What Is Fallon Health?

Fallon Health has been providing employer-based, individual, and Medicare health insurance plans since 1977, and the company also offers healthcare services. The plans that are available through Fallon meet the unique needs of consumers who want flexible options for their insurance needs. If you have health insurance through Fallon Health, chances are good that your substance use treatment is covered in whole or in part.

Types of Plans Available Through Fallon

Fallon Health offers the following employer and individual health insurance plans:

  • PPO
  • POS
  • HMO
  • Medicaid
  • Medicare Advantage

Fallon PPO Plans

Fallon offers Preferred Provider Organization (PPO) plans that are the most common type of insurance coverage structures. Under these plans you can choose from any provider that is considered “in-network,” meaning that the provider has a contract with Fallon Health. If you need specialty care, you do not have to get a referral from your primary physician. You also do not need to have a primary care physician if you prefer to use various clinicians for your care. This can be a benefit for people who want to save time and get their specialty appointments set up without waiting for a referral.

Fallon POS Plans

Point-of-Service (POS) plans may require you to get referrals from your primary care physician for specialty care, but this is not always the case. You should review your policy information or contact Fallon Health directly to determine if a referral is needed for substance use treatment. Your plan may have some level of coverage for providers that are outside the network, meaning that the facility does not have a contract with Fallon Health. While using an out-of-network provider may seem convenient or be necessary, out-of-pocket costs are significantly higher compared to in-network providers.

Fallon HMO Plans

Health Maintenance Organization (HMO) plans are good for people who want easy access and affordable costs for preventive services, such as annual screenings, immunizations, and other routine care. You have to choose a primary care physician under the HMO plan, and that physician must make referrals to specialists. If you do not get a referral, you may be responsible for the entire cost of care through the HMO. The benefits of using the HMO plan through Fallon Health is that your out-of-pocket costs tend to be lower. The disadvantage is that these plans do not provide any level of coverage for out-of-network providers.

Fallon Medicaid Plans

Medicaid is a state-managed insurance program for low-income individuals who do not otherwise have access to health insurance. Fallon Health is a Medicaid provider.

Fallon Medicare Advantage Plans

Medicare is a type of insurance that is available to certain groups of people, including people over 65, people living with end stage renal failure, and some with certain disabilities. Medicare offers Part A for hospital coverage, Part B for medical insurance, and Part D for prescriptions. A Medicare Advantage plan, also known as Part C, fills in some of the gaps in coverage, such as dental, vision, and hearing services.

Benefits of Health Insurance for Substance Use Disorder Treatment

Financial considerations for substance use disorder treatment can be a barrier for many people. The Affordable Care Act has opened the door for many people in the United States to access health insurance and the valuable substance use disorder treatment they need to overcome addiction. Having health insurance minimizes your out-of-pocket costs so you can focus on recovery without the worry of paying for treatment. This gives many the peace of mind they need to transform their lives through addiction treatment.

Insurance Coverage for Substance Use Treatment

Coverage for substance use disorder treatment will vary greatly by provider and plan. For some plans, inpatient medical detox and treatment are covered in full. Some of the plans require cost-sharing for office visits and outpatient care. The best way to find out your coverage level is to call the insurance carrier directly and have them explain what is allowed under your specific policy.

In most cases, Medicaid and Medicare programs cover substance use disorder treatment. Because Medicaid is intended to help low-income individuals, you may not have any out-of-pocket expenses, and your treatment may be covered in full. This does vary by the type of coverage that you have, so you should contact your insurance provider, Medicaid, or Medicare directly.

Out-of-Pocket Expenses for Substance Use Treatment

Your health plan may require some type of cost-sharing in the form of co-payments, deductibles, and co-insurance. Out-of-pocket expenses may include co-payments, deductibles, and/or co-insurance. Co-payments are paid at the time of service. Deductibles are amounts that you must pay before the insurance begins coverage. Co-insurance is a cost-sharing after you meet the deductible

Types of Substance Use Treatment Covered by Fallon Plans

Coverage for substance use disorder treatment under Fallon Health plans varies by type of insurance and policy. Most Fallon Health plans cover outpatient office visits, medical detox, and inpatient treatment. Office visits may involve meeting with a substance use counselor to provide support along your journey of recovery from a substance use disorder. Medical detox is the first step in addiction recovery. The process helps to eliminate the drug from your body. Clinical staff monitor you to manage any symptoms of withdrawal. Inpatient treatment includes the counseling services you need to cope with the effects of addiction and learn new life skills.

