Fallon Health
Fallon Health is a Worcester, Massachusetts-based health plan offering Medicare Advantage, Dual Special Needs Plans (NaviCare), MassHealth ACO Partnership Plans, individual/family coverage via Massachusetts Health Connector, and a PACE program (Summit ElderCare) to residents across most Massachusetts counties.
- Company typePrivate
- Founded-
- HeadquartersWorcester, United States
- Headcount—
- GTM typeB2C
- OfferingServices
What Fallon Health does
Fallon Health is a privately-held, Worcester, Massachusetts-based health insurance company offering a portfolio of government and commercial health plans to Massachusetts residents. Its core products include Fallon Medicare Plus (Medicare Advantage), NaviCare (Dual Special Needs Plans combining Medicare and MassHealth Standard benefits for dual-eligible seniors), three MassHealth ACO Partnership Plans (Berkshire Fallon Health Collaborative with Berkshire Health Systems, Fallon 365 Care with Reliant Medical Group, and Fallon Health-Atrius Health Care Collaborative), Community Care individual and family plans sold through the Massachusetts Health Connector, and Summit ElderCare, a Program of All-inclusive Care for the Elderly (PACE) based in Worcester.
The company operates a health insurance administration platform with FHIR R4-based interoperability APIs exposing practitioner, organization, location, insurance plan, and practitioner role data, plus a CMS-required Patient Access API integrated with third-party apps via 1up.health. Member-facing digital tools include the MyFallon portal, Care Connect 24/7 nurse line, Teladoc-powered telehealth, and the Sapphire365 cost and provider comparison tool. Utilization management is delegated to specialty partners including eviCore healthcare (diagnostic imaging), CareCentrix (sleep diagnostics), Carelon Behavioral Health, Prime Therapeutics Management (medical benefit drugs), and IHCS (durable medical equipment), while pharmacy benefit management is handled by OptumRx and medication therapy management by Clarest Health.
Fallon Health generates revenue primarily through government program premiums (CMS Medicare Advantage and D-SNP capitation, plus MassHealth ACO capitation from the Commonwealth of Massachusetts) and commercial premiums from employer-sponsored and individual market plans. Distribution is multi-channel, combining dedicated phone-based sales lines per product, provider referrals through contracted health systems, broker partnerships for employer groups, and enrollment via the CMS Medicare Online Enrollment Center and Massachusetts Health Connector marketplace. The company also publicly reports prior authorization metrics (94% approval rate for NaviCare HMO SNP standard requests in 2025, 85% for NaviCare SCO) as part of new federal transparency requirements beginning in 2026.
Fallon Health firmographics
Firmographics- Name
- Fallon Health
- Legal name
- Fallon Health
- Website
- https://fchp.org
- Company type
- Private
- Operating status
- Operating
- Short description
- Fallon Health is a Worcester, Massachusetts-based health plan offering Medicare Advantage, Dual Special Needs Plans (NaviCare), MassHealth ACO Partnership Plans, individual/family coverage via Massachusetts Health Connector, and a PACE program (Summit ElderCare) to residents across most Massachusetts counties.
- Ownership category
- akta.pro rank
Fallon Health industry classification
Industry- Product category
- Health Insurance
- NAICS
- Direct Life, Health, and Medical Insurance Carriers (52411), Nursing and Residential Care Facilities (623)
- SIC
- Hospital & Medical Service Plans (6324), Services-Nursing & Personal Care Facilities (8050)
- akta.pro primary industry
- Medicare Advantage (MA) Plans (FSAIAGAA)
- akta.pro secondary industries
- Integrated Physical-Behavioral-Social Care (Whole-Person) Medicaid Plans (HLAEAEAI), Social Care & Long-Term Care Benefits Administration (BPAIAKAK), Benefits, Insurance & Entitlement Navigation (Medicare/Medicaid/VA/LTC) (HSABAIAG)
Keywords
Where Fallon Health is headquartered
LocationHeadquarters
- HQ city
- Worcester
- HQ country
- United States
- HQ region
- North America
Offices2 records
Markets served
Fallon Health business model
Business model- GTM type
- B2C
- Offering type
- Services
- Cost components
- Personnel, Operations, Technology or R&D, Marketing or Sales, Infrastructure, Others
Revenue model
- Government Program Premiums: Revenue from Medicare Advantage (Fallon Medicare Plus), Dual Special Needs Plans (NaviCare), and MassHealth/Medicaid ACO plans. Premiums paid by CMS and the Commonwealth of Massachusetts for eligible beneficiaries.
