Broker frequently asked questions
To better serve our Fallon Community Health Plan brokers, we've compiled some of the most frequently asked questions below.
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On this page:
Provider networks
Products and plan designs
Administration
Provider networks
Question:
What's the difference between FCHP Select Care and FCHP Direct Care?
Answer:
FCHP Direct Care, a limited provider network, is a subset of the FCHP Select Care network, custom-built around some of the state’s premier physician groups and hospitals, giving you access to quality providers at a significantly lower premium cost.
FCHP Select Care offers a much broader choice of providers to help us better meet the needs of employers who have personnel throughout western, central and eastern Massachusetts. Members can choose from thousands of providers and contracted hospitals throughout the state and in southern New Hampshire.
Employers can offer both networks, as well as our PPO product and FCHP Steward Community Care, side by side for a “quadruple option.” (Only employers with 10 or more employees can offer side-by-side limited network options.)
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Question:
What is FCHP Steward Community Care?
Answer:
FCHP Steward Community Care is a new limited network plan developed in partnership with Fallon Community Health Plan and Steward Health Care. It is available throughout Eastern Massachusetts. The provider network includes all of the Steward Health Care system community doctors and hospitals.
These plan designs can be offered alongside any one of our other network options, including FCHP Select Care, Fallon Preferred Care, and for groups sized 10+, our other limited network option FCHP Direct Care. More information about FCHP Steward Community Care »
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Question:
Why is FCHP launching another limited network?
Answer:
FCHP has had a tremendous amount of success with FCHP Direct Care, the state’s original limited network. That’s because we understand how limited networks need to work in order to be effective, and to maintain member satisfaction. We also understand that limited networks are not for everyone.
By working in partnership with Steward Health Care to create FCHP Steward Community Care, we are providing a new limited network option that will offer even greater savings than FCHP Direct Care, and that will be attractive to a slightly different audience. The two products include two distinct sets of providers and hospitals—both focused on community care.
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Question:
Can members go to Boston hospitals with FCHP Steward Community Care?
Answer:
Yes, but only in some circumstances. With a prior authorization from the plan, members may receive medically necessary services that are not available at an FCHP Steward Community Care facility from either Brigham and Women’s Hospital or Massachusetts General Hospital.
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Question:
What's the difference between Reliant Medical Group (formerly Fallon Clinic) and FCHP?
Answer:
FCHP is a nonprofit, mixed-model HMO that provides health insurance coverage for its members through a vast network of physicians and hospitals in Massachusetts and southern New Hampshire. FCHP offers a range of health plan options to meet the needs of employers of all sizes.
Reliant Medical Group (formerly Fallon Clinic) is a multispecialty group practice.
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Question:
Does FCHP cover out-of-state employees?
Answer:
FCHP has plans that will cover out-of-state employees. Employees who work in Massachusetts but live in New Hampshire can join FCHP Select Care, and access doctors and hospitals throughout southern New Hampshire. Fallon Preferred Care is a preferred provider organization (PPO) which has a nationwide service area and network of nearly 600,000 providers and health care facilities.
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Question:
Are there plans available for retirees outside of Worcester? Outside of Massachusetts?
Answer:
FCHP’s Fallon Senior Plan network covers retirees who live outside of Worcester. The service area for this plan includes the following counties: Hampden and Worcester counties and portions of Franklin, Hampshire, Middlesex and Norfolk counties. It also includes some cities and towns bordering these counties, both in and outside of Massachusetts.
We also offer Fallon Companion Care, a Medicare wrap plan, to retirees who live anywhere in the country. There is no provider network, so members may choose any doctor who accepts Medicare. More about the retiree group service area »
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Question:
Will FCHP cover out-of-state students?
Answer:
Students attending school outside of FCHP’s service area who don’t have easy access to their local doctors and hospitals are covered for certain services while out-of-area, as long it’s authorized in advance by FCHP. They must work with their primary care physician to get authorization. Services include:
- Non-routine medical office visits
- Diagnostic lab and X-ray connected with a non-routine office visit
- Non-elective inpatient services
- Speech therapy
- Outpatient services to diagnose and/or treat mental conditions
- Short-term rehabilitation services, including physical and occupational therapy covered for up to 60 visits combined in each benefit year (combined with any in-area visits).
