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2021年计划文件

Fidelis Dual Advantage Flex (HMO SNP) Plan 001

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, 2021. 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)

承保福利說明 (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.

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 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.

2021年Medicare A和B部分保费和免赔额

Fidelis Medicare Advantage Flex (HMO POS) Plan 002
Medicaid Advantage Plus (HMO SNP) Plan 003

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, 2021. 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)

承保福利說明 (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.

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 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 $0 Premium (HMO) Plan 004

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, 2021. 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)

承保福利說明 (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.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

Краткий обзор страховых выплат на 2021 год (PDF)

2021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 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

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, 2021. 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)

承保福利說明 (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.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

Краткий обзор страховых выплат на 2021 год (PDF)

2021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.

Fidelis Dual Advantage (HMO SNP) Plan 006

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, 2021. 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)

承保福利說明 (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.

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 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

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, 2021. 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 (Evidence of Coverage) (PDF)

承保福利說明 (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.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

Краткий обзор страховых выплат на 2021 год (PDF)

2021年度福利介紹 (PDF)


Flex Reimbursement

Flex Reimbursement Account Information


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.

Medicaid Advantage Plus (HMO SNP) Plan 008

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, 2021. 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)

承保福利說明 (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.

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 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 $0 Premium (HMO) Plan 009

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, 2021. 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)

承保福利說明 (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.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

Краткий обзор страховых выплат на 2021 год (PDF)

2021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 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.

 

 

远程医疗服务

在家中的安全性,舒适性和便利性有两种让您使用医疗收益的方式:

  • 与您的网络初级保健提供商或专家安排一次远程医疗访问。 许多Fidelis Care提供商可以通过电话或视频预约访问。 
  • 通过Teladoc,您可以每周7天,每天24小时从董事会认证的纽约州州立医生那里获得在线护理。

    在您第一次进行虚拟护理访问之前,最好的开始方法是下载 Teladoc应用程序 (可从App Store或Google Play获取),或通过下面的网站链接在线开始。

    扩展利益

    Fidelis Care还通过电话为会员提供案例管理:

    • 在收益用尽时,案例管理员可以提供支持和协助,以识别替代方案和资源。

    • 案例管理员是可以帮助您管理健康,了解更多有关您的健康或状况,与提供者协调护理并获得必要服务的健康专业人员。

     

    要获取更多信息,请通过以下电话致电Fidelis Care临床服务:

     

     

    药房福利

    CVS Caremark涵盖您的药房福利。 
    访问CVS Caremark网站.

    为了方便起见,Fidelis Care还提供了一个在线表格,用于事先授权(PA)和补充药物请求:

    您的信息受到保护

    《健康保险可移植性和责任法案》(HIPAA)隐私规则适用于所有形式的受保护健康信息,无论是电子形式,书面形式还是口头形式。

    要了解有关HIPAA和您的隐私权的更多信息,请访问 美国卫生与公共服务部

     

     

     

    有关服务区中计划的完整列表,请联系该计划。 Fidelis Care已与Medicare签定了HMO,HMO D-SNP和HMO-POS计划以及州Medicaid计划。 Fidelis Care的注册取决于续签合同。

    从10月1日到3月31日,您可以每周7天从早上8点到晚上8点给我们打电话。 从4月1日至9月30日,您可以在周一至周五的上午8点至晚上8点致电我们。 下班后,周末和联邦假日使用邮件系统。

    多语言插入 (PDF)

    非歧视通知 (PDF)

    隐私政策

    H5599_22019WEB_2021_Accepted_12262020

    Medicare時事通訊

    閱讀最新的《Your Advantage for Medicare》會員時事通訊,並瀏覽檔案。

    尋找醫生

    在飛達利斯保健網絡中搜尋醫療專業人士、服務或機構。

    會員入口網站

    登入或註冊進行支付、列印會員卡、選擇或更換PCP,等等。