2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Fidelis Medicare Advantage without Rx (HMO-POS) | ||||
Location: | Schenectady, New York Click to see other locations | ||||
Plan ID: | H3328 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-800-247-1447 TTY users 1-800-695-8544 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Fidelis Medicare Advantage without Rx (HMO-POS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Local HMO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Number of Members enrolled in this plan in (H3328 - 001): | 170 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$0.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$6 700 out-of-pocket limit. | |||||
This limit includes only Medicare-covered services. | |||||
$150 yearly deductible. Contact the plan for services that apply. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
Referral required for network specialists (for certain benefits). | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Physical Exams | |||||
When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
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Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$40 copay for Medicare-covered dental benefits. | |||||
Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$0.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$6 700 out-of-pocket limit. | |||||
This limit includes only Medicare-covered services. | |||||
$150 yearly deductible. Contact the plan for services that apply. | |||||
Doctor and Hospital Choice | |||||
Referral required for network specialists (for certain benefits). | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
Plan covers 90 days each benefit period. | |||||
$1 100 copay for each Medicare-covered hospital stay | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
$1 100 copay for each Medicare-covered hospital stay. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
Days 1 - 100: $50 copay per day | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$20 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$20 copay for each in-area network urgent care Medicare-covered visit. | |||||
$40 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
50% of the cost for each Medicare-covered visit. | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
Podiatry Services | |||||
Authorization rules may apply. | |||||
$40 copay for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$40 copay for each Medicare-covered individual or group therapy visit. | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$40 copay for Medicare-covered individual or group visits. | |||||
Outpatient Hospital Services | |||||
Authorization rules may apply. | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit. | |||||
20% to 30% of the cost for each Medicare-covered outpatient hospital facility visit. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
Worldwide coverage. | |||||
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$40 copay for Medicare-covered Occupational Therapy visits. | |||||
$40 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$40 copay for Medicare-covered Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Diabetes self-monitoring training. | |||||
$0 copay for Nutrition Therapy for Diabetes. | |||||
$0 copay for Diabetes supplies. | |||||
Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams | |||||
Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
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Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
Authorization rules may apply. | |||||
20% of the cost for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$40 copay for Medicare-covered dental benefits. | |||||
Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
Hearing Services | |||||
In general routine hearing exams and hearing aids not covered. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
| |||||
Separate Office Visit cost sharing of $20 to $40 may apply. | |||||
Physical Exams | |||||
When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests. | |||||
Health/Wellness Education | |||||
$0 copay for each Medicare-covered smoking cessation counseling session. | |||||
$0 copay for each Medicare-covered HIV screening. | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
Point of Service | |||||
Authorization rules may apply. | |||||
Point of Service coverage is available for the following benefits:
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$1 600 copay per hospital stay. | |||||
$1 600 per Inpatient Psychiatric Hospital stay. | |||||
For each SNF stay: | |||||
Days 1 - 100: $50 copay per SNF day | |||||
$0 copay for
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30% of the cost for
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20% of the cost for
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20% to 40% of the cost for
| |||||
50% of the cost for
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