Directs member's care
  • Provides medical services

Nurse Case Manager (or Advanced Practitioner)

  • Evaluates member's clinical and daily needs
  • Teaches member about their medications 
  • Makes sure members gets the care and services they need after a stay in a medical facility

Behavioral Health Case Manager (as needed)

  • Coordinates services to support member's emotional health and well-being

Geriatric Support Services Coordinator (if needed)

  • Connects member's needed in-home services

Clinical pharmacist (if needed)

  • Calls or visits member after a hospitalization to review their medications and work with their medical providers

Benefits that go beyond what Medicare and MassHealth Standard provide

In addition to having a Navigator and a Care Team, NaviCare members have access to all benefits and services offered through Medicare and MassHealth Standard. Plus, they receive additional benefits, items, and services at no cost. 
Learn more about NaviCare benefits and services » 

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 giving us permission to speak with you 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 10/1/2023.

Learn more

Benefits and services 
Primary care team
Provider network

Important forms

Personal Representative Authorization form - SCO only 
Appointment of Representative form