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HomeAbout usCommitment to Quality

Get the Most from Your Coverage

You Deserve Quality Healthcare. And you also deserve to have the information you need to get the most from your coverage. Goals for quality are set and reviewed by your health plan to make sure you get the care you need.

This information is part of a Quality Program designed to improve the services and care you receive. It provides details about your coverage and services available to you. 

Know Your Rights

Being a member means there are things you should expect from your health plan. These are some of your rights:

  • You should have access to all the services available to members
  • You should be treated with courtesy and respect
  • You should be able to get a copy of your medical record
  • You should know your medical data will be kept private. There are policies in place to guard your health records and protected health information.
  • You should have access to oral interpretation and written translation services.

It’s also important to know what you can do to get the most from your coverage:

  • Ask questions if you don’t understand your rights
  • Be sure to keep your scheduled appointments
  • Keep your Member ID Card with you so you have it at appointments
  • Tell your doctor if you have gotten care in an emergency room.

Our General Statement of Rights and Responsibilities lists what you can expect from Fidelis Care, including being treated with dignity and respect. The full list of rights and responsibilities are also available in your:

We are committed to keeping your race, ethnicity, and language (REL), and sexual orientation and gender identity (SOGI) information confidential. We use some of the following methods to protect your information:

  • Maintaining paper documents in locked file cabinets
  • Requiring that all electronic information remain on physically secure media
  • Maintaining your electronic information in password-protected files

We may use or disclose your REL and SOGI information to perform our operations. These activities may include:

  • Designing intervention programs
  • Designing and directing outreach materials
  • Informing health care practitioners and providers about your language needs
  • Assessing health care disparities

We will never use your REL and SOGI information for underwriting, rate setting or benefit determinations or disclose your REL or SOGI information to unauthorized individuals.

Getting the Care You Need

Primary Care Provider (PCP)
Your PCP is the doctor you’ll see for routine checkups and care. Your PCP will help find other types of healthcare providers if you need one. You can also search Find-a-Doctor on your health plan website.
Children and Teens
As children get older, they should change from seeing a pediatrician to seeing an adult doctor. Teens don’t need checkups as often as young kids do, but they should see their PCP at least once a year. Regular visits will help them stay up to date on vaccines. If teens have a condition such as diabetes or asthma, it’s very important that they keep seeing their doctors and not miss a visit. Call your health plan if you need help finding an adult provider.
Making Appointments

You should be able to schedule an appointment with your PCP and get medical care when you need it. You may have to wait a little longer to get in to see certain other types of providers, like specialists. Call your health plan if you can’t get an appointment in a timely manner.

Getting Prescriptions Filled

Available on the member resource page under Medicaid Managed Care, NYRx website lists the prescription medications, including restrictions and preferences, covered under your plan, as well as:

• Explanations of terms, such as “copays,” “quotas,” and “limits;” how to use the document; and the steps to follow to get your medications

• How providers can request coverage exceptions if the formulary does not cover your medical needs

• The process for getting generic substitutions, therapeutic interchange, and step therapy

Knowing if a Service is Covered

The Utilization Management (UM) Department looks at your health records and may also talk with your doctor to decide if a service you need is covered. These decisions are not based on financial reasons. And doctors and staff are not rewarded for saying no to care. All UM decisions are based on:

  • If the service is medically necessary
  • If the service works well
  • If the service is right for you
    • New Services and Technology
    New medications, tests, and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by your health plan. Your plan covers care that is medically necessary. Not every new medical service is covered for all members.
    If a Service is Denied
    If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to your request, condition and benefits.
    Getting More Help if You Need It
    Care Management is for members who may need extra help taking care of their health. Some people have several health conditions and see more than one doctor. Others need help arranging the services their doctors may have ordered. Working with a care manager lets you understand major health problems, work well with your doctors and get the care you need.
    Care Management

    Fidelis Care members can get personalized help from a Care Manager. Care Managers can help coordinate care and services, help members learn more about their health, or help them find helpful resources in their community. Visit the Care Management section on our Health Resources webpage to learn:

    • About eligibility requirements, which can include, but are not limited, to having certain health conditions

    • How to use these services to remind you to have your yearly flu shot, get referrals to Health Homes, get services for behavioral and physical health care, help you make sure your medications work together, and get coaching to support self-care habits

    • How to start or stop receiving these services

    You can get more information about Care Management by calling 1-800-247-1441 (TTY: 711). Fidelis Care also offers additional health programs designed to meet the needs of our members.

    Population Health Management

    Help is also available from our Population Health Management programs. They can help you by:

    • Reminding you to have your flu shot or other care you may need
    • Referring you to Health Homes 
    • Offering services for behavioral and physical health needs, like those listed above
    • Helping ensure your medications work together
    • Coaching you to support self-care habits
    • Controlling high blood pressure and living with a severe and persistent mental illness such as schizophrenia, bipolar disorder, and major depression
    Other Languages & Format Needs

    Interpreter services are provided free of charge to you when talking with your health plan or doctors and during the grievance process. This includes American Sign Language and real-time oral interpretation by certified medical interpreters. Our interpreters have demonstrated proficiency in both English and the non-English language of the member.

    If you need something translated into a language other than English, please call at 1-888-343-3547 (TTY: 711). We can also provide materials in other formats such as Braille, CD or large print.

    If you need an interpreter for your medical appointment, contact before your appointment. We will arrange for an interpreter to be at your appointment.

    Get More Information

    You can contact Member Services for additional help at 1-888-343-3547 (TTY: 711). Oral interpretation and written translation services are available if you need them.