- Commercial Premiums: Revenue from employer-sponsored health insurance (Community Care plans) and individual market plans sold through Massachusetts Health Connector.
- Pharmacy Benefit Management: Revenue from pharmacy claims processing through OptumRx partnership, including specialty pharmacy services for commercial and Medicaid members.
Pricing tiers
| Model | Billing | Price |
|---|---|---|
| Subscription | Monthly | NaviCare HMO SNP - Dual Special Needs Plan for dual-eligible Medicare/Medicaid beneficiaries |
Go-to-market motion2 records
Distribution channels5 records
Marketing channels4 records
Fallon Health product offering
Product offeringCore offering
Fallon Health is a Massachusetts-based health insurance company that underwrites and administers Medicare Advantage plans (Fallon Medicare Plus), Dual Special Needs Plans (NaviCare), MassHealth ACO Partnership Plans, a Program of All-inclusive Care for the Elderly (Summit ElderCare), and individual/family plans (Community Care) distributed through the Massachusetts Health Connector. The company provides care coordination through interdisciplinary teams and supports members with digital tools, telehealth, fitness benefits, and a 24/7 nurse call line. Revenue is generated primarily through recurring government and commercial premiums paid for covered members.
Product overview
Fallon Health is a Massachusetts-based health insurance company offering a portfolio of health plans and care coordination services. The core products include Community Care (individual/family plans via Massachusetts Health Connector), Fallon Medicare Plus (Medicare Advantage), NaviCare (Dual Special Needs Plans for dual-eligible seniors), Summit ElderCare PACE (Program of All-inclusive Care for the Elderly), and three MassHealth ACO plans (Berkshire Fallon Health Collaborative, Fallon 365 Care, and Fallon Health-Atrius Health Care Collaborative). These plans are supported by member-facing digital tools including the MyFallon portal, telehealth via Teladoc, Care Connect nurse line, and Sapphire365 cost comparison tool. Provider operations are enabled by FHIR R4 APIs, pharmacy benefit management through OptumRx, and utilization management partnerships with eviCore healthcare, CareCentrix, and Carelon Behavioral Health.
Differentiator
Problem solved
Functional benefit
Products and services
- Community Care Low-cost health insurance plans offered to individuals and families in Massachusetts through the Massachusetts Health Connector, providing preventive care, telehealth via Teladoc, the It Fits! fitness reimbursement benefit, free annual eye exams, and care management programs. Available in Berkshire, Bristol, Hampden, Middlesex, Plymouth, Suffolk, and Worcester counties, and part of Norfolk County.
- Fallon Medicare Plus Medicare Advantage plan for Medicare-eligible individuals in Massachusetts, combining Medicare Part D prescription drug coverage with medical benefits and supplemental extras such as dental care, prescription eyewear, and Benefit Bank card fitness benefits.
- NaviCare Dual Special Needs Plan (D-SNP) for individuals aged 65 and older who are eligible for both MassHealth Standard and Medicare. Encompasses NaviCare HMO SNP (HMO-based plan requiring Parts A and B and MassHealth Standard) and NaviCare SCO (Senior Care Options for MassHealth members with Original Medicare). Features $0 copays, premiums, coinsurance, and deductibles, with coordinated care teams including Navigators and Nurse Case Managers and additional benefits such as free rides to medical appointments.
- Berkshire Fallon Health Collaborative MassHealth Accountable Care Organization plan for Massachusetts Medicaid members in Berkshire County and parts of western Massachusetts, delivered through a partnership between Fallon Health, Berkshire Health Systems, and Community Health Programs.
- Fallon 365 Care MassHealth Accountable Care Organization plan for Massachusetts Medicaid members in central and eastern Massachusetts, delivered through a partnership with Reliant Medical Group.
