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We Want to Give You Good Care!

 

Senior Whole Health works with your providers to give you good health care. We make choices about your care based on what you need. We also look at your benefits. We do not reward providers to deny you care. We also do not reward staff or other people to deny you care or give you less care. We do not pay extra money to providers or our staff members to deny tests or treatments that you need to get better or stay healthy.

 

Please call Member Services, if you ever have a concern about your health care. You can also talk to our nurses about getting needed care. Our nurse staff is here to take your call 7 days a week (except holidays) during normal business hours. They can answer questions about how we make health care choices.

 

We also want to remind you that Senior Whole Health has a Nurse Advice Line to help answer questions you may have about your health. There are nurses ready to help you 24 hours a day, 7 days a week.

 

Click here for our frequently asked questions.

 

Get expert health care from the comfort of home.

 

Senior Whole Health is pleased to offer you virtual care through additional telehealth services. You can simply search the Senior Whole Health Provider Online Directory to find a Primary Care Physician who is able to provide services online or over the phone.

 

Virtual Care means:

 

• Convenient online or phone visits, from wherever you are.
• You’re treated at NO COST! Visits are free for Senior Whole Health members.

 

If at any point your symptoms worsen or you feel like you are experiencing a medical emergency, call 911 or proceed to the nearest emergency room.

 

Living with health problems and managing them can be hard. We have programs that can help. Case Management is when a trained nurse at Senior Whole Health works with you and your Primary Care Provider (PCP). The nurse will help you get the care you need.

 

We also have a Complex Case Management program for members with difficult health problems who need extra help with their health care needs. Both programs allow you to work with a nurse. The nurse can help you learn more about your health problems. He or she can teach you how to better manage them.

 

The nurse also will work with your family or others who help care for you. The nurse will work with your provider to make sure you get the care you need.

 

There are many ways you can be referred to a program. One way to enroll is through your provider. You also can self-refer to the program by calling Member Services. There are certain requirements that you must meet.

 

This program is voluntary and is offered at no cost to you. You can choose to be removed from the program at any time.

Care Coordination is a service for any adult or child who is receiving health services for an ongoing health problem. This health problem can be either physical or mental.

 

A Care Coordinator’s job is to:

 

• Help you find services that are not benefits. This could be physical therapy with the schools or "Meals on Wheels".
• Help you access services that you are eligible to receive.
• Help coordinate appointments and tests.
• Help coordinate transportation.
• Help access resources to help individuals with special health care needs and/or their caregivers deal with day to day stress.

 

How can I help my Care Coordinator help me?

 

• Write down your questions. This will help you remember things when you have a lot to talk about.
• Tell your Care Coordinator about all your appointments and tests. Not being aware of all the details of your case can make it harder for your Care Coordinator to help you.

 

If you feel that you need emergency treatment, please get help first or call 911.

Caregiving is the act of giving help to someone to keep them safe and healthy in their home. A caregiver can be a family member, friend, or neighbor. Caregiving needs can be both planned and unplanned.

 

Unplanned caregiving needs can happen in times of:

 

• An unexpected surgery
• An unexpected health issue such as a stroke

 

Planned caregiving is when a health issue or surgery is known before. In the most common cases, caregivers are needed to help a member with a long-term sickness or to support those who cannot handle some part of their daily needs without help. For Medicare members, many often want to age-in-place in their own home. Having a part-time or full-time caregiver can help them.

 

Many caregivers and members want to talk to Senior Whole Health of New York about benefits or making health care choices. There are levels of forms and approvals based on what the caregiver needs to do. Some of these forms come from the state.

 

Protected Health Information Form: The member or their Personal Representative can complete this form. This lets SWH of NY share PHI but does not require them to do so.

 

Appointment of Representative Form (CMS-1696): An appointed representative is a family member, friend, doctor or other person approved to act on your behalf in filing a grievance, coverage determination or appeal.

 

If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to SWH of NY at:

 

SWH of NY
Attn: Service Fulfillment
200 Oceangate Ste 100
Long Beach, CA 90802

 

Durable Power of Attorney: If a member needs help in making health care choices, they should fill out the Durable Power of Attorney form for their state, which can be found here.

 

This information does not, and is not intended to, constitute legal advice. Readers of this information should talk to a lawyer to get help about any legal matter.

 

For more help about caregiving, including a caregiving checklist, and forms, visit MolinaCaregiving.com

 

Local support for members and caregivers can be found at findhelp.org and care.com

 

 

Guided Care is a type of specialized health care that focuses on you and your serious illness or condition, such as:

 

• Cancer
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• A combination of serious conditions like diabetes or stroke

 

Our focus is to reduce pain, stress, and confusion.

