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Learn about your plan options
Fallon Community Health Plan offers you two HMO plans: FCHP Direct Care and FCHP
Select Care. The choice of two plans lets you find a level of benefits that best
fits your health care needs.
What should I look for in a health plan?
Choosing a health plan can be a confusing process, but we’re here to make it easier.
Here are a few questions you can ask that will help you make the right choice:
- How much will I pay for office visits, hospitalization, prescription drugs and vision care?
- Which doctors, hospitals and other medical providers are part of the plan?
- Does the plan cover mental health counseling, obstetrical-gynecological care or care for chronic conditions?
What services are not covered?
- What are my options for chiropractic or alternative health care, such as acupuncture?
- Will I be able to receive care close to home or work?
- Does the plan offer discounts or reimbursements for fitness centers or healthy activities?
What types of wellness programs would be available to me?
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Your plan options
FCHP Direct Care
FCHP Direct Care is one of two HMO plans we offer to Commonwealth of Massachusetts
employees and retirees. With FCHP Direct Care, you’ll have access to care from Acton Medical Associates, Charles River Medical Associates,
Lahey Clinic, Lawrence General, Lowell General, Mount Auburn Cambridge IPA, Northeast PHO, Southboro Medical Group, Fallon
Clinic, Saint Vincent Hospital, and MetroWest Medical Center, among others. You’ll also enjoy a variety
of health and wellness programs — from fitness reimbursements to discounts
on acupuncture, chiropractic care, and massage therapy.
Learn more about FCHP Direct Care
Find a doctor in the FCHP network
FCHP Select Care
FCHP Select Care is the second HMO plan available to Commonwealth of Massachusetts employees and retirees. This plan gives you a wider
choice of health care providers, including all those in the FCHP Direct Care network plus physicians and facilities throughout western, central, and eastern Massachusetts.
Tier 1,
2 and 3 measurements of plan physician quality and cost-efficiency
Fallon Community Health Plan is committed to giving all our members access to a network of high-quality,
cost-efficient plan physicians. The tiering
works as follows:
***Tier 1 (excellent): Plan physicians practicing at an excellent level of cost-efficiency
and quality. You will pay the lowest copayment
when you see a Tier 1 plan physician.
**Tier 2 (good): Plan physicians practicing at a good level of cost-efficiency and
quality. Also included in this tier’s copayment are providers that didn’t have sufficient
data with which to rate them, and providers that belong to a specialty or subspecialty
that is not being tiered by the health plan.
*Tier 3 (standard): Plan physicians practicing at a standard level of cost-efficiency
and quality. You will pay a higher copayment when
you see a Tier 3 plan physician.
Note: Copayments to visit plan providers in specialties that are not tiered, for
example mental health and substance abuse providers, chiropractors and optometrists,
will not be tiered and will have a copayment of $15.
Also, please be aware that the tiering level of plan physicians will be re-evaluated
on an annual basis. The re-evaluation may result in a change to a plan physician’s
tiering level. You should check the annual provider directory or the "Find
a doctor" tool for annual tiering level changes.
The plan physician quality and cost-efficient measures are only one factor you should
consider when selecting a primary care physician or specialty physician. Tier 1
plan physicians may not be available in certain areas.
Learn more about FCHP Select Care
Find a doctor in the FCHP network
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What are some of the differences between the two plans?
While both plans offer the highest quality of care, they differ in their provider
network and copayments (your out-of-pocket costs) for services. The table below
compares some of these differences. For more detailed information on either FCHP
Direct Care or FCHP Select Care, visit the links below.
Learn more about FCHP Direct Care
Learn more about FCHP Select Care
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FCHP Direct Care
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FCHP Select Care
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Tier 1 *** (excellent) |
Tier 2 ** (good) |
Tier 3 * (standard) |
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Network
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Access to hundreds of high-quality physicians contracted through Acton Medical
Associates, Charles River Medical Associates, Fallon Clinic, Lahey Clinic, Lawrence General, Lowell General, Mount Auburn Cambridge IPA,
Northeast PHO and Southboro Medical
Group.
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Access to all physicians in the FCHP Direct Care plus an expanded network including physician practices, community hospitals
and medical facilities across our service area, giving you a wide choice of health
care providers.
Note: FCHP may not necessarily
have providers in all towns and cities.
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Copayments |
PCP office visits
(adult and children) |
$10 per visit |
$10 per visit
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$15 per visit
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$25 per visit
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Routine wellness exams |
$10 per visit for adults
$0 per visit for children |
$10 per visit for adults
$0 per visit for children |
$15 per visit for adults
$5 per visit for children |
$25 per visit for adults
$10 per visit for children |
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Specialist office visits |
$15 per visit
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$15 per visit
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$25 per visit |
$35 per visit |
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Routine eye exams |
$10 per visit |
$15 per visit
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Prescription drugs (based on three tiers) |
$10/$25/$40 per 30 day supply for retail
$20/$50/$90 per 90 days for mail order |
$10/$25/$40 per 30 day supply for retail
$20/$50/$90 per 90 days for mail order
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Inpatient hospital service |
$200 per admission
(max of 4 per calendar year)
Copayment waived if readmitted within 30 days of discharge from
an acute care.
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$250 per admission
(max of 4 per calendar year)
Copayment waived if readmitted within 30 days of discharge from
an acute care.
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Outpatient day surgery |
$100 per visit
(max of 4 per calendar year) |
$125 per visit
(max of 4 per calendar year)
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Emergency room services |
$75 per visit
(waived if admitted)
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$75 per visit
(waived if admitted)
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Mental health outpatient visits |
$10 per visit
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$15 per visit |
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