Recursos de Medicare

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.

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.

Fidelis Medicare Advantage Without Rx (HMO POS) Plan 005

Annual Notice of Changes

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.

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

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

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.

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.

Краткий обзор страховых выплат (PDF)

Resumen de Beneficios (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

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.

Границы страховой ответственности (Evidence of Coverage) (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.

Flex Reimbursement Account Information

Flex Reimbursement

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

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.

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.