Fidelis Care Silver Coverage Period: 01/01/2015-12/31/2015
Coverage for: Individual/Family | Plan Type: HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.fideliscare.org or by calling 1-888-FIDELIS.
Important Questions Answers Why this Matters:
For in-network providers You must pay all the costs up to the deductible amount before this plan begins to pay for
What is the overall $2,000 individual / $4,000 covered services you use. Check your policy or plan document to see when the deductible
deductible? family. Doesn’t apply to in- starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
network preventive care. much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services, but see the chart starting on page
services? 2 for other costs for services this plan covers
Is there an out–of– $5,500 individual / $11,000
pocket limit on my family The out-of-pocket limit is the most you could pay during a coverage period (usually one
expenses? Premiums, balance-billed year) for your share of the cost of covered services. This limit helps you plan for health
What is not included in charges, and health care this care expenses.
the out–of–pocket plan doesn’t cover
limit? Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall No.
annual limit on what The chart starting on page 2 describes any limits on what the plan will pay for specific
the plan pays? covered services, such as office visits.
Does this plan use a Yes. For a list of in-network If you use an in-network doctor or other health care provider, this plan will pay come or
network of providers? providers, see all of the costs of covered services. Be aware, your in-network doctor or hospital may use
www.fideliscare.org or call 1- an out-of-network provider for some services. Plans use the term in-network, preferred, or
888-FIDELIS participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
Do I need a referral to No
see a specialist? Yes You can see the specialist you choose without permission from this plan.
Are there services this
plan doesn’t cover? Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan
document for additional information about excluded services.
Questions: Call 1-888-FIDELIS or visit us at www.fideliscare.org. OMB Control Numbers 1545-2229, 1 of 8
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1210-0147, and 0938-1146
at www.fideliscare.org or call 1-888-FIDELIS to request a copy.
Released on April 23, 2013 (corrected)
Fidelis Care Silver Coverage Period: 01/01/2015-12/31/2015
Coverage for: Individual/Family | Plan Type: HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common Services You May Need Your Cost If Your Cost If Limitations & Exceptions
Medical Event You Use an You Use an
In-network Out-of-network --------------------none----------------------
If you visit a health Primary care visit to treat an injury or illness --------------------none----------------------
care provider’s office Specialist visit Provider Provider --------------------none----------------------
or clinic Other practitioner office visit $30 Not covered For preventive care visits/services as
$50 Not covered defined in section 2713 of ACA no
Preventive care/screening/immunization $30 Not covered deductible or cost sharing applies.
Otherwise, PCP/Specialist copay per
$0 Not covered visit applies to all services in this
benefit service category.
If you have a test Diagnostic test (x-ray, blood work) $50 Not covered --------------------none----------------------
Imaging (CT/PET scans, MRIs) $50 Not covered --------------------none----------------------
If you need drugs to Generic drugs $10 Not covered Rx through Caremark. For questions,
treat your illness or Preferred brand drugs $35 Not covered
condition please call: 1-888-FIDELIS
Non-preferred brand drugs $70
More information Not covered Retail: 30-day supply
Mail Order: 90-day supply
Questions: Call 1-888-FIDELIS or visit us at www.fideliscare.org. 2 of 8
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.fideliscare.org or call 1-888-FIDELIS to request a copy.
Fidelis Care Silver Coverage Period: 01/01/2015-12/31/2015
Coverage for: Individual/Family | Plan Type: HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common Services You May Need Your Cost If Your Cost If Limitations & Exceptions
Medical Event Specialty drugs You Use an You Use an
In-network Out-of-network
about prescription
drug coverage is Provider Provider
available at
www.fideliscare.org $70 Not covered --------------------none----------------------
Facility fee (e.g., ambulatory surgery center) $100 Not covered Precertification is required
Not covered
If you have Physician/surgeon fees $100 Precertification is required. One such
outpatient surgery Not covered copay per surgery and applies only to
surgery performed in a hospital
Emergency room services $150 Not covered inpatient or hospital outpatient facility
setting, including freestanding
If you need Emergency medical transportation $150 Not covered surgicenters, not to office surgery.
