1. Care In a Hospital
You are covered for Medically Necessary care as an inpatient in a Hospital if all the following conditions are met:
- Except if you are admitted to the Hospital in an Emergency or your PCP has arranged for your admission to a non-Participating Hospital, the Hospital must be a Participating Hospital.
- Except in an emergency, your admission is authorized in advance by your PCP.
- You must be a registered bed patient for the proper treatment of an illness, injury or condition that cannot be treated on an outpatient basis.
2. Covered Inpatient Services
Covered inpatient services under this Contract include the following:
- Daily bed and board, including special diet and nutritional therapy;
- General, special and critical care nursing service, but not private duty nursing service;
- Facilities, services, supplies and equipment related to surgical operations, recovery facilities, anesthesia, and facilities for intensive or special care;
- Oxygen and other inhalation therapeutic services and supplies;
- Drugs and medications that are not experimental;
- Sera, biologicals, vaccines, intravenous preparations, dressings, casts, and materials for diagnostic studies;
- Blood products, except when participating in a volunteer blood replacement program is available;
- Facilities, services, supplies and equipment related to diagnostic studies and the monitoring of physiologic functions, including but not limited to laboratory, pathology, cardiographic, endoscopic, radiologic and electroencephalographic studies and examinations;
- Facilities, services and supplies related to physical medicine and occupational therapy and rehabilitation;
- Facilities, services and supplies and equipment related to radiation and nuclear therapy;
- Facilities, services, supplies and equipment related to emergency medical care;
- Facilities, services, supplies and equipment related to mental health, substance abuse and alcohol abuse services;
- Radiation therapy; and
- Any additional medical, surgical, or related services, supplies and equipment that are customarily furnished by the Hospital, except to the extent that they are excluded by this Contract.
3. Maternity Care
Other than for perinatal complications, we will pay for inpatient hospital care for at least 48 hours after childbirth for any delivery other than for a Cesarean Section. We will pay for inpatient hospital care for at least 96 hours after a Cesarean Section. Maternity care coverage includes parent education, assistance and training in breast or bottle feeding and performance of necessary maternal and newborn clinical assessments.
You have the option to be discharged earlier than 48 hours (96 hours for Cesarean Section). If you choose an early discharge, we will pay for one home care visit if you ask us within 48 hours of the delivery hours (96 hours for Cesarean Section). The home care visit will be delivered within 24 hours of the later of your discharge from the Hospital or your request for home care. The home care visit will be in addition to the home care visits covered under Section Seven of this Contract.
4. Limitations and Exclusions
- We will not provide any benefits for any day that you are out of the hospital, even for a portion of the day. We will not provide benefits for any day when inpatient care was not medically necessary.
- Benefits are paid in full for a semi-private room. If you are in a private room at a Hospital, the difference between the cost of a private room and a semi-private room must be paid by you unless the private room is medically necessary and ordered by your physician.
- We will not pay for non-medical items such as television rental or telephone charges.
1. Your PCP Must Provide, Arrange or Authorize all Medical Services
Except in an emergency or for certain obstetric and gynecological services, you are covered for the medical services listed below only if your PCP provides, arranges or authorizes the services. You are entitled to medical services provided at one of the following locations:
- Your PCP's office
- Another provider's office or a facility if your PCP determines that care from that provider or facility is appropriate for the treatment for your condition.
- The outpatient department of a Hospital.
- As an inpatient in a Hospital, you are entitled to medical, surgical and anesthesia services.
2. Covered Medical
We will pay for the following medical services:
- General medical and specialist care, including consultations.
- Preventative health services and physical examinations. We will pay for preventative health services including:
- Well child visits in accordance with the visitation schedule established by the American Academy of Pediatrics,
- Nutrition education and counseling,
- Hearing Testing,
- Medical social services,
- Eye screening,
- Routine immunizations in accordance with the New York State Department of Health recommended immunization schedule,
- Tuberculin testing,
- Dental and developmental screening,
- Clinical laboratory and radiological testing; and
- Lead screening,
- Diagnosis and treatment of illness, injury or other conditions.We will pay for the diagnosis and treatment of illness or injury including:
- Outpatient surgery performed in a provider's office or at an ambulatory surgery center, including anesthesia services,
- Laboratory tests, x-rays and other diagnostic procedures,
- Renal dialysis,
- Radiation therapy,
- Injections and medications administered in a physician's office,
- Second surgical opinion from a board certified specialist,
- Second medical opinion provided by an appropriate specialist, including one affiliated with a specialty care center, where there has been a positive or negative diagnosis of cancer, or a recommendation of a course of treatment of cancer, and
- Medically necessary audiometric testing.
