Fallon Health Announces Predominant Focus on Medicare and Medicaid Programs

WORCESTER — Fallon Health announced it will focus predominantly on offering government-sponsored health-insurance programs such as Medicare and Medicaid. Beginning today, April 1, 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 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, the Senior Care Options Program (SCO), MassHealth Accountable Care Organization Partnership Plans, PACE (Program of All-Inclusive Care for the Elderly), 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 healthcare 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% 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%, 44%, and 24%, respectively, have enrolled in these programs.