Fidelis Care FIDA Plan: Summary of Benefits

Transcription

1 Fidelis Care FIDA Plan: Summary f Benefits H1916_FC FIDA R1_Accepted This is a summary f health services cvered by Fidelis Care FIDA Plan fr This is nly a summary. Please read the Participant Handbk fr the full list f benefits. Fidelis Care FIDA Plan is a managed care plan that cntracts with bth Medicare and the New Yrk State Department f Health (Medicaid) t prvide benefits f bth prgrams t Participants thrugh the Fully Integrated Duals Advantage (FIDA) Demnstratin. It is fr peple with bth Medicare and Medicaid and wh meet ther eligibility requirements fr the FIDA Demnstratin. Under Fidelis Care FIDA Plan yu can get yur Medicare and Medicaid services in ne managed care plan called a FIDA Plan. A Fidelis Care FIDA Plan Care Manager will help manage yur care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Participant Handbk. Limitatins and restrictins may apply. Fr mre infrmatin, call Fidelis Care FIDA Plan Participant Services r read the Fidelis Care FIDA Plan Participant Handbk. This means that yu need t fllw certain rules t have Fidelis Care FIDA Plan pay fr yur services. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits may change n January 1 f each year. Yu can get this infrmatin fr free in ther languages. Call r (TTY) between 8 AM and 8 PM Mnday thrugh Friday. The call is free. Usted puede btener esta infrmación de frma gratuita en trs idimas. Llame al al (TTY) entre las 8 a.m. y las 8 p.m., de lunes a viernes. La llamada es gratuita. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 1

2 È pssibile ttenere queste infrmazini gratuitamente in altre lingue. Telefnare al numer ppure (TTY) tra le 8 e le 20 da lunedì a venerdì. La telefnata è gratuita. Вы можете получить данную информацию бесплатно на других языках. Звоните или (Телетайп) с 8:00 до 20:00 с понедельника по пятницу. Звонок бесплатный. 您可以通過其他語言免費獲取該信息 週一至週五上午 8 點至晚 8 點, 撥打 或 該電話免費 다른언어로된정보를무료로받을수있습니다. 월 ~ 금요일오전 8 시에서오후 8 시까지 또는 (TTY) 로전화해주십시오. 통화는무료입니다. Ou kapab jwenn enfòmasyn sa gratis nan lòt lang y. Rele swa (TTY) ant 8 AM ak 8 PM Lendi jiska Vandredi. Apèl la gratis. Yu can get this infrmatin fr free in ther frmats, such as large print, braille, r audi. Call (TTY: ) Mnday thrugh Friday, frm 8 AM t 8 PM. The call is free. When Fidelis calls yu as a newly enrlled Participant t welcme yu t the FIDA plan, we will ask yu t cnfirm yur preferred language r ther frmat t receive written materials. Fidelis will stre this infrmatin and send yu materials in this language r alternative frmat ging frward. Yu can request t receive yur materials in a different language r alternative frmat at any time by calling (TTY: ) Mnday thrugh Friday, frm 8 AM t 8 PM. The call is free. The State f New Yrk has created a participant mbudsman prgram called the Independent Cnsumer Advcacy Netwrk (ICAN) t prvide Participants free, cnfidential assistance n any services ffered by Fidelis Care FIDA Plan. ICAN may be reached tll-free at between 8 AM t 8 PM Mnday thrugh Friday, r nline at (TTY users call 711, then fllw the prmpts t dial ) If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 2

3 The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Fully Integrated Duals Advantage (FIDA) Plan What is a Fidelis Care FIDA Plan Care Manager and Interdisciplinary Team (IDT) Answers A Fully Integrated Duals Advantage (FIDA) Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has Care Managers and Interdisciplinary Teams t help yu plan and manage all yur prviders and services. They all wrk tgether t prvide the care yu need. Fidelis Care FIDA Plan is a FIDA Plan that prvides benefits f Medicaid and Medicare t Participants in the FIDA Demnstratin. A Fidelis Care FIDA Plan Care Manager is ne main persn that yu may cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. This persn is part f yur Interdisciplinary Team (IDT), which als includes yu and yur designee(s) Yu may als chse t have any f the fllwing peple participate in any r all f yur IDT meetings: Yur Primary Care Prvider (PCP) r a designee frm yur PCP s ffice (r practice) wh has clinical experience and knwledge f yur needs; Yur Behaviral Health (BH) Prfessinal, if yu have ne, r a designee frm yur BH Prfessinal s ffice (r practice) wh has clinical experience and knwledge f yur needs; Yur hme care aide(s), r a designee with clinical experience frm the hme care agency wh has knwledge f yur needs, if yu are getting hme care; A clinical representative frm yur nursing facility, if getting nursing facility care; and Additinal individuals including:» Other prviders either as asked fr by yu r yur designee, r as recmmended by the IDT members as necessary fr adequate care planning and apprved by yu r yur designee; r» The registered nurse (RN) wh cmpleted yur assessment If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 3

