new york quality healthcare corporation dba fidelis care ... · family $2,054.74 $1,695.86...
TRANSCRIPT
New York Quality Healthcare Corporation dba
Fidelis Care New York
Rate Manual - Individual Market
Effective Date: January 1, 2020
Table of Contents
Rate Pages Page 2-8
Counties Within Each Rating Region Page 9
Regional and Plan Variation Factors Page 10
HIOS ID Mapping Page 11
Form Numbers and Benefits Page 12-25
Rating Instructions and Example Page 26
Expected Loss Ratios Page 27
Broker Program Page 28
Page 1 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Base Rate
Albany
Metal Level Platinum Gold Silver Bronze Catastrophic
HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001
Individual $821.86 $678.32 $568.17 $399.67 $163.33
Ind+Sp $1,643.72 $1,356.64 $1,136.34 $799.34 $326.66
Ind+Ch(ren) $1,397.16 $1,153.14 $965.89 $679.44 $277.66
Family $2,342.30 $1,933.21 $1,619.28 $1,139.06 $465.49
Buffalo
Metal Level Platinum Gold Silver Bronze Catastrophic
HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001
Individual $720.96 $595.04 $498.42 $350.60 $143.27
Ind+Sp $1,441.92 $1,190.08 $996.84 $701.20 $286.54
Ind+Ch(ren) $1,225.63 $1,011.57 $847.31 $596.02 $243.56
Family $2,054.74 $1,695.86 $1,420.50 $999.21 $408.32
Long Island
Metal Level Platinum Gold Silver Bronze Catastrophic
HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001
Individual $846.01 $698.25 $584.86 $411.41 $168.12
Ind+Sp $1,692.02 $1,396.50 $1,169.72 $822.82 $336.24
Ind+Ch(ren) $1,438.22 $1,187.03 $994.26 $699.40 $285.80
Family $2,411.13 $1,990.01 $1,666.85 $1,172.52 $479.14
Mid-Hudson
Metal Level Platinum Gold Silver Bronze Catastrophic
HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001
Individual $940.87 $776.54 $650.44 $457.55 $186.98
Ind+Sp $1,881.74 $1,553.08 $1,300.88 $915.10 $373.96
Ind+Ch(ren) $1,599.48 $1,320.12 $1,105.75 $777.84 $317.87
Family $2,681.48 $2,213.14 $1,853.75 $1,304.02 $532.89
Page 2 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Base Rate
New York City
Metal Level Platinum Gold Silver Bronze Catastrophic
HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001
Individual $899.48 $742.38 $621.82 $437.42 $178.75
Ind+Sp $1,798.96 $1,484.76 $1,243.64 $874.84 $357.50
Ind+Ch(ren) $1,529.12 $1,262.05 $1,057.09 $743.61 $303.88
Family $2,563.52 $2,115.78 $1,772.19 $1,246.65 $509.44
Rochester
Metal Level Platinum Gold Silver Bronze Catastrophic
HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001
Individual $765.81 $632.05 $529.42 $372.42 $152.19
Ind+Sp $1,531.62 $1,264.10 $1,058.84 $744.84 $304.38
Ind+Ch(ren) $1,301.88 $1,074.49 $900.01 $633.11 $258.72
Family $2,182.56 $1,801.34 $1,508.85 $1,061.40 $433.74
Syracuse
Metal Level Platinum Gold Silver Bronze Catastrophic
HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001
Individual $827.04 $682.59 $571.74 $402.19 $164.36
Ind+Sp $1,654.08 $1,365.18 $1,143.48 $804.38 $328.72
Ind+Ch(ren) $1,405.97 $1,160.40 $971.96 $683.72 $279.41
Family $2,357.06 $1,945.38 $1,629.46 $1,146.24 $468.43
Metal Level Platinum Gold Silver Bronze Catastrophic
HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001
Individual $795.13 $656.26 $549.69 $386.67 $158.02
Ind+Sp $1,590.26 $1,312.52 $1,099.38 $773.34 $316.04
Ind+Ch(ren) $1,351.72 $1,115.64 $934.47 $657.34 $268.63
Family $2,266.12 $1,870.34 $1,566.62 $1,102.01 $450.36
Utica/Watertown
Page 3 of 28
Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29
HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001
Individual $862.95 $712.24 $596.58 $419.65 $728.01 $611.77
Ind+Sp $1,725.90 $1,424.48 $1,193.16 $839.30 $1,456.02 $1,223.54
Ind+Ch(ren) $1,467.02 $1,210.81 $1,014.19 $713.41 $1,237.62 $1,040.01
Family $2,459.41 $2,029.88 $1,700.25 $1,196.00 $2,074.83 $1,743.54
Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29
HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001
Individual $757.01 $624.79 $523.34 $368.13 $638.63 $536.67
Ind+Sp $1,514.02 $1,249.58 $1,046.68 $736.26 $1,277.26 $1,073.34
Ind+Ch(ren) $1,286.92 $1,062.14 $889.68 $625.82 $1,085.67 $912.34
Family $2,157.48 $1,780.65 $1,491.52 $1,049.17 $1,820.10 $1,529.51
Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29
HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001
Individual $888.31 $733.17 $614.11 $431.98 $749.39 $629.75
Ind+Sp $1,776.62 $1,466.34 $1,228.22 $863.96 $1,498.78 $1,259.50
Ind+Ch(ren) $1,510.13 $1,246.39 $1,043.99 $734.37 $1,273.96 $1,070.58
Family $2,531.68 $2,089.53 $1,750.21 $1,231.14 $2,135.76 $1,794.79
Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29
HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001
Individual $987.92 $815.37 $682.97 $480.43 $833.42 $700.36
Ind+Sp $1,975.84 $1,630.74 $1,365.94 $960.86 $1,666.84 $1,400.72
Ind+Ch(ren) $1,679.46 $1,386.13 $1,161.05 $816.73 $1,416.81 $1,190.61
Family $2,815.57 $2,323.80 $1,946.46 $1,369.23 $2,375.25 $1,996.03
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Includes Through Age 29 Rider
Albany
Buffalo
Long Island
Mid-Hudson
Page 4 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Includes Through Age 29 Rider
Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29
HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001
Individual $944.45 $779.50 $652.92 $459.29 $796.76 $669.54
Ind+Sp $1,888.90 $1,559.00 $1,305.84 $918.58 $1,593.52 $1,339.08
Ind+Ch(ren) $1,605.57 $1,325.15 $1,109.96 $780.79 $1,354.49 $1,138.22
Family $2,691.68 $2,221.58 $1,860.82 $1,308.98 $2,270.77 $1,908.19
Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29
HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001
Individual $804.10 $663.65 $555.88 $391.04 $678.36 $570.04
Ind+Sp $1,608.20 $1,327.30 $1,111.76 $782.08 $1,356.72 $1,140.08
Ind+Ch(ren) $1,366.97 $1,128.21 $945.00 $664.77 $1,153.21 $969.07
Family $2,291.69 $1,891.40 $1,584.26 $1,114.46 $1,933.33 $1,624.61
Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29
HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001
Individual $868.39 $716.72 $600.33 $422.30 $732.59 $615.63
Ind+Sp $1,736.78 $1,433.44 $1,200.66 $844.60 $1,465.18 $1,231.26
Ind+Ch(ren) $1,476.26 $1,218.42 $1,020.56 $717.91 $1,245.40 $1,046.57
Family $2,474.91 $2,042.65 $1,710.94 $1,203.56 $2,087.88 $1,754.55
Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29
HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001
Individual $834.88 $689.07 $577.17 $406.00 $704.33 $591.87
Ind+Sp $1,669.76 $1,378.14 $1,154.34 $812.00 $1,408.66 $1,183.74
Ind+Ch(ren) $1,419.30 $1,171.42 $981.19 $690.20 $1,197.36 $1,006.18
Family $2,379.41 $1,963.85 $1,644.93 $1,157.10 $2,007.34 $1,686.83
Syracuse
Utica/Watertown
New York City
Rochester
Page 5 of 28
Metal Level Platinum Gold Silver Bronze
HIOS ID 25303NY0080001 25303NY0070001 25303NY0060001 25303NY0050001
Albany $338.61 $279.47 $234.09 $164.66
Buffalo $297.04 $245.16 $205.35 $144.45
Long Island $348.56 $287.68 $240.96 $169.50
Mid-Hudson $387.64 $319.93 $267.98 $188.51
New York City $370.59 $305.86 $256.19 $180.22
Rochester $315.51 $260.40 $218.12 $153.44
Syracuse $340.74 $281.23 $235.56 $165.70
Utica/Watertown $327.59 $270.38 $226.47 $159.31
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Child Only Rate
Page 6 of 28
Metal Level Gold ADV Silver ADV
HIOS ID 25303NY0550001 25303NY0460001
Individual $693.34 $582.64
Ind+Sp $1,386.68 $1,165.28
Ind+Ch(ren) $1,178.68 $990.49
Family $1,976.02 $1,660.52
Metal Level Gold ADV Silver ADV
HIOS ID 25303NY0550001 25303NY0460001
Individual $608.22 $511.11
Ind+Sp $1,216.44 $1,022.22
Ind+Ch(ren) $1,033.97 $868.89
Family $1,733.43 $1,456.66
Metal Level Gold ADV Silver ADV
HIOS ID 25303NY0550001 25303NY0460001
Individual $713.71 $599.76
Ind+Sp $1,427.42 $1,199.52
Ind+Ch(ren) $1,213.31 $1,019.59
Family $2,034.07 $1,709.32
Metal Level Gold ADV Silver ADV
HIOS ID 25303NY0550001 25303NY0460001
Individual $793.74 $667.01
Ind+Sp $1,587.48 $1,334.02
Ind+Ch(ren) $1,349.36 $1,133.92
Family $2,262.16 $1,900.98
Albany
Buffalo
Long Island
Mid-Hudson
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Non-Standard Plan Rates
Page 7 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Non-Standard Plan Rates
Metal Level Gold ADV Silver ADV
HIOS ID 25303NY0550001 25303NY0460001
Individual $758.82 $637.67
Ind+Sp $1,517.64 $1,275.34
Ind+Ch(ren) $1,289.99 $1,084.04
Family $2,162.64 $1,817.36
Metal Level Gold ADV Silver ADV
HIOS ID 25303NY0550001 25303NY0460001
Individual $646.05 $542.90
Ind+Sp $1,292.10 $1,085.80
Ind+Ch(ren) $1,098.29 $922.93
Family $1,841.24 $1,547.27
Metal Level Gold ADV Silver ADV
HIOS ID 25303NY0550001 25303NY0460001
Individual $697.71 $586.31
Ind+Sp $1,395.42 $1,172.62
Ind+Ch(ren) $1,186.11 $996.73
Family $1,988.47 $1,670.98
Metal Level Gold ADV Silver ADV
HIOS ID 25303NY0550001 25303NY0460001
Individual $670.79 $563.69
Ind+Sp $1,341.58 $1,127.38
Ind+Ch(ren) $1,140.34 $958.27
Family $1,911.75 $1,606.52
Syracuse
Utica/Watertown
New York City
Rochester
Page 8 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Counties within each Rating Region
Albany Region Rochester Region
Albany Livingston
Columbia Monroe
Fulton Ontario
Greene Seneca
Montgomery Wayne
Rensselaer Yates
Saratoga
Schenectady Syracuse Region
Schoharie Broome
Warren Cayuga
Washington Chemung
Cortland
Buffalo Region Onondaga
Allegany Schuyler
Cattaraugus Steuben
Chautauqua Tioga
Erie Tompkins
Genesee
Niagara Utica/Watertown Region
Orleans Chenango
Wyoming Clinton
Essex
Long Island Region Franklin
Nassau Hamilton
Suffolk Herkimer
Jefferson
MidHudson Region Lewis
Delaware Madison
Dutchess Oneida
Orange Oswego
Putnam Otsego
Sullivan St. Lawrence
Ulster
New York City Region
Bronx
Kings
New York City
Queens
Richmond
Rockland
Westchester
Page 9 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Regional Factors
Region 2020 Regional Factors
Albany 0.949
Buffalo 0.832
Long Island 0.976
Mid-Hudson 1.086
New York City 1.038
Rochester 0.884
Syracuse 0.955
Utica/Watertown 0.918
Plan Variation Factors
Plan Description 2020 Adjustment Factors
With coverage through Age 26 Only 1.000
With Domestic Partner Coverage 1.000
Without Pediatric Dental Coverage 1.000
With coverage through Age 29 Only 1.050
