Other important information and forms
Member magazine: To Your Health
To Your Health is published at different times throughout the year. Each time it's published, we will link to the latest edition below. In To Your Health, you’ll find interesting articles on how to improve your general health and well-being, and information about your health insurance plans and programs.
Download "To Your Health" (H9001_N_2013_396 Accepted, pdf)
Rights and responsibilities
Below you can find information that explains your rights and protections as a member of NaviCare HMO SNP or NaviCare SCO and also explain what you can do if you think you are being treated unfairly or your rights are not being respected.
- For members who are enrolled in NaviCare HMO SNP (have Medicare Part A and Part B and MassHealth Standard), you can find information about your rights and responsibilities in your Evidence of Coverage (H9001_N_2013_34 Accepted, pdf) in Chapter 7, Your rights and responsibilities.
- For members who are enrolled in NaviCare SCO (have MassHealth Standard alone or MassHealth Standard and Medicare Part A or B), you can find information about your rights and responsibilities in your Evidence of Coverage (SCO_2013_147 Approved 12042012, pdf) in Chapter 7, Your rights and responsibilities.
Potential for contract termination
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, plans decide whether to continue for another year. If NaviCare HMO SNP leaves the program, you will not lose your Medicare nor MassHealth Standard coverage (provided that you continue to meet the eligibility requirements for MassHealth). If NaviCare HMO SNP decided not to continue, you would be notified by letter at least 90 days before your coverage ended. The letter would explain your options.
Other important information and forms
2013 Medicare Plan rankings
The Medicare Program rates how well Medicare health and drug plans perform in different categories (for example, detecting and preventing illness, ratings from patients, patient safety, drug pricing and customer service). The information in this document is an overall plan rating of our plan's performance.
Fallon Community Health Plan - CY 2013 Medicare Plan Ratings (H9001_N_2013_248_r1 Accepted, pdf)
Request for Medicare prescription drug coverage determination form (SCO_2012_299 EOHHSApproved 05222012, pdf)
Use this form for you to request an exception or coverage determination. You can also access an online version of this form.
Medicare Part D coverage determination request form
The provider who prescribes your drugs may use this form to request an exception or coverage determination.
Request for prescription coverage decision SCO-only (SCO_2012_300 EOHHSApproved 05222012, pdf)
The provider who prescribes your drugs may use this form to request a coverage decision.
Request for redetermination of Medicare prescription drug denial (pdf)
Use this form to request a redetermination of a decision if coverage for a prescription was denied.
Prior authorization form (pdf, 70 KB)
This form may be filled out by the provider who prescribes your drugs that require prior authorization.
CMS' Appointment of Representative form (pdf, 68 KB)
This form may be used to appoint someone to handle a grievance or coverage determination, or to deal with any level of the appeal process.
Amendment Request for Personal Information form (pdf, 36 KB)
Request changes to your record if you think it is inaccurate or incomplete. This form is not required for corrections to your address, date of birth or name.
Authorization for Release of Personal Information form (pdf, 36 KB)
Allow another individual/entity to receive your personal information from FCHP (such as your employer, if they are working on your behalf to resolve a claim issue).
Veteran’s Office Authorization for Release of Personal Information form (pdf, 47 KB)
Allow a veteran’s office to receive your personal information from FCHP.
Notice of Privacy Practices (pdf, 33 KB)
This document is Fallon Community Health Plan’s notice of privacy practices.
Personal Representative Authorization Form - Accessing Personal Information (MH MCO 08/17/10 SCO_2010_130 08/20/10, pdf)
Identify a personal representative—someone FCHP can release your personal information to. Complete a form for each person you want to have as a representative.
Personal Representative Authorization Form – Filing an Appeal (H9001_2011_735_11 CMSApproved 05022011, pdf)
This form is to be used by NaviCare members to authorize someone to file an appeal on the member’s behalf. Note: This form automatically expires after a year.
Request for an Accounting of Disclosures of Personal Information form (pdf, 36 KB)
Request a listing of who FCHP has shared your information with (after April 14, 2003) for reasons other than treatment, payment or health care operations.
Restriction form (pdf, 36 KB)
Request a limit on how we use or share your personal information.
NaviCare is a Coordinated Care plan with a Medicare contract and a contract with the Massachusetts Medicaid program. NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS. Plan performance Star Ratings are assessed each year and may change from one year to the next.
To view the PDF files above, you may need to download a free copy of
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H9001_N_2013_15 Approved 10292012
The information on this page was last updated on 10/1/2012.