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Benefit summaries and Summaries of Benefits and Coverage (SBC) for our health insurance plans

A variety of low cost plan designs with flexible benefit options and a choice of networks.

To download a benefit summary or SBC for your current plan year, click the "See more" link that corresponds to your plan's effective date. Please note: These documents do not include customizations. These are the standard plan designs. If you need documents for a plan with an earlier effective date, please contact Jen Lavigne at jennifer.lavigne@fallonhealth.org.

Download the Glossary of Health Coverage and Medical Terms (pdf)

Quick look at plans

January 1, 2021 effective dates and beyond

Benefit comparison grids (pdf)
Out-of-pocket maximum guidelines (pdf)

January 1, 2020 effective dates and beyond

Benefit comparison grids (pdf)
Out-of-pocket maximum guidelines (pdf)

2021

Effective dates of January 1, 2021 and beyond

Copay: affordable options that include inpatient copayments at premium savings
Direct Care network (HMO)	Select Care network (HMO)
Copay 1000 Benefit summary SBC Schedule of benefits	Copay 1000 Benefit summary SBC Schedule of benefits

Deductible: plan designs that provide premium savings by offering deductibles for inpatient services and diagnostic testing
Direct Care network (HMO)	Select Care network (HMO)	Preferred Care network (PPO)
Deductible 1250 Benefit summary SBC Schedule of benefits	Deductible 1250 Benefit summary SBC Schedule of benefits
Deductible 2000 Low Benefit summary SBC Schedule of benefits	Deductible 2000 Low Benefit summary SBC Schedule of benefits	Deductible 2000 Low Benefit summary SBC Schedule of benefits
Deductible 2000 High Benefit summary SBC Schedule of benefits	Deductible 2000 High Benefit summary SBC Schedule of benefits
Deductible 3000 High Benefit summary SBC Schedule of benefits	Deductible 3000 High Benefit summary SBC Schedule of benefits
Deductible 5000 Low Benefit summary SBC Schedule of benefits	Deductible 5000 Low Benefit summary SBC Schedule of benefits
Bronze Deductible 3000 Benefit summary SBC Schedule of benefits	Bronze Deductible 3000 Benefit summary SBC Schedule of benefits
Bronze Deductible 5000 Benefit summary SBC Schedule of benefits	Bronze Deductible 5000 Benefit summary SBC Schedule of benefits

QHD: qualified high deductible plans that may be partnered with a Health Savings Account (HSA)
Direct Care network (HMO)	Select Care network (HMO)	Preferred Care network (PPO)
QHD 2000 HSA Benefit summary SBC Schedule of benefits	QHD 2000 HSA Benefit summary SBC Schedule of benefits	QHD 2000 HSA Benefit summary SBC Schedule of benefits
QHD 3000 HSA Benefit summary SBC Schedule of benefits	QHD 3000 HSA Benefit summary SBC Schedule of benefits

Connector plans - individuals and families

Direct Care network (HMO)	Select Care network (HMO)	Community Care network (HMO)
Connector Platinum Benefit summary SBC Schedule of benefits	Connector Platinum Benefit summary SBC Schedule of benefits
Connector High Gold Benefit summary SBC Schedule of benefits	Connector High Gold Benefit summary SBC Schedule of benefits
Connector Low Gold Benefit summary SBC Schedule of benefits	Connector Low Gold Benefit summary SBC Schedule of benefits
Connector High Silver Connector II Benefit summary SBC Schedule of benefits	Connector High Silver Connector II Benefit summary SBC Schedule of benefits	Connector High Silver Connector II Benefit summary SBC Schedule of benefits
Connector Bronze #1 Benefit summary SBC Schedule of benefits	Connector Bronze #1 Benefit summary SBC Schedule of benefits
Connector Catastrophic Benefit summary SBC Schedule of benefits

