Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2024–12/31/2024
Ambe
tter from Fidelis Care: Bronze
Coverage for: Individual/Family | Plan Type: HMO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan
. The SBC shows you how you and the
plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium)
will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of
coverage, visit www.fideliscare.org or call 1-888-FIDELIS (1-888-343-3547). For general definitions of common terms, such as allowed amount,
balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at
www.fideliscare.org or call 1-888-FIDELIS (1-888-343-3547) to request a copy.
Important Questions Answers Why This Matters:
What is the overall
deductible
?
$4,600 individual / $9,200
Family
You must pay all the costs up to the deductible amount before this plan begins to pay
for covered services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1
st
). See the chart starting on
page 2 for how much you pay for covered services after you meet the deductible.
Are there services
covered before you
meet your
deductible
?
Yes – Preventive care and 3
visits (any combination of
PCP, specialist, allergy,
second opinion, ABA
treatment, BH/SA) in a year
are covered before the
deductible.
This plan covers some items and services even if you haven’t yet met the deductible
amount. Copayments or coinsurance may still apply. For example, this plan covers
certain preventive services without cost-sharing and before you meet your deductible.
See a list of covered preventive services at:
https://www.healthcare.gov/coverage/preventive-care-benefits/
Are there other
deductibles
for
specific services?
No.
You don’t have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers
What is the
out-of-
pocket limit
for this
plan
?
$9,450 individual / $18,900
family
The out-of-pocket limit is the most you could pay during a coverage period (usually
one year) for your share of the cost of covered services. This limit helps you plan for
health care expenses.
What is not included in
the
out-of-pocket
limit
?
Premiums, balance-billed
charges, and health care this
plan doesn’t cover
Even though you pay these expenses, they don’t count toward the out-of-pocket
limit.
Will you pay less if
you use a
network
provider
?
Yes – This plan does not cover
most services provided out of
network
It is important to make sure your provider is in-network, otherwise your claim might not
be covered. This plan covers emergency services out of network.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
leased on April 6, 2016
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Do you need a referral
to see a
specialist?
No
You can see the in-network specialist you choose without permission from this plan.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common
Medical Event
Services You May Need
Network Provider
(You will pay the
least)
Out--of--Network
Provider
(You will pay the
most)
Limitations, Exceptions, & Other
Impor
tant Information
If you visit a health
care
provider’s
office or clinic
Primary care visit to treat an
injury or illness
First 3 visits (any
combination of PCP,
specialist, allergy,
second opinion, ABA
treatment, BH/SA) in a
year covered before the
deductible with a $50
copay applying, then
$50 copay after
deductible.
Not covered
First 3 visit limit not subject to
deductible is combined, with no more
than three total visits being exempt
from deductible
Specialist
visit
First 3 visits (any
combination of PCP,
specialist, allergy,
second opinion, ABA
treatment, BH/SA) in a
year covered before the
deductible with a $75
copay applying, then
$75 copay after
deductible.
Not covered
First 3 visit limit not subject to
deductible is combined, with no more
than three total visits being exempt
from deductible
Preventive care
/
screening
/
immunization
No charge
Not covered
No cost-sharing applies for services
provided according to the guidelines
outlined in section 2713 of the
Affordable Care Act (ACA).
If you have a test
Diagnostic test
(x-ray, blood
work)
$50 Copayment after
deductible
Not covered
Prior authorization required for
diagnostic radiology except x-ray.
* For more information about limitations and exceptions, see the plan or policy document at www.fideliscare.org.
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What You Will Pay
Common
Medical Event
Services You May Need
Network Provider
(You will pay the
least)
Provider
(You will pay the
most)
Limitations, Exceptions, & Other
Important Information
Imaging (CT/PET scans,
MRIs)
$75 Copayment after
deductible
Not covered
Prior authorization is required for
certain blood work and diagnostic
imaging except x-ray.
