Medicaid Managed Care offers comprehensive coverage for children and adults who meet income, resource, age, and/or disability requirements.

There are no copays for covered services and no monthly premiums. Always check with your Primary Care Provider to find out if a referral is required for any additional health services you might need.

Prescription drugs listed in the formulary are covered by Medicaid Managed Care, but not all prescription drug costs may be covered.

There is no per-service cost-sharing for Child Health Plus -- there is no copay, coinsurance, or deductible.

Child Health Plus monthly premiums are income-based, which means you may be responsible for a portion of your child’s total premium based on how much money you earn.

If there is an increase or decrease in your contribution toward the premium based on changes in income, we will notify you at least 30 days in advance.

Fidelis Care offers four “tiers” of the Essential Plan. The plan tier you qualify for will depend on your income eligibility. Fidelis Care Essential Plans do not have deductibles, and carry copays of either $0 or $15-$35 for medical services and prescription drugs.

Here are some common terms you will see in your plan details and what they mean:

Copay, copayment: A copay/copayment is a fee that an individual pays for medical services that do not apply to the deductible.

How it works: Depending on the terms of your plan, you will have to pay a set amount when you visit the doctor for care outside of your annual checkup. Your copay is usually listed on your insurance card, and can differ between primary care providers and specialists.

Out-of-pocket maximum: The most you’ll have to pay out of pocket for health care services in a given year. Out-of-pocket maximums can vary by plan. Deductibles, copays, and coinsurance costs all count toward your out-of-pocket maximum.

How it works: Essential Plans carry out-of-pocket maximums of either $200, or $2,000, depending on which plan you qualify for.

Grace period: A set number of days past the due date of a premium payment during which medical coverage may not be canceled, and through which the premium payment may be made. 

Cost-sharing: 

Essential Plan members pay a copay according to their prescription tier (Tier 1, Tier 2, or Tier 3).  Please note that prior authorization may be required, our formulary contains a complete listing of all covered medications, as well as their tier and any prior authorization requirements.

Diabetic Drugs

Diabetic drugs and supplies will follow the cost sharing associated with Primary Care Provider visits for your plan. You can find information about your plan’s copays and coinsurance right on your insurance card. If you have further questions, call us at 1-888-FIDELIS (1-888-343-3547). 

All Fidelis Care Qualified Health Plans carry some combination of cost sharing between you and Fidelis Care. Some examples of cost-sharing include deductibles, coinsurance, and/or copays. Here are some common terms and what they mean:

Copay, copayment: A copay/copayment is a fee that an individual pays for medical services that do not apply to the deductible.

How it works: Depending on the terms of your plan, you will have to pay a set amount when you visit the doctor for care outside of your annual checkup. Your copay is usually listed on your insurance card, and can differ based on the nature of the doctor visit. For example: visiting your Primary Care Provider (PCP) for a sick appointment might cost $15, while visiting a specialist might cost $35.

Deductible: A portion of health care expenses that an insured individual must pay before benefits are paid by a health plan. Deductibles are usually based on a calendar year.

How it works: If your plan has a $1,000 deductible, that means you pay all of your health care costs out of pocket up to that amount. For example: You visit the hospital, and the bill is $2,000. You would pay $1,000 of that, and then the plan would help pay the remainder according to the terms of your health plan.

Coinsurance: An amount a member may be required to pay as their share of the cost for services or prescription drugs. Coinsurance is usually a percentage, such as 10 percent. Coinsurance often begins AFTER a plan deductible is met.

How it works: Consider a health plan with a coinsurance of 10 percent. If you have a $1,000 bill, you would pay $100, and the plan pays the rest. If your plan has a deductible, coinsurance usually doesn’t begin until after your deductible is met.

Out-of-pocket maximum: The most you’ll have to pay out of pocket for health care services in a given year. Out-of-pocket maximums can vary by plan. Deductibles, copays, and coinsurance costs all count toward your out-of-pocket maximum.

How it works:

Consider a plan with a $1,000 deductible, 10 percent coinsurance, and a $5,000 out-of-pocket maximum for the year.

You reach your $1,000 deductible (which means you have $4,000 left before you reach your out-of-pocket max).

Then, coinsurance begins, so you pay 10 percent of each bill you receive for health care services.

If you pay $4,000 worth of coinsurance before the end of the year, you’ll reach your out-of-pocket maximum. If you need more health care services beyond that point, your health insurer will cover your health care needs in full.

Grace period: A set number of days past the due date of a premium payment during which medical coverage may not be canceled, and through which the premium payment may be made.