Connector plans - small group

Direct Care network (HMO)	Select Care network (HMO)	Community Care network (HMO)	Preferred Care network(PPO)
Connector Platinum Benefit summary SBC Schedule of benefits	Connector Platinum Benefit summary SBC Schedule of benefits
Connector High Gold Benefit summary SBC Schedule of benefits	Connector High Gold Benefit summary SBC Schedule of benefits
Connector Low Gold Benefit summary SBC Schedule of benefits	Connector Low Gold Benefit summary SBC Schedule of benefits
Connector Silver Benefit summary SBC Schedule of benefits	Connector Silver Benefit summary SBC Schedule of benefits	Connector Silver Benefit summary SBC Schedule of benefits
Connector Low Silver HSA Benefit summary SBC Schedule of benefits	Connector Low Silver HSA Benefit summary SBC Schedule of benefits
Connector Bronze #1 Benefit summary SBC Schedule of benefits	Connector Bronze #1 Benefit summary SBC Schedule of benefits
			Deductible 2000 Low Benefit summary SBC Schedule of benefits

ConnectorCare (subsidy) plans

Community Care network (HMO)

Wrap Type I

Wrap Type II

Wrap Type III

2020

Effective dates of January 1, 2020 and beyond

Copay: affordable options that include inpatient copayments at premium savings
Direct Care network (HMO)	Select Care network (HMO)
Copay 500 Benefit summary SBC Schedule of benefits	Copay 500 Benefit summary SBC Schedule of benefits
Copay 1000 Hybrid Benefit summary SBC Schedule of benefits	Copay 1000 Hybrid Benefit summary SBC Schedule of benefits

Coinsurance: plan designs that provide premium savings by offering coinsurance for inpatient services and diagnostic testing
Direct Care network (HMO)	Select Care network (HMO)
Coinsurance 35% Benefit summary SBC Schedule of benefits	Coinsurance 35% Benefit summary SBC Schedule of benefits

QHD: qualified high deductible plans that may be partnered with a Health Savings Account (HSA)
Direct Care network (HMO)	Select Care network (HMO)	Preferred Care network (PPO)
QHD 2000 HSA Benefit summary SBC Schedule of benefits	QHD 2000 HSA Benefit summary SBC Schedule of benefits	QHD 2000 HSA Benefit summary SBC Schedule of benefits
QHD 3000 HSA Benefit summary SBC Schedule of benefits	QHD 3000 HSA Benefit summary SBC Schedule of benefits

Connector plans - individuals and families

Direct Care network (HMO)	Select Care network (HMO)	Community Care network (HMO)
Platinum Connector Benefit summary SBC Schedule of benefits	Platinum Connector Benefit summary SBC Schedule of benefits
Gold Connector High Benefit summary SBC Schedule of benefits	Gold Connector High Benefit summary SBC Schedule of benefits
Gold Connector Low Benefit summary SBC Schedule of benefits
Deductible 2000 Hybrid Benefit summary SBC Schedule of benefits	Deductible 2000 Hybrid Benefit summary SBC Schedule of benefits
Silver Connector II Benefit summary SBC Schedule of benefits	Silver Connector II Benefit summary SBC Schedule of benefits	Silver Connector II Benefit summary SBC Schedule of benefits
Bronze Connector Benefit summary SBC Schedule of benefits	Bronze Connector Benefit summary SBC Schedule of benefits
Catastrophic Benefit summary SBC Schedule of benefits

Connector plans - small group

Direct Care network (HMO)	Select Care network (HMO)	Community Care network (HMO)	Preferred Care network(PPO)
Platinum Connector Benefit summary SBC Schedule of benefits	Platinum Connector Benefit summary SBC Schedule of benefits
Gold Connector High Benefit summary SBC Schedule of benefits	Gold Connector High Benefit summary SBC Schedule of benefits
Gold Connector Low Benefit summary SBC Schedule of benefits
Deductible 2000 Hybrid Benefit summary SBC Schedule of benefits	Deductible 2000 Hybrid Benefit summary SBC Schedule of benefits
Silver Connector Benefit summary SBC Schedule of benefits	Silver Connector Benefit summary SBC Schedule of benefits	Silver Connector Benefit summary SBC Schedule of benefits
Silver Connector Low HSA Benefit summary SBC Schedule of benefits	Silver Connector Low HSA Benefit summary SBC Schedule of benefits
Bronze Connector Benefit summary SBC Schedule of benefits	Bronze Connector Benefit summary SBC Schedule of benefits
			Deductible 2000 Low Benefit summary SBC Schedule of benefits

