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Fallon Community Health Plan (Fallon Health) Medicare Review

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UPDATED: Nov 30, 2018

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Fallon Health is a Massachusetts-based health system that includes their own health plan. With more than 40 years in business, they were the first federally qualified HMO in the state and now offer coverage in New York and New Hampshire.

About Fallon Health Plan

Fallon Community Health Plan (FCHP), was founded in 1977, and by the following year became federally qualified to offer HMO health insurance plans. The company became one of the first HMOs in the state to be given a special Medicare contract in 1980, making them one of the top choices for senior health care.

Their success and first continued; in 1994 they were the first HMO to be accredited by the National Committee for Quality Assurance. In 1999 they earned the rank of Newsweek’s best HMO in the country.

Fallon expanded into New Hampshire in 2009, offering coverage in some parts of the state. A 2014 partnership with the Weinberg Campus created Fallon Weinberg and expanded the company further, into Western New York. Fallon officially dropped the Community from its name, but still uses the FCHP acronym.

Fallon today remains a leader in senior health care and offers Medicare Advantage, Medicare Supplement, and several other plans and programs for comprehensive care.

Fallon Medicare Plans

Fallon goes beyond the usual plans to offer extra benefits and options for seniors. Plan choices vary by location, so for the purpose of this review we used the zip code for the company’s corporate headquarters in Worcester, MA to obtain plan information.

Medicare Advantage

In our sample area, Fallon offers five plans that include Part D coverage and one plan without.

The Flex Enhanced Rx is the only $0 premium (above and beyond your regular Medicare premium) offered by Fallon. It is an HMO plan and has copays of $20 for primary care visits and $50 for specialist visits. Inpatient hospital stays have a copay of $370 a day for the first five days. This plan has a $300 prescription deductible on Tiers 3 and up, with Tier 1 drugs starting at $1.

The Super Saver Rx plan is also an HMO plan, and it has copays of $30 for primary care and $50 for specialist visits. The hospital copay is the same as the Enhanced plan. Prescriptions are covered starting at a $2 copay for Tier 1, with a $415 deductible on Tiers 3 and up.

The Saver Enhanced Rx plan is an HMO-POS plan with copays of $20 for primary care visits, $40 for specialists, and $300 a day for the first five days of inpatient hospital stays. Prescriptions start at $1 copays for Tier 1 with a deductible of $300 on Tiers 3 and up.

Standard Enhanced Rx is an HMO plan with copays of $15 for primary care visits and $30 for specialist visits. Inpatient hospital stays have a copay of $200 a day for the first five days. This plan has prescription coverage starting at $1 for Tier 1 and a $200 deductible applied to Tiers 3 and up.

Plus Enhanced Rx is an HMO plan with the lowest copays and the highest premiums. Copays are $10 for primary care and $20 for specialist visits. Inpatient hospital stays have a flat $225 per admission copay. Prescription drugs start at $1 for Tier 1, and this is the only plan with no pharmacy deductible.

The only plan without Part D coverage is the Saver HMO. Copays are $25 for primary care visits and $40 for specialists, and there is a $300 a day copay for the first five days of an inpatient hospital stay.

Medicare Supplement

We checked the available plans for a 65-year-old female in the same zip code for Medicare Supplement. Fallon’s two available plans follow the state of Massachusetts’ standards, which differ from most of the country.

The Core plan covers the first three pints of blood each year, along with most coinsurance amounts and emergency travel medical. The step up from this plan is the 1 plan, which covers nearly all out of pocket costs not covered by Medicare.

Other Products

Fallon offers some other products and assistance for seniors.

NaviCare is Fallon’s combined program for those that qualify for both Medicare and MassHealth standard (Medicaid). It includes a number of extra benefits on top of what is covered by those two services.

Summit ElderCare is a program designed to assist those show want to live at home but require assistance with things like medication and at-home care for daily tasks.


As mentioned, there is one $0 premium plan that is available from Fallon. This means you do not pay anything more than your usual Medicare premiums. From there, rates climb, with the Super Saver Rx at $22 on the low end, and the Plus Enhanced Rx plan at $275 on the high end.

Supplement plans come in at $126 for Core and $229 for 1.

We are unable to compare to other plans on a national level, particularly since Massachusetts’ Supplement plans differ from most other places, but from what we have seen overall and particularly in this state, Fallon is expensive. There are a few lower-priced plans, but the copays are on the high side. The highest cost plans are well above what we have seen elsewhere, and still have higher copays.

Supplement plans as well appear to be priced on the high side.


Like most health insurance companies, Fallon handles billing directly with the provider, so there is really no claims information to be found on the website. They operate as an HMO, which means most claims should be fairly straightforward as out-of-network providers would only be used in an emergency.

Ratings and Consumer Reviews

Fallon Community Health Plan has an A- rating with the Better Business Bureau (BBB), with the rating brought down a notch by one complaint to which they failed to respond. Only three complaints were closed in the past three years, and two of those were in the past 12 months.

Fallon has a solid 4.0 out of 5 rating with the National Committee for Quality Assurance. That is a pretty good score, but there is some room for improvement in the Consumer Satisfaction area of the survey as well as a few other categories.

Medicare gave Fallon’s Medicare Advantage plans an overall 4.5 out of 5 rating, which is excellent.

There are 11 reviews on Yelp, and the overall rating is two stars. A couple of five-star ratings help bring that up a bit, but most of the reviews are negative. The overall volume of complaints, however, is low.

The Bottom Line

Fallon has a pretty good selection of plans and they have a good reputation across the board, but they are on the pricey side. For an HMO, their rates are high, and the copays tend to be on the high side too for the cost of the monthly premiums. If you are willing to pay more for an insurance company with a good reputation, put Fallon on the list.

For a list of companies that we recommend, visit our Best Insurance Companies page.

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Fallon Community Health Plan (Fallon Health) Medicare
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About Eric Stauffer

Author: Eric StaufferI am a former insurance agent and banker turned consumer advocate. My priority is to help educate individuals and families about the different types of insurance they need, and assist them in finding the best place to get it.

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