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Choose Your County:
Choose your county and click "Next" to continue.
 
 
 
Choose a Plan:
Choose a plan below and click "Next" to continue.
For more information on the details of each plan, please visit the Fidelis Medicare Advantage 2014 home page or contact Fidelis Care by phone at 1-888-FIDELIS (1-888-343-3547).
 
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Medicaid Advantage Plus - for enrollment into this plan, please contact Fidelis Care at 1-800-860-8707 Sunday through Friday from 8 a.m. to 8 p.m.
Fidelis Long Term Care Advantage - for enrollment into this plan, please contact Fidelis Care at 1-800-860-8707 Sunday through Friday from 8 a.m. to 8 p.m.

* May be waived if you qualify for Medicaid or the Low Income Subsidy
 
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Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you. It is okay to check more than one box. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.



If none of these statements applies to you or you’re not sure, please contact Fidelis Care at 1-800-247-1447 (TTY users should call 1-800-695-8544) to see if you are eligible to enroll. We are open 8am to 8pm, seven days a week between October 1 through February 14, or 8am to 8pm, Monday through Friday from February 15 through September 30.
 
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Personal Information:
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Title:
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Gender:
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By supplying my email address, I agree Fidelis may send me member material by email. I understand that if I supply my email address and no longer want to have member material sent to me via email, I must contact Member Services. If I do not want to have member material sent to my email address at this time, check the box below.
 
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Permanent Residence Address
 
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Mailing Address [If different than Permanent Residence Address]
 
Emergency Contact Information [Optional]
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Medicare Insurance Information
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Gender:
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Plan Premium:
You can pay your monthly premium by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security check each month.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare does not cover. If you don't select a payment option, you will receive a bill each month.
 
You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, credit card or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Fidelis Care the Part D-IRMAA. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn't cover. If you don't select a payment option, you will get a bill each month.
 
Please select a premium payment option:


 
Important Questions:
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1. Do you have End Stage Renal Disease (ESRD)?
 
 
If you have had a successful kidney transplant and/or you don't need regular dialysis anymore, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don't need dialysis, otherwise we may need to contact you to obtain additional information.
 
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2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs (EPIC). Will you have other prescription drug coverage in addition to Fidelis Medicare Advantage or Fidelis Dual Advantage?
 
 
• If "yes," please list your other coverage and your identification (ID) number(s) for this coverage:
 
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3. Are you a resident in a long-term care facility, such as a nursing home?
 
 
• If "yes," please provide the following information:
 
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4. Are you enrolled in your State Medicaid program?
 
 
• If "yes," please provide your Medicaid number:
 
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5. Do you or your spouse work?
 
 
6. Please check one of the boxes below if you prefer us to send you information in a language other than English or in another format:
 

 
 
Choose a Doctor:
Please make a choice below and click "Next" to continue.


Confirm Information:
Plan Information:
Plan:
County:
Begin Month:
Your Situation:
Your Description:
 
Personal Information:
Title/Name:
Birth Date:
Gender:
Social Security No.:
Home Phone No.:
Email Address:
Please do not send me member material by email.
 
Medicare Insurance Information
Name:
Claim No.:
Gender:
Hospital (Part A):
Medical (Part B):
Permanent Residence Address:
Mailing Address:
Emergency Contact Information:
Contact Name:
Email Address:
Phone No.:
Relationship:
 
Plan Premium:
 
Important Questions:
1. Do you have End Stage Renal Disease (ESRD)?
2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs (EPIC). Will you have other prescription drug coverage in addition to Fidelis Medicare Advantage or Fidelis Dual Advantage?
Name of Other Coverage:
ID No. for this Coverage:
Group No. for this Coverage:
3. Are you a resident in a long-term care facility, such as a nursing home?
Name of Institution:
Address & Phone No. of Institution [Number and Street]:
4. Are you enrolled in your State Medicaid program?
Medicaid No.:
5. Do you or your spouse work?
6. Please check one of the boxes below if you prefer us to send you information in a language other than English or in another format:
 
Choose a Doctor:
 
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The information that I have given in my application is true to the best of my knowledge. I understand enrollment in Medicaid Advantage is voluntary. I have been told the rights and benefits that I will have as a member of Medicaid Advantage, and the conditions of participation. I know that I must be enrolled in the same health plan’s Medicare Advantage product to enroll or stay enrolled in Medicaid Advantage. I consent to the release of any medical information about me:
  • By my primary care provider (PCP), by any other health care provider, or by the New York State Department of Health (SDOH) to my health plan and any health care providers involved in caring for me, as reasonably necessary for my health plan or my providers to carry out treatment, payment or health care operations. This may include pharmacy and other medical claims information needed to help manage my care;
  • By my health plan and any health care providers to SDOH and other authorized federal, state and local agencies for purposes of administration of the Medicaid and/or Medicare programs; and
  • By my health plan to other persons or organizations, as reasonably necessary for my health plan to carry out treatment, payment or heath care operations.
I also agree that HIV/AIDS, mental health or alcohol and substance abuse information about me may be released, to the extent permitted by law, for as long as I remain enrolled in this Medicaid Advantage plan. I know that I can revoke this consent at any time by notifying the health plan in writing, except that this would not apply to information that has already been released. I understand that other federal, state and local laws may also protect the confidentiality of my personal health information.
 