4 Frequently Asked Questins (FAQ) What are lng-term services and supprts Can I direct my wn care r hire my wn aides Will yu get the same Medicare and Medicaid benefits in Fidelis Care FIDA Plan that yu get nw Answers Lng-term services and supprts are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing facility r hspital. Yu have the right t chse t direct yur wn care by selecting Cnsumer Directed Persnal Assistance Services (CDPAS). Thrugh CDPAS, yu can hire yur wn aides and make ther decisins abut hw t get services. Yu will get yur cvered Medicare and Medicaid benefits directly frm Fidelis Care FIDA Plan. Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. Yu will get almst all f yur cvered Medicare and Medicaid benefits directly frm Fidelis Care FIDA Plan, but yu will get fur benefits the same way yu d nw, utside f the plan. These benefits include: Hspice, Out-f-Netwrk Family Planning Services, Methadne Maintenance Treatment Prgram, and Directly Observed Therapy fr Tuberculsis Disease. When yu enrll in Fidelis Care FIDA Plan, yu and yur Interdisciplinary Team (IDT) will wrk tgether t develp a Persn-Centered Service Plan (PCSP) t address yur health and supprt needs. When yu first enrll in Fidelis Care FIDA Plan, yu can keep seeing yur dctrs and getting yur current services fr 90 days, r until yur PCSP is cmplete, whichever is later. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Fidelis Care FIDA Plan des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Fidelis Care FIDA Plan t cver yur drug, if medically necessary. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 4

5 Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw Can yu remain in the same nursing facility yu live in nw What happens if yu need a service but n ne in Fidelis Care FIDA Plan Plan s netwrk can prvide it Where is Fidelis Care FIDA Plan available Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with Fidelis Care FIDA Plan and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in Fidelis Care FIDA Plan s netwrk, unless Fidelis Care FIDA Plan r yur IDT has authrized yu t see an ut-f-netwrk prvider. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f Fidelis Care FIDA Plan. T find ut if yur dctrs are in the plan s netwrk, call Participant Services r read Fidelis Care FIDA Plan Plan s Prvider and Pharmacy Directry. If Fidelis Care FIDA Plan is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr 90 days r until yur Persn-Centered Service Plan is cmplete, whichever is later. If yu currently get behaviral health services, yur Interdisciplinary Team (IDT) will review yur current episde f care t decide if yu can cntinue the services with the same prvider yu see nw. If they decide yu can see the same prvider yu see nw, yu will be able t see that prvider fr 24 mnths fllwing yur enrllment in Fidelis Care FIDA Plan. Yes. If yu live in a nursing facility when yu enrll in Fidelis Care FIDA Plan, yu can remain in that nursing facility fr the entire time that yu are in a FIDA Plan like Fidelis Care FIDA Plan, even if that nursing facility is ut-f-netwrk and des nt participate with Fidelis Care FIDA Plan. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, Fidelis Care FIDA Plan will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes: Brnx, Kings, Nassau, New Yrk, Queens, and Richmnd Cunties, NY. Yu must live in these areas t jin the plan. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 5

6 Frequently Asked Questins (FAQ) D yu pay a mnthly amunt (als called a premium) under Fidelis Care FIDA Plan What is prir authrizatin What is a referral Answers Yu will nt pay any mnthly premiums t Fidelis Care FIDA Plan fr yur cverage. Yu als will nt have any cpays r ther csts when yu get care frm netwrk prviders. Prir authrizatin means that yu must get apprval frm Fidelis Care FIDA Plan r yur Interdisciplinary Team (IDT) befre yu can get a specific service, item, r drug r befre yu can see an ut-f-netwrk prvider. Fidelis Care FIDA Plan may nt cver the service, item, r drug if yu dn t get apprval frm Fidelis Care FIDA Plan r yur IDT. A small number f services require prir authrizatin by a specialist and nt by Fidelis Care FIDA Plan r yur IDT. Please refer t Chapter 4 f yur Participant Handbk fr mre infrmatin. Fidelis Care FIDA Plan can als prvide yu with a list f services r prcedures that require yu t get prir authrizatin frm a prvider ther than yur IDT. Sme services d nt require any prir authrizatin, such as emergency r urgently needed care, ut-f-area dialysis services, primary care prvider visits, and wmen s health specialist services. Fr the full list f services that d nt require prir authrizatin, please see Chapter 4 f yur Participant Handbk r call Fidelis Care FIDA Plan. A referral means that yur Primary Care Prvider gives yu apprval t see smene that is nt yur Primary Care Prvider. Referrals are nt necessary in Fidelis Care FIDA Plan and will nt be required. Hwever, prir authrizatin rules must be fllwed. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 6

