Frequently asked questions for members

To better serve our Fallon Health members, we have compiled some of the most frequently asked questions below.*

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On this page:

Benefits and plans

Doctor visits and provider networks

Prescription drugs

Manage your health

Benefits and plans

Question:
Do you have more than one health insurance plan? And which one do I have?

Answer:
The simplest way to tell which health plan you have is to check your member ID card. The name of your plan is on the right-hand side of this membership card, under our logo.

We offer a wide array of health insurance plans. To learn more about your particular plan, contact Fallon's Customer Service Department:

  • By phone at the number on the back of your ID card (TTY users, please call TRS Relay 711).

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Question:
What is the difference between Direct Care and Select Care?

Answer:
Direct Care (our plan with a limited provider network) allows you to receive high quality care at an affordable price, from some of the best performing physician groups in Massachusetts. Direct Care features a high-performing network of providers at medical centers you know and trust. You benefit from coordinated care while taking advantage of our lowest premium plan.

Select Care offers you access to a broader choice of providers. You can choose from thousands of providers and more than 40 contracted hospitals throughout the state, including the Bay State Health system, Anna Jaques Hospital, Brockton Hospital, Emerson Hospital, Reliant Medical Group (formerly Fallon Clinic), Greater Milford Health Alliance, Lawrence General Hospital, Mount Auburn Cambridge IPA, Nashoba Valley Medical Center, Northeast Medical Associates and the UMass Memorial Health Care System. Learn more about our networks.

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Question:
What is the difference between a referral and a prior authorization request?

Answer:
A referral is simply a recommendation from your physician for you to see another physician or provider, typically for services outside of your provider’s scope of practice. Getting a referral is not a guarantee that Fallon will cover the service. Please note that referrals are not required for behavioral health services.

Prior authorization is approval – in advance – that your physician gets so that you can receive certain services or medications. If you do not get prior authorization when required, we typically will not cover the service or medication.

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Question:
What is the autism mandate?

Answer:
The autism mandate assures members that their insurance company will cover the cost of diagnosis and treatment of certain autism spectrum disorders. More information about the autism mandate »

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Question:
What’s the difference between an HRA and an FSA?

Answer:
A health reimbursement account (HRA) is an account funded by your employer to help cover some of your out-of-pocket medical costs, such as copayments and deductibles. Often, unused funds are allowed to roll over to the next year.

A flexible spending account (FSA) is an account that you fund to pay uncovered medical, dental, optical and dependent care expenses on a pretax basis. You decide how much you want to contribute to the account, and your contributions are typically deducted from your pay before taxes. You then pay for eligible expenses with pretax dollars in the account. An FSA can help you save money on taxes by allowing you to pay for eligible expenses with pretax dollars, but your funds typically don’t roll over from year to year.

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Question:
What factors contribute to premium rates?

Answer:
Premium rates are determined by several factors and depends on if you are purchasing insurance on your own or as part of an employer group. For those purchasing on their own, premium rate factors include age, where you live, how many people are going to be on your contract, and when you want your health insurance to start. If you are part of a large employer group, other factors like claims history may be included in establishing the rate.

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Doctor visits and provider networks

Question:
Is my doctor on the plan?

Answer:
To check if your doctor accepts Fallon Health, check your Provider Network directory or our online provider locator. These directories list all network providers affiliated with the plan you belong to. You can also verify this information by contacting Fallon's Customer Service Department:

  • By phone at the number on the back of your ID card.

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Question:
How do I choose or change my primary care provider (PCP)?

Answer:
To choose or change your PCP, first check to see if the provider is in the network of the plan you belong to. You can do this by looking in your Provider Network directory, our online provider locator or by calling Fallon Customer Service.

You should also confirm that the provider you want to choose is accepting new patients. Call the doctor’s office and ask if he or she is accepting new patients. It’s also a good idea to ask when the next available appointment is.