Applicant Attestation:
Did you complete this application yourself?
 
 
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Agreement:

PLEASE READ IMPORTANT INFORMATION

If you currently have health coverage from an employer or union, joining Fidelis Medicare Advantage/Fidelis Dual Advantage could affect your employer or union health benefits. You could lose your employer or union health coverage if your join Fidelis Medicare Advantage or Fidelis Dual Advantage. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

By completing this enrollment application, I agree to the following:

Fidelis Medicare Advantage/Fidelis Dual Advantage are Medicare Advantage plans and have a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can only be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I do not have Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare's), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances.

Fidelis Medicare Advantage/Fidelis Dual Advantage serves a specific service area. If I move out of the area that Fidelis Medicare Advantage/Fidelis Dual Advantage serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Fidelis Medicare Advantage/Fidelis Dual Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Fidelis Medicare Advantage/Fidelis Dual Advantage when I get it to know which rules I must follow in order to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. Border.

I understand that beginning on the date Fidelis Medicare Advantage/Fidelis Dual Advantage coverage begins, I must get all of my health care from Fidelis Medicare Advantage/Fidelis Dual Advantage, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Fidelis Medicare Advantage and other services contained in my Fidelis Medicare Advantage/Fidelis Dual Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR FIDELIS MEDICARE ADVANTAGE WILL PAY FOR THE SERVICES.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contract with Fidelis Medicare Advantage/Dual Advantage, he/she may be paid on my enrollment in Fidelis Medicare Advantage/Dual Advantage.

Release of Information: By joining this Medicare health plan, I acknowledge that the Fidelis Medicare Advantage/Dual Advantage will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Fidelis Medicare Advantage/Fidelis Dual Advantage will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by Fidelis Medicare Advantage/Fidelis Dual Advantage or by Medicare.

 
NOTE: Medicare must review all enrollments. We will send your enrollment to Medicare, and they will do a final review. When Medicare finishes its review, we will send you a letter to confirm your enrollment with Fidelis Medicare Advantage.
 
 
Unknown Error At this time, Fidelis Care does not offer any Medicare plans in the chosen county. You must select a plan before you can continue. You must select a month to begin coverage. "First Name" is required. "Last Name" is required. "Title" is required. "Birth Date" must be in a valid format. "Birth Date" is invalid. Please verify the information entered and correct any mistakes. "Gender" is required "Home Phone No." is required. "Home Phone No." is invalid. Please verify the information entered and correct any mistakes. "Email Address" is invalid. Please verify the information entered and correct any mistakes. "Street Address" is required. "City" is required. "State" is required. "Zip Code" is required. "Emergency Email Address" is invalid. Please verify the information entered and correct any mistakes. "Emergency Phone No." is invalid. Please verify the information entered and correct any mistakes. "Medicare Name" is required. "Medicare Claim No." is required. "Medicare Claim No." is invalid. Please verify the information entered and correct any mistakes. "Medicare Gender" is required. "Medicare Hospital (Part A)" must be in a valid format. "Medicare Hospital (Part A)" is invalid. Please verify the information entered and correct any mistakes. "Medicare Medical (Part B)" must be in a valid format. "Medicare Medical (Part B)" is invalid. Please verify the information entered and correct any mistakes. "Zip Code" is invalid. Please verify the information entered and correct any mistakes. "Mailing Zip Code" is invalid. Please verify the information entered and correct any mistakes. "Social Security No." is invalid. Please verify the information entered and correct any mistakes. You must select a premium payment option. You must read the disclaimer and check the email confirmation box. Question 1 is required. Question 2 is required. You must enter name, ID number and group number for any addtional drug coverage. (Question 2) Question 3 is required. You must enter name and address for the care facility. (Question 3) Question 4 is required. You must enter Medicaid number. (Question 4) Medicaid number is invalid. Please verify the information entered and correct any mistakes. Question 5 is required. You must make a choice on choosing a provider. Please choose one of the three provided options. Provider information is required. Please enter as much information as possible including name, address and phone number. No plans available for the chosen year. Thank you! Your application has been submitted. Here is your confirmation number: You must choose one of the senarios that best describes your situation. You must provide a description for your situation. Name is required Phone Number is required Relationship to Enrollee is required Address is required City is required State is required Zip is required Sales Rep. is required. Please select at least one option from the reasons for enrollment. Please enter a valid date for all fields requiring one.