Without Domestic Partner Coverage 1.000
With Pediatric Dental Coverage 1.000
Page 10 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
HIOS ID Mapping
HIOS ID Plan Name
25303NY0010001 Fidelis Care Bronze, Bronze, ST, INN, Pediatric Dental, Dep25, Free Telehealth
25303NY0020001 Fidelis Care Silver, Silver, ST, INN, Pediatric Dental, Dep25, Free Telehealth
25303NY0030001 Fidelis Care Gold, Gold, ST, INN, Pediatric Dental, Dep25, Free Telehealth
25303NY0040001 Fidelis Care Platinum, Platinum, ST, INN, Pediatric Dental, Dep25, Free Telehealth
25303NY0050001 Fidelis Care Bronze for Children, Child Only, ST, INN, Pediatric Dental, Free Telehealth
25303NY0060001 Fidelis Care Silver for Children, Child Only, ST, INN, Pediatric Dental, Free Telehealth
25303NY0070001 Fidelis Care Gold for Children, Child Only, ST, INN, Pediatric Dental, Free Telehealth
25303NY0080001 Fidelis Care Platinum for Children, Child Only, ST, INN, Pediatric Dental, Free Telehealth
25303NY0090001 Fidelis Care Catastrophic, Catastrophic, ST, INN, Pediatric Dental, Free Telehealth
25303NY0110001 Fidelis Care Bronze, Bronze, ST, INN, Pediatric Dental, Dep29, Free Telehealth
25303NY0140001 Fidelis Care Silver, Silver, ST, INN, Pediatric Dental, Dep29, Free Telehealth
25303NY0170001 Fidelis Care Gold, Gold, ST, INN, Pediatric Dental, Dep29, Free Telehealth
25303NY0200001 Fidelis Care Platinum, Platinum, ST, INN, Pediatric Dental, Dep29, Free Telehealth
25303NY0460001 Fidelis Care Silver Enhanced, Silver, NS, INN, Family Dental, Dep25, Family Vision, Free Telehealth
25303NY0500001 Fidelis Care Silver Enhanced, Silver, NS, INN, Family Dental, Dep29, Family Vision, Free Telehealth
25303NY0550001 Fidelis Care Gold Enhanced, Gold, NS, INN, Family Dental, Dep25, Family Vision, Free Telehealth
25303NY0560001 Fidelis Care Gold Enhanced, Gold, NS, INN, Family Dental, Dep29, Family Vision, Free Telehealth
Page 11 of 28
Fidelis Care New York
Rate Manual - Individual Market
2019
Rate Table Reference Marketing Name Subscriber Contract Schedule of Benefits
Platinum Fidelis Care Platinum Subscriber Contract_FC-HBX-001_5142018 FC-HBX-001-Platinum_5142018
Gold Fidelis Care Gold Subscriber Contract_FC-HBX-001_5142018 FC-HBX-001-Gold_5142018
Silver Fidelis Care Silver Subscriber Contract_FC-HBX-001_5142018 FC-HBX-001-Silver_5142018
Silver 250 Fidelis Care Silver Subscriber Contract_FC-HBX-001_5142018 FC-HBX-001-Silver 1_5142018
Silver 200 Fidelis Care Silver Subscriber Contract_FC-HBX-001_5142018 FC-HBX-001-Silver 2_5142018
Silver 150 Fidelis Care Silver Subscriber Contract_FC-HBX-001_5142018 FC-HBX-001-Silver 3_5142018
Bronze Fidelis Care Bronze Subscriber Contract_FC-HBX-001_5142018 FC-HBX-001-Bronze_5142018
Catastrophic Fidelis Care Catastrophic Coverage Subscriber Contract_FC-HBX-003_5142018 FC-HBX-003-Catastrophic_5142018
Platinum Child Only Fidelis Care Platinum for Children Subscriber Contract_FC-HBX-002_5142018 FC-HBX-002-Platinum_5142018
Gold Child Only Fidelis Care Gold for Children Subscriber Contract_FC-HBX-002_5142018 FC-HBX-002-Gold_5142018
Silver Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_5142018 FC-HBX-002-Silver_5142018
Silver 250 Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_5142018 FC-HBX-002-Silver 1_5142018
Silver 200 Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_5142018 FC-HBX-002-Silver 2_5142018
Silver 150 Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_5142018 FC-HBX-002-Silver 3_5142018
Bronze Child Only Fidelis Care Bronze for Children Subscriber Contract_FC-HBX-002_5142018 FC-HBX-002-Bronze_5142018
Platinum Fidelis Care Platinum Subscriber Contract_FC-HBX-006_5142018 FC-HBX-006-Platinum_5142018
Gold Fidelis Care Gold Subscriber Contract_FC-HBX-006_5142018 FC-HBX-006-Gold_5142018
Silver Fidelis Care Silver Subscriber Contract_FC-HBX-006_5142018 FC-HBX-006-Silver_5142018
Bronze Fidelis Care Bronze Subscriber Contract_FC-HBX-006_5142018 FC-HBX-006-Bronze_5142018
Catastrophic Fidelis Care Catastrophic Coverage Subscriber Contract_FC-HBX-008_5142018 FC-HBX-008-Catastrophic_5142018
Platinum Fidelis Care Platinum for Children Subscriber Contract_FC-HBX-007_5142018 FC-HBX-007-Platinum_5142018
Gold Fidelis Care Gold for Children Subscriber Contract_FC-HBX-007_5142018 FC-HBX-007-Gold_5142018
Silver Fidelis Care Silver for Children Subscriber Contract_FC-HBX-007_5142018 FC-HBX-007-Silver_5142018
Bronze Fidelis Care Bronze for Children Subscriber Contract_FC-HBX-007_5142018 FC-HBX-007-Bronze_5142018
Age 29 Rider is available for Platinum, Gold, Silver, Silver 250 and the Bronze plans.
Subscriber Contract_FC-HBX-004_5142018
An American Indian who earns less than 300% of the federal poverty level can be on a Bronze, Silver, Gold or Platinum plan. There will be no cost-sharing.
Fidelis Care [Metal Tier] Subscriber Contract_FC-HBX-005_5142018 Schedule of Benefits_FC-HBX-005-Zero Cost-Sharing_5142018
An American Indian who earns more than 300% of the federal poverty level can be on a Bronze, Silver, Gold, or Platinum plan. There will be no cost-sharing at certain providers.