When you know which PCP you want to select, you notify us by:

  • Selecting a new PCP using myFallon.
  • Phone at the number on the back of your member ID card.

Note: Preferred Care members are not required to designate a primary care provider.

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Question:
Where can I learn more about physicians than just their name and specialty?

Answer:
The Massachusetts Board of Registration in Medicine Physician Profile System offers a wealth of information on physicians registered to practice medicine in the Commonwealth. This includes education history, disciplinary actions, and honors and awards.

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Question:
How do I use the Peace of Mind Program?

Answer:
Direct Care members can use the Peace of Mind Program for second opinions to Boston hospitals. You first need to see a specialist in your plan network for a condition. If you’d like a second opinion for that condition, ask your PCP for a prior authorization to see a specialist at one of the hospitals that participate in our Peace of Mind Program, no later than three months beyond when you first saw your plan specialist. Care is only covered for specialty services as described in your Member Handbook.

The Peace of Mind Program cannot be used for mental health, substance abuse, chiropractic services, obstetrics, speech therapy and infertility services are excluded. Also, members cannot use the Peace of Mind Program for primary care services.

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Question:
What should I do in an emergency?

Answer:
Your plan covers emergency care worldwide. When you have an emergency medical condition you should go to the nearest emergency room for care or call your local emergency communications system (e.g., police, fire department or 911) to request ambulance transportation.

If you are out of the country and receive emergency care, you will be billed by the facility. You will first need to pay the bill. Then, submit the receipt and bill to us so that we may reimburse you for what you paid.

An emergency medical condition is a condition, whether physical or mental, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • serious jeopardy to the health of the individual (or unborn child)
  • serious impairment to bodily functions or
  • serious dysfunction of any bodily organ or part.

Examples of covered emergencies are stroke, unconsciousness, heart attack symptoms or severe bleeding.

All Fallon members except for Preferred Care members 
Emergency services do not require preauthorization, but you (or someone acting on your behalf) should notify your PCP of the visit as soon as possible, so that arrangements can be made to coordinate any needed follow-up care. Your PCP will work with the plan to assure that any follow-up or continuing care that is medically necessary will be arranged for you. It is important to note that follow-up care in an emergency room often will not meet a prudent layperson definition and that most emergency room follow-up care can be provided in a setting other than an emergency room.

Preferred Care members
Emergency services do not require referral or authorization. If your condition requires that you be admitted directly from the emergency room to the hospital for inpatient emergency care, must notify Private Healthcare Systems' (PHCS) Medical Management Services as soon as possible, but not later than 72 hours following your admission. You may reach them at 1-866-416-6489 (TDD/TTY: 1-800-257-8595). If you do not notify PHCS, coverage of your inpatient hospitalization will be subject to a penalty.

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Question:
Where can I go for urgent care?

Answer:
There are several urgent care facilities throughout Massachusetts. These include the Urgent Care Centers at Reliant Medical Group locations, ReadyMed and MinuteClinic.

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Question:
What is CBHI?

Answer:
CBHI, which stands for the Childrens’ Behavioral Health Initiative, is a program for MassHealth members under age 21 who need behavioral health care. Get the list of contacts for CBHI providers.

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Prescription drugs

Question:
What is the Fallon Health drug formulary?

Answer:
Our prescription drug formulary is one of the ways Fallon takes some of the work out of saving money. Most HMOs have one. The Fallon formulary is a list of the drugs that we cover for our members, arranged into three or four tiers—revealing at a glance the drugs with the lowest out-of-pocket costs. Tier 1 drugs have the lowest copayments, Tier 2 drugs are in the middle, and Tier 3 and 4 drugs have the highest copayments or cost sharing. The tiers and the criteria for prior authorization are based on effectiveness and cost.

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Question:
How do I know which formulary I use?

Answer:
The formulary you use is based on what plan you are in. To find out which formulary you have, visit the Online drug formulary.

