Member FAQ

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

Don't see your question listed here? Let us know and we'll work on adding it to our list!

On this page:

• Do you have more than one health insurance plan? And which one do I have?
• What is the difference between FCHP Direct Care and FCHP Select Care?
• Is my doctor on the plan?
• How do I select or change my PCP?
• What is the Fallon Community Health Plan formulary?
• What if I lose my membership card?
• What should I do in an emergency?
• My covered dependent is away at college. Is he/she covered?
• Where is Fallon Community Health Plan headquartered?
• What should you do in an emergency?
• How do you find an interpreter?
• Are all members treated equally?
• Does FCHP have post-mastectomy benefits?

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

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

• By phone at 1-800-868-5200 (TTDD/TTY: 1-877-608-7677), Monday through Friday, from 8 a.m. to 6 p.m. MassHealth members can call FCHP Customer Service at: 1-800-341-4848 (TDD/TTY: 1-877-608-7677) Monday through Friday, 8 a.m. to 6 p.m.
• By secure email. You must be a registered My FCHP user with an activated PIN to access secure email. If you have questions about using secure email, please call the customer service number above.  

The simplest way to tell which health plan you have is to check your member ID card. The name of your plan is in the upper left corner of this membership card near our logo.

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

Answer:
FCHP Direct Care 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.

FCHP Select Care offers you access to a much 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, 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.

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Question:
Is my doctor on the plan?

Answer:
Your Provider Network directory lists all network providers affiliated with the health insurance plan you belong to. You can verify this information by using our online provider locator. You also may contact FCHP's Customer Service Department:

• By phone at 1-800-868-5200 (TTDD/TTY: 1-877-608-7677), Monday through Friday, from 8 a.m. to 6 p.m. MassHealth members can call FCHP Customer Service at: 1-800-341-4848 (TDD/TTY: 1-877-608-7677) Monday through Friday, 8 a.m. to 6 p.m.
• By secure email. You must be a registered My FCHP user with an activated PIN to access secure email. If you have questions about using secure email, please call the customer service number above.

Fallon Preferred Care members should call 1-888-468-1541 (TDD/TTY: 1-877-608-7677), Monday through Friday, 8 a.m. to 6 p.m.

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Question:
How do I choose or change my PCP?

Answer:
With the exception of Fallon Preferred Care members, every covered family member must select a plan provider or doctor as a primary care provider (PCP) when you join FCHP. Your relationship with your PCP is very important, because he or she will work with us to provide or arrange most of your health care.

Each of our health insurance plans has a different list of participating physicians. When choosing a provider, it is important to verify that he or she participates in the plan you belong to. In addition to checking for plan participation, you should confirm that the provider you want to choose is accepting new patients. You can verify this information by using our online provider locator.

When you know which PCP you want to select, you may do so :

• By completing the online provider change form
• By phone at 1-800-868-5200 (TTDD/TTY: 1-877-608-7677), Monday through Friday, from 8 a.m. to 6 p.m. MassHealth members can call FCHP Customer Service at: 1-800-341-4848 (TDD/TTY: 1-877-608-7677) Monday through Friday, 8 a.m. to 6 p.m.

• By secure email. You must be a registered My FCHP user with an activated PIN to access secure email. If you have questions about using secure email, please call the customer service number above.

Note: The online provider change form is for FCHP Direct Care, FCHP Select Care, FCHP Flex Care Direct, Flex Care Select, Fallon Affiliates, Fallon Plus, FCHP Flex Care and FCHP MassHealth members only. Fallon Senior Plan^™ members must call 1-800-868-5200 (TDD/TYY: 1-877-608-7677).

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

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Question:
What is the online drug formulary?

Answer:
The FCHP formulary is a list of prescription drugs and medications that we cover. Our formulary has a tiered copayment structure with a different copayment for each tier. The tiers and the criteria for prior authorization are based on efficacy and cost-effectiveness.

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Question:
What if I lose my membership card?

Answer:
If you lose your membership card, you can order a new one online or call Customer Service, Monday through Friday, 8 a.m. to 6 p.m. at 1-800-868-5200 (TDD/TTY: 1-877-608-7677) to request a replacement. MassHealth members can call FCHP Customer Service at: 1-800-341-4848 (TDD/TTY: 1-877-608-7677) Monday through Friday, 8 a.m. to 6 p.m. Fallon Preferred Care members, please call 1-888-468-1541 (TDD/TTY: 1-877-608-7677), Monday through Friday, 8 a.m. to 6 p.m. Eastern time. Please allow a minimum of two weeks to receive your new card in the mail.

Note: The online membership card request form is for FCHP Direct Care, FCHP Select Care, FCHP Flex Care Direct, FCHP Flex Care Select, Fallon Preferred Care and FCHP MassHealth members only. Fallon Senior Plan-members must call 1-800-868-5200 (TDD/TYY: 1-877-608-7677), Monday through Friday, 8 a.m. to 6 p.m.

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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.

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 FCHP members except for Fallon Preferred Care
Emergency services do not require preauthorization, but you must notify the plan of any emergency services that you receive. Within 48 hours after receiving emergency care, you or someone acting on your behalf should notify the plan by calling 1-800-868-5200 (TDD/TTY: 1-877-608-7677), Monday through Friday, 8 a.m. to 6 p.m. MassHealth members can call FCHP Customer Service at: 1-800-341-4848 (TDD/TTY: 1-877-608-7677) Monday through Friday, 8 a.m. to 6 p.m. Your PCP should be notified 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.

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

Answer:

Full-time student dependents attending school outside of the FCHP service area are covered for a limited number of services while out-of-area, if authorized in advance by the plan. These services include:

• Nonroutine medical office visits.
• Diagnostic lab and X-ray connected with nonroutine office visits.
• Nonelective inpatient services if the plan is notified within 48 hours of admission.
• 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 FCHP service area.
• Outpatient services to diagnose and/or treat mental conditions.
• Short-term rehabilitation services, including physical, occupational and speech therapy. Coverage for physical and occupational therapy is provided for up to 20 office visits in each calendar year per illness or injury (combined with any in-area visits). Coverage for speech therapy is determined by medical necessity.

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 FCHP service area.

Services that are not covered for students while out of the FCHP service area include:

• Routine physical, gynecological exams and vision and hearing screening.
• Routine preventive care.
• Nonemergency prescription medication. You may use the prescription medication mail-order program to fill medication refills.
• Second opinion.
• Preventive dental care or minor restorative care (e.g., fillings).
• Chiropractic care services.
• Home health care.
• Outpatient surgical procedures that could be delayed until return to the FCHP service area.
• Maternity care or delivery.
• Durable medical equipment (e.g., wheelchairs), including maintenance or replacement.

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

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