Fallon Health Is Guided by a Holistic, Member-First Approach
December 1, 2025 · NCQA Communications
What does high-quality health care look like—and what does it take to get there? We gathered insights and success stories from the top-performing plans in NCQA’s 2025 Health Plan Ratings. High ratings demonstrate a commitment to quality, patient-centered care and continuous improvement. We hope these stories foster shared learning, inspire action and help elevate performance across the industry.
Organization: Fallon Health
Rating: 4.5 out of 5 Stars
Product Line: Medicaid
State: MA
NCQA Health Plan Accreditation Status: Accredited
Fallon Health’s Quality Story
Fallon Health is a not-for-profit organization that is both an insurer and a care provider. Fallon Health was launched in 1977 to deliver high-quality, community-based care at an affordable cost. It was the first health plan in Massachusetts to cover Medicaid recipients. Fallon Health is committed to the communities it serves, taking time to understand their unique needs and working to identify and address barriers to affordability, access and equity.
What does earning a 4.5-star rating from NCQA’s Health Plan Ratings mean to your organization?
Earning a 4.5-star rating from NCQA’s Health Plan Ratings isn’t just recognition of our performance; it’s a reflection of the heart behind our mission. It tells the story of thousands of moments where our teams went above and beyond to ensure our members felt heard, supported and cared for.
This achievement affirms our unwavering commitment to delivering high-quality, equitable and person-centered care. It demonstrates our ability to meet rigorous national standards across HEDIS®, CAHPS® and NCQA Accreditation domains while never losing sight of the human experience behind every measure.
More than a benchmark, this rating symbolizes our culture of continuous improvement. It’s a testament to how we align clinical excellence with operational integrity and member experience, always striving to do better—because our members deserve nothing less.
What strategic priorities guided your journey toward achieving a 4.5-star rating?
We were guided by a clear and deeply rooted priority: excellence in care, driven by compassion for those we serve. Our strategy is centered on improving clinical quality and enhancing the member experience, exemplifying our commitment to whole-person care.
We’ve long held NCQA Accreditation, and that legacy reflects our dedication to a robust quality improvement framework. But this year’s achievement tells a deeper story—one of resilience, responsiveness and a focus on what matters most: our members.
Every initiative we pursued, every metric we tracked and every improvement we made was grounded in a simple but powerful question: Is this helping our members feel cared for?
What unique processes or tools have you implemented to improve patient experience or clinical outcomes?
Our commitment to improving the member experience and clinical outcomes is guided by a holistic, member-first approach. Our success is rooted in thoughtful innovation, strong partnerships and a culture of continuous learning.
We’ve prioritized initiatives that close care gaps, strengthen data-informed decision making and enhance care coordination. By deepening collaboration with provider partners and refining how we understand and respond to members’ needs, we created a more connected and responsive care experience.
Equally important is our investment in people. Through cross-functional collaboration and ongoing education, we foster a culture where quality is shared, accountability is embraced and innovation is celebrated.
These efforts are supported by a strong governance framework and seamless alignment across clinical, quality and technology teams. This ensures that every improvement is purposeful, sustainable and centered on the well-being of those we serve.
What lessons did you learn that could help other health plans improve performance?
Build a strong foundation. We focus on strengthening the foundational elements that support quality, ensuring we have the right infrastructure, insights and partnerships in place to adapt and respond to evolving member needs. We prioritize alignment across teams, fostering collaboration and transparency to keep everyone focused on shared goals.
Agility matters. Building flexibility into our processes allows us to respond quickly to opportunities for improvement while maintaining compliance and operational integrity.
Focus on the member. When you keep members at the center of every decision—when care and compassion guide your strategy—performance follows. That mindset helps us stay grounded, even as we pursue ambitious goals.
How does your organization cultivate a culture of quality?
As a mission-driven, not-for-profit organization, Fallon Health has built a culture where excellence in care is a shared responsibility and a core part of our identity. Our approach begins with intentional alignment. Quality is embedded into strategic planning, regularly reinforced at the leadership level and reflected in how we engage teams across the organization. We foster collaboration across disciplines, ensuring that clinical, operational and technical perspectives are integrated into our decision making.
Transparency and accountability are also key. We believe that when people understand the “why” behind our goals, and see progress toward them, they become more invested in the outcome. That clarity helps drive engagement, and reinforces our commitment to continuous improvement.
Ultimately, our culture of quality is sustained by a deep sense of purpose. Every initiative, every conversation and every improvement effort is grounded in our commitment to delivering compassionate, person-centered care. It’s that shared purpose that keeps us focused and our standards high.
What are your next steps to continue improving HEDIS and CAHPS scores?
Fallon Health is focused on advancing strategies that prioritize member well-being and equitable, high-quality care. Next steps include:
- Deepening member engagement through more personalized outreach and support
- Strengthening population health efforts to improve outcomes and reduce disparities
- Enhancing use of data and technology to inform decisions and drive performance
- Fostering a culture of continuous learning and improvement across the organization
These efforts reflect our ongoing commitment to delivering care that is effective and tailored to the needs of those we serve.
Learn More
Explore the 2025 Health Plan Ratings and find out how we calculate the ratings.
Learn more about NCQA’s Health Plan Accreditation.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