To be covered for all other services other than emergency care, they must be obtained when the student returns to FCHP’s service area.
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Products and plan designs
Question:
What plan designs can be offered with FCHP Steward Community Care?
Answer:
FCHP has a number of plan designs—and all of them are available with FCHP Steward Community Care—from traditional copayment plans to qualified high deductible options with HRA, HSA or FSA integration.
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Question:
What is FCHP Tiered Choice?
Answer:
FCHP Tiered Choice is a new tiered plan that is available with three different plan design options. It is currently available in Berkshire, Hampden, Hampshire and Worcester counties.
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Question:
What is tiered with FCHP Tiered Choice?
Answer:
For all three plan designs, the following services/facilities are tiered:
- Inpatient hospital admissions
- Outpatient surgery
- High-tech imaging
Additionally, for two of our plan designs, PCPs and specialists are also tiered.
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Question:
How is FCHP Tiered Choice different than other tiered network products in the marketplace?
Answer:
There are a number of reasons why we believe FCHP Tiered Choice to be the best, but here are just some reasons:
- Lab, X-ray and pathology are covered in full with all three plan designs.
- Premier hospitals including UMass Memorial, Saint Vincent Hospital and Berkshire Medical Center are all in the lowest cost Tier 1.
- We offer a plan design that does not tier PCPs and specialists.
- We tier on total medical expense, not unit cost.
- FCHP Tiered Choice premiums are, on average, 7% lower than our broad HMO network premiums.
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Question:
Does FCHP offer alternate funding arrangements?
Answer:
Yes, through FCHP’s wholly owned subsidiary, UltraBenefits, Inc., we are able to accommodate the full spectrum of alternative funding for your clients. Our funding and administrative options include Health Reimbursement Arrangement (HRA), flexible spending accounts (FSA) and high-deductible administration, available with all FCHP plan design options, as well as a complete array of partial self-funding capabilities and choices. More about funding arrangements »
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Question:
Does FCHP offer a qualified high-deductible health plan that's compatible with a health savings account?
Answer:
Yes, FCHP has a full array of qualified high-deductible health plans available through FCHP Care Choice.
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Question:
Can an employer group offer Fallon Senior Plan if they aren’t presently offering a FCHP commercial plan?
Answer:
Yes. To get a quote, contact Brian Guagnini at 508-368-9578 or brian.guagnini@fchp.org
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Administration
Question:
How do I find out the name of my assigned sales executive?
Answer:
Please contact Ursula Arello, Manager of Broker Relations, at 508-368-9454 or ursula.arello@fchp.org.
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Question:
Are rates affected by broker involvement?
Answer:
Standard broker commissions are part of FCHP's overall administrative cost, and rates are not loaded or discounted based on the involvement of a broker.
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FCHP Direct Care is a plan with a limited provider network. This plan provides access to a network that is smaller than FCHP Select Care. In this plan, members have access to network benefits only from the providers in FCHP Direct Care. Please visit our Find a Doctor tool or consult the FCHP Direct Care provider directory to determine which providers are included in FCHP Direct Care. A paper copy can be requested by calling our Customer Service Department at 1-800-868-5200.
FCHP Steward Community Care provides access to a network that is smaller than FCHP Select Care. In this plan, members have access to network benefits only from the providers in FCHP Steward Community Care. Please consult the FCHP Steward Community Care provider directory to determine which providers are included in FCHP Steward Community Care.
Tiered Choice provides access to a network that is smaller than the FCHP Select Care provider network, and includes the tiered provider network called Tiered Choice. In this plan, members have access to network benefits only from the providers in Tiered Choice, and may pay different levels of copayments, coinsurance and/or deductibles depending on the tier of the provider delivering a covered service or supply. This plan may make changes to a provider’s benefit tier annually on January 1. Please consult the Tiered Choice provider directory to determine which providers are included in Tiered Choice.