H5599-003 Wellcare Fidelis Dual Align: Costs, LTC, and Spendables Card

Wellcare Fidelis Dual Align H5599-003 is a Dual Eligible Special Needs Plan in New York for adults who have both Medicare and full Medicaid and who need a nursing-home level of care but want to stay in their own home. It carries a $0 monthly premium, $0 copays for virtually all in-network services, and a $242 monthly benefits card, and it bundles Medicare, Medicaid, and long-term services and supports under a single plan. The plan serves Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk, and Westchester counties.¹ For 2026, it was renamed from Wellcare Fidelis Dual Plus to Wellcare Fidelis Dual Align, effective January 1, 2026.²

Who Qualifies

This is a Medicaid Advantage Plus (MAP) plan, New York’s version of a Fully Integrated Dual Eligible Special Needs Plan.³ Eligibility is tighter than a standard Medicare Advantage plan. To enroll, you must:

Be enrolled in Medicare Part A and Part B and be eligible for full Medicaid benefits in New York.
Be assessed as needing a nursing-home level of care through an independent clinical evaluation.
Be expected to need at least one community-based long-term care service for more than 120 days from the date of enrollment.
Be able to live safely at home or in the community despite that level of need.
Be 18 or older and live in the plan’s service area.¹

If you qualify medically for Medicaid long-term care but do not need a nursing-home level of care, this plan is not the right fit. The clinical finding is the gate.

What You Pay

Because members are dually eligible, the plan is built around $0 out-of-pocket costs. The monthly premium is $0, and the Part D prescription drug deductible is $0. Copays for primary care, specialist visits, inpatient hospital stays, skilled nursing, mental health care, dental, vision, and hearing services are $0 when you use in-network providers.⁴

The plan’s Evidence of Coverage lists a $9,250 maximum out-of-pocket for 2026, down from $9,350 in 2025, but dually eligible members are not responsible for paying toward that amount for covered Part A and Part B services.⁵ The one exception is worldwide emergency or urgent care received outside the plan’s network, which carries a $115 copay per service in 2026 (up from $110), with a $50,000 annual plan maximum.²

Part D prescription drugs are included at $0 copay because Medicaid eligibility makes members eligible for Extra Help, and there is no Part D deductible. All covered forms of insulin have a copay of $35 or less through all phases of coverage. If you lose dual-eligible status, standard cost-sharing and a possible Part D Late Enrollment Penalty would apply; the national base beneficiary premium used to calculate the penalty is $38.99 for 2026.⁵

What’s Covered Medically

The plan is an HMO. For non-emergency care, you must use in-network providers, and a primary care provider coordinates your care and specialist referrals. Many services require prior authorization. When a needed service cannot be delivered inside the network for staffing or expertise reasons, the plan will authorize an out-of-network provider.⁵

Covered services include inpatient and outpatient hospital care, ambulatory surgery, primary and specialty care, and preventive care such as wellness visits, immunizations, and cancer screenings. Mental health and substance use disorder treatment is covered inpatient and outpatient, including crisis services and medication-assisted treatment. Occupational, physical, and speech therapy are covered in outpatient and home settings.⁴

Long-Term Care at Home

The reason this plan exists, and what sets it apart from a standard Medicare Advantage plan, is its integration of Managed Long-Term Services and Supports. These services let members who need a nursing-home level of care stay in their homes and communities. MLTSS covers everyday assistance such as bathing, dressing, meal preparation, and medication management.⁴

Under New York’s Managed Long Term Care framework, community-based services covered by the plan include home health aide services, personal care services, adult day health care, private duty nursing, the Consumer Directed Personal Assistance Program (CDPAP), nursing and therapy in the home, and care management that can include home-delivered meals and social supports. Ancillary benefits include podiatry, dentistry, optometry, hearing aids, durable medical equipment, and non-emergency transportation.⁶

Each member is assigned a Care Manager who is the main point of contact at the plan. The Care Manager, the member, and an Interdisciplinary Care Team develop an Individualized Plan of Care covering health needs, preferences, and goals.⁴ If a proposed plan of care calls for more than 12 hours of services per day on average, an Independent Review Panel reviews whether that care plan can keep the member safe at home.⁶

The $242 Spendables Card

Every H5599-003 member gets a Wellcare Spendables card preloaded with $242 per month. The allowance can be used on over-the-counter items like bandages, pain relievers, cold remedies, vitamins, and dental hygiene products, and on dental, vision, and hearing expenses. Unused funds roll over month to month but expire at the end of the calendar year. The card has to be activated through the member portal, the Wellcare Spendables app, or by calling 1-833-647-9661.⁷

Members with qualifying chronic conditions may also receive Special Supplemental Benefits for the Chronically Ill (SSBCI), which open up additional spending categories on the same card: healthy food such as fruits, vegetables, and dairy; rent and utilities assistance; gas pay-at-pump at participating stations; home improvement and safety items with professional installation; and pest control.⁷

