What is Fallon Health?
Based in Massachusetts, Fallon Health is an insurance care provider that offers care throughout Massachusetts, Vermont, and New Hampshire. If you have Fallon Health and are struggling with addiction, it is important to understand your treatment options. Our guide will make it easy to figure out just how much of your substance use disorder treatment will be covered by Fallon Health.
An Overview of Fallon Health Plans
Fallon offers a variety of both group and non-group health plans, including:
- HMO
- POS
- PPO
- Medicaid
- Medicare Advantage
The main difference between all these plans is the types of deductibles, copay, and coinsurance patients pay for their health care.
Most of the plans can be divided into either the Direct Care or the Select Care based on which Fallon Health network you are a part of. The Direct Care network is a group of 38,000 providers located throughout Massachusetts. It tends to have lower deductibles, premiums, and copay costs. The Select Care network has slightly higher costs, but in exchange, patients have more options. The network includes 60,000 providers throughout Massachusetts, New Hampshire, and Vermont.
Will Fallon Cover Addiction Treatment?
Thanks to new regulations provided by the Affordable Care Act, Fallon and all other insurance companies are required to provide coverage for mental health issues like substance use disorder. This means that the insurance company will treat addiction treatment just like a treatment for any other medical emergency, regardless of which Fallon Health plan you have. However, Fallon actually goes above and beyond standard requirements by making sure it has special services available for clients dealing with addiction.
Fallon has a partnership with Beacon Health Strategies that focuses on providing behavioral health services for clients. Due to this service, Fallon clients do not need a referral from a primary care provider before they see a therapist. This makes it even easier to speak with a mental health professional about any addiction issues you may face. Fallon’s clients can just call 1-888-421-8861 at any hour on any day of the week to learn more about Beacon’s substance use disorder care.
Does Fallon Pay the Full Cost of Addiction Treatment?
Generally, Fallon clients can expect their insurance policy to cover most of their treatment. The exact amount covered by Fallon will depend on both the type of treatment and your plan. Fallon usually just charges a basic copay of around $20 for each visit to an outpatient mental health or substance use disorder specialist. Treatments of a more medical nature may require a copay of about $30 to $60 per visit. If your addiction treatment involves visits to the emergency room, you may have additional copay requirements of around $100.
Keep in mind that Fallon tends to have lower deductibles of about $500 to $1,000. Once this deductible is met, you typically do not need to pay copays anymore. At this point, Fallon will usually cover the whole cost of your addiction treatment if you are working with an in-network provider. If you choose to go with a treatment provider that is not part of Fallon’s network of providers, you may still be responsible for some of the costs yourself.
Types of Addiction Treatment Covered by Fallon
Fallon covers a full spectrum of addiction care. However, the exact type of treatment you can get will usually depend on your situation. Fallon typically only covers more intensive levels of care for those with very severe addictions. Depending on your health and level of addiction, Fallon may cover one or more of these types of treatment as long as they are located within their network of providers.
Medical Detox
For all people with an addiction, the first step of recovery is detoxing to clear out all remaining traces of the drug from their system. Since many addictive drugs cause people to develop a physical dependence, addicts may experience withdrawal symptoms like irregular heart rates, nausea, or anxiety. The best way to manage these symptoms is with a medical detox. In this process, patients are monitored and given medication for their various withdrawal symptoms.
Fallon will usually only cover this stage of rehab treatment if its professionals think it’s necessary. Withdrawal from drugs like benzodiazepines can cause potentially fatal seizures, so in these cases, medical detox is a medical necessity. You may also be able to argue that withdrawal management is an essential part of your care because the process is so intense that it threatens your sobriety. However, these sorts of requests for detox coverage are usually handled on a more case-by-case situation.
Granite Recovery Centers provides medical detoxification for people who do not need immediate medical intervention, are not a danger to themselves, and are capable of self-evacuation in the event of an emergency.
Outpatient Rehab
Outpatient rehab is a type of addiction treatment where a patient can visit a rehab center during the day and then go back to his or her usual home at night. This type of rehab comes with many benefits. It is very flexible with scheduling, so you can get care while still going to work or school. There are all sorts of outpatient rehab clinics, ranging from offices where you can go for standard mental health counseling to clinics that provide customized treatment plans with a blend of treatment techniques. Patients may also have access to group therapy, cognitive behavioral therapy, neurofeedback therapy, or other forms of treatment.
Almost all types of outpatient rehab are covered by Fallon. Depending on the clinic you select, Fallon may cover the costs on a visit-by-visit basis. However, some clinics just charge a flat rate for all your care during a set amount of time. Fallon will also usually cover this type of rehab charge, but they may only approve coverage for a few months at a time.
Inpatient Rehab
Also called residential rehab, inpatient programs require patients to live in the treatment facility for an extended amount of time. Residential rehab can last anywhere from 28 days to six months, and it is very intensive care. Patients in residential rehab have more support and fewer temptations, so it can be very useful for those dealing with severe addiction. The types of therapies offered in an inpatient center are similar to outpatient rehab. However, inpatient rehab may also offer more exercise and art-based therapies as a way of helping residents find healthy ways of managing their free time.
Whether or not Fallon will cover inpatient rehab is less definite. The insurer feels that residential rehab is not required for all patients, so it will not cover this treatment if its doctors think it’s not necessary. Generally, residential rehab is covered by Fallon in cases where a person has a fairly intense substance use disorder. Factors such as the type of drug used, the length of addiction, and the effect of the addiction on your life may affect whether or not Fallon covers inpatient rehab. Some of Fallon’s providers of inpatient rehab may offer extra luxuries, like private rooms, that may not be covered if they’re considered medically unnecessary.
Do You Always Have to Get Approval From Fallon Before Seeking Care?
Some insurance companies make you get authorization before visiting the doctor if you want them to cover your medical bills. Fallon does not typically require this for mental health patients. In addition to being able to speak to a therapist without prior authorization, clients can also get outpatient addiction counseling without authorization. You can go to outpatient rehab eight times in one benefit year before needing approval. After that, Fallon asks the outpatient provider to submit an authorization request.
For residential rehab and types of outpatient care that do not involve mental health counseling, Fallon will usually require patients to get prior approval for coverage. This means that medical services, like detox or methadone maintenance, will need authorization. Depending on your plan, treatments like acupuncture and massage, which can help reduce stress levels during recovery, may also require prior approval.
The Benefits of Getting Addiction Care With Fallon
If you are struggling with a substance use disorder, getting addiction care through Fallon Health can be extremely helpful. Having your insurance cover your rehab can take one more worry off your mind, so you can focus on getting better instead of stressing about health care. Fallon recognizes that recovering from addiction helps improve physical and mental health, so they do everything possible to get clients the care they need. If you have insurance through Fallon, know that it is possible to seek help and overcome your addiction.