Page 12 of 28
Fidelis Care New York
Rate Manual - Individual Market
2020
Rate Table Reference Marketing Name Subscriber Contract Schedule of Benefits
Platinum Fidelis Care Platinum Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Platinum_7152019
Gold Fidelis Care Gold Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Gold_7152019
Silver Fidelis Care Silver Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Silver_7152019
Silver 250 Fidelis Care Silver Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Silver 1_7152019
Silver 200 Fidelis Care Silver Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Silver 2_7152019
Silver 150 Fidelis Care Silver Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Silver 3_7152019
Bronze Fidelis Care Bronze Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Bronze_7152019
Catastrophic Fidelis Care Catastrophic Coverage Subscriber Contract_FC-HBX-003_852019 FC-HBX-003-Catastrophic_7152019
Platinum Child Only Fidelis Care Platinum for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Platinum_7152019
Gold Child Only Fidelis Care Gold for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Gold_7152019
Silver Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Silver_7152019
Silver 250 Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Silver 1_7152019
Silver 200 Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Silver 2_7152019
Silver 150 Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Silver 3_7152019
Bronze Child Only Fidelis Care Bronze for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Bronze_7152019
Platinum Fidelis Care Platinum Subscriber Contract_FC-HBX-006_852019 FC-HBX-006-Platinum_7152019
Gold Fidelis Care Gold Subscriber Contract_FC-HBX-006_852019 FC-HBX-006-Gold_7152019
Silver Fidelis Care Silver Subscriber Contract_FC-HBX-006_852019 FC-HBX-006-Silver_7152019
Bronze Fidelis Care Bronze Subscriber Contract_FC-HBX-006_852019 FC-HBX-006-Bronze_7152019
Catastrophic Fidelis Care Catastrophic Coverage Subscriber Contract_FC-HBX-008_852019 FC-HBX-008-Catastrophic_7152019
Platinum Fidelis Care Platinum for Children Subscriber Contract_FC-HBX-007_852019 FC-HBX-007-Platinum_7152019
Gold Fidelis Care Gold for Children Subscriber Contract_FC-HBX-007_852019 FC-HBX-007-Gold_7152019
Silver Fidelis Care Silver for Children Subscriber Contract_FC-HBX-007_852019 FC-HBX-007-Silver_7152019
Bronze Fidelis Care Bronze for Children Subscriber Contract_FC-HBX-007_852019 FC-HBX-007-Bronze_7152019
Silver Enhanced Fidelis Care Silver Enhanced Subscriber Contract_FC-HBX-010_852019 FC-HBX-010_Silver Enhanced_7152019
Silver Enhanced_250 Fidelis Care Silver Enhanced Subscriber Contract_FC-HBX-010_852019 FC-HBX-010_Silver Enhanced_1_7152019
Silver Enhanced_200 Fidelis Care Silver Enhanced Subscriber Contract_FC-HBX-010_852019 FC-HBX-010_Silver Enhanced_2_7152019
Silver Enhanced_150 Fidelis Care Silver Enhanced Subscriber Contract_FC-HBX-010_852019 FC-HBX-010_Silver Enhanced_3_7152019
Gold Enhanced Fidelis Care Gold Enhanced Subscriber Contract_FC-HBX-010_852019 FC-HBX-010_Gold Enhanced_7152019
Silver Enhanced Fidelis Care Silver Enhanced Subscriber Contract_FC-HBX-012_852019 FC-HBX-012_Silver Enhanced_7152019
Gold Enhanced Fidelis Care Gold Enhanced Subscriber Contract_FC-HBX-012_852019 FC-HBX-012_Gold Enhanced_7152019
Age 29 Rider is available for Platinum, Gold, Silver, Silver 250 and the Bronze plans.
Subscriber Contract_FC-HBX-004_5202019
An American Indian who earns less than 300% of the federal poverty level can be on a Bronze, Silver, Silver Enhanced, Gold, Gold Enhanced or Platinum plan. There will be no cost-sharing.
Fidelis Care [Metal Tier] Schedule of Benefits_FC-HBX-005-Zero Cost-Sharing_7152019
Fidelis Care [Metal Tier] Schedule of Benefits_FC-HBX-013_Zero Cost-Sharing Enhanced_7152019
An American Indian who earns more than 300% of the federal poverty level can be on a Bronze, Silver, Silver Enhanced, Gold, Gold Enhanced or Platinum plan. There will be no cost-sharing at certain providers.