7 Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help Answers If yu have general questins r questins abut ur plan, services, service area, billing, r Participant ID Cards, please call Fidelis Care FIDA Plan Participant Services: CALL TTY , 8 AM t 8 PM Mnday thrugh Friday Calls t this number are free. Yu can als visit fideliscare.rg. Participant Services als has free language interpreter services available fr peple wh d nt speak English , 8 AM t 8 PM Mnday thrugh Friday Calls t this number are free. Yu can als visit fideliscare.rg. If yu have questins abut yur health, please call the Nurse Advice Call line: CALL TTY , 8 AM t 8 PM Mnday thrugh Friday Calls t this number are free , 8 AM t 8 PM Mnday thrugh Friday Calls t this number are free. Wh shuld yu cntact if yu have questins r need help (cntinued) If yu need immediate behaviral health services, please call the Behaviral Health Crisis Line: CALL TTY , 8 AM t 8 PM Mnday thrugh Friday Calls t this number are free. On-call emergency services are available after hurs, hlidays, and weekends by dialing the same tll free number and fllwing the vice prmpts t reach the n-call services , 8 AM t 8 PM Mnday thrugh Friday Calls t this number are free. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 7

8 The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Call Participant Services r read the Participant Handbk t find ut abut ther cvered services. Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu want t see a dctr Visits t treat an injury r illness $0 Authrizatin rules may apply Wellness visits, such as a physical $0 In-netwrk nly Transprtatin t a dctr s ffice $0 Authrizatin rules may apply Specialist care $0 Authrizatin rules may apply Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 In-netwrk nly $0 In-netwrk nly Yu need medical tests Lab tests, such as bld wrk $0 Authrizatin rules may apply X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 Authrizatin rules may apply $0 Authrizatin rules may apply If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 8

9 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin Generic drugs (n brand name) $0 fr a 30-day r 90-day supply at a netwrk pharmacy r thrugh mailrder. There may be limitatins n the types f drugs cvered. Please see Fidelis Care FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. $0 fr a 34-day r 90-day supply at a netwrk lng-term care pharmacy. $0 fr up t a 30-day supply at ut-fnetwrk pharmacies. Cverage is limited t certain cases. See Chapter 5 Sectin TBD (will fill in sectin reference when chapter is available) fr details. Brand name drugs $0 fr a 30-day r 90-day supply at a netwrk pharmacy r thrugh mailrder. There may be limitatins n the types f drugs cvered. Please see Fidelis Care FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. $0 fr a 34-day r 90-day supply at a netwrk lng-term care pharmacy. $0 fr up t a 30-day supply at ut-fnetwrk pharmacies. Cverage is limited t certain cases. See Chapter 5 Sectin TBD (will fill in sectin reference when chapter is available) fr details. Yu need drugs t treat yur illness r cnditin (cntinued) Over-the-cunter drugs $0 Fidelis Care FIDA Plan cvers sme OTC drugs when they are written as prescriptins by yur prvider. Please see Fidelis Care FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 9

10 Health need r prblem Yu need therapy after a strke r accident Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Medicare Part B prescriptin drugs $0 Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Participant Handbk fr mre infrmatin n these drugs. Occupatinal, physical, r speech therapy $0 Authrizatin rules may apply Yu need emergency care Emergency rm services $0 N limitatins. Emergency rm services will be prvided bth in and ut f netwrk withut prir authrizatin. Ambulance services $0 Authrizatin rules may apply Urgent care $0 N limitatins. Urgent Care services will be prvided bth in and ut f netwrk withut prir authrizatin. Yu need hspital care Hspital stay $0 Authrizatin rules may apply Dctr r surgen care $0 Authrizatin rules may apply Yu need help getting better r have special health needs Rehabilitatin services $0 Authrizatin rules may apply Medical equipment fr hme care $0 Authrizatin rules may apply Skilled nursing care $0 Authrizatin rules may apply Yu need eye care Eye exams $0 In-netwrk nly Glasses r cntact lenses $0 In-netwrk nly Yu need dental care Dental check-ups $0 In-netwrk nly If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 10