    Call Member Services to get:

  • A paper copy of your Member Handbook, Privacy Notice, or anything on your health plan website
  • Help finding a doctor and making an appointment
  • Help speaking with a care manager
  • Help with an appeal for a service that’s been denied
  • Help with a ride to your appointment

    •  

    Creating an online Member Portal account is free and easy. With it, you can:

  • Find or change your PCP
  • Request a new Member ID Card or print a temporary ID Card
  • View and update your personal information


    • Your Member Resources are a great source of information for information about your coverage and benefits. Find your plan materials including your Member Handbook or Subscriber Contract, your Drug Formulary, and more in the below section.

    Medicaid Managed Care
    Formularies

    Effective April 1, 2023, members enrolled in Medicaid Managed Care plans will receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program.

    Medicaid List of Covered Drugs and Over the Counter (OTC) Products (NYRx)

    Search for a Pharmacy or Medical Equipment Supplier (NYRx)

    Virtual Support

    Telemedicine Benefits

    Member Handbook

    Medicaid Managed Care Member Handbook

    Member Handbook Insert - Dental Services

    Member Handbook Insert - Medicaid NYRx, the Medicaid Pharmacy Program (Effective April 1, 2023)

    Member Handbook Insert - Mobile Crisis Telephonic Triage Response Service

    Member Handbook Insert - Undocumented Non-Citizens Age 65 and Over

    Member Notices

    Applied Behavior Analysis (ABA) Therapy  (Effective January 1, 2023)

    Gambling Disorder Treatment  (Effective January 1, 2023) 

    Subscriber and Renewal Documents

    Renewal Information Checklist

    Appeal and Informal Review Process

    Child Health Plus
    Formularies

    2024 Drug Formulary

    Virtual Support

    Telemedicine Benefits

    Member Notices

    Member Notice - Expanded Coverage  (Effective January 1, 2023)

    Member Notice - Family Planning

    Subscriber Contract and Additional Information

    Subscriber Contract

    Subscriber Contract Rider

    Additional Information for CHPlus Members

    HealthierLife | Health and Recovery Plan (HARP)
    Formularies

    Effective April 1, 2023, members enrolled in HealthierLife (HARP) plans will receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program.

    HARP List of Covered Drugs and Over the Counter (OTC) Products (NYRx)

    Search for a Pharmacy or Medical Equipment Supplier (NYRx)

    Virtual Support

    Telemedicine Benefits

    Member Handbook Materials

    Member Handbook

    Member Handbook Insert - Medicaid NYRx, the Medicaid Pharmacy Program (Effective April 1, 2023)

    Member Handbook Insert – Behavioral Health Community Oriented Recovery and Empowerment (CORE) Services

    Member Handbook Insert - Children and Family Treatment and Support Services (CFTSS)

    Member Handlbook Insert - Dental Services

    Member Handbook Insert - Family Planning Coverage

    Member Handbook Insert - Interoperability and Patient Access rule

    Member Handbook Insert - Maximum Pharmacy Copay

    Member Handlbook Insert - Mobile Crisis Telephonic Triage Response Service

    Member Handbook Insert - National Diabetes Prevention Program (NDPP)

    Member Handbook Insert - Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST)

    Member Notices

    Member Notice - Smoking Cessation Counseling

    Subscriber and Renewal Documents

    Appeal and Informal Review Process

    Renewal Information Checklist

    Essential Plan

    Essential Plan Information ⇒

    Fidelis Care at Home | Managed Long Term Care (MLTC)
    Member Handbook Materials

    Member Handbook

    Member Handbook Insert - Dental Services

    Member Handbook Insert - Important Updates Regarding Coronavirus COVID-19

    Member Handbook Insert - New York Independent Assessor - Initial Assessment Process

    Member Handbook Insert – Non-Emergency Medical Transportation

    Member Handbook Insert - Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST)

    Member Handbook Insert - Plan Transfers

    Subscriber and Renewal Documents 

    Annual Disenrollment Notice

    Appeal and Informal Review Process

    SSBCI (Special Supplemental Benefits for the Chronically Ill)

    Ambetter from Fidelis Care | Qualified Health Plans (QHP)

    Ambetter from Fidelis Care Qualified Health Plans Information ⇒

    Wellcare By Fidelis Care | Medicare and Dual Advantage

    Wellcare By Fidelis Care Medicare and Dual Advantage Plan Information ⇒

    Exhausted Benefits

    Fidelis Care offers care management services to members by phone. Our Care Managers can provide support and assistance in identifying alternatives and resources when benefits have been exhausted. 

    Care 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.

    Language Assistance

    Free language assistance services are available to you, such as:

    • Qualified interpreters
    • Information written in other languages

    If you need these services, call Fidelis Care at 1-888-343-3547. For TTY/TDD services, call 711.

    Language Assistance Services (PDF)

    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. 

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

    Authorization to Use and Disclose Health Information (PDF)

    Revocation of Authorization to Use and/or Disclose Health Information (PDF)

    Notice of Privacy Practices

    Fidelis Care Notice of Privacy Practices


    Health Resources

    Click below to view additional resources, sorted by health categories.

    Health Resources

    Member How To Videos

    Get the most from your Fidelis Care plan and our Member Portal by watching our videos, including how to change your PCP, requesting new ID cards, and more.

    Videos

    Find a Doctor

    Search for a Doctor in your area. 

    Customized filters enable members to sort by medical specialty, plan type, and location to display all applicable, in-network providers.

    Find a Doctor