Page 13 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Standard Plans
Type of Service Platinum Gold Silver Bronze Catastrophic
Deductible $0 $600 $1,300 $4,425 $8,150
Maximum Out-of-Pocket $2,000 $4,000 $7,900 $8,150 $8,150
Includes the deductible
COST SHARING SUMMARY
Inpatient Facility/SNF/Hospice $500
per admission
$1,000
per admission
$1,500
per admission
50% cost sharing 0% cost sharing
Outpatient Facility-Surgery,
including freestanding surgicenters
$100 $100 $150 50% cost sharing 0% cost sharing
Surgeon - Inpatient facility, $100 $100 $150 50% cost sharing 0% cost sharing
outpatient facility, including
freestanding surgicenters
PCP $15 $25 $30 50% cost sharing 0% cost sharing
Specialist $35 $40 $50 50% cost sharing 0% cost sharing
PT/OT/ST - rehabilitative &
habilitative therapies
$25 $30 $30 50% cost sharing 0% cost sharing
ER $100 $150 $250 50% cost sharing 0% cost sharing
Ambulance $100 $150 $150 50% cost sharing 0% cost sharing
Urgent Care $55 $60 $70 50% cost sharing 0% cost sharing
DME/Medical supplies 10% cost sharing 20% cost sharing 30% cost sharing 50% cost sharing 0% cost sharing
Hearing aids 10% cost sharing 20% cost sharing 30% cost sharing 50% cost sharing 0% cost sharing
Eyewear 10% cost sharing 20% cost sharing 30% cost sharing 50% cost sharing 0% cost sharing
INPATIENT HOSPITAL SERVICES
Observation stay ER copay per case 50% cost sharing 0% cost sharing
Hospital services - non-maternity Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing
Maternity care stay (covers mother
and well newborn combined)
Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing
Mental health/Behavorial health care Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing
Detoxification Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing
Substance abuse disorder services Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing
Skilled nursing facility Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing
Hospice (inpatient) Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing
Page 14 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Standard Plans
Type of Service Platinum Gold Silver Bronze Catastrophic
EMERGENCY MEDICAL SERVICES
Facility charge - Emergency Room ER copay per case 50% cost sharing 0% cost sharing
Physician charge - Emergency Room
visit
$0 copay per visit 50% cost sharing 0% cost sharing
Facility charge - Freestanding urgent
care center
Urgent Care copay per visit 50% cost sharing 0% cost sharing
Physician charge - Free standing
urgent care center visit
$0 copay per visit 50% cost sharing 0% cost sharing
Prehospital emergency services/
transportation, includes air
ambulance
Ambulance copay per case 50% cost sharing 0% cost sharing
OUTPATIENT HOSPITAL/FACILITY SERVICES
Outpatient facility surgery - hospital
facility charge, including
freestanding surgicenters
Outpatient Facility-Surgery copay per case 50% cost sharing 0% cost sharing
Pre-admission/pre-operative testing $0 copay 50% cost sharing 0% cost sharing
Diagnostic and routine laboratory
and pathology
Specialist copay per visit 50% cost sharing 0% cost sharing
Diagnostic and routine imaging
services including Xray; excluding
CAT/PET scans, MRI
Specialist copay per visit 50% cost sharing 0% cost sharing
Imaging: CAT/PET scans, MRI Specialist copay 50% cost sharing 0% cost sharing
Chemotherapy PCP copay per visit 50% cost sharing 0% cost sharing
Radiation therapy PCP copay per visit 50% cost sharing 0% cost sharing
Hemodialysis/Renal dialysis PCP copay per visit 50% cost sharing 0% cost sharing
Mental health/Behavorial health care PCP copay per visit 50% cost sharing 0% cost sharing
Substance abuse disorder services PCP copay per visit 50% cost sharing 0% cost sharing
Covered therapies (PT, OT, ST) -
rehabilitative & habilitative
PT/OT/ST copay per visit 50% cost sharing 0% cost sharing
Home care PCP copay per visit 50% cost sharing 0% cost sharing
Hospice PCP copay per visit 50% cost sharing 0% cost sharing
Page 15 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Standard Plans
Type of Service Platinum Gold Silver Bronze Catastrophic
PREVENTIVE & PRIMARY CARE SERVICES
Bone density testing NOTE: For preventive care visits/services as defined in section 2713 of ACA no deductible or cost sharing applies.
Cervical cytology Otherwise the cost sharing indicated below applies to all services in this benefit service category.
Colonoscopy screening
Gynecological exams
Immunizations PCP/Specialist copay per visit (based on type of physician performing the
service)
50% cost sharing 0% cost sharing
Mammography
Prenatal maternity care
Prostate cancer screening
Routine exams
Women's preventive health services
PHYSICIAN/PROFESSIONAL SERVICES
Inpatient hospital surgery - surgeon Surgeon copay per case 50% cost sharing 0% cost sharing
Outpatient hospital and freestanding
surgicenter - surgeon
Surgeon copay per case 50% cost sharing 0% cost sharing
Office surgery PCP/Specialist copay per visit (based on type of physician performing the
service)
50% cost sharing 0% cost sharing
Anesthesia (any setting) Covered in full, no deductible and no cost sharing applies 50% cost sharing 0% cost sharing
Covered therapies (PT, OT, ST) -
rehabilitative & habilitative
PT/OT/ST copay per visit 50% cost sharing 0% cost sharing
Additional surgical opinion Specialist copay per visit 50% cost sharing 0% cost sharing
Second medical opinion for cancer Specialist copay per visit 50% cost sharing 0% cost sharing
Maternity delivery and post natal
care - physician or midwife
Surgeon copay per case for delivery and post natal care services combined
(only one such copay per pregnancy)
50% cost sharing 0% cost sharing
In-hospital physician visits $0 copay per visit 50% cost sharing 0% cost sharing
Diagnostic office visits PCP/Specialist copay per visit (based on type of physician performing the
service)
50% cost sharing 0% cost sharing
Diagnostic and routine laboratory
and pathology
PCP/Specialist copay per visit 50% cost sharing 0% cost sharing
Diagnostic and routine imaging
services including Xray; excluding
CAT/PET scans, MRI
PCP/Specialist copay per visit 50% cost sharing 0% cost sharing
Imaging: CAT/PET scans, MRI Specialist copay per visit 50% cost sharing 0% cost sharing
Allergy testing PCP/Specialist copay per visit 50% cost sharing 0% cost sharing
Allergy shots PCP/Specialist copay per visit 50% cost sharing 0% cost sharing
Office/outpatient consultations PCP/Specialist copay per visit (based on type of physician performing the
service)
50% cost sharing 0% cost sharing
Mental health/Behavorial health care PCP copay per visit 50% cost sharing 0% cost sharing
Substance abuse disorder services PCP copay per visit 50% cost sharing 0% cost sharing
Chemotherapy PCP copay per visit 50% cost sharing 0% cost sharing
Radiation therapy PCP copay per visit 50% cost sharing 0% cost sharing
Hemodialysis/Renal dialysis PCP copay per visit 50% cost sharing 0% cost sharing
Chiropractic care Specialist copay per visit 50% cost sharing 0% cost sharing
Page 16 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Standard Plans
Type of Service Platinum Gold Silver Bronze Catastrophic
ADDITIONAL BENEFITS/SERVICES
ABA treatment for Autism Specturm
Disorder
PCP copay per visit 50% cost sharing 0% cost sharing
Assistive Communiciation Devices
for Autism Spectrum Disorder
PCP copay per device 50% cost sharing 0% cost sharing
Durable medical equipment and
medical supplies
DME/Medical supplies coinsurance cost sharing applies 50% cost sharing 0% cost sharing
Hearing evaluations/testing Specialist copay per visit 50% cost sharing 0% cost sharing
Hearing aids Hearing aid coinsurance cost sharing applies 50% cost sharing 0% cost sharing
Diabetic drugs and supplies PCP copay per 30 days supply 50% cost sharing 0% cost sharing
Diabetic education and self-
management
PCP copay per visit 50% cost sharing 0% cost sharing
Home care PCP copay per visit 50% cost sharing 0% cost sharing
Exercise facility reimbursements Deductible does not apply. $200/$100 reimbursement every six months for member/spouse.