If you are uncertain about your out-of-pocket expenses for substance use treatment, you can contact Fallon Health. They will ask for your name, policy number, and other identifying information. They will then review your coverage and out-of-pocket expenses for substance use treatment at our facility.

Does Fallon Require Pre-Authorization?

Depending on the type of Fallon Health plan that you have, pre-authorization may be required to ensure that you maximize coverage. If you have the HMO plan, get a referral from your primary care physician for our facility. Once you have the referral, contact us to schedule an assessment with one of our addiction treatment counselors. We will contact Fallon Health on your behalf to obtain the necessary pre-authorization.

Next Steps When Seeking Treatment for Substance Use Disorder

Once you understand the benefits that are available under your Fallon Health insurance policy for substance use disorder treatment, you will feel more confident about your choice to seek treatment and overcome addiction. You will not be burdened by any unexpected expenses when you follow our program. You can focus on recovery.

What to Expect During Your Substance Use Treatment

We work with you as you follow each stage of your treatment for addiction. First, we take the time to sit with you and understand your drug of choice and the effects on your life. The assessment for substance use disorder treatment is covered by Fallon Health insurance policies, although coverage levels vary by policy. During the assessment, we get to know you as a person, and we want to hear your story. The conversation allows us to determine a course of treatment that not only gets you off drugs and alcohol, but also helps you get your life back on track.

Medical Detox

Medical detox is the first part of the program. Medical detox is covered by Fallon Health plans. During this stage, you are placed under the supervision of doctors, nurses, and counselors while the drugs are eliminated from your body. This is not the same as going cold turkey on your own. The benefit of medical detox is that our clinical staff can administer medications to help with nausea, fatigue, restlessness, body aches, and other symptoms that develop during detox.

Treatment Planning

Once you complete detox, you meet with a substance use disorder counselor to develop an individualized treatment plan. This is the time when you can speak openly about any dreams, goals, and aspirations that you have for your life, even if you feel that addiction has robbed you of any opportunities. With the right support, life skills, and coping mechanisms, you can achieve all that you desire during recovery.

Inpatient Counseling

Inpatient individual and group counseling are covered by Fallon Health plans. Counseling is when you come to understand yourself better and then learn new ways of viewing the world along with gaining life skills and healthy coping mechanisms. When you master these techniques, you will no longer need to rely on drugs and alcohol. If you have a co-occurring mental health disorder, such as anxiety or PTSD, we teach you how to properly manage the symptoms with medications and proven therapeutic techniques.

Continued Outpatient Counseling

When you achieve specific goals in your inpatient treatment plan, you are ready to return to life armed with new knowledge and skills. You re-enter life with a renewed sense of freedom, responsibility, hope, and confidence, yet you will not be alone. We continue to monitor your progress and provide support as needed through outpatient counseling that is covered by Fallon Health plans.

Sober Living Facilities

It is normal to feel overwhelmed and intimidated about returning to life after treatment. No matter how confident you feel at our facility, you will be faced with new challenges and relationships. In some cases, we recommend sober living facilities as a half-way point between inpatient and outpatient care. After being in the facility for a period of time, you can transition back into society and receive outpatient counseling services that are covered by Fallon Health plans.

How to Verify Your Coverage for Substance Use Treatment

If you have questions about your policy, contact us, and we will help in every possible way. We are familiar with most Fallon Health plans. If we are not familiar with your specific policy or if you have additional questions about your coverage, you can contact Fallon Health directly at the phone number listed on the back of your insurance card. If your Fallon Health insurance is through your employer, your Human Resources Department may be able to help as well.

Filing Claims for Substance Use Treatment

Because we are contracted with Fallon Health, we can file claims on your behalf directly with the company in most cases. We have experienced situations in which the individual needed to file claims or be involved on some level. If this is the case, we will take every step possible to ensure that such matters do not disrupt your treatment at our facility.

Remember that you aren’t alone in your struggle with addiction. There are professionals that want to help you. The last thing you want to do is worry if you’re covered or not. Reach out to Fallon so you can get a better idea of your benefits. Then, all you have to do is focus on your treatment.

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