Fallon Community Health Plan
Fallon Health is a Worcester, Massachusetts-based health insurance plan founded in 1977, serving Medicare beneficiaries, individuals and families, MassHealth (Medicaid) members, employer groups, and PACE seniors across Massachusetts via Medicare Advantage, commercial, and Medicaid product lines.
- Company typePrivate
- Founded1977
- HeadquartersWorcester, United States
- Headcount1,001–5,000
- GTM typeB2C
- OfferingServices
What Fallon Community Health Plan does
Fallon Community Health Plan, doing business as Fallon Health, is a Worcester, Massachusetts-based health insurance organization founded in 1977. It sells a portfolio of health plans across Medicare (Fallon Medicare Plus, NaviCare for dual-eligibles), individual and family coverage (Community Care), Massachusetts Medicaid (MassHealth), employer group plans, and the Summit ElderCare Program of All-inclusive Care for the Elderly (PACE). The company serves residents throughout Massachusetts via direct phone sales, broker partnerships, employer group sales, and government program enrollment channels, supported by a multi-language member service operation and a dedicated call center (1-800-868-5200, TRS 711).
The company's technology stack centers on standard health insurance administrative infrastructure: a MyFallon member portal for claims, deductibles, and authorization tracking; public FHIR R4 APIs for provider directory data (Practitioner, Organization, Location, InsurancePlan, PractitionerRole); and Transparency in Coverage Machine Readable Files. Fallon's revenue model is subscription/recurring, driven by monthly insurance premiums collected across its Medicare, commercial, and MassHealth lines of business. Distribution is multi-channel and regional (Massachusetts only), combining direct sales, broker channel, employer group sales, and government program enrollment.
Fallon is pursuing a strategic partnership with Mass General Brigham, one of Massachusetts' largest health systems, while simultaneously divesting its former Worcester headquarters via a $51.2 million office-to-residential conversion project. The company has filed a proposed 25.7% premium increase for 2027 individual and small business plans — the highest in Massachusetts versus a 12.9% market average — signaling either aggressive rate adequacy action or significant medical cost pressure. The company is private, headquartered at 1 Mercantile St., Ste. 400, Worcester, MA, and operates with 1,001-5,000 employees. A litigation matter with health analytics vendor Innovaccer over alleged fraudulent misrepresentation reflects accountability enforcement in population health IT procurement.
Fallon Community Health Plan firmographics
Firmographics- Name
- Fallon Community Health Plan
- Legal name
- Fallon Health
- Website
- https://fchp.org
- Company type
- Private
- Founded year
- 1977
- Operating status
- Operating
- Headcount range
- 1,001–5,000 employees
- Short description
- Fallon Health is a Worcester, Massachusetts-based health insurance plan founded in 1977, serving Medicare beneficiaries, individuals and families, MassHealth (Medicaid) members, employer groups, and PACE seniors across Massachusetts via Medicare Advantage, commercial, and Medicaid product lines.
- Ownership category
- akta.pro rank
Where Fallon Community Health Plan is headquartered
LocationHeadquarters
- HQ city
- Worcester
- HQ country
- United States
- HQ region
- North America
Offices1 record
Markets served
Fallon Community Health Plan business model
Business model- GTM type
- B2C
- Offering type
- Services
- Cost components
- Operations, Personnel, Technology or R&D, Marketing or Sales, Infrastructure
Revenue model
- Health Insurance Premiums: Fallon Health generates revenue primarily through collected insurance premiums from members enrolled in their Medicare, individual/family, and MassHealth plans. Premium revenue is recurring based on monthly enrollment.
Pricing tiers
| Model | Billing | Price |
|---|---|---|
| Subscription | Monthly | Individual/Small Business Plans - Proposed 25.7% increase for 2027 |
Go-to-market motion1 record
Distribution channels5 records
Marketing channels7 records
Fallon Community Health Plan product offering
Product offeringCore offering
Fallon Health is a regional health maintenance organization (HMO) selling managed care health insurance plans to individuals, families, seniors, dual-eligible beneficiaries, and MassHealth recipients in Massachusetts. Its portfolio includes commercial Community Care coverage, the Fallon Medicare Plus Medicare Advantage HMO, the NaviCare HMO SNP for dual-eligible members, the Summit ElderCare PACE program for frail seniors, and MassHealth (Medicaid) plans.
Product overview
Fallon Health is a health insurance provider offering a portfolio of health plans across multiple market segments including Medicare/older adults, individuals and families, and MassHealth (Medicaid). The company operates as a single unified health plan with distinct product lines: Fallon Medicare Plus and NaviCare serve Medicare beneficiaries; Community Care serves individuals and families; Summit ElderCare (PACE) provides all-inclusive care for elderly individuals; and MassHealth covers Medicaid recipients. The portfolio also includes a digital member portal (MyFallon) for plan management and administrative functions.
Differentiator
Problem solved
Functional benefit
Brands
- Community Care: Health insurance plan for individuals and families
- Fallon Medicare Plus
- NaviCare
- Summit ElderCare
Quantifiable outcome
- Proposed 25.7% premium increase for 2027 (highest in Massachusetts market where average is 12.9%)
Companies that use Fallon Community Health Plan
Customer profileSegments5 records
Ideal customer profiles6 records
Fallon Community Health Plan technology and API
TechnologyAPI detail
- Has API
- Yes
- API docs
- API detail
Core technology
AI maturity
App detail
Integration1 record
Feature3 records
Fallon Community Health Plan partnerships and signals
Strategic signalPartnerships
Two partnerships are on record, tiered core.
