Fallon Health Insurance Review & Complaints: Health Insurance

Fallon Health, or Fallon community Health Plan, is a full-service HMO health system. Their plans have a $5 copay for primary care office visits, no charge for routine lab and other tests, and prescription coverage starting at $1 for Tier 1 drugs.

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Eric Stauffer is a former insurance agent and banker turned consumer advocate. His 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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Leslie Kasperowicz holds a BA in Social Sciences from the University of Winnipeg. She spent several years as a Farmers Insurance CSR, gaining a solid understanding of insurance products including home, life, auto, and commercial and working directly with insurance customers to understand their needs. She has since used that knowledge in her more than ten years as a writer, largely in the insuranc...

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Reviewed by Leslie Kasperowicz
Farmers CSR for 4 Years

UPDATED: Sep 16, 2020

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Fallon Health

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Fallon Community Health Plan is the better-known name of Massachusetts-based Fallon Health, a full-service HMO health system. They offer a range of different plans including individual and Medicare coverage to residents of three states.

About Fallon Health

Fallon Community Health Plan was founded in 1977, to provide insurance and services to Massachusetts residents. They were the state’s first HMO to be qualified by the federal government, and among the first HMOs to receive a Medicare contract. By 1989, Fallon Health was the fourth largest HMO in Massachusetts, and they went on to earn more accolades, including the first accreditation of an HMO by the National Committee for Quality Assurance, and being named among Newsweek’s top HMOs in 1999.

Fallon Health expanded to parts of New Hampshire in 2009, and in 2014 expanded into New York through a partnership with the Weinberg Campus. In that same year, the word Community was dropped and the name Fallon Health became official. Today they are the only health system in the state that is both an insurer and a provider of care.

Fallon Health offers individual and group health insurance plans as well as being a leader in Medicare Advantage plans. As we have covered their Medicare plans in a separate review, this review will focus on their individual health products. Their headquarters is in Worcester, MA.

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Fallon Health Plans

We found the Fallon website to be frustrating in terms of finding information on the available plans, even during the open enrollment period when this review was written. In the section that is aimed at individuals shopping for insurance, there is no comparison chart, no quick link to a list of plans with benefits overviews, not even a list of which plans are available and what levels are offered.

There was a very basic overview of the coverage without a breakdown by plan level. The overview stated that plans have a $5 copay for primary care office visits, no charge for routine lab and other tests, and prescription coverage starting at $1 for Tier 1 drugs.

We were able to obtain plan information through the individual page by requesting a quote, which re-directed to the eHealth website and returned information for plans from other local companies as well.

By entering a quote request for a 30-year-old male living in Worcester who does not qualify for financial assistance, we were given a list of six HMO plans at the Gold and Platinum levels. While it seemed unlikely that Fallon would not have Bronze or Silver level plans, none of these were given as an option on our search.

Our search did confirm that primary care office visits have a $5 copay across the board, but deductibles vary. The two Platinum plans had no deductible, while the four Gold plans had either $1,200 or $2,000 deductibles. The search also confirmed the prescription coverage starting at $1 for preferred generics (Tier 1) drugs.

The Gold plans have a $15 specialist visit copay, while the Platinum plans have a $10 specialist copay.

All of these plans are HMO and offer no out-of-network coverage with the exception of emergency care.

After more searching through the website, we found a plan chart in the section aimed at brokers. This chart includes an incredibly confusing array of plans including HMO and PPO options at every level and not a clear way to compare them.

Plans are broken down into copay, coinsurance, deductible, and qualified high deductible, and then again by metal level from Catastrophic to Platinum. The chart lists plans with the Direct Care limited network, the HMO network, and the few that offer a PPO network.

Overall, the system for providing plan information on the site is clearly aimed at brokers who understand insurance and not at individuals shopping for insurance. The broker section listed far more plans than we saw when searching for plans and rates as an individual. It is unclear why the quoting system returns so few options on a quote request, and yet many more are offered when a broker is obtaining a quote (through a different system).

Rates

We were able to return rate quotes, but only for the Gold and Platinum level plans that the system offered. The lowest priced option was the Direct Care Deductible 2000 at the Gold level, with a premium of $413.66 a month.

As an individual shopping for insurance, a system that returns a Gold plan as the most affordable level option needs some attention. We would expect to see a Bronze level plan offered at the very least, if not a Catastrophic plan at half the price of this Gold plan. This is particularly strange for a quote that is being offered to a single male of 30 years old, generally the target market for lower monthly premiums with more out of pocket costs.

Claims

The Fallon Health website does not offer much in the way of claims information. Most of Fallon’s plans are HMO, therefore claims would likely be handled internally.

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Ratings and Consumer Reviews

Fallon Health has an A+ rating with the Better Business Bureau (BBB), with only one complaint in the past three years.

The National Committee for Quality Assurance gives Fallon Health an overall rating of 4.5, which is very good. It is well worth noting however that in the breakdown by category, they earn only a 3.0 in consumer satisfaction, with rankings of 2.0 for getting care quickly and primary care satisfaction.

We found very little in the way of other reviews, especially noting a lack of direct consumer reviews of Fallon’s services.

The Bottom Line

Fallon Health appears to have a good reputation but makes shopping for insurance frustrating and confusing due to a poorly organized website that appears to place brokers above consumers in terms of information provided. We are unable to give a clear picture of rates since our search only returned six of Fallon’s highest-priced plans and no budget options. Fallon Health may well have great plan options, but customers will have to contact a broker or call directly to get a clear picture of what’s available.

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