- Physical and Occupational Therapy. We will pay for Short Term physical and occupational therapy services. The therapy must be a skilled therapy. Short Term means services and treatments provided for no longer than six weeks.
- Radiation Therapy, Chemotherapy and Hemodialysis. We will pay for radiation therapy and chemotherapy, including injections and medications provided at the time of therapy. We will pay for hemodialysis services in your home or at a facility, whichever we deem appropriate.
- Obstetrical and Gynecological Services including prenatal, labor and delivery and postpartum services are covered with respect to pregnancy. You do not need your PCP's authorization for care related to pregnancy if you seek care from a qualified Participating Provider of obstetric and gynecological services. You may also receive the following services from a qualified Participating Provider of obstetric and gynecologic services without your PCP's authorization:
- Up to two annual examinations for primary and preventative obstetric and gynecologic care; and
- Care required as a result of the annual examination or as a result of an acute obstetric gynecological condition.
- Cervical Cancer Screening. If you are a female who is eighteen years old, we will pay for an annual cervical cancer screening. We will pay for an annual pelvic examination, Pap smear and evaluation of the Pap smear.
1. Hospital Emergency Room Visits
We will pay for Emergency Services provided in a Hospital emergency room. You may go directly to any emergency room to seek care. You do not have to call your PCP first. Emergency care is not subject to our prior approval.
If you go to the emergency room, you or someone on your behalf must notify us within 48 hours of your visit or as soon as it is reasonably possible. If, in our sole judgment, the emergency room services rendered were not in treatment of an Emergency Condition as defined in Section One, the visit to the emergency room will not be covered.
2. Emergency Hospital Admissions
If you are admitted to the Hospital you or someone on your behalf must notify us within 48 hours of your admission, or as soon as it is reasonably possible. If you are admitted to a non-Participating Hospital, we may require that you be moved to a Participating Hospital as soon as your condition permits.
MENTAL HEALTH AND ALCOHOL AND SUBSTANCE ABUSE SERVICES
1. Inpatient Mental Health and Alcohol and Abuse Services
We will pay for a combined thirty days per calendar year for inpatient mental health services, inpatient detoxification and inpatient rehabilitation when such services are provided in a facility that is:
- Operated by the Office of Mental Health under sec. 7.17 of the Mental Hygiene Law;
- Issuing an operating certificate pursuant to Article 23 or Article 31 of the Mental Hygiene Law; or
- A general hospital as defined in Article 28 of the Public Health Law.
2. Outpatient Visits For Treatment of Mental Health Conditions and For Treatment of Alcoholism and Substance Abuse.
We will pay for an aggregate of sixty outpatient visits in each calendar year for the diagnosis and treatment of alcohol and substance abuse and mental illness. Visits are available to your family members if such services are related to your alcoholism or substance abuse.
If you need these services, please call the Fidelis Care Member Services Department at 1-888-FIDELIS.
1. Diabetic Equipment and Supplies
We will pay for the following equipment and supplies for the treatment of diabetes which are Medically Necessary and prescribed or recommended by your PCP or other Participating Provider legally authorized to prescribe to under Title 8 of the New York State Education Law:
- Blood glucose monitors;
- Blood glucose monitors for legally blind;
- Data management systems;
- Test strips for monitoring and visual reading;
- Urine test strips;
- Injection aids;
- Cartridges for legally blind;
- Insulin pumps and appurtenances thereto;
- Insulin infusion devices;
- Oral agents; and
- Additional equipment and supplies designated by the Commissioner of Health as appropriate for the treatment of diabetes.
2. Diabetes Self Management Education
We will pay for diabetes self management education provided by your PCP or another Participating Provider.
Education will be provided upon the diagnosis of diabetes, a significant change in your condition, the onset of a condition which makes changes in self-management necessary or where re-education is medically necessary as determined by us. We will also pay for home visits if medically necessary.
