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About Fallon Health
Fallon Community Health Plan (FCHP) was founded in Massachusetts in 1977, and the next year became the first federally qualified HMO in the state. In 1980, they became one of the first HMOs to be offered a special Medicare contract, cementing them as a leader in senior care options. Expansion over the following years led them to a position as the fourth largest HMO in the state by 1989.
In 1994, they were the first HMO in the state to be accredited by the National Committee for Quality Assurance (NCQA), and in 1999 were named best HMO in the nation by Newsweek.
In 2009, the service area was expanded to include parts of southern New Hampshire. In 2014, Fallon formed a partnership with Weinberg Campus in western New York, creating Fallon Health Weinberg. That same year the company re-branded, dropping the Community to become Fallon Health.
Since its founding, Fallon Health has been a leader in senior health care options and has continued to innovate and expand their programs. Today, they offer Medicare Advantage, Medicare Supplement, and additional plans that help create comprehensive care for seniors.
Fallon Health brands itself as a strong senior-focused company, so it is not surprising that they have multiple health plan options and extras for seniors. Plan choices appear to vary by location, and the website requires you enter a zip code to receive a list of choices. For the purposes of this review, we used the zip code where the company’s headquarters is located – Worcester, MA.
Fallon Health’s Fallon Senior Plans are all HMO plans, and there are options with or without Part D prescription drug coverage.
The base plan, the Super Saver Rx HMO, has no additional premium beyond the Original Medicare premium. The plan has no deductible, and a $20 co pay for primary care office visits. The limited information provided doesn’t give information on specialist, Urgent Care, or ER co pays (it is unclear whether they are not listed, or whether there is no charge for these services), but inpatient hospital co pays are $360 per day for the first five days. The included Part D coverage starts at $2 for Tier 1 (preferred generic) drugs. Tiers 2-5 are $7, $42, $95, and 25% coinsurance respectively. All tiers have a $400 deductible before coverage kicks in.
The next step up premium-wise is the Saver Enhanced Rx. This plan is an HMO-POS plan which allows for some coverage outside the health system. Office visits have a $25 co pay and specialists a $40 co pay, whether in or out of network. In network hospital stays have a $275 per day co pay, which rises to $325 per day out of network – both are for the first five days. Prescription coverage starts at $1 for Tier 1, with the remaining Tiers at $6, $32, $86, and 27% coinsurance. Tiers 3-5 have a $300 annual deductible.
The Standard Enhanced Rx plan takes a pretty big jump in premium (we will look at rates in the next section), nearly doubling the previous plan. This plan has a $15 co pay for office visits, but lists no specialist or other co pays. Hospital stays have a $160 per day co pay for the first five days. Part D coverage has the same co pays as the Saver Enhanced Plan, but the deductible is lower at $200 and the Tier 5 coinsurance goes up to 29%.
The most expensive plan offered is the Plus Enhanced Rx HMO. This plan has a $10 co pay for office visits. As with previous plans, there are no co pays listed for other types of visits, and again, it is not made clear whether or not this means there is no charge for these visits. Inpatient hospital has a flat co pay of $200 per admission. Part D coverage is the same as the previous two plans, except that Tier 5 drugs have a slightly higher coinsurance at 33%, and there is no deductible.
There are also two plans that do not include Part D coverage. The Saver Plan has $25 office visit co pays and $40 specialist co pays, with a $200 per day cost for inpatient hospital stays for the first five days. The Standard Plan drops the co pays to $15 for office visits and $30 for specialists with a $160 per day charge for hospital stays up to five days. Since neither of these includes drug coverage, members will have to look elsewhere if needed.
None of the plans list any information regarding dental, vision, or hearing coverage.
Medicare Supplement plans in Massachusetts follow a state-specific standard that differs from most other states. Fallon Health offers two standard plans, Core and 1.
The Core Plan pays for all co pays and coinsurance that is out of pocket on Original Medicare. The 1 Plan steps this coverage up to also cover deductibles and other potential out of pocket expenses. Either plan can be purchased by those enrolled in Original Medicare, but not with an Advantage plan.
While not Medicare products directly, Fallon Health also has a couple of add-on options that are designed to streamline care and help seniors with multiple needs that may not be met by a Medicare plan.
NaviCare is a free add-on product for those who qualify – there are two versions, one for those who qualify for MassHealth Standard, and one for those who qualify for both MassHealth Standard and Medicare Parts A & B. NaviCare provides personal assistance with obtaining the services you need and includes extras such as home care assistance and help with meals.
The Summit ElderCare program is not Medicare related, but is a program designed to assist seniors who qualify for nursing home care to continue to live at home instead.
Medicare Supplement rates are based on date of birth; using a same date of 1/1/1950, we returned rates of $126 and $229 per month for Core and 1 respectively. These are slightly higher than rates we have seen for other Massachusetts companies.
The Super Saver Rx Plan, as noted, is a $0 premium plan, although Original Medicare Premiums are still required. The Saver Enhanced plan comes in at $82 per month, and the Enhanced plan doubles to $190 per month. Plus Enhanced has a premium of $247 per month. For the most expensive plans, the rates are somewhat higher than similar companies in the state. The limited information provided makes it difficult to determine what the top two plans offer in terms of coverage and lower costs to make up for the large jump in premium cost over the Saver plan.
For plans with no Part D coverage, rates are $69 for the Saver Plan and $142 for the Standard plan. Based on comparison to the plans that do include Part D, there appears to be more value in the comprehensive plans – however, it depends on whether or not Part D is obtained elsewhere.
Since this is a regional company, we are not able to compare the rates to national companies, nor to our usual sample area. Overall, however, we found Fallon Health to be more expensive than similar companies in the same state.
Ratings and Reviews
The Better Business Bureau rates Fallon under the previous name, Fallon Community Health Plan, with an A+ rating. There are no complaints on record in the past three years.
There are a few reviews on Yelp from members. Two of them are positive, and the remaining four negative. The negative reviews center mainly on denied claims and difficulty getting clear answers from customer service personnel.
The National Committee for Quality Assurance (NCQA) gives the company an overall rating of 4.5. The areas on major importance in the breakdown of rating factors, customer satisfaction, are largely rated quite high. This is nice to see as many companies fail in this area but rank high enough in other areas to bump up the overall score, giving a false sense of a solidly high ranking.
Medicare ranks the company’s plans at a 4.5 overall.
Overall, reviews and ratings for this company are encouraging. There are a few negative reviews, however, there does not seem to be any red flags or major areas of concern.
The Bottom Line
For those who live in the coverage area, Fallon Health offers a stable option with a good reputation. Rates are a little on the high side, but there are several plan options to meet a variety of budgets. For those who are comparing HMO options in this area, Fallon could be a strong contender with the caveat that the plans are not fully outlined on the site. Information on further services such as dental, hearing, and vision would allow a better picture of what value they provide.
For a list of companies that we recommend, visit our Best Insurance Companies page.