Frequently asked questions

Overview

Doctors and hospitals

Benefits, copayments, deductibles and cost savings

Value-added extra benefits

Overview

Q. What is The Advantage Plan and how does it work?

A. The Advantage Plan is a two-tiered network that gives you the power to choose what you pay out of your own pocket, based on where you get your care. It is built around the area’s finest providers, such as UMass Memorial Health Care, Saint Vincent Hospital and Reliant Medical Group, all of which are in the lower-cost Tier 1. That means you will pay lower copayments when you get your health care locally. In addition to these local providers, you also have access to a larger group of providers—more than 40,000 throughout Massachusetts and southern New Hampshire—in Tier 2.

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Q. What is Direct Care?

A. Direct Care has over 28,000 providers to choose from—many right here in Central Massachusetts. You pay the same out-of-pocket costs, no matter where you go; and you have no deductible with Direct Care.

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Doctors and hospitals

Q. How do I know if my doctor is in Direct Care?

A. The Direct Care network includes over 28,000 providers throughout Massachusetts.

To find a doctor in the Direct Care network:

  • You can use the Find a Doctor tool.
  • You can call our dedicated sales team at 1-855-240-1200 and a representative can look up your doctor for you.
  • Or, you can visit an information session to speak to a representative.

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Q. How do I know if my doctor is in The Advantage Plan? How will I know what tier he/she is on?

A. The Advantage Plan network includes all the local providers you know and trust in Tier 1, such as:

  • UMass Memorial Health Care
  • Saint Vincent Hospital
  • Reliant Medical Group 

The network, based on the Select Care network, also includes more than 40,000 doctors and hospitals throughout Massachusetts and southern New Hampshire.

To find out what doctors are included in The Advantage Plan, you can:

  • Use the Find a Doctor tool.
  • Call our dedicated sales team at 1-855-240-1200 and a representative can look up your doctor for you.  

You can also call your doctor directly to find out if he/she is in The Advantage Plan. If your doctor is unfamiliar with The Advantage Plan, ask if they accept Fallon Health Select Care. If the answer is yes, then they also accept The Advantage Plan.

If your doctor belongs to UMass Memorial, Reliant Medical Group or Saint Vincent Physician Services, great news—they are included in Tier 1! In the Find a Doctor tool, alongside the provider name, specialty and location, there is a note to show what tier each doctor is in—Tier 1 or Tier 2. You can also call us at 1-855-240-1200, and we can help you determine what tier your doctor is in.

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Q. How did Fallon Health decide what doctors and hospitals are on what tiers?

A. Fallon tiers PCPs, specialists, and hospitals based on our strong relationship with local providers. We believe that local care is the best care—we have world-renowned hospitals and doctors right here in the area. That’s why Fallon includes UMass Memorial, Saint Vincent Hospital, Reliant Medical Group, and other local doctors and hospitals in the lower-cost Tier 1 of The Advantage Plan. The rest of The Advantage Plan doctors and hospitals are on Tier 2.

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Q. I'm a Direct Care member. What if I want to go to a Boston hospital?

A. Fallon provides guaranteed access to Boston for members of Direct Care through the Peace of Mind Program™. You can receive a second opinion and treatment for specialty services at one of five of Boston’s best hospitals: Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Children’s Hospital, Dana-Farber Cancer Institute and Massachusetts General Hospital.

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Q. How does the Peace of Mind Program benefit work?

A. The Peace of Mind Program is a benefit available to Direct Care members. It provides you with access to receive a second opinion and treatment for specialty services at one of five Boston hospitals. There are some eligibility requirements for the Peace of Mind Program:

  • You must be a Direct Care member.
  • You must have seen a specialist in your network for the same condition within the past three months. For example, if you have seen an in-network orthopedic surgeon within the past three months, you can see an orthopedic surgeon at a Peace of Mind Program facility. However, if you have seen an in-network orthopedic specialist within the past three months, you can see an orthopedic specialist at a Peace of Mind Program facility, but not an orthopedic surgeon.
  • The specialty services you are seeking must be covered services (see your Member Handbook/Evidence of Coverage for a listing of services covered with your plan). Services that are not available through the Peace of Mind Program include primary care services, mental health, substance abuse, dental care, chiropractic services, obstetrics, speech therapy and infertility services.
  • Your PCP must request a prior authorization from Fallon for you to see a Peace of Mind Program specialist. Your PCP cannot deny you the right to request access to your Peace of Mind Program benefit.

As long as you have met the eligibility requirements, you have the right to access your Peace of Mind Program benefit. Your PCP cannot deny you that right. If you have difficulty receiving a referral from your PCP, call the Fallon customer service team.

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Q. If I go to a Peace of Mind hospital, what would I pay as a member of Direct Care?

If you are on the Direct Care plan, there is just one copay no matter where you go.

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Q. If I choose The Advantage plan, can I only see Tier 1 doctors?

A. No. You can see any doctor—or visit any hospital—included in The Advantage Plan network.

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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. Both Direct Care and The Advantage Plan are HMO plans. That means that in order for you to receive coverage for services with either plan, 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 1-855-240-1200.

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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. With The Advantage Plan, your deductible amount depends on what tier your provider is in, but with Direct Care, there is no deductible. See deductible amounts for The Advantage Plan »

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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. For example, if a family member receives same day surgery services from a Tier 1 facility in The Advantage Plan, which has a $1,500 family deductible, no one member of that family will have to pay more than $500 toward that deductible. The family as a whole will pay no more than $1,500.

When seeing Tier 2 providers, a family on The Advantage Plan will have a separate $2,250 family deductible, but no one member of that family will have to pay more than $750 towards the Tier 2 deductible.

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Q. For services that say “copayment, or coinsurance, after deductible,” would I have to pay the deductible as well as a copay/coinsurance until I’ve paid my whole deductible?

A. Yes. For example, Scott needs to have surgery on his knee. He chooses to have it done at a Tier 1 facility. Because outpatient surgery charges go toward the deductible, and Scott hasn’t paid his $500 deductible yet, he would pay the full cost for the surgery up to $500. He may also have to pay the 20% coinsurance depending on the total cost of the surgery.

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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 that only provides imaging services—a place where you would have an MRI or a CT scan, but you would not stay overnight or go for emergency care. With The Advantage Plan, when you have imaging (MRIs, CT scans, etc) done in a non-hospital setting, you will pay less than if you have those kinds of tests done in a hospital setting.

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Q. What is an out-of-pocket maximum?

A. The out-of-pocket maximum—the amount that you would have to pay out of your own pocket annually in deductibles, copayments and coinsurance—protects you by capping the amount that you will have to pay for your health care in any given year. See the out-of-pocket maximum amounts for Direct Care and The Advantage Plan » 

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Q. What happens if I have an emergency and I am traveling?

A. With both of your Fallon options, 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 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. What is the It Fits! benefit?

A. It Fits! is one of the richest, most flexible fitness benefit available in Massachusetts. With Fallon, you can use your It Fits! annual reimbursement of $500 for families/$250 for individuals to pay for all kinds of healthy activities, including school and town sports, a gym membership at the gym of your choice, Weight Watchers®, aerobics, Pilates and yoga classes, ski lift tickets, and even new cardiovascular home fitness equipment. Most fitness benefits offer “discounts,” or reimbursements at a limited list of gyms. With It Fits!, you go where you want to go, and you get paid back.

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Q. How do I get the $500/$250 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 an It Fits! 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 4-6 weeks to get your check in the mail. It’s that easy!

Please note: This incentive payment may be considered taxable income. Please consult your tax advisor if you have questions.

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Q. What is covered through Naturally Well?

A.Naturally Well gives you discounts on acupuncture, chiropractic care (in addition to your chiropractic benefit) and massage therapy from the American Specialty Health (ASH) network of qualified providers. Health and wellness products also are available at a reduced rate through ChooseHealthyTM, an affiliate of ASH. The services and products are not covered benefits under your health plan coverage, but are an extra value if you wish to use them.

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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 convertible toddler 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 Fallon members get?

A. Fallon provides its members with lots of extras to keep you and your wallet healthy, including:

  • $0 wellness benefit! Copayments are $0 for routine physicals, gynecological exams, well-child care visits and annual vision exams.
  • 20% discount at CVS/pharmacy—You get a 20% discount on more than 1,500 CVS/pharmacy-brand health-related products, good at any CVS/pharmacy store or online at cvs.com.
  • EyeMed Vision Care® discounts—members save up to 35% on frames and additional discounts on contact lenses, laser vision correction and nonprescription sunglasses at thousands of locations nationwide.
  • Pet care discount—members get discounts on pet care at participating VCA hospitals. Get a free initial physical exam for new patients and a 10% discount on general services such as consultations, lab tests and X-rays.
  • Nurse Connect—For those times when you’re not feeling well, but don’t think it’s an emergency, call the registered nurses at Nurse Connect. Fallon members get free access—by phone and online—24 hours a day, seven days a week, 365 days a year.
  • Quit to Win —Smokers get access to this free counseling program with tobacco cessation experts by telephone.
  • Healthwise® Knowledgebase—This free online encyclopedia features information on diseases, treatment, medications and other important health topics.
  • Out-of-area student coverage—Students attending school outside the service area are covered for certain services with plan authorization.

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Important information