If you have a question about what formulary you should use, call our Customer Service Department at the number on the back of your ID card.

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Question:
How does Fallon determine what tier my drug is on?

Answer:
The tiers for medications are based on effectiveness and cost.

Tier 1 contains mostly lower-cost generic drugs, which have the same active ingredients and effects as brand-name drugs. With the lowest copayments, this tier gives you greater savings for many medications you commonly use.
Tier 2 contains more costly generic drugs.
Tier 3 contains cost-effective, preferred brand-name drugs.
Tier 4 contains all other brand-name drugs, including brand-name drugs for which generic alternatives are available in Tier 1 or Tier 2, specialty drugs, new drugs and very expensive drugs. These have the highest copayments or cost sharing.

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Question:
Why do some of my medications require prior authorization?

Answer:
A number of medications are used for more than one purpose, and it’s important to be sure the best drug is used for each individual’s situation. Prior authorization helps us make that determination.

The criteria for which drugs require prior authorization is based on drug effectiveness and cost.

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Managing your health

Question:
What if I lose my membership card?

Answer:
If you lose your membership card, you can order a new one using myFallon or request a replacement by calling Customer Service at 1-800-868-5200 (TTY users, please call TRS Relay 711). Please allow a minimum of two weeks to receive your new card in the mail.

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Question:
What’s the address to mail in claims that I need to pay to Fallon Health?

Answer:
You can mail your claims to:
Fallon Health
Claims Department
PO Box 15121
Worcester, MA 01615

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Question:
Do I need to pay the bill I received from a lab/doctor/hospital?

Answer:
To see if you owe a provider payment, log in to myFallon to look at details about your medical claims. You may owe copayments, coinsurance or an amount that would apply to your deductible. More information about what to do if you get a bill »

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Question:
My covered dependent is away at college. Is he/she covered?

Answer:
Students attending school outside the service area may not have easy access to the plan provider network. They are covered for a limited number of services while out-of-area, if authorized in advance by the plan. You must work with your PCP to get prior authorization. These services include:

  • Nonroutine medical office visits
  • Diagnostic lab and X-ray connected with a nonroutine office visits
  • Nonelective inpatient services
  • Outpatient services to diagnose and/or treat mental conditions
  • Speech therapy
  • Short-term rehabilitation services, including physical and occupational therapy are covered for up to 60 visits combined in each calendar year (combined with any in-area visits).

Aside from emergency care, the services listed above are the only services that are covered for students on an out-of-network basis. To be covered, all other services must be obtained when they return to the plan’s service area.

Services that are not covered for students while out of the plan’s service area include:

  • Routine physical, gynecological exams, vision screening and hearing screening
  • Routine preventive care
  • Non-emergency prescription medication. Students may use a network pharmacy or the prescription medication mail-order program to fill medication refills.
  • Second opinion
  • Chiropractic care services
  • Home health care
  • Outpatient surgical procedures that could be delayed until return to the plan’s service area
  • Maternity care or delivery
  • Durable medical equipment (e.g., wheelchairs), including maintenance or replacemen

Preferred Care (PPO) members
Preferred Care members can utilize any provider at any hospital, but receive greater benefits by seeing a participating provider.

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Question:
Where is Fallon Health headquartered?

Answer:
10 Chestnut St., Worcester, MA. Our building is labeled One Chestnut Place. Directions to Fallon Health.

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Direct Care and Steward Community Care are plans with a limited provider network. These plans provide access to a network that is smaller than Select Care. In this plan, members have access to network benefits only from the providers in Direct Care or Steward Community Care, respectively. Please visit our Find a Doctor tool or consult your provider directory to determine which providers are included in your plan’s network. A paper copy can be requested by calling our Customer Service Department at the number on the back of your ID card.

* Benefits and coverage may vary by product, plan design and employer. For specific details regarding your Fallon plan, benefits and features, please check with your employer or contact a member of our customer service team at the number on the back of your ID card.