Fidelis Medicare Advantage $0 Premium (HMO)
2017 Program Benefits Comparison Grid
This tool highlights our 2017 Medicare Advantage program benefits using a side-by-side layout so you can select the program that is right for you.
For those that reside in the following counties: Albany, Allegany, Bronx, Broome, Cattaraugus, Cayuga, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Greene, Hamilton, Herkimer, Kings, Lewis, Montgomery, Nassau, New York, Niagara, Oneida, Onondaga, Orleans, Otsego, Oswego, Queens, Rensselaer, Richmond, St. Lawrence, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, Steuben, Suffolk, Tioga, Warren, Washington, Wyoming, and Yates Counties.
For those that reside in the following counties: Dutchess, Putnam, Sullivan, Ulster, and Orange Counties.
Personal Benefits Worksheet
Each year, you are asked to review your Medicare coverage to make your choices for the coming year. Fidelis Care offers an easy-to-use form to help you. Our Personal Benefits worksheet helps you with the key factors you need to consider when making your program selection and helps you understand your options so that you can make the best choices for your care.
Evidence of Coverage
This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2017. It explains how to get coverage for the health care services and prescription drugs you need.
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.
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.
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: 1-800-695-8544). From October 1 to February 14, our office hours are 8:00 a.m. to 8:00 p.m. seven days a week. From February 15 through September 30, our office hours are Monday through Friday, 8:00 a.m. to 8:00 p.m.
Questions? Call our Member Services Department at 1-800-247-1447 (TTY: 1-800-695-8544). From October 1 to February 14, our office hours are 8:00 a.m. to 8:00 p.m. seven days a week and from February 15 through September 30, our office hours are Monday through Friday, 8:00 a.m. to 8:00 p.m.
Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal.
Fidelis Care 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.
(Updated 10/12/2016) H3328_FC 16153 Approved