 

Members who begin Guided Care can see:

 

• Improved symptoms
• Reduced hospitalizations
• Fewer unnecessary or unwanted treatments
• Support for both the member and their family and caregivers

 

In short, we want to give you and your family the best quality of life possible.

 

Guided Care may be available to those who have Medicare Advantage or who have both Medicare and Medicaid, also known as D-SNP (Dual Eligible – Special Needs Plan).

 

Your primary care physician (PCP) can refer you to a Guided Care provider. Talk to your PCP if you or someone you care about has a serious illness or condition. Your PCP can tell you if it would be helpful to start Guided Care.

 

Sometimes a member is not able to make the decision to start Guided Care themselves. In these cases, a family member or caregiver may need the member’s approval to make healthcare choices.

 

There are forms and approvals based on what the caregiver needs to do. Some of these forms come from the state.

 

Protected Health Information Form: The member or their Personal Representative can complete this form. This lets Molina share PHI but does not require them to do so.

 

Appointment of Representative Form (CMS-1696): An appointed representative is a family member, friend, doctor or other person approved to act on your behalf in filing a grievance, coverage determination or appeal.

 

If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Molina Healthcare at:

 

Molina Healthcare
Attn: Service Fulfillment
200 Oceangate Ste 100
Long Beach, CA 90802

 

Durable Power of Attorney: If a member needs help in making health care choices, they should fill out the Durable Power of Attorney form for their state, which can be found here.

 

This information does not, and is not intended to, constitute legal advice. Readers of this information should talk to a lawyer to get help about any legal matter.

 

For more information about Molina Guided Care, visit MolinaGuidedCare.com

 

Local support for members and caregivers can be found at MolinaHelpFinder.com.

 

Senior Whole Health of New York NHC (HMO D-SNP)

 

You have a combined monthly allowance to spend on Transportation to a health-related location at your discretion on your pre-funded debit card (Healthy You Card). It does not correspond to a set number of “rides” but can be used to pay for non-emergency medical rides to a doctor's office, hospital, or pharmacy.

 

Things to remember:

 

• If you don’t use all of your monthly benefit amount, the remaining balance will expire and not rollover to the next benefit period.
• You may use your allowance to purchase rides on ride-hailing applications, on taxi services, or towards other forms of non-emergency transportation, such as bus passes, rail cards, or other forms of public transit.
• This allowance is to be used for any services not covered by Original Medicare and/or Medicaid

 

Please see the Pre-funded Debit Card (Healthy You Card) section for a complete list of benefit and services that are included in the combined allowance.

 

Senior Whole Health of New York NHC (HMO D-SNP)

 

In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare.

 

We cover additional dental benefits that Original Medicare does not cover. We have established a partnership with a vendor to provide comprehensive dental coverage that aligns with the services offered by New York State Medicaid. These services will be covered when they are received from an affiliated provider through our vendors network.

 

Supplemental dental services covered include, but not limited to:

 

Preventive Dental

• Oral Exams
• Prophylaxis (cleaning)
• Fluoride Treatment
• Dental X-rays
• Other Diagnostic and Preventive Dental Services

 

Comprehensive Dental

Comprehensive dental services include:

• Extractions
• Endodontics
• Periodontics
• Prosthodontics (removable)
• Prosthodontics (fixed)
• Maxillofacial Prosthetics
• Implant Services
• Oral and Maxillofacial Surgery
• Adjunctive General Services

 

Note: The above coverage is for Medicare Supplemental Dental Benefit. Your New York Medicaid Dental Benefit is also administered by your Senior Whole Health of New York NHC (HMO D-SNP). Please contact the Plan with any questions on this Medicaid benefit.

 

To learn more about your benefits, see Chapter 4 of your Evidence of Coverage (see our Member Materials and Forms page).

 

Senior Whole Health of New York NHC (HMO D-SNP)

 

We have partnered with a Vision Vendor to give you more value for your routine vision needs!

 

Supplemental Vision services covered include, but not limited to:

 

• One routine eye exam every calendar year
• An eyewear allowance

 

You can use your eyewear allowance to purchase:

 

• Contact lenses*
• Eyeglasses (lenses and frames)
• Eyeglass lenses and / or frames
• Upgrades (such as, tinted, U-V, polarized or photochromatic lenses)

 

*If you choose contact lenses, your eyewear allowance can also be used to pay down all or a portion of your contact lens fitting fee. You are responsible for paying for any corrective eyewear over the limit of the plan’s eyewear allowance.

 

You pay $0 for up to one routine eye exam (and refraction) for eyeglasses every calendar year. You have an eyewear allowance every calendar year.