* Partial reimbursement for facility fees every six months if member attains at least 50 visits.
PEDIATRIC DENTAL SERVICES
Dental office visit PCP copay per visit 50% cost sharing 0% cost sharing
PEDIATRIC VISION SERVICES
Eye exam visit PCP copay per visit 50% cost sharing 0% cost sharing
Prescribed lenses and frames Eyewear coinsurance cost sharing applies to combined cost of lenses and
frames
50% cost sharing 0% cost sharing
Contact lenses Eyewear coinsurance cost sharing applies 50% cost sharing 0% cost sharing
PRESCRIPTION DRUGS
Generic or Tier 1 $10 $10 $10 $10 0% cost sharing
Formulary Brand or Tier 2 $30 $35 $35 $35 0% cost sharing
Non-Formulary Brand or Tier 3 $60 $70 $70 $70 0% cost sharing
Above are retail copay amounts; mail order copays are 2.5 times retail (except for Catastrophic Plans) for a 90 day supply
Page 17 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Cost Sharing Reduction Variations
These plans are only available to individuals and families who meet certain income qualifications or who are an American Indian.
Silver - CSR Versions American Indians
Type of Service 200 - 250 % FPL 150 - 200 % FPL 100 - 150 % FPL Less than or equal to 300% FPL
Deductible $1,100 $250 $0 $0
Maximum Out-of-Pocket $6,500 $2,100 $1,000 $0
Includes the deductible
COST SHARING SUMMARY
Inpatient Facility/SNF/Hospice $1,500
per admission
$250
per admission
$100
per admission
0% cost sharing
Outpatient Facility-Surgery, including
freestanding surgicenters
$150 $75 $25 0% cost sharing
Surgeon - Inpatient facility, $150 $75 $25 0% cost sharing
outpatient facility, including freestanding
surgicenters
PCP $30 $15 $10 0% cost sharing
Specialist $50 $35 $20 0% cost sharing
PT/OT/ST - rehabilitative & habilitative
therapies
$30 $25 $15 0% cost sharing
ER $250 $75 $50 0% cost sharing
Ambulance $150 $75 $50 0% cost sharing
Urgent Care $70 $50 $30 0% cost sharing
DME/Medical supplies 25% cost sharing 10% cost sharing 5% cost sharing 0% cost sharing
Hearing aids 25% cost sharing 10% cost sharing 5% cost sharing 0% cost sharing
Eyewear 25% cost sharing 10% cost sharing 5% cost sharing 0% cost sharing
INPATIENT HOSPITAL SERVICES
Observation stay ER copay per case 0% cost sharing
Hospital services - non-maternity Inpatient Facility copay per admission # 0% cost sharing
Maternity care stay (covers mother and well
newborn combined)
Inpatient Facility copay per admission # 0% cost sharing
Mental health/Behavorial health care Inpatient Facility copay per admission # 0% cost sharing
Detoxification Inpatient Facility copay per admission # 0% cost sharing
Substance abuse disorder services Inpatient Facility copay per admission # 0% cost sharing
Skilled nursing facility Inpatient Facility copay per admission # 0% cost sharing
Hospice (inpatient) Indicated copay per admission is waived if direct transfer from
hospital inpatient setting to skilled nursing facility
0% cost sharing
Page 18 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Cost Sharing Reduction Variations
These plans are only available to individuals and families who meet certain income qualifications or who are an American Indian.
Silver - CSR Versions American Indians
Type of Service 200 - 250 % FPL 150 - 200 % FPL 100 - 150 % FPL Less than or equal to 300% FPL
EMERGENCY MEDICAL SERVICES
Facility charge - Emergency Room ER copay per case 0% cost sharing
Physician charge - Emergency Room visit $0 copay per visit 0% cost sharing
Facility charge - Freestanding urgent care
center
Urgent Care copay per visit 0% cost sharing
Physician charge - Free standing urgent care
center visit
$0 copay per visit 0% cost sharing
Prehospital emergency services/
transportation, includes air ambulance
Ambulance copay per case 0% cost sharing
OUTPATIENT HOSPITAL/FACILITY SERVICES
Outpatient facility surgery - hospital facility
charge, including freestanding surgicenters
Outpatient Facility-Surgery copay per case 0% cost sharing
Pre-admission/pre-operative testing $0 copay 0% cost sharing
Diagnostic and routine laboratory and
pathology
Specialist copay per visit 0% cost sharing
Diagnostic and routine imaging services
including Xray; excluding CAT/PET scans,
MRI
Specialist copay per visit 0% cost sharing
Imaging: CAT/PET scans, MRI Specialist copay 0% cost sharing
Chemotherapy PCP copay per visit 0% cost sharing
Radiation therapy PCP copay per visit 0% cost sharing
Hemodialysis/Renal dialysis PCP copay per visit 0% cost sharing
Mental health/Behavorial health care PCP copay per visit 0% cost sharing
Substance abuse disorder services PCP copay per visit 0% cost sharing
Covered therapies (PT, OT, ST) -
rehabilitative & habilitative
PT/OT/ST copay per visit 0% cost sharing
Home care PCP copay per visit 0% cost sharing
Hospice PCP copay per visit 0% cost sharing
Page 19 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Cost Sharing Reduction Variations
These plans are only available to individuals and families who meet certain income qualifications or who are an American Indian.
Silver - CSR Versions American Indians
Type of Service 200 - 250 % FPL 150 - 200 % FPL 100 - 150 % FPL Less than or equal to 300% FPL
PREVENTIVE & PRIMARY CARE SERVICES
Bone density testing NOTE: For preventive care visits/services as defined in section 2713 of ACA no deductible or cost sharing
applies.
Cervical cytology Otherwise the cost sharing indicated below applies to all services in this benefit service category.