- Fallon Health-Atrius Health Care Collaborative MassHealth Accountable Care Organization Partnership Plan combining Fallon Health, Atrius Health, and select community providers for Medicaid members in central and eastern Massachusetts.
- Summit ElderCare (PACE) Program of All-inclusive Care for the Elderly (PACE) operating in the Worcester, Massachusetts area, providing comprehensive medical, social, and long-term care services that enable frail elderly participants to remain living in the community.
Quantifiable outcome
- 94% approval rate for standard prior authorization requests (NaviCare HMO SNP)
- +2 more outcomes
Companies that use Fallon Health
Customer profileNamed customers2 records
Segments5 records
Ideal customer profiles5 records
Fallon Health technology and API
TechnologyTechnology focussed No
API detail
- Has API
- Yes
- API docs
- API detail
Core technology
AI maturity
App detail
Integration13 records
AI capability2 records
Feature3 records
Fallon Health partnerships and signals
Strategic signalPartnerships
14 partnerships are on record, tiered core and supporting.
- Berkshire Health SystemscoreStrategic partnership for Berkshire Fallon Health Collaborative ACO, serving MassHealth members in western Massachusetts with integrated care delivery through Berkshire County community physician practices.
- Reliant Medical GroupcorePartnership for Fallon 365 Care ACO serving MassHealth members in central and eastern Massachusetts with coordinated care through Reliant Medical Group providers.
- Atrius HealthcorePartnership for Fallon Health-Atrius Health Care Collaborative, a MassHealth ACO Partnership Plan serving members in central and eastern Massachusetts.
- Community Health ProgramscoreCommunity health center partnership supporting Berkshire Fallon Health Collaborative with primary care and community-based services in Berkshire County.
- OptumRxcorePharmacy Benefit Manager (PBM) partnership handling prescription drug benefits, prior authorizations, specialty pharmacy, and mail-order pharmacy services for all Fallon Health plans.
- Prime Therapeutics ManagementcoreReviews medical benefit drugs (physician-administered drugs including home infusion) for Fallon Health plans through the Prime provider portal.
- CareCentrixcoreSleep diagnostic and therapy management services for selected Fallon Health product lines, including home sleep studies and sleep therapy equipment.
- eviCore healthcarecoreAuthorization services for high-tech outpatient diagnostic imaging including CT, MRI, MRA, nuclear cardiac imaging, and PET scans.
- Carelon Behavioral HealthcoreBehavioral health services partnership providing criteria and guidelines for behavioral health care, provider resources, and behavioral health provider contracting.
- Clarest HealthsupportingMedication Therapy Management (MTM) program partner conducting pharmacy clinical team outreach calls to eligible NaviCare members.
- IHCS (Independent Health Corporation)supportingAuthorization services for durable medical equipment and home health services for Fallon Health members.
- Mass General BrighamcoreStrategic announcement of Fallon Health and Mass General Brigham partnership for healthcare delivery expansion.
- 1up.healthsupportingThird-party app partner enabling members to access their Fallon Health health data through the app, with HIPAA-compliant API integration.
- DentaQuestsupportingDental benefits vendor that experienced a cybersecurity event affecting certain individuals' personal information.
Scale indicators5 records
Recent moves6 records
Expansion highlights4 records
Fallon Health competitors and assessment
Company assessmentDirect peers
- Blue Cross Blue Shield of Massachusetts: Massachusetts' largest health insurer offering Medicare Advantage, commercial, and Medicaid plans across the same counties Fallon serves. Directly competes for Medicare Advantage and Connector members with overlapping provider networks.
- Point32Health (Harvard Pilgrim Health Care & Tufts Health Plan): Combined Harvard Pilgrim and Tufts Health Plan entity offering Medicare Advantage, Medicaid (Tufts Health Together), and commercial plans in Massachusetts. Most direct head-to-head competitor across Fallon's full product portfolio.
- Commonwealth Care Alliance: Massachusetts-based health plan specializing in dual-eligible and complex-needs populations through Senior Care Options and One Care programs. Direct competitor in the NaviCare SCO segment with similar whole-person care orientation.
Broad incumbents
- UnitedHealthcare: Largest national Medicare Advantage carrier with significant Massachusetts presence. Competes with Fallon Medicare Plus and NaviCare D-SNP while offering broader national scale, larger provider networks, and deeper PBM leverage through Optum.