immediate medical Not covered
attention Not covered Copay is waived if patient is admitted
as an inpatient (including as an
If you have a Urgent care $70 observation stay) directly from the ER
hospital stay Facility fee (e.g., hospital room) $1,500 per
Physician/surgeon fee admission Covered in-network, subject to
meeting “emergency” criteria. When
$100 services are delivered by an out-of-
network land ambulance provider that
is not licensed under the NY Public
Health Law, you may be required to
pay up to the difference between the
reasonable and customary allowed
amount and the provider’s total
charges.
--------------------none----------------------
Precertification is required for elective
hospitalizations
Precertification is required for elective
hospitalizations
Questions: Call 1-888-FIDELIS or visit us at www.fideliscare.org. 3 of 8
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.fideliscare.org or call 1-888-FIDELIS to request a copy.
Fidelis Care Silver Coverage Period: 01/01/2015-12/31/2015
Coverage for: Individual/Family | Plan Type: HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common Services You May Need Your Cost If Your Cost If Limitations & Exceptions
Medical Event You Use an You Use an
Mental/Behavioral health outpatient services In-network Out-of-network Precertification is required
If you have mental Mental/Behavioral health inpatient services Precertification is required
health, behavioral Substance use disorder outpatient services Provider Provider Precertification is required
health, or substance Substance use disorder inpatient services Not covered Precertification is required
abuse needs $30 Not covered Copay is based on the type of
$1,500 Not covered physician performing the service
If you are pregnant $30 Not covered Precertification is required
$1,500 Not covered Coverage for up to 40 home health
Not covered care visits per condition, per lifetime.
Prenatal and postnatal care $0 Not covered Covered for up to 60 visits per
Not covered condition, per lifetime.
Delivery and all inpatient services $1,500 Not covered Covered for up to 60 visits per
condition, per lifetime.
Home health care $30 Not covered Coverage for up to 200 days. Indicated
copay per admission is waived if direct
Rehabilitation services $30 Not covered transfer from hospital inpatient setting
or skilled nursing facility to hospice
Habilitation services $30 Not covered facility
Not covered Repairs and replacements are covered
If you need help Skilled nursing care $1,500 Not covered when necessary due to normal wear
recovering or have Not covered and tear. Repairs and replacements that
other special health result from misuse or abuse are not
needs covered.
Precertification is required
Durable medical equipment 30% coinsurance
Eyewear coinsurance cost sharing
If your child needs Hospice service $30 applies to combined cost of lenses and
dental or eye care Eye exam $30 frames; also applies to contact lenses
30% coinsurance See stand-alone dental provider
Glasses Not Covered
Dental check-up
Questions: Call 1-888-FIDELIS or visit us at www.fideliscare.org. 4 of 8
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.fideliscare.org or call 1-888-FIDELIS to request a copy.
Fidelis Care Silver Coverage Period: 01/01/2015-12/31/2015
Coverage for: Individual/Family | Plan Type: HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Cosmetic Surgery Long-Term Care Routine Dental Care (Adult)
Private-Duty Nursing Routine Foot Care Routine Eye Care (Adult)
Interruption of Pregnancy
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Chiropractic Care
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are
exceptions, however, such as if:
• You commit fraud
• The insurer stops offering services in the State
• You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at Fidelis Member Services Department – 1-888-FIDELIS.
You may also contact your state insurance department at:
Department of Financial Service
Consumer Assistance Unit
One Commerce Plaza
Albany, New York 12257
Fax: (212) 480-6282
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: Fidelis Member Services Department – 1-888-FIDELIS.
Questions: Call 1-888-FIDELIS or visit us at www.fideliscare.org. 5 of 8
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.fideliscare.org or call 1-888-FIDELIS to request a copy.
Fidelis Care Silver Coverage Period: 01/01/2015-12/31/2015
Coverage for: Individual/Family | Plan Type: HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-888-FIDELIS.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-FIDELIS.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码 1-888-FIDELIS.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-FIDELIS.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-888-FIDELIS or visit us at www.fideliscare.org. 6 of 8
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.fideliscare.org or call 1-888-FIDELIS to request a copy.