If you need drugs to
treat your illness or
condition
More information
about
prescription
drug coverage
is
available at
www.fideliscare.org
Generic drugs
$10 copay after
deductible/prescription
(retail), $25 copay after
deductible/prescription
(mail order)
Not covered
Preferred brand drugs
$35 copay after
deductible/prescription
(retail), $87.50 copay
after
deductible/prescription
(mail order)
Not covered
Non-preferred brand drugs
$70 copay after
deductible/prescription
(retail), $175 copay
after
deductible/prescription
(mail order)
Not covered
Specialty drugs
$70 copay after
deductible/prescription
(retail)
Not covered
Covers up to 30 day supply at retail
and up to 90 day supply through mail
order. Prior authorization/step therapy
may be required. Covered through
ExpressScripts.
Retail: 30 day supply
Mail Order: 90 day supply
Diabetic medication and supplies are
subject to the primary care provider
cost-sharing.
If you have
outpatient surgery
Facility fee (e.g.,
ambulatory surgery center)
$150 Copayment after
deductible
Not covered
Prior authorization is required.
Physician/surgeon fees
$150 Copayment after
deductible
Not covered
Prior authorization is required.
If you need
immediate medical
attention
Emergency room care
$500 Copayment after
deductible
50% Coinsurance
after deductible
None.
Emergency medical
transportation
$300 Copayment after
deductible
50% Coinsurance
after deductible
None.
* For more information about limitations and exceptions, see the plan or policy document at www.fideliscare.org.
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Out-of-Network
- -
What You Will Pay
Common
Medical Event
Services You May Need
Network Provider
(You will pay the
least)
Provider
(You will pay the
most)
Limitations, Exceptions, & Other
Important Information
Urgent care
$75 Copayment after
deductible
Not covered
None.
If you have a
hospital stay
Facility fee (e.g., hospital
room)
$1,500 Copayment after
deductible
Not covered
Prior authorization is required for
elective hospitalizations.
Physician/surgeon fees
$150 Copayment after
deductible
Not covered
Prior authorization is required for
elective hospitalizations.
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services
First 3 visits (any
combination of PCP,
specialist, allergy,
second opinion, ABA
treatment, BH/SA) in a
year covered before the
deductible with a $50
copay applying, then
$50 copay after
deductible.
Not covered
First 3 visit limit not subject to
deductible is combined, with no more
than three total visits being exempt
from deductible
Inpatient services
$1,500 Copayment after
deductible
Not covered
Prior authorization is required except
for emergency admissions.
If you are pregnant
Office visits
$50 Copayment after
deductible
Not covered
None.
Childbirth/delivery
professional services
$150 Copayment after
deductible
Not covered
Prior authorization is required.
Childbirth/delivery facility
services
$1,500 Copayment after
deductible
Not covered
Prior authorization is required.
If you need help
recovering or have
other special health
needs
Home health care
$50 Copayment after
deductible
Not covered
Up to 40 home health care visits are
covered per condition per year.
Rehabilitation services
$50 copay after
deductible
Not covered
Up to 60 visits are covered per
condition per year.
Habilitation services
$50 copay after
deductible
Not covered
Up to 60 visits are covered per
condition per year.
Skilled nursing care
$1,500 Copayment after
deductible
Not covered
Up to 200 days are covered per year.
Durable medical equipment
50% Coinsurance after
deductible
Not covered
Repairs and replacements are covered
when necessary due to normal wear
* For more information about limitations and exceptions, see the plan or policy document at www.fideliscare.org.
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Out-of-Network
What You Will Pay
Common
Medical Event
Services You May Need
Network Provider
(You will pay the
least)
Provider
(You will pay the
most)
Limitations, Exceptions, & Other
Important Information
- -
and tear. Repairs and replacements
that result from misuse or abuse are
not covered.
Hospice services
$50 Copayment after
deductible
Not covered
Prior authorization required. Up to 210
days covered / year. Inpatient hospice
is subject to inpatient hospital cost-
sharing.
If your child needs
dental or eye care
Children’s eye exam
$50 Copayment after
deductible
Not covered
1 per 12-month period for children
under the age of 19.