3. Durable Medical Equipment, Prosthetic Appliances, and Orthotic Devices
- Durable Medical Equipment
We will pay for devices and equipment ordered by a participating provider, including equipment servicing, for the treatment of a specific medical condition. Covered durable medical equipment includes:
- Hospital beds and accessories;
- Oxygen and oxygen supplies;
- Pressure pads;
- Volume ventilators;
- Therapeutic ventilators;
- Nebulizers and other equipment for respiratory care;
- Traction equipment;
- Walkers, wheelchairs and accessories;
- Commode chairs and toilet rails;
- Apnea monitors;
- Patient lifts;
- Nutrition infusion pumps; and
- Ambulatory infusion pumps.
- Prosthetic Appliances
We will pay for appliances and devices ordered by a qualified practitioner which replace any missing part of the body, except that there is no coverage for cranial prostheses (i.e. wigs). Further, dental prostheses are excluded from coverage under this section, except those: (1) made necessary due to an accidental injury to sound natural teeth and treatment is provided within twelve months of the accident and/ or (2) needed in the treatment of a congenital abnormality or as part of reconstructive surgery.
- Orthotic Devices
We will pay for devices which are used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body. There is no coverage for orthotic devices that are prescribed solely for use during sports.
4. Prescription and Non-prescription Drugs
- Scope of Coverage
We will pay for those FDA approved drugs, which require a prescription and which are listed in our formulary. Vitamins are not covered except when necessary to treat a diagnostic condition. We will pay for those non-prescription drugs which are authorized by a professional licensed to write prescription and which appear in the Medicaid drug formulary. We will also pay for medically necessary enteral formulas for the treatment of specific diseases and for modified solid food products used in the treatment of certain inherited diseases of amino acid and organic acid metabolism. Coverage for modified solid food products shall not exceed $2,500 per calendar year.
- Participating Pharmacy
We will only pay for prescription drugs and non-prescription drugs for use outside of a Hospital. Except in an emergency, the prescription must be issued by a Participating Provider and filled at a Participating Pharmacy.
- Exclusions and Limitations
Under this Section we will not pay for the following:
- Administration or injection of any drugs.
- Replacement of lost or stolen prescriptions.
- Prescribed drugs used for cosmetic purposes only.
- Experimental or investigational drugs.
- Nutritional supplements taken electively.
- Non-FDA approved drugs except that we will pay for a prescription drug that is approved by the FDA for treatment of cancer when the drug is prescribed for a different type of cancer than the type of which FDA approval was obtained. However the drug must be recognized for treatment of the type of cancer for which it has been prescribed by one of these publications:
- AMA Drug Evaluations;
- American Hospital Formulary Service;
- U.S. Phamacopoeia Drug Information; or
- A review article or editorial comment in a major peer-reviewed professional journal.
- Devices and supplies of any kind.
- See Subscriber Contract/Family Planning for information on how to obtain such services.
5. Home Health Care
We will pay for up to forty visits per calendar year for home health care provided by a certified home health agency that is a Participating Provider. We will pay for home health care only if you would have to be admitted to a Hospital if home care was not provided.
Home care includes one or more of the following services:
- Part-time or intermittent home nursing care by or under the supervision of a registered professional nurse;
- Part-time or intermittent home health aide services which consist primarily of caring for the patient;
- Physical, occupational or speech therapy if provided by the home health agency; and
- Medical supplies, drugs and medications prescribed by a physician and laboratory services by or on behalf of a certified home health agency to the extent such items would have been covered if the covered person had been in a Hospital.
6. Preadmission Testing
We will pay for preadmission testing when performed at the Hospital where surgery is scheduled to take place, if:
- Reservation for a Hospital bed and for an operating room at that Hospital have been made, prior to performance of tests;
- Your physician has ordered the tests; and
- Surgery actually takes place within seven days of such preadmission tests.
If surgery is cancelled because of the preadmission test findings, we will still cover the cost of these tests.
7. Speech and hearing
We will pay for speech and hearing services, including hearing aids, hearing aid batteries, and repairs. These services include one hearing examination per year to determine the need for corrective action. Speech therapy required for a condition amenable to significant clinical improvement within a two-month period, beginning with the first day of therapy, will be covered when performed by an audiologist, language pathologist, a speech therapist, and/or otolaryngologist.
