Annual Notice of Changes
Annual Notice of Changes (PDF)
Aviso anual de cambios (PDF)
Ежегодное уведомление об изменениях (PDF)
Evidence of Coverage
This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. 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)
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 2020 (PDF)
Краткий обзор страховых выплат на 2020 год (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
- Part B Prescription Drugs
- Durable Medicare Equipment & Prosthetic Devices
- 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.