Fallon Health Announces Predominant Focus on Medicare and Medicaid Programs

Worcester, Mass., March 31, 2021— Fallon Health, a nationally recognized, not-for-profit health care services organization, today announced it will focus predominantly on offering government-sponsored health insurance programs such as Medicare and Medicaid. Beginning April 1, 2021, the organization will shift away from most commercial products in order to focus on programs that serve older adults and lower-income individuals.

Continuing along a strategic path that is unique among independent health plans in Massachusetts, Fallon has set its sights on becoming the leading provider of government programs in the region. The move, which is consistent with Fallon’s history, mission and recent direction, will leverage Fallon’s brand, expertise and experience to provide integrated and coordinated care, coverage and services to high-needs individuals.

Products on which Fallon will focus include Medicare Advantage, Senior Care Options (SCO) Program, MassHealth Accountable Care Organization (ACO) Partnership Plans, Program of All-Inclusive Care for the Elderly (PACE), and a limited number of products on the Massachusetts Health Connector, including ConnectorCare. Fallon also intends to develop new products to address the diverse, changing and unique needs of populations it currently serves and hopes to serve in the future.

“This path forward aligns with Fallon’s mission, vision and values,” said Richard Burke, President and CEO of Fallon Health. “It supports the needs of the communities we serve and it fills an important need in the Commonwealth. The COVID-19 pandemic exposed significant health care disparities in society, and we believe Fallon is well-positioned to address barriers to health access and equity.”

“We are grateful for the support and business of our commercial members, many of whom have been with us for years,” Burke added. “To help ease their transition to other health plan options, we have created a runway that extends out over 18 months.”

Fallon has been steadily increasing its government line of business relative to its commercial customer base for several years. Between 2017 and 2020, members of Fallon’s government-sponsored programs grew from 31 to 57 percent of total membership.  Eighty-four percent of Fallon’s revenue now comes from government programs. Much of this growth has come through the organization’s participation in the state’s groundbreaking reform of MassHealth and in the delivery of senior care through innovative programs pioneered by Fallon.

Fallon has been committed to government-sponsored programs from its start in 1977.  It was the first health plan in Massachusetts to cover Medicaid recipients (in 1979), one of the first health plans in America to have a Medicare risk product (in 1980), and the first health plan in the state to operate a Program of All-Inclusive Care for the Elderly (in 1995).

Government-sponsored programs continue to offer significant growth opportunities for health plans. Of the populations in Massachusetts eligible for PACE, SCO and Medicare Advantage, only 11 percent, 44 percent and 24 percent, respectively, have enrolled in these programs.

Melissa Randall
Corporate Communications Manager, Fallon Health

About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products.