To qualify for SSBCI, a member has to meet three conditions: require intensive care management based on hospitalization history and risk level, be at high risk for unplanned hospitalization, and have a documented active chronic condition that is life-threatening or significantly limits function. Qualifying conditions include diabetes, chronic heart failure, chronic lung disorders, cancer, dementia, HIV/AIDS, chronic kidney disease, and others. The plan identifies most eligible members automatically from claims data; new members without that data can qualify through an electronic provider attestation. Approved members get a notice within 10 business days, and the benefits load onto the Spendables card within four business days of qualification.⁸

Dental, Vision, and Hearing

Dental coverage is $0 and includes preventive and comprehensive services. Preventive care covers exams, cleanings every six months, and X-rays. Comprehensive dental covers fillings, crowns, extractions, dentures, endodontics, periodontics, and oral surgery.⁴

Vision covers one annual eye exam and Medicaid-covered eyeglasses or contact lenses, limited to one pair every two calendar years. Refraction exams are covered every two years unless medically necessary more often.⁴

Hearing includes one routine hearing exam and one fitting or evaluation per year, plus a hearing-aid allowance of up to $500 per ear annually in 2026, up from $350 per ear in 2025, with a limit of two hearing aids per year.²

What’s New for 2026

Beyond the plan’s new name, three changes stand out. Prior authorization is no longer required for Medicare-covered eyewear. The out-of-network emergency copay rose from $110 to $115. The hearing-aid allowance roughly doubled.²

The plan also launched a Chronic Respiratory Management Program for members diagnosed with COPD or chronic bronchitis who participate in care management. Qualifying members get $0 copays on durable medical equipment, nebulizer and respiratory supplies, and Part B respiratory medications ordered through mail order under the program.² The program is run with Conversio Health and adds clinical pharmacist and respiratory therapist support, virtual pulmonary rehabilitation, medication management, and remote monitoring through Bluetooth-enabled devices.⁹

For 2026, the preferred diabetic supply brands changed from OneTouch to Accu-Chek Guide and True Metrix. If you are already taking a Part D drug the plan doesn’t normally cover, a temporary supply is available while you transition to an alternative or request an exception for medical necessity.²

How to Enroll

New applicants who are not already receiving community-based long-term care have to go through the New York Independent Assessor Program (NYIAP), which replaced the older Conflict Free Evaluation and Enrollment Center process in 2022. NYIAP is run by Maximus Health Services. The assessment has two parts: a Community Health Assessment by a registered nurse using the state’s Uniform Assessment System, and a clinical exam by an independent practitioner with no prior relationship to the applicant.¹⁰

To schedule a NYIAP evaluation, call 1-855-222-8350. For enrollment help with the Wellcare Fidelis Dual Align plan itself, call 1-800-860-8707 (TTY: 711). Hours are 8 a.m. to 8 p.m. daily from October through March, and Monday through Friday the rest of the year.¹¹ MAP plans can also be compared through the New York State of Health website.

New York also uses default enrollment: when a Medicaid managed care member becomes newly eligible for Medicare, the state may automatically enroll them into their health plan’s aligned D-SNP. You can opt out of a default enrollment.³

If You Need to Appeal a Denial

The plan runs separate processes for coverage decisions, appeals, and grievances, all detailed in Chapter 9 of the Evidence of Coverage.⁵ For 2026, a Level 1 standard appeal can be filed by phone or in writing. If the plan upholds a denial on appeal and the benefit at issue is covered by Medicaid, you have 120 days to request a state Fair Hearing. Up to five levels of appeal are available for unfavorable decisions, and there are separate tracks if you believe you are being discharged from a hospital too soon or that coverage of medical services is ending prematurely.² For help filing a complaint or requesting a coverage decision, call Member Services at 1-800-247-1447 (TTY: 711).

1
Fidelis Care. Wellcare Fidelis Dual Plus Summary of Benefits Plans 003 and 008
2
Fidelis Care. Wellcare Fidelis Dual Align Annual Notice of Changes 2026
3
New York State Department of Health. Integrated Care for Dual Eligible Beneficiaries
4
Fidelis Care. Wellcare Fidelis Dual Align Summary of Benefits 2026
5
Fidelis Care. Wellcare Fidelis Dual Align Evidence of Coverage 2026
6
New York State Department of Health. Managed Long Term Care Overview
7
Fidelis Care. Wellcare Spendables Over-the-Counter Benefit
8
Fidelis Care. SSBCI Eligibility Information
9
Fidelis Care. COPD Management Program Provider Information
10
New York State Department of Health. New York Independent Assessor Program
11
Fidelis Care. Medicaid Advantage Plus Enrollment