Colonoscopy screening
Gynecological exams
Immunizations PCP/Specialist copay per visit (based on type of physician
performing the service)
0% cost sharing
Mammography
Prenatal maternity care
Prostate cancer screening
Routine exams
Women's preventive health services
PHYSICIAN/PROFESSIONAL SERVICES
Inpatient hospital surgery - surgeon Surgeon copay per case 0% cost sharing
Outpatient hospital and freestanding
surgicenter - surgeon
Surgeon copay per case 0% cost sharing
Office surgery PCP/Specialist copay per visit (based on type of physician
performing the service)
0% cost sharing
Anesthesia (any setting) Covered in full, no deductible and no cost sharing applies 0% cost sharing
Covered therapies (PT, OT, ST) -
rehabilitative & habilitative
PT/OT/ST copay per visit 0% cost sharing
Additional surgical opinion Specialist copay per visit 0% cost sharing
Second medical opinion for cancer Specialist copay per visit 0% cost sharing
Maternity delivery and post natal care -
physician or midwife
Surgeon copay per case for delivery and post natal care services
combined (only one such copay per pregnancy)
0% cost sharing
In-hospital physician visits $0 copay per visit 0% cost sharing
Diagnostic office visits PCP/Specialist copay per visit (based on type of physician
performing the service)
0% cost sharing
Diagnostic and routine laboratory and
pathology
PCP/Specialist copay per visit 0% cost sharing
Diagnostic and routine imaging services
including Xray; excluding CAT/PET scans,
MRI
PCP/Specialist copay per visit 0% cost sharing
Imaging: CAT/PET scans, MRI Specialist copay per visit 0% cost sharing
Allergy testing PCP/Specialist copay per visit 0% cost sharing
Allergy shots PCP/Specialist copay per visit 0% cost sharing
Office/outpatient consultations PCP/Specialist copay per visit (based on type of physician
performing the service)
0% cost sharing
Mental health/Behavorial health care PCP copay per visit 0% cost sharing
Substance abuse disorder services PCP copay per visit 0% cost sharing
Chemotherapy PCP copay per visit 0% cost sharing
Radiation therapy PCP copay per visit 0% cost sharing
Hemodialysis/Renal dialysis PCP copay per visit 0% cost sharing
Chiropractic care Specialist copay per visit 0% cost sharing
Page 20 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Cost Sharing Reduction Variations
These plans are only available to individuals and families who meet certain income qualifications or who are an American Indian.
Silver - CSR Versions American Indians
Type of Service 200 - 250 % FPL 150 - 200 % FPL 100 - 150 % FPL Less than or equal to 300% FPL
ADDITIONAL BENEFITS/SERVICES
ABA treatment for Autism Specturm
Disorder
PCP copay per visit 0% cost sharing
Assistive Communiciation Devices for
Autism Spectrum Disorder
PCP copay per device 0% cost sharing
Durable medical equipment and medical
supplies
DME/Medical supplies coinsurance cost sharing applies 0% cost sharing
Hearing evaluations/testing Specialist copay per visit 0% cost sharing
Hearing aids Hearing aid coinsurance cost sharing applies 0% cost sharing
Diabetic drugs and supplies PCP copay per 30 days supply 0% cost sharing
Diabetic education and self-management PCP copay per visit 0% cost sharing
Home care PCP copay per visit 0% cost sharing
Exercise facility reimbursements Deductible does not apply. $200/$100 reimbursement every six months for member/spouse.
* Partial reimbursement for facility fees every six months if member attains at least 50 visits.
PEDIATRIC DENTAL SERVICES
Dental office visit PCP copay per visit 0% cost sharing
PEDIATRIC VISION SERVICES
Eye exam visit PCP copay per visit 0% cost sharing
Prescribed lenses and frames Eyewear coinsurance cost sharing applies to combined cost of
lenses and frames
0% cost sharing
Contact lenses Eyewear coinsurance cost sharing applies 0% cost sharing
PRESCRIPTION DRUGS
Generic or Tier 1 $10 $9 $6 0% cost sharing
Formulary Brand or Tier 2 $35 $20 $15 0% cost sharing
Non-Formulary Brand or Tier 3 $70 $40 $30 0% cost sharing
Above are retail copay amounts; mail order copays are 2.5 times retail (except for Catastrophic Plans) for a 90 day supply
Page 21 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Non-Standard Plans
Type of Service Non-Standard Gold Non-Standard Silver
Deductible $600 $1,300
Maximum Out-of-Pocket $4,000 $7,900
Includes the deductible
COST SHARING SUMMARY
Inpatient Facility/SNF/Hospice $1,000 $1,500
Outpatient Facility-Surgery, including $100 $150
Surgeon - Inpatient facility, $100 $150
outpatient facility, including
PCP $25 $30
Specialist $40 $50
PT/OT/ST - rehabilitative & $30 $30
ER $150 $250
Ambulance $150 $150
Urgent Care $60 $70
DME/Medical supplies 20% cost sharing 30% cost sharing
Hearing aids 20% cost sharing 30% cost sharing
Eyewear 20% cost sharing 30% cost sharing
INPATIENT HOSPITAL SERVICES
Observation stay ER copay per case
Hospital services - non-maternity Inpatient Facility copay per admission #
Maternity care stay (covers mother
and well newborn combined)
Inpatient Facility copay per admission #
Mental health/Behavorial health care Inpatient Facility copay per admission #
Detoxification Inpatient Facility copay per admission #
Substance abuse disorder services Inpatient Facility copay per admission #
Skilled nursing facility Inpatient Facility copay per admission #
Hospice (inpatient) Inpatient Facility copay per admission #
Page 22 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Non-Standard Plans
Type of Service Non-Standard Gold Non-Standard Silver
EMERGENCY MEDICAL SERVICES
Facility charge - Emergency Room ER copay per case
Physician charge - Emergency Room
visit
$0 copay per visit
Facility charge - Freestanding urgent
care center
Urgent Care copay per visit
Physician charge - Free standing
urgent care center visit
$0 copay per visit
Prehospital emergency services/
transportation, includes air
ambulance
Ambulance copay per case
OUTPATIENT HOSPITAL/FACILITY SERVICES
Outpatient facility surgery - hospital
facility charge, including freestanding
surgicenters
Outpatient Facility-Surgery copay per case
Pre-admission/pre-operative testing $0 copay
Diagnostic and routine laboratory and
pathology
Specialist copay per visit
Diagnostic and routine imaging
services including Xray; excluding
CAT/PET scans, MRI
Specialist copay per visit
Imaging: CAT/PET scans, MRI Specialist copay
Chemotherapy PCP copay per visit
Radiation therapy PCP copay per visit
Hemodialysis/Renal dialysis PCP copay per visit
Mental health/Behavorial health care PCP copay per visit
Substance abuse disorder services PCP copay per visit
Covered therapies (PT, OT, ST) -
rehabilitative & habilitative
PT/OT/ST copay per visit
Home care PCP copay per visit
Hospice PCP copay per visit
Page 23 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Non-Standard Plans
Type of Service Non-Standard Gold Non-Standard Silver
PREVENTIVE & PRIMARY CARE SERVICES
Bone density testing NOTE: For preventive care visits/services as defined in section 2713 of ACA no
deductible or cost sharing applies.