If you have questions, please call
Davis Vision at: 1-800-999-5431
Children’s glasses
50% Coinsurance after
deductible
Not covered
Eyewear coinsurance applies to the
combined cost of lenses and frame,
also applies to contact lenses – Limits
may apply. Covered for children under
the age of 19.
If you have questions, please call
Davis Vision at: 1-800-999-5431
Children’s dental check-up
$50 Copayment after
deductible
Not covered
1 per 6-month period for children
under the age of 19.
If you have questions, please call
Dentaquest at: 1-800-516-9615
Excluded Services & Other Covered Services:
Services Your
Plan
Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other
excluded services
.)
• Cosmetic surgery
• Routine foot care
• Private duty nursing
• Routine dental care (adult)
• Long-term care
• Routine eye care (adult)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your
plan
document.)
• Chiropractic care
• Fitness center reimbursement
* For more information about limitations and exceptions, see the plan or policy document at www.fideliscare.org.
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Out-of-Network
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information
for those agencies is:
Department of Financial Service
Consumer Assistance Unit
One Commerce Plaza
Albany, New York 12257
Fax: (212) 480-6282
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For
more information about the Marketplace, contact: Fidelis Member Services at 1-888-FIDELIS, or visit www.nystateofhealth.ny.gov or call 1-855-
355-5777.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This
complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical
claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more
information about your rights, this notice, or assistance, contact:
New York State Department of Health
Office of Health Insurance Programs
Bureau of Consumer Services – Complaint Unit
Corning Tower – OCP Room 1609
Albany, NY 12237
E-mail: [email protected]
Website: www.health.ny.gov
1-800-206-8125
New York State Department of Financial Services
Consumer Assistance Unit
One Commerce Plaza
Albany, NY 12257
Website: www.dfs.ny.gov
1-800-342-3736
If You need assistance filing a Grievance or Appeal, You may also contact the state independent Consumer Assistance Program at:
Community Health Advocates
633 Third Avenue, 10th Floor
New York, NY 10017
Or call toll free: 1-888-614-5400, or e-mail cha@cssny.org
* For more information about limitations and exceptions, see the plan or policy document at www.fideliscare.org.
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Website: www.communityhealthadvocates.org
Does
this plan
provide
Minimum
Essential
Coverage?
Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market
policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.
If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan
doesn’t
meet the Minimum
Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the
Marketplace
.
Language Access
Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-888-FIDELIS (1-888-343-3547)
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-FIDELIS (1-888-343-3547)
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-888-FIDELIS (1-888-343-3547)
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-FIDELIS (1-888-343-3547)
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next
section.––––––––––––
* For more information about limitations and exceptions, see the plan or policy document at www.fideliscare.org
.
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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this
plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (
deductibles
,
copayments and coinsurance
) and
excluded services under the plan
. Use this information to compare the portion of
costs you might pay under different health
plans
. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care
and a hospital delivery)
◼ The plan’s overall deductible $4,600
◼ Specialist copayment $75
◼ Hospital (facility) copayment $1,500
◼ Other coinsurance 50%
This EXAMPLE event includes services
like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood
work)
Specialist visit (anesthesia)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
$4,600
Copayments
$1,600
Coinsurance
$0
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is $6,460
Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a
well-controlled condition)
◼ The plan’s overall deductible $4,600
◼ Specialist copayment $75
◼ Hospital (facility) copayment $1,500
◼ Other coinsurance 50%
This EXAMPLE event includes services
like:
Primary care physician office visits
(including disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles
$4,600
Copayments
$50
Coinsurance
$40
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is $4,910
Mia’s Simple Fracture
(in-network emergency room visit and
follow up care)
◼ The plan’s overall deductible $4,600
◼ Specialist copayment $75
◼ Hospital (facility) copayment $1,500
◼ Other coinsurance 50%
This EXAMPLE event includes services
like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles
$2,400
Copayments
$0
Coinsurance
$0
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is $2,400
The plan
would be responsible for the other costs of these EXAMPLE covered services.
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