Fidelis Care Silver Coverage Period: 01/01/2015-12/31/2015
Coverage for: Individual/Family | Plan Type: HMO
Coverage Examples
About these Coverage Having a baby Managing type 2 diabetes
Examples:
(normal delivery) (routine maintenance of
These examples show how this plan might cover a well-controlled condition)
medical care in given situations. Use these Amount owed to providers: $7,540
examples to see, in general, how much financial Plan pays $3,520 Amount owed to providers: $5,400
protection a sample patient might get if they are Patient pays $4,020 Plan pays $2,570
covered under different plans. Patient pays $ 2,830
This is Sample care costs: $2,700 Sample care costs: $2,900
not a cost Hospital charges (mother) $2,100 Prescriptions $1,300
estimator. Routine obstetric care Medical Equipment and Supplies
Hospital charges (baby) $900 Office Visits and Procedures $700
Don’t use these examples to Anesthesia $900 Education $300
estimate your actual costs Laboratory tests $500 Laboratory tests $100
under this plan. The actual Prescriptions $200 Vaccines, other preventive $100
care you receive will be Radiology $200 Total $5,400
different from these Vaccines, other preventive $40
examples, and the cost of Total $7,540 Patient pays: $2,000
that care will also be Deductibles $480
different. Patient pays: $2,000 Copays $270
Deductibles $1,870 Coinsurance $80
See the next page for Copays Limits or exclusions
important information about Coinsurance $0 Total $2,830
these examples. Limits or exclusions $150
Total $4,020
Questions: Call 1-888-FIDELIS or visit us at www.fideliscare.org. 7 of 8
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.fideliscare.org or call 1-888-FIDELIS to request a copy.
Fidelis Care Silver Coverage Period: 01/01/2015-12/31/2015
Coverage for: Individual/Family | Plan Type: HMO
Coverage Examples
Questions and answers about the Coverage Examples:
What are some of the What does a Coverage Example Can I use Coverage Examples
show? to compare plans?
assumptions behind the
For each treatment situation, the Coverage Yes. When you look at the Summary of
Coverage Examples? Example helps you see how deductibles,
copayments, and coinsurance can add up. It Benefits and Coverage for other plans,
Costs don’t include premiums. also helps you see what expenses might be left you’ll find the same Coverage Examples.
Sample care costs are based on national up to you to pay because the service or When you compare plans, check the
treatment isn’t covered or payment is limited. “Patient Pays” box in each example. The
averages supplied by the U.S. smaller that number, the more coverage
Department of Health and Human Does the Coverage Example the plan provides.
Services, and aren’t specific to a predict my own care needs?
particular geographic area or health plan. Are there other costs I should
The patient’s condition was not an No. Treatments shown are just examples. consider when comparing
excluded or preexisting condition. plans?
All services and treatments started and The care you would receive for this
ended in the same coverage period. condition could be different based on your Yes. An important cost is the premium
There are no other medical expenses for doctor’s advice, your age, how serious your
any member covered under this plan. condition is, and many other factors. you pay. Generally, the lower your
Out-of-pocket expenses are based only premium, the more you’ll pay in out-of-
on treating the condition in the example. Does the Coverage Example pocket costs, such as copayments,
The patient received all care from in- predict my future expenses? deductibles, and coinsurance. You
network providers. If the patient had should also consider contributions to
received care from out-of-network No. Coverage Examples are not cost accounts such as health savings accounts
providers, costs would have been higher. (HSAs), flexible spending arrangements
estimators. You can’t use the examples to (FSAs) or health reimbursement accounts
estimate costs for an actual condition. They (HRAs) that help you pay out-of-pocket
are for comparative purposes only. Your expenses.
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Questions: Call 1-888-FIDELIS or visit us at www.fideliscare.org. 8 of 8
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.fideliscare.org or call 1-888-FIDELIS to request a copy.