 

For your routine eye exam, to find an in-network routine preventive vision provider close to you can:

 

Search online – using our supplemental vision provider online search tool at MolinaHealthcare.com/Medicare

 

Supplemental benefits are offered by the plan to help with items or services that are generally not covered by Medicare.  All benefits must be used in the plan year and are only available if you are enrolled at the time services are rendered.

 

You may be able to access additional vision services, including eye exams, through your Medicaid benefit. Limitations may apply.

 

As a MAP plan, we can coordinate your Medicare and Medicaid benefits.

 

To learn more about your benefits, see Chapter 4 of your Evidence of Coverage (see our Member Materials and Forms page).

 

Senior Whole Health of New York NHC (HMO D-SNP)

 

Our plan covers one routine hearing exam every year, one fitting for hearing aid/evaluation every year and up to 2 pre-selected hearing aids covered from a plan approved provider every 2 years.

 

Senior Whole Health of New York NHC (HMO D-SNP)

You have a combined monthly allowance on your pre-funded debit card (Healthy You card) for non-prescription OTC health and wellness items like vitamins, sunscreen, pain relievers, bandages, and cough and cold medicine. Unused allowances does not carry over to the next month.

 

OTC hearing aids are covered and included in the combined OTC allowance.

 

 You can use your pre-funded debit card (Healthy You card):

 

• In Store: At select participating retail locations.
• Online: Visit www.Molina.NationsBenefits.com
• By Phone: Call 877-208-9243 (TTY: 711) Monday to Friday, 8 a.m. to 7 p.m., EST.
• By Mail: Fill out and return the OTC Order Form in the OTC Product Catalog.

 

Things to remember:

 

• You can visit www.Molina.NationsBenefits.com for information about your pre-funded debit card (Healthy You card).

 

Please see the Pre-funded Debit Card (Healthy You Card) section for a complete list of benefit and services that are included in the combined allowance.

 

To learn more about your benefits, see Chapter 4 of your Evidence of Coverage (see our Member Materials and Forms page).

 

Senior Whole Health of New York NHC (HMO D-SNP)

 

 You receive a combined monthly allowance on a pre-funded debit card that may be used towards select supplemental plan benefits such as:

 

• Over-the-Counter items
• Transportation (Non-Emergency)
• Food and Produce*
• Transportation non-medical needs*
• Utilities*

 

Funds are loaded onto the card each month. At the end of each month, any unused allocated funds will not carry out to the following month or plan year.

 

*Eligibility requirements applicable

 

 

The Silver&Fit® program offers you access to participating fitness centers and/or a Home Fitness Kit.

 

If you have a caregiver, you can bring them with you to help you use the fitness center’s services and equipment.

 

There are two ways to start using your Silver&Fit benefit:

 

• Go to SilverandFit.com. After registering on the website, you can find fitness centers, pick a Home Fitness Kit, and search for online classes.
• Call Silver&Fit customer service at (877) 427-4711 (TTY: 711), Monday to Friday, 8 a.m. to 6 p.m., local time, excluding holidays.

 

To learn more about your benefits, see Chapter 4 of your Evidence of Coverage (see our Member Materials and Forms page).

 

Senior Whole Health of New York NHC (HMO D-SNP)

 

You receive a monthly allowance on a pre-funded debit card that may be used towards select supplemental plan benefits such as:

 

• Food and produce
• Utility bills (electricity, natural gas, and water)
• Transportation non-medical needs

 

Please see the Pre-funded Debit Card (Healthy You Card) section for a complete list of benefit and services that are included in the combined allowance. Unused allowance does not carry over to next month.

 

Members must meet the criteria outlined in Chapter 4 of the Evidence of Coverage.

 

To learn more about your benefits, see Chapter 4 of your Evidence of Coverage (see our Member Materials and Forms page).

 

Senior Whole Health Medicare's Nurse Advice Line has highly trained nurses that can help you 24 hours a day, 365 days a year. They can help you decide what to do to get your family feeling better fast. A nurse can help you decide if you or your child should see a provider right away. There are times where you have questions, but you do not think you need to see your provider. We can look up health information from a trusted source and provide recommendations based on symptoms. Call the Nurse Advice Line. You can talk to a nurse in your language about any health problem. Our Nurse Advice Line receives more than 500,000 health advice calls from Senior Whole Health members across the United States every year.

 

Our call center has been reviewed and approved by a national quality review organization (URAC) since 2007. They will help you 24 hours a day, 7 days a week.

 

English & Spanish: (877) 353-0185

 

For the deaf and hard of hearing, please call TTY: 711

 

 

Check your Member Materials and Forms to see all the standard benefits offered by Senior Whole Health.