- Synergy (Real Estate Development)coreAn affiliate of Synergy real estate development company is leading the office-to-residential conversion of the former Fallon Community Health Plan headquarters. The project includes 41 two-bedroom, 85 one-bedroom, and 72 studio units, with construction expected to complete in August 2026.
- Mass General BrighamcoreFallon Health announced a partnership with Mass General Brigham, one of Massachusetts' largest healthcare systems. The announcement is highlighted as a quick link on their website, indicating a significant strategic relationship.
Scale indicators2 records
Recent moves6 records
Expansion highlights3 records
Fallon Community Health Plan competitors and assessment
Company assessmentDirect peers
- Blue Cross Blue Shield of Massachusetts: The largest health plan in Massachusetts, offering a full portfolio of HMO/PPO products across commercial, Medicare Advantage, and Medicaid. Directly comparable to Fallon as a Massachusetts-licensed health plan serving the same employers, brokers, and member populations.
- Harvard Pilgrim Health Care (Point32Health): A New England regional health plan (part of Point32Health) offering commercial, Medicare Advantage, and Medicaid products. Comparable to Fallon in scale, regional concentration, and HMO-led product structure serving Massachusetts and adjacent states.
- Tufts Health Plan (Point32Health): Massachusetts-based health plan offering HMO/POS products including Medicare Advantage (Tufts Medicare Preferred) and Medicaid. Directly comparable to Fallon's Fallon Medicare Plus, NaviCare, and MassHealth product lines.
- Health New England: A Massachusetts-based regional health plan offering commercial HMO, Medicare Advantage, and Medicaid products in western and central Massachusetts. Closely comparable to Fallon given shared geography, member profile, and product mix.
- WellSense Health Plan (BMC HealthNet Plan): A Massachusetts Medicaid managed care plan serving MassHealth members. Directly comparable to Fallon's MassHealth product line as both compete for state Medicaid contracts in the same geography.
- AllWays Health Partners (Neighborhood Health Plan): A Massachusetts-based health plan (affiliated with Mass General Brigham) offering commercial, Medicare, and Medicaid products. Comparable to Fallon as a Massachusetts HMO competitor with a Mass General Brigham provider relationship, creating direct overlap in market positioning.
Broad incumbents
- Humana: A large national health insurer with a significant Medicare Advantage footprint in Massachusetts. Comparable to Fallon as a Medicare Advantage competitor in the same geography, though Humana's scale and national diversification are substantially greater.
- UnitedHealthcare: The largest U.S. health insurer, offering commercial, Medicare Advantage, and Medicaid products nationally including in Massachusetts. Comparable to Fallon as a multi-segment competitor in the same MA market, with materially greater scale and provider leverage.
- Centene Corporation: A national health insurer heavily focused on Medicaid managed care and Medicare. Comparable to Fallon on the MassHealth/Medicaid side, where Centene's WellCare and other subsidiaries compete for state contracts in overlapping segments.
- CVS Health (Aetna): A diversified health services company whose Aetna unit offers commercial, Medicare Advantage, and Medicaid plans in Massachusetts. Comparable to Fallon as a multi-segment Massachusetts competitor, with substantially greater capital, retail footprint, and care-delivery assets.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat4 records
Key risks6 records
Key highlights6 records
Customer concentration
Fallon Community Health Plan social profiles
Digital presenceFallon Community Health Plan compliance and trust
Trust signalCompliance1 record
Fallon Community Health Plan financial estimates
Financial estimateRevenue estimate
Valuation estimate
Fallon Community Health Plan leadership team
Management profileNumber of profiles
Fallon Community Health Plan subsidiaries and ownership
Company hierarchySubsidiaries1 record
Fallon Community Health Plan funding detail
Funding detailFunding overview
Funding rounds
Investors
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
Fallon Community Health Plan M&A and investment
M&A and investmentM&A
Investments1 record
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about Fallon Community Health Plan
What does Fallon Community Health Plan do?
Fallon Health is a regional health maintenance organization (HMO) selling managed care health insurance plans to individuals, families, seniors, dual-eligible beneficiaries, and MassHealth recipients in Massachusetts. Its portfolio includes commercial Community Care coverage, the Fallon Medicare Plus Medicare Advantage HMO, the NaviCare HMO SNP for dual-eligible members, the Summit ElderCare PACE program for frail seniors, and MassHealth (Medicaid) plans.
Is Fallon Community Health Plan a public or private company?
Fallon Community Health Plan is a private company. It is classified as corporate owned and is currently operating.
When was Fallon Community Health Plan founded?
Fallon Community Health Plan was founded in 1977. It employs 1,001 to 5,000 people.
Where is Fallon Community Health Plan based?
Fallon Community Health Plan is headquartered in Worcester, United States, in the North America region.
How does Fallon Community Health Plan make money?
One revenue line is on record: health Insurance Premiums.
Who are Fallon Community Health Plan's main competitors?
Direct peers on record are Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care (Point32Health), Tufts Health Plan (Point32Health), Health New England, WellSense Health Plan (BMC HealthNet Plan) and AllWays Health Partners (Neighborhood Health Plan). Broad incumbents are Humana, UnitedHealthcare, Centene Corporation and CVS Health (Aetna).
Does Fallon Community Health Plan have an API?
Yes. Fallon Health provides FHIR R4 public APIs for provider directory data. Available endpoints include Practitioner, Organization, Location, InsurancePlan, and PractitionerRole. These are read-only public APIs that allow third-party systems to access provider directory information. The APIs use standard FHIR R4 specification and are accessible at api.fallonhealthfhir.com/r4/public/. Developer documentation is at api.fallonhealthfhir.com/r4/public/Practitioner.