Cervical cytology Otherwise the cost sharing indicated below applies to all services in this benefit service
category.
Colonoscopy screening
Gynecological exams
Immunizations PCP/Specialist copay per visit (based on type of physician performing the service)
Mammography
Prenatal maternity care
Prostate cancer screening
Routine exams
Women's preventive health services
PHYSICIAN/PROFESSIONAL SERVICES
Inpatient hospital surgery - surgeon Surgeon copay per case
Outpatient hospital and freestanding
surgicenter - surgeon
Surgeon copay per case
Office surgery PCP/Specialist copay per visit (based on type of physician performing the service)
Anesthesia (any setting) Covered in full, no deductible and no cost sharing applies
Covered therapies (PT, OT, ST) -
rehabilitative & habilitative
PT/OT/ST copay per visit
Additional surgical opinion Specialist copay per visit
Second medical opinion for cancer Specialist copay per visit
Maternity delivery and post natal
care - physician or midwife
Surgeon copay per case for delivery and post natal care services combined (only one
such copay per pregnancy)
In-hospital physician visits $0 copay per visit
Diagnostic office visits PCP/Specialist copay per visit (based on type of physician performing the service)
Diagnostic and routine laboratory and
pathology
PCP/Specialist copay per visit
Diagnostic and routine imaging
services including Xray; excluding
CAT/PET scans, MRI
PCP/Specialist copay per visit
Imaging: CAT/PET scans, MRI Specialist copay per visit
Allergy testing PCP/Specialist copay per visit
Allergy shots PCP/Specialist copay per visit
Office/outpatient consultations PCP/Specialist copay per visit (based on type of physician performing the service)
Mental health/Behavorial health care PCP copay per visit
Substance abuse disorder services PCP copay per visit
Chemotherapy PCP copay per visit
Radiation therapy PCP copay per visit
Hemodialysis/Renal dialysis PCP copay per visit
Chiropractic care Specialist copay per visit
Page 24 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Benefit Descriptions - Non-Standard Plans
Type of Service Non-Standard Gold Non-Standard Silver
ADDITIONAL BENEFITS/SERVICES
ABA treatment for Autism Specturm
Disorder
PCP copay per visit
Assistive Communiciation Devices
for Autism Spectrum Disorder
PCP copay per device
Durable medical equipment and
medical supplies
DME/Medical supplies coinsurance cost sharing applies
Hearing evaluations/testing Specialist copay per visit
Hearing aids Hearing aid coinsurance cost sharing applies
Diabetic drugs and supplies PCP copay per 30 days supply
Diabetic education and self-
management
PCP copay per visit
Home care PCP copay per visit
Exercise facility reimbursements Deductible does not apply. $200/$100 reimbursement every six months for
member/spouse.
* Partial reimbursement for facility fees every six months if member attains at least 50
visits.
PEDIATRIC DENTAL SERVICES
Dental office visit PCP copay per visit
ADULT DENTAL SERVICES
Dental office visit
PEDIATRIC VISION SERVICES
Eye exam visit PCP copay per visit
Prescribed lenses and frames Eyewear coinsurance cost sharing applies to combined cost of lenses and frames
Contact lenses Eyewear coinsurance cost sharing applies
ADULT VISION SERVICES
Eye exam visit PCP copay per visit
Prescribed lenses and frames Eyewear coinsurance cost sharing applies to combined cost of lenses and frames
Contact lenses
PRESCRIPTION DRUGS
Generic or Tier 1 $10 $10
Formulary Brand or Tier 2 $35 $35
Non-Formulary Brand or Tier 3 $70 $70
Above are retail copay amounts; mail order copays are 2.5 times retail (except for Catastrophic Plans) for a 90 day supply
PCP copay per visit
Eyewear coinsurance cost sharing applies
Page 25 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Rating Instructions and Example
Instructions
2) Determine the rating region where the applicant lives
3) Determine which plan the applicant wants.
5) Look up the rate in the rate table.
Example:
1) The desired tier is Individual + Child(ren)
2) The rating region is Buffalo
3) The applicant wants a Silver plan
5) The rate is $889.68 per month
The unsubsidized premium will be $889.68 monthly.
4) Determine if there is a child between the ages of 26 and up to 30 to be covered: If so,
use the appropriate rate table with the rider included.
4) Since there is a child over the age of 26 but younger than 30, the family is eligible for
the "Through Age 29" rider. Use the rate table labeled "Includes Through Age 29 Rider"
An applicant lives in Erie county. The applicant wished to cover themselves, a 22-year
old child and a 28 year-old child. The applicant desires a Silver plan.
1) Determine which tier is desired: Child Only, Individual, Individual+Spouse,
Individual+Child(ren), or Family
Page 26 of 28
Fidelis Care New York
Effective Date: January 1, 2020
Rate Manual - Individual Market
Expected Loss Ratio
Plan Expected Loss Ratio
Platinum 86.30%
Gold 86.30%
Silver 86.30%
Bronze 86.30%
Catastrophic 86.30%
Platinum through Age 29 86.30%
Gold through Age 29 86.30%
Silver through Age 29 86.30%
Bronze through Age 29 86.30%
Silver Enhanced 86.30%
Gold Enhanced 86.30%
Silver Enhanced through Age 29 86.30%
Gold Enhanced through Age 29 86.30%
Page 27 of 28
Fidelis Care New York
Rate Manual - Individual Market
Broker Program
Full Assistance Standard:
.
Fidelis Care will offer commissions to certain licensed insurance brokers.
In this program, the broker assists the individual with enrollment and renewal. A per contract payment
of $12 per month is paid to the broker for each of the first 24 months. This fee does not increase based
on volume and is recouped if the individual dis-enrolls in the first 90 days.
Page 28 of 28