11 Health need r prblem Yu need hearing/auditry services Yu have a chrnic cnditin, such as diabetes r heart disease Yu have a mental health cnditin Yu have a substance abuse prblem Yu need lng-term mental health services Services yu may need Yur csts fr in-netwrk prviders Hearing screenings $0 In-netwrk nly Hearing aids $0 In-netwrk nly Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Services t help manage yur disease $0 Authrizatin rules may apply Diabetes supplies and services $0 Authrizatin rules may apply Mental r behaviral health services $0 Authrizatin rules may apply Substance abuse services $0 Authrizatin rules may apply Inpatient care fr peple wh need mental health care $0 Authrizatin rules may apply If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 11

12 Health need r prblem Yu need durable medical equipment (DME) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wheelchairs $0 Authrizatin rules may apply Canes $0 Authrizatin rules may apply Crutches $0 Authrizatin rules may apply Walkers $0 Authrizatin rules may apply Oxygen $0 Authrizatin rules may apply Yu need help living at hme Yu need a place t live with peple available t help yu Meals brught t yur hme $0 In-netwrk nly Hme services, such as cleaning r husekeeping Changes t yur hme, such as ramps and wheelchair access Persnal care assistant (Yu may be able t emply yur wn assistant. Call Participant Services fr mre infrmatin.) $0 In-netwrk nly $0 In-netwrk nly $0 In-netwrk nly Training t help yu get paid r unpaid jbs $0 In-netwrk nly Hme health care services $0 In-netwrk nly Services t help yu live n yur wn $0 In-netwrk nly Adult day services r ther supprt services $0 In-netwrk nly Assisted living r ther husing services $0 In-netwrk nly Nursing facility care $0 In-netwrk nly If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 12

13 Health need r prblem Yur caregiver needs sme time ff Services yu may need Yur csts fr in-netwrk prviders Respite care $0 In-netwrk nly Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Other services that Fidelis Care FIDA Plan cvers This is nt a cmplete list. Call Participant Services r read the Participant Handbk t find ut abut ther cvered services. Other services cvered by Fidelis Care FIDA Plan Yur csts fr in-netwrk prviders Cmprehensive Psychiatric Emergency Prgram (CPEP) $0 Crisis Interventin Services $0 Residential Addictin Services $0 Benefits cvered utside f Fidelis Care FIDA Plan This is nt a cmplete list. Call Participant Services t find ut abut ther services nt cvered by Fidelis Care FIDA Plan but available thrugh Medicare r Medicaid. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 13

14 Other services cvered by Medicare r Medicaid Yur csts Day Treatment $0 Freestanding birth center services $0 Out f netwrk family planning services $0 Methadne Maintenance Treatment Prgram (MMTP) $0 Directly bserved therapy fr tuberculsis (TB) $0 Hspice services $0 Services that Fidelis Care FIDA Plan, Medicare, and Medicaid d nt cver This is nt a cmplete list. Call Participant Services t find ut abut ther excluded services. Services nt cvered by Fidelis Care FIDA Plan, Medicare, r Medicaid A private rm in a hspital, except when it is medically needed Persnal items in yur rm at a hspital r a nursing facility, such as a telephne r a televisin Surgical treatment fr mrbid besity, except when it is medically needed and Medicare pays fr it Radial kerattmy, LASIK surgery, visin therapy, and ther lw-visin aids Supprtive devices fr the feet, except fr rthpedic r therapeutic shes fr peple with diabetic ft disease Acupuncture Services cnsidered nt medically necessary accrding t the standards f Medicare and Medicaid, unless these services are listed by ur plan as cvered services Elective r vluntary enhancement prcedures r services (including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, anti-aging and mental perfrmance), except when medically needed If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 14

15 Yur rights as a Participant f the plan As a Participant f Fidelis Care FIDA Plan, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur services frm Fidelis Care FIDA Plan. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Participant Handbk. This is nt a cmplete list f all yur rights. Yur rights include, but are nt limited t, the fllwing: If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 15

16 Yu have a right t respect, fairness and dignity. This includes the right t: Get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English Ask fr infrmatin in ther frmats (e.g., large print, braille, r audi) Be free frm any frm f restraint r seclusin Nt be billed by netwrk prviders Have yur questins and cncerns answered cmpletely and curteusly Freely apply yur rights withut any negative effect n the way Fidelis Care FIDA Plan r yur prvider treats yu Participate in Interdisciplinary Team meetings abut yur care Get yur cvered services and drugs quickly Knw abut all treatment ptins, n matter what they cst r whether they are cvered Refuse treatment, even if yur dctr advises against it Stp taking medicine Ask fr a secnd pinin. Fidelis Care FIDA Plan will pay fr the cst f yur secnd pinin visit Create and apply an advance directive, such as a living will r health care prxy Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t: Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services Get medical care timely Get in and ut f a health care prvider s ffice. This means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act Have interpreters t help with cmmunicatin with yur dctrs and yur health plan Hw much services will cst yu Names f prviders and care managers Yu have the right t seek emergency and urgent care when yu need it. This means yu have the right t: Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right t: Chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time Get emergency services withut prir apprval in an emergency See an ut f netwrk urgent r emergency care prvider, when necessary If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 16

