Frequently asked questions

Doctors and hospitals

Benefits, copayments, deductibles and cost savings

Value-added Extra benefits

Doctors and hospitals

Q. How do I know if my doctor is in Select Care?
A. The Select Care Network includes over 42,000 providers throughout Massachusetts and southern New Hampshire.

If you’re not sure if your doctor belongs to the Select Care network, there are a few ways to find out if he/she is in the network:

  • You can use the Find a Doctor tool.
  • You can call our dedicated team at 1-855-574-5027 and a representative can look up your doctor for you.
  • Or, you can visit a benefit fair to speak with a representative.

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Q. If I see a specialist now that is not in the network, will I be able to continue to see that specialist and have it covered?
A. Select Care is an HMO plans, which means that in order for you to receive coverage for services, you need to see in-network providers. If you choose to see a provider who is not in the network, services will not be covered. The only exception is emergency care—with Fallon, you are covered for worldwide emergency care, no matter where you receive it.

However, if you are currently in medical treatment with a provider who is not in the network, you can work with our care coordination team who can help to try to prevent any interruptions in care by finding a participating provider for your needs. If you’d like to speak with someone about how your care would be transitioned with Fallon, please call our dedicated team at 1-855-574-5027.

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Benefits, copayments, deductibles and cost savings

Q. How does a deductible work?
A. You are probably already familiar with the idea of a deductible, since most likely you have a deductible on your car insurance policy—it’s that first $500 or $1,000 you have to pay before your insurance covers repair costs. Much the same way, your health insurance deductible is a set dollar amount that you must pay out of your pocket before your plan will pay for services.

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Q. What does it mean when you say: The most any one person will pay toward the deductible?
A. That refers to the maximum amount that any one family member will pay before their portion of the deductible is fulfilled. So, if a family has a $300 family deductible, no one member of that family will have to pay more than $150 toward that deductible. The family as a whole will pay no more than $300.

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Q. For services that say “copayment after deductible,” would I have to pay the deductible as well as a copay until I’ve paid my whole deductible?
A. The best way to explain this is through an example.

For instance, Sally hurt her elbow playing tennis. She goes to the emergency room, where X-rays are taken. She then has a follow-up appointment with her primary care provider. He sends her home with a clean bill of health.

Sally has a $150 deductible as part of her health insurance plan. She also has a $20 copayment per PCP office visit. Sally has not paid anything toward her deductible for this plan year. Here's an example of what costs Sally may be responsible for with her health plan:

Services and types of payment required
Emergency room visit with X-ray: Deductible, then copayment
Doctor: Copayment only
Services and actual costs
ER visit and X-ray cost $1,200
Sally owes: $150 (toward deductible)
$150 (copayment for ER)
Office visit cost: $160
Sally owes: $20 copayment


Sally has satisfied her yearly deductible of $150. For the remainder of her plan year, Sally will only have to pay copayments or coinsurance for covered medical services.

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Q. What does out-of-pocket maximum mean?
A. The out-of-pocket maximum is the total amount of deductible, coinsurance and copayments you are responsible for in a benefit period. The out-of-pocket maximum does not include your premium charge or any amounts you pay for services that are not covered by the plan.

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Q. What is a “hospital setting” versus a “non-hospital setting?”
A. A hospital setting is just that—a medical center that provides inpatient stays and emergency care plus other types of services.

A non-hospital setting would be a facility when you could access lab or imaging services, but where you would not stay overnight or go for emergency care.

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Q. What happens if I have an emergency and I am traveling?
A. With Fallon, you have worldwide emergency coverage. That means that if you, or a dependent covered on your plan, experience a medical emergency while away from home, you can go to any emergency room and be covered. You would then need to notify Fallon of any emergency services received, and we recommend that you also contact your PCP to coordinate any follow-up care.

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Q. I have a dependent child who is a student out-of-state. Is that child covered by Fallon?
A. Yes, but the services they can access while at school are limited. Students attending school outside the Fallon service area may not have easy access to the plan provider network. They would be covered for a limited number of services while out-of-area, if those services are authorized in advance by Fallon. You must work with your PCP to get plan authorization. These services include:

  • Non-routine medical office visits
  • Diagnostic lab and X-ray connected with a non-routine office visits
  • Non-elective inpatient services
  • Outpatient services to treat the abuse of or addiction to alcohol or drugs, up to 20 office visits in each calendar year while out of the Fallon service area
  • Outpatient services to diagnose and/or treat mental conditions
  • Short-term rehabilitation services, including physical, respiratory, speech and occupational therapy. Coverage is provided for up to 20 office visits per discipline in each calendar year per illness or injury (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 the student returns to the Fallon service area.

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Value-added Extra benefits

Q. How do I get the $300 fitness money?
A. Once you have a receipt for a healthy, reimbursable activity, like school and town sports fees, a gym membership at the gym of your choice, or even ski lift tickets, you can send those receipts in with a fitness reimbursement form. You can decide to send all of your receipts for the year in at once to make things easier for you. Once we receive the form, we ask that you allow 2-4 weeks to get your check in the mail. It’s that easy!

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Q. What is the Oh Baby! program all about?
A. As a Fallon member, and as a new parent-to-be, the Oh Baby! program provides you with free prenatal vitamins, a car seat, a breast pump, a home safety kit and more—plus reimbursements on childbirth or sibling classes, discounts on birth announcements, and even a chance to win an American Express® Gift Cheque.

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Q. What other extras do members get?
A. Fallon provides its members with lots of extras to keep you and your wallet healthy. See the list of healthy extras you receive as a Fallon member.

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