Is Fidelis Care a Medicaid Plan?

Fidelis Care is a Medicaid managed care plan, not Medicaid itself

Fidelis Care is a private insurance company that contracts with the state to deliver Medicaid benefits. When you enroll in Fidelis Care, you are choosing one of several managed care organizations (MCOs) that administer your Medicaid coverage. The state of New York pays Fidelis Care to manage your healthcare — to coordinate your doctors, approve referrals, and handle claims — but Medicaid is the actual program funding your coverage.

Think of it this way: Medicaid is the government program that pays for your healthcare. Fidelis Care is the company you interact with day-to-day to use that coverage. You do not apply to Fidelis Care directly. Instead, you apply for Medicaid through your state, and then you choose which managed care plan — Fidelis Care or another — will administer your benefits.

Fidelis Care operates only in New York State. It serves Medicaid members across all five boroughs of New York City and in surrounding counties. If you live outside New York, Fidelis Care is not an option for you.

Key Takeaways

Fidelis Care is a managed care plan that delivers Medicaid benefits in New York State, not a separate program you apply to.
You apply for Medicaid through the state first; choosing Fidelis Care happens after you are found may be able to access for Medicaid.
Fidelis Care coordinates your doctors, referrals, and claims, but the state Medicaid program is what actually funds your coverage.
Fidelis Care is available only in New York; if you live elsewhere, you will choose from your state's own managed care plans.

How Fidelis Care fits into New York's Medicaid system

New York's Medicaid program requires most members to join a managed care plan. Fidelis Care is one of several options available to you. Other plans in New York include Empire BlueCross BlueShield, Healthfirst, Molina Healthcare, and others, depending on which county you live in and which Medicaid category you fall into (such as emergency services only, parent/caregiver, or disabled/blind).

When you apply for Medicaid in New York, you will be told whether you must choose a plan or whether you can remain in fee-for-service Medicaid (where the state pays providers directly instead of through a managed care company). If you must choose, you will receive a list of plans available in your area. Fidelis Care will be one option if you live in a county where it operates.

Once you enroll in Fidelis Care, you receive a member ID card and a handbook explaining your coverage. Your primary care doctor must be in Fidelis Care's network, and most specialist visits require a referral from that doctor. Fidelis Care also manages your prescription drug coverage and decides which medications require prior approval before your pharmacy can fill them.

What Fidelis Care covers and what Medicaid covers

Fidelis Care does not decide what Medicaid covers — New York State does. Fidelis Care administers the coverage that Medicaid provides. This means Fidelis Care must cover everything the state says Medicaid covers in your category, but Fidelis Care cannot cover anything beyond that.

New York Medicaid covers doctor visits, hospital care, emergency services, prescription drugs, mental health and substance use treatment, dental care (limited), vision care (limited), and other services depending on your age and category. Fidelis Care processes your claims for these services, manages your network of doctors, and handles prior authorization requests — but the state determines the actual benefits.

If Fidelis Care denies a claim or refuses to authorize a service, you have the right to appeal. The appeal goes to Fidelis Care first, and if you disagree with their decision, you can request a state-level review called a Fair Hearing. The state, not Fidelis Care, makes the final decision on whether a service is covered under Medicaid.

How to enroll in Fidelis Care

You do not apply directly to Fidelis Care. Instead, you apply for Medicaid through the New York State Department of Social Services, either online at mybenefits.ny.gov, by phone at 1-800-342-3009, or in person at your local DSS office. During the Medicaid application, you will be asked which managed care plan you prefer if you are required to choose one.

If you are already enrolled in Medicaid and want to switch to Fidelis Care, you can change your plan during the annual open enrollment period (usually November through January) or if you have a may have access to life event such as moving to a new county or losing other health coverage. You can request a plan change through mybenefits.ny.gov or by calling the New York State Medicaid Customer Service Center at 1-800-541-2831.

When you enroll in Fidelis Care, you will receive your member ID card and welcome materials within two weeks. You should choose a primary care doctor from Fidelis Care's network before you need medical care. You can find in-network doctors on Fidelis Care's website or by calling their member services line.

What to do if you have a problem with Fidelis Care

If Fidelis Care denies a claim, refuses a referral, or provides poor service, you have several options. First, contact Fidelis Care's member services to explain the problem and ask for a resolution. Their phone number is on your member ID card.

If Fidelis Care does not resolve the issue, you can file a complaint with the New York State Department of Financial Services (DFS), which regulates insurance companies including Medicaid plans. You can file a complaint online at dfs.ny.gov or by calling 1-800-342-3736. The state will investigate and can require Fidelis Care to correct the problem.

If Fidelis Care denies coverage for a service you believe you need, you can request an appeal directly to Fidelis Care. If you disagree with their appeal decision, you can request a state Fair Hearing, where a hearing officer reviews the case and decides whether the service should be covered under Medicaid. You do not need a lawyer, though you can bring one if you choose.

Switching away from Fidelis Care

You can change to a different Medicaid managed care plan during open enrollment or if you have a may have access to life event. may have access to events include moving to a different county, losing your current coverage, or having a significant change in your household income or family size.

If you want to leave managed care entirely and return to fee-for-service Medicaid (if your category allows it), you can request that change through mybenefits.ny.gov or by contacting the state Medicaid office. Not all Medicaid categories allow fee-for-service; some require managed care enrollment.

If you are unhappy with Fidelis Care because of network problems — for example, your doctor left the network or you cannot find a specialist — document the issue and explain it when you request a plan change. The state may allow you to switch outside the normal open enrollment period if you can show that Fidelis Care's network does not meet your needs.

Frequently Asked Questions

Do I have to use Fidelis Care if I am on Medicaid in New York?

Not necessarily. Some Medicaid categories in New York allow you to stay in fee-for-service Medicaid, where the state pays providers directly. However, most working-age adults and parents must choose a managed care plan. When you apply for Medicaid, you will be told whether you must choose a plan and which options are available in your county.

What is the difference between Fidelis Care and Medicaid?

Medicaid is the government program that pays for your healthcare. Fidelis Care is a private company that manages your Medicaid benefits — it coordinates your doctors, processes claims, and handles referrals. You apply for Medicaid through the state; Fidelis Care is one option for how your Medicaid coverage is delivered.

Can I use Fidelis Care if I live outside New York?

No. Fidelis Care operates only in New York State. If you live in another state, you will choose from managed care plans available in your state's Medicaid program. Each state has different plans and different rules about which plans are available in each county.

How do I know if my doctor is in Fidelis Care's network?

You can search for in-network doctors on Fidelis Care's website or call their member services line (the number is on your member ID card). You can also ask your doctor's office directly whether they accept Fidelis Care. If your current doctor is not in the network, you will need to choose a different primary care doctor or request a plan change.

What happens if Fidelis Care denies coverage for something I need?

You can appeal the denial to Fidelis Care first. If you disagree with their decision, you can request a state Fair Hearing, where a hearing officer decides whether the service is covered under Medicaid. Contact Fidelis Care's member services or the state Medicaid office to start an appeal.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.