Medicare Advantage and Dual Advantage

Fidelis Legacy Plan

Medicare Resources

View and download plan documents. 

2019 Plan Documents

Fidelis Dual Advantage Flex (HMO SNP) 017

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, 2019. It explains how to get coverage for the health care services and prescription drugs you need. 

Evidence of Coverage (PDF)

Evidence of Coverage Update - BFCC-QIO Program (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 Legacy Plan 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 Legacy Plan 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. 
The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.
Limitations, copayments, and restrictions may apply.
Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

This information is available for free in other languages. Please call our customer service number at 1-800-247-1447 (TTY: 711). Hours are 8 AM to 8 PM.  Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.

Fidelis Dual Advantage (HMO SNP) 002

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, 2019. It explains how to get coverage for the health care services and prescription drugs you need. 

Evidence of Coverage (PDF)

Evidence of Coverage Update - BFCC-QIO Program (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 Legacy Plan 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 Legacy Plan 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.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.

Limitations, copayments, and restrictions may apply.

Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

This information is available for free in other languages. Please call our customer service number at 1-800-247-1447 (TTY: 711). Hours are 8 AM to 8 PM.  Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.

Fidelis Medicare Advantage Flex (HMO POS) 003

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2018. It explains how to get coverage for the health care services and prescription drugs you need. 

Evidence of Coverage (PDF)

Evidence of Coverage Update - BFCC-QIO Program (PDF)

Evidencia de cobertura (PDF)


Summary of Benefits

You can use this document to compare Fidelis Legacy Plan 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 2019 (PDF)

Краткий обзор страховых выплат на 2019 год (PDF)

2019年度福利介紹 (PDF)


Flex Reimbursement

    Flex Reimbursement Form Guidelines (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.

    The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.

    Limitations, copayments, and restrictions may apply.

    Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

    This information is available for free in other languages. 


    Hours are 8 AM to 8 PM.  Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.


    Fidelis Medicare Advantage $0 Premium (HMO) 021

    Annual Notice of Changes

    Annual Notice of Changes (PDF)

    Aviso anual de cambios (PDF)


    Evidence of Coverage

    This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2019. It explains how to get coverage for the health care services and prescription drugs you need. 

    Evidence of Coverage (PDF)

    Evidence of Coverage Update - BFCC-QIO Program (PDF)

    Evidencia de cobertura (PDF)


    Summary of Benefits

    You can use this document to compare Fidelis Legacy Plan 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 2019 (PDF)

    Краткий обзор страховых выплат на 2019 год (PDF)

    2019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 Legacy Plan 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. 
    The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.
    Limitations, copayments, and restrictions may apply.
    Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year

    This information is available for free in other languages. Hours are 8 AM to 8 PM. Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.

    Fidelis Medicare Advantage Without Rx (HMO POS) 001

    Annual Notice of Changes

    Annual Notice of Changes (PDF)

    Aviso anual de cambios (PDF)


    Evidence of Coverage

    This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2019. It explains how to get coverage for the health care services and prescription drugs you need.

    Evidence of Coverage (PDF)

    Evidence of Coverage Update - BFCC-QIO Program (PDF)

    Evidencia de cobertura (PDF)


    Summary of Benefits

    You can use this document to compare Fidelis Legacy Plan 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 2019 (PDF)

    Краткий обзор страховых выплат на 2019 год (PDF)

    2019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.

    The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.

    Limitations, copayments, and restrictions may apply.

    Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.

    This information is available for free in other languages. Please call our customer service number at 1-800-247-1447 (TTY: 711). Hours are 8:00 a.m. to 8:00 p.m.  Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.
    Medicaid Advantage Plus (HMO SNP) 016

    Evidence of Coverage

    This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2019. It explains how to get coverage for the health care services and prescription drugs you need. 

    Evidence of Coverage (PDF)

    Evidence of Coverage Update - BFCC-QIO Program (PDF)

    Evidencia de cobertura (PDF)


    Annual Notice of Changes

    Annual Notice of Changes (PDF)

    Aviso anual de cambios (PDF)


    Summary of Benefits

    You can use this document to compare Fidelis Legacy Plan 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)


    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 Legacy Plan 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. 
    The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.
    Limitations, copayments, and restrictions may apply.
    Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

    This information is available for free in other languages. Please call our customer service number at 1-800-247-1447 (TTY: 711). Hours are 8 AM to 8 PM.  Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.

    Pharmacy Benefits

    Your pharmacy benefits are covered through CVS Caremark. Visit the CVS Caremark website (By clicking this link, you will leave the Fidelis Care website.) for more information or to register. 

    Fidelis Care also provides Medicare Members an online form for your convenience:

    Exhausted Benefits

    Fidelis Care offers case management services to members by phone. Our 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 1-800-247-1441.

    Your Health Information is Protected

    The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provides national standards to protect individuals’ medical records and other personal health information. The Privacy Rule applies to all forms of your protected health information, whether electronic, written, or oral. 

    The HIPAA Security Rule protects health information in electronic form and requires providers and others covered under HIPAA to ensure that electronic protected health information is secure. 

    To learn more about HIPAA and your privacy rights, visit the U.S. Department of Health and Human ServicesBy clicking this link, you will leave the Fidelis Care website.

    Authorization to Disclose Personal Health Information Form (PDF)


    Questions?

    Call our Member Services Department at 1-800-247-1447 (TTY: 711).

    Hours are 8 AM to 8 PM.  Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.

    Fidelis Legacy Plan is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal.
    Fidelis Legacy Plan is a Coordinated Care plan with a Medicare contract and a contract with the New York State Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal.

    Multi-Language insert (PDF)

    Non-Discrimination Notice (PDF)

    Privacy Policy (PDF)


    H3328_FC 19063_M


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