17 Yu have a right t cnfidentiality and privacy. This includes the right t: Direct yur wn care r hire yur wn aides thrugh Cnsumer-Directed Persnal Assistance Services Ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected Have yur persnal health infrmatin kept private Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: File a cmplaint r grievance against us r ur prviders Get a detailed reasn fr why services were denied Fr mre infrmatin abut yur rights, yu can read the Fidelis Care FIDA Plan Participant Handbk. If yu have questins, yu can als call Fidelis Care FIDA Plan Participant Services. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 17

18 If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Fidelis Care FIDA Plan shuld cver smething we denied, call Fidelis Care FIDA Plan at (TTY: ). Yu may be able t appeal ur decisin. Fr questins abut grievances (cmplaints) and appeals, yu can read Chapter 9 f the Fidelis Care FIDA Plan Participant Handbk. Yu can als call Fidelis Care FIDA Plan Participant Services. Additinally, yu can get help frm the Independent Cnsumer Advcacy Netwrk (ICAN). ICAN can give yu free, cnfidential assistance n any services ffered by Fidelis Care FIDA Plan, including any prblems getting quality care. ICAN may be reached at tllfree at r nline at (TTY users call 711, then fllw the prmpts t dial ) If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at Fidelis Care FIDA Plan Participant Services. Phne numbers are n the cver f this summary. Or, call Medicare at MEDICARE ( ). TTY users shuld call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. If yu have questins, please call Fidelis Care FIDA Plan at (TTY: ) Mnday thrugh Friday, 8 AM t 8 PM. The call is free. Fr mre infrmatin, visit fideliscare.rg. 18

19 Fidelis Care cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. Fidelis Care des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. Fidelis Care: Prvides free aids and services t peple with disabilities t cmmunicate effectively with us, such as: Qualified sign language interpreters Written infrmatin in ther frmats (large print, audi, accessible electrnic frmats, ther frmats) Prvides free language services t peple whse primary language is nt English, such as: Qualified interpreters Infrmatin written in ther languages If yu need these services, cntact Fidelis Care Member Services Department at (TTY: ). If yu believe that Fidelis Care has failed t prvide these services r discriminated in anther way n the basis f race, clr, natinal rigin, age, disability, r sex, yu can file a grievance with: Rbert Fazzlari, Senir Vice President Queens Bulevard Reg Park, NY Phne: (TTY: ) Fax: rfazzlari@fideliscare.rg Yu can file a grievance in persn r by mail, fax, r . If yu need help filing a grievance, Fidelis Care Member Services at (TTY: ). is available t help yu. Yu can als file a civil rights cmplaint with the U.S. Department f Health and Human Services, Office fr Civil Rights, electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, available at r by mail r phne at: U.S. Department f Health and Human Services 200 Independence Avenue, SW Rm 509F, HHH Building Washingtn, D.C , (TDD) Cmplaint frms are available at

20 LANGUAGE ASSISTANCE H1916_FC FIDA English: ATTENTION: If yu speak English, language assistance services, free f charge, are available t yu. Call (TTY: ). Spanish: ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al (TTY: ). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). French Crele: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pu lang ki dispnib gratis pu u. Rele (TTY: ). Krean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Italian: ATTENZIONE: In cas la lingua parlata sia l'italian, sn dispnibili servizi di assistenza linguistica gratuiti. Chiamare il numer (TTY: ) خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں Yiddish: (TTY: ). Bengali: লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১ (TTY: ১ ) Plish: UWAGA: Jeżeli mówisz p plsku, mżesz skrzystać z bezpłatnej pmcy językwej. Zadzwń pd numer (TTY: ). )رقم هاتف ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم Arabic:.( (TTY: الصم والبكم:- French: ATTENTION : Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le (ATS : ) خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں Urdu: (TTY: ). Tagalg: PAUNAWA: Kung nagsasalita ka ng Tagalg, maaari kang gumamit ng mga serbisy ng tulng sa wika nang walang bayad. Tumawag sa (TTY: ). Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispzicin shërbime të asistencës gjuhësre, pa pagesë. Telefnni në (TTY: ).