8. Hospice Services
Hospice services include palliative and supportive care provided to a patient to meet the special needs arising out of physical, psychological, spiritual, social and economic stress, which are experienced during the final stages of illness and during dying and bereavement. Hospice organizations must be certified under Article 40 of the NYS Public Health Law. All services must be provided by qualified employees and volunteers of the hospice or by qualified staff through contractual arrangement to the extent permitted by federal and state requirement. All services must be provided according to a written plan of care, which reflects the changing needs to the patient/family. Family members are eligible for up to five visits for bereavement counseling.
1. Emergency, Preventative and Routine Vision Care
We will pay for emergency preventative, and routine vision care. You do not need your PCP's authorization for covered vision care if you seek care from a qualified Participating Provider of vision care services.
2. Vision Examinations
We will pay for vision examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses. We will pay for one vision examination in any twelve (12) month period, unless required more frequently with the appropriate documentation. The vision examination may include, but is not limited to:
- Case history;
- External examination of the eye or internal examination of the eye
- Opthalmoscopic exam
- Determination of refractive status
- Binocular distance
- Tonometry tests for glaucoma
- Gross visual fields and color vision testing
- Summary findings and recommendation for corrective lenses
3. Prescribed Lenses
We will pay for quality standard lenses once in any twelve (12) month period, unless required more frequently with appropriate documentation. Prescription lenses may by constructed of either glass or plastic.
We will pay for standard frames adequate to hold lenses once in any twelve (12) month period, unless required more frequently with appropriate documentation.
5. Contact Lenses
We will pay for contact lenses only when deemed medically necessary.
Fidelis Care New York uses a company called Davis Vision to manage our vision benefits. To find out which Davis Vision provider is nearest to your home, please call the Fidelis Care New York member services department at 1-888-FIDELIS (1-888-343-3547).
1. Dental Care
We will pay for the dental care services set forth in this contract when you seek care from a qualified Participating Provider of dental services.
2. Emergency Dental Care
We will pay for emergency dental care, which includes emergency treatment required to alleviate pain and suffering caused by dental disease or trauma.
3. Preventative Dental Care
We will pay for preventative dental care, which includes procedures which help to prevent oral disease from occurring including:
- Prophylasis (scaling and polishing the teeth at six (6) month intervals);
- Topical fluoride application at six (6) month intervals where the local water supply is not fluoridated;
- Sealants on unrestored permanent molar teeth.
4. Routine Dental Care
We will pay for routine dental care, including:
- Dental examinations, visits and consultations covered once within a six (6) month consecutive period (when primary teeth erupt);
- X-ray, full mouth x-rays at thirty-six (36) month intervals if necessary, bitewing x-rays at six (6) to twelve (12) month intervals, or panoramic x-rays at thirty-six (36) month intervals if necessary, and other x-rays as required (once teeth erupt);
- All necessary procedures for simple extractions and other routine dental surgery not requiring hospitalization, including preoperative care and postoperative care;
- In-office conscious sedation;
- Amalgam, composite restorations and stainless steel crowns; and
- Other restorative materials appropriate for children.
We will pay for endodontic services, including all necessary procedures for treatment of diseased pulp chamber and pulp canals, where hospitalization is not required.
We will pay for periodontal services, except for those services in anticipation of, or leading to, orthodontia.
We will pay for prosthodontic services as follows:
- Removable complete or partial dentures, including six (6) months follow up care. Additional services include insertion of identification slips, repairs, relines and rebases;
- Fixed bridges are not covered unless they are required:- For replacement of a single upper anterior (central/lateral incisor or cusid) in a patient with an otherwise full compliment of natural, functional and/or restored teeth;
- For cleft-palate stabilization; or
- Due to the presence of any neurologic or physiologic condition that would preclude the placement of removable prosthesis, as demonstrated by medical documentation.
- Unilateral or bilateral space maintainers will be covered for placement in a restored deciduous and/or mixed dentition to maintain space for normally developing permanent teeth.
- Orthodontia is not a covered service.
Fidelis Care New York uses a company called DentaQuest to manage your dental care. You must use a DentaQuest dentist for your dental care. If you have any questions related to your dental care, please call us at 1-888-FIDELIS (1-888-343-3547).