Your benefits and services

Senior Whole Health of New York’s Medicaid Managed Long Term Care Plan is committed to maximizing your quality of life, health, security and independence.

As part of our ongoing commitment to your well-being, your Senior Whole Health of New York Care Manager monitors your medical and social needs and makes the necessary changes to your plan of care as your conditions and needs change.

Our Senior Whole Health of New York Medicaid Managed Long Term Care Plan has $0 copays and no deductibles for any of the services or benefits we offer.

  • Covered Services

    Care and services provided in a residential health care facility or approved extension site must be provided: 
    Under the medical direction of a physician 
    By Adult Day Health Care staff 
    Based on the member’s comprehensive needs assessment and care plan 
    With ongoing coordination of the health care plan 
    Includes transportation.

    Prior authorization required.

    Treatment and equipment to help you hear better. Hearing exams and hearing aids are provided by a network of local, independent audiologists in the SWH of NY service area. Every exam is performed by a fully licensed audiologist. If you think you need a hearing exam, we may ask you to see your doctor first to be sure that another health problem is not affecting your ability to hear. We also cover batteries for your hearing aids.

    Prior authorization required.

    Services for members with chronic illnesses or physical disabilities who have a medical need for help with activities of daily living (ADL) or skilled nursing services. Includes any of the services provided by a personal care aide (home attendant), home health aide or nurse.

    You have flexibility and freedom in choosing your caregivers. You, or the person acting on your behalf, are responsible for hiring, firing, training, supervising and terminating, if necessary.

    Prior authorization required.

    A service by a special type of provider that treats your teeth and gums. Dental services are provided by DentaQuest. You can contact them at 

    Your coverage includes:
    Annual oral examination and cleanings
    Medically needed dentures, fitting and alignment (one full set every 4 years)
    Dental implants, subject to medical necessity*

    *Prior authorization required for dental implants. Request must be accompanied by a physician’s letter explaining how the implants will help with your medical problem. Additionally, a dentist’s letter explaining why other alternatives will not correct your condition and why you require implants. 

    Items to help with your health care and to take care of yourself. DME includes medical/surgical supplies, enteral and parenteral formula, hearing aid batteries, prosthetics, orthotics and orthopedic footwear, canes, hospