Medicare Resources

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2021 Plan Documents

Fidelis Dual Advantage Flex (HMO D-SNP) Plan 001
Fidelis Medicare Advantage Flex (HMO POS) Plan 002
Fidelis Medicaid Advantage Plus (HMO D-SNP) Plan 003
Fidelis Medicare $0 Premium (HMO) Plan 004

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2021. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

Краткий обзор страховых выплат на 2021 год (PDF)

2021年度福利介紹 (PDF)


Out-of-Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Fidelis Medicare Advantage Without Rx (HMO POS) Plan 005

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2021. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

Краткий обзор страховых выплат на 2021 год (PDF)

2021年度福利介紹 (PDF)


Out-of-Network Coverage Rules

Under a Point-of-Service (POS) option, you may use non-plan providers to get your some covered services (see Section 2.4 for the definition of Point-of-Service in your Evidence of Coverage). However, your out of pocket costs may be higher if you use non-plan providers (for more information about this, see Section 2 in your Evidence of Coverage). The exception is if you use non-plan providers for emergency care.
Medicare requires that we have or arrange for enough providers to give you medically necessary plan covered services at the in-network cost-sharing level. This is called our "network" of providers. When you get services from non-plan providers, we call these "out-of-network" services. 
You don't need to get a referral when you get care from non-plan providers. However, before getting these services you may want to confirm with us that the services you are receiving are covered by us and are medically necessary. If we later determine that the services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the costs.
You will be allowed $10,000 worth of out-of-network services.  Your cost-sharing amount for these services is $5,000. We will pay the other $5,000. Once the $10,000 maximum is met, you will be responsible for all costs associated with out-of-network care you receive.
The following services are not covered out-of-network and you will be responsible for all of the costs if you obtain these services:
  • Inpatient Acute Care
  • Inpatient Mental Health Care
  • Skilled Nursing Facility Care
  • Primary Care Physicians
  • Home Health
  • X-rays
  • Part B Prescription Drugs
  • Durable Medicare Equipment & Prosthetic Devices
  • Dialysis
  • Outpatient Services including Surgery, X-rays, Outpatient Diagnostic Radiology (e.g. CT scans, PET scans, MRI's, nuclear medicine) and Therapeutic Radiology (e.g. radiation therapy, chemotherapy)
  • Diabetic Supplies

If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You will need to obtain “prior authorization” from us to get this care. In this situation, you will pay the same as you would pay if you got the care from a network provider.

The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 of your Evidence of Coverage.

Fidelis Dual Advantage (HMO D-SNP) Plan 006

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2021. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Care Programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios (PDF)

Краткий обзор страховых выплат (PDF)

福利介紹 (PDF)


Over-the-Counter Benefit Information


Out of Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.
Fidelis Medicare Advantage Flex (HMO POS) Plan 007

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知 (PDF)

 

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2021. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (Evidence of Coverage) (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

Краткий обзор страховых выплат на 2021 год (PDF)

2021年度福利介紹 (PDF)


Flex Reimbursement

Flex Reimbursement Account Information


Out of Network Coverage Rules:

The following services are not covered out-of-network and you will be responsible for all of the costs if you obtain these services: 

Inpatient Acute Care 

Inpatient Mental Health Care 

Skilled Nursing Facility Care 

Primary Care Physicians 

Home Health 

X-rays 

Part B Prescription Drugs 

Durable Medicare Equipment & Prosthetic Devices 

Dialysis 

Outpatient Services including Surgery, X-rays, Outpatient Diagnostic Radiology (e.g. CT scans, PET scans, MRI's, nuclear medicine) and Therapeutic Radiology (e.g. radiation therapy, chemotherapy) 

Diabetic Supplies 

If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You will need to obtain “prior authorization” from us to get this care. In this situation, you will pay the same as you would pay if you got the care from a network provider. 

The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 of your Evidence of Coverage.

Fidelis Medicaid Advantage Plus (HMO D-SNP) Plan 008
Fidelis Medicare $0 Premium (HMO) Plan 009

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知 (PDF)

 

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2021. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

Краткий обзор страховых выплат на 2021 год (PDF)

2021年度福利介紹 (PDF)


Out-of-Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Telehealth Services

There are 2 ways for you to use your telehealth benefit from the safety, comfort and convenience of your home:

  • Schedule a telehealth visit with your network primary care provider or specialist. Many Fidelis Care providers can make an appointment for a visit by phone or video. 
  • Through Teladoc, you can receive online care from board-certified, NY State-licensed doctors, 24 hours a day, 7 days a week.

    Before your first virtual care visit, the best place to start is by downloading the Teladoc app (available from the App Store or Google Play) or get started online by following the website link below.

     

     

    Pharmacy Benefits

    Your pharmacy benefits are covered through CVS Caremark. 
    Visit the CVS Caremark website.

    For your convenience, Fidelis Care also provides an online form for Prior Authorization (PA) and supplemental medication requests:

    Extended Benefits

    Fidelis Care also offers case management to members by phone:

    • Case Managers can provide support and assistance in identifying alternatives and resources when benefits have been exhausted.

    • Case Managers are health professionals available to assist you in managing your health, learning more about your health or conditions, coordinating care with providers and receiving necessary services.

     

    To receive more information, please call Fidelis Care Clinical Services at the number below:

     

     

    Your Information is Protected

    The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule applies to all forms of your protected health information, whether electronic, written, or oral. 

    To learn more about HIPAA and your privacy rights, visit the U.S. Department of Health and Human Services

     

     

     

    Additional Information

    For a complete listing of plans in your service area, contact the plan.  Fidelis Care is contracted with Medicare for HMO, HMO D-SNP, and HMO-POS plans, and with the state Medicaid program. Enrollment in Fidelis Care depends on contract renewal.

    From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends and on federal holidays.

    Multi-Language insert (PDF)

    Non-Discrimination Notice (PDF)

    Privacy Policy

    H5599_22019WEB_2021_Accepted_12262020

     

     

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