- Humana: National Medicare Advantage leader and major D-SNP carrier. Competes with Fallon Medicare Plus in Massachusetts and represents the type of scaled incumbent that pressures regional plans on rebate capture and broker commissions.
- Molina Healthcare: Government-program-focused insurer with strong Medicaid presence including Massachusetts. Competes with Fallon for MassHealth contracts and dual-eligible members under a similar low-margin, high-volume model.
- Aetna (CVS Health): National health insurer with Medicare Advantage and Medicaid offerings in Massachusetts. Overlaps with Fallon's commercial Connector plans and Medicare Advantage product, leveraging CVS retail footprint and Caremark PBM.
- Centene Corporation: Largest US Medicaid managed care operator with WellCare and other state-level plans. Relevant competitive benchmark for Fallon's MassHealth ACO contracts and dual-eligible programs.
Regional players
- Boston Medical Center HealthNet Plan: Massachusetts-based Medicaid and Connector plan owned by Boston Medical Center. Directly competes with Fallon in MassHealth ACO contracting and Connector individual market plans.
Emerging players
- WelbeHealth: PACE program operator expanding across multiple states. Competes with Fallon's Summit ElderCare PACE in the high-acuity elderly care segment and represents the type of growth-focused PACE entrant targeting Fallon's specialty franchise.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat6 records
Key risks7 records
Key highlights7 records
Customer concentration
Fallon Health compliance and trust
Trust signalCompliance3 records
Fallon Health financial estimates
Financial estimateRevenue estimate
Valuation estimate
Fallon Health leadership team
Management profileNumber of profiles
Fallon Health subsidiaries and ownership
Company hierarchySubsidiaries4 records
Fallon Health funding detail
Funding detailFunding overview
Funding rounds
Investors
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
Fallon Health M&A and investment
M&A and investmentM&A
Investments
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about Fallon Health
What does Fallon Health do?
Fallon Health is a Massachusetts-based health insurance company that underwrites and administers Medicare Advantage plans (Fallon Medicare Plus), Dual Special Needs Plans (NaviCare), MassHealth ACO Partnership Plans, a Program of All-inclusive Care for the Elderly (Summit ElderCare), and individual/family plans (Community Care) distributed through the Massachusetts Health Connector. The company provides care coordination through interdisciplinary teams and supports members with digital tools, telehealth, fitness benefits, and a 24/7 nurse call line. Revenue is generated primarily through recurring government and commercial premiums paid for covered members.
Is Fallon Health a public or private company?
Fallon Health is a private company. It is classified as unknown and is currently operating.
When was Fallon Health founded?
Fallon Health was founded in -1.
Where is Fallon Health based?
Fallon Health is headquartered in Worcester, United States, in the North America region.
How does Fallon Health make money?
Three revenue lines are on record. Government Program Premiums are the primary driver. The others are commercial Premiums and pharmacy Benefit Management.
Who are Fallon Health's main competitors?
Direct peers on record are Blue Cross Blue Shield of Massachusetts, Point32Health (Harvard Pilgrim Health Care & Tufts Health Plan) and Commonwealth Care Alliance. Broad incumbents are UnitedHealthcare, Humana, Molina Healthcare, Aetna (CVS Health) and Centene Corporation. Boston Medical Center HealthNet Plan is listed as a regional player. WelbeHealth is listed as an emerging player.
Does Fallon Health have an API?
Yes. Fallon Health provides FHIR R4 public APIs for provider directory data including Practitioner, Organization, Location, InsurancePlan, and PractitionerRole endpoints. These APIs enable interoperability for health information sharing as required by CMS rules. Additionally, a Transparency in Coverage MRF link is provided for machine-readable files on plan pricing. Developer documentation is at api.fallonhealthfhir.com/r4/public.
What industry is Fallon Health in?
Fallon Health's product category is Health Insurance. Its primary akta.pro industry code is FSAIAGAA, Medicare Advantage (MA) Plans, with a secondary code of HLAEAEAI, Integrated Physical-Behavioral-Social Care (Whole-Person) Medicaid Plans. Its NAICS code is 52411 and its SIC code is 6324.