ConnectorCare (subsidy) plans

Community Care network (HMO)

Wrap Type I

Wrap Type II

Wrap Type III

2019

Effective dates of April 1, 2019 and beyond

Copay: affordable options that include inpatient copayments at premium savings
Direct Care network (HMO)	Select Care network (HMO)
Copay 500 Benefit summary SBC Schedule of benefits	Copay 500 Benefit summary SBC Schedule of benefits
Copay 1000 Hybrid Benefit summary SBC Schedule of benefits	Copay 1000 Hybrid Benefit summary SBC Schedule of benefits

Coinsurance: plan designs that provide premium savings by offering coinsurance for inpatient services and diagnostic testing
Direct Care network (HMO)	Select Care network (HMO)
Coinsurance 35% Benefit summary SBC Schedule of benefits	Coinsurance 35% Benefit summary SBC Schedule of benefits

QHD: qualified high deductible plans that may be partnered with a Health Savings Account (HSA)
Direct Care network (HMO)	Select Care network (HMO)	Preferred Care network (PPO)
QHD 2000 HSA Benefit summary SBC Schedule of benefits	QHD 2000 HSA Benefit summary SBC Schedule of benefits	QHD 2000 HSA Benefit summary SBC Schedule of benefits
QHD 3000 HSA Benefit summary SBC Schedule of benefits	QHD 3000 HSA Benefit summary SBC Schedule of benefits

Connector plans - individuals and families

Direct Care network (HMO)	Select Care network (HMO)	Community Care network (HMO)
Platinum Connector Benefit summary SBC Schedule of benefits	Platinum Connector Benefit summary SBC Schedule of benefits
Gold Connector High Benefit summary SBC Schedule of benefits	Gold Connector High Benefit summary SBC Schedule of benefits
Gold Connector Low Benefit summary SBC Schedule of benefits
Deductible 2000 Hybrid Benefit summary SBC Schedule of benefits	Deductible 2000 Hybrid Benefit summary SBC Schedule of benefits
Silver Connector II Benefit summary SBC Schedule of benefits	Silver Connector II Benefit summary SBC Schedule of benefits	Silver Connector II Benefit summary SBC Schedule of benefits
Bronze Connector Benefit summary SBC Schedule of benefits	Bronze Connector Benefit summary SBC Schedule of benefits
Catastrophic Benefit summary SBC Schedule of benefits

Connector plans - small group

Direct Care network (HMO)	Select Care network (HMO)	Community Care network (HMO)	Preferred Care network(PPO)
Platinum Connector Benefit summary SBC Schedule of benefits	Platinum Connector Benefit summary SBC Schedule of benefits
Gold Connector High Benefit summary SBC Schedule of benefits	Gold Connector High Benefit summary SBC Schedule of benefits
Gold Connector Low Benefit summary SBC Schedule of benefits
Deductible 2000 Hybrid Benefit summary SBC Schedule of benefits	Deductible 2000 Hybrid Benefit summary SBC Schedule of benefits
Silver Connector Benefit summary SBC Schedule of benefits	Silver Connector Benefit summary SBC Schedule of benefits	Silver Connector Benefit summary SBC Schedule of benefits
Silver Connector Low HSA Benefit summary SBC Schedule of benefits	Silver Connector Low HSA Benefit summary SBC Schedule of benefits
Bronze Connector Benefit summary SBC Schedule of benefits	Bronze Connector Benefit summary SBC Schedule of benefits
			Deductible 2000 Low Benefit summary SBC Schedule of benefits

ConnectorCare (subsidy) plans

Community Care network (HMO)

Wrap Type I

Wrap Type II

Wrap Type III

Direct Care is a plan with a limited provider network. This plan provides 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. Please visit our Find a Doctor tool or consult the Direct Care provider directory to determine which providers are included in Direct Care. A paper copy can be requested by calling our Customer Service Department at 1-800-868-5200.

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1-800-868-5200 (TRS 711), Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.

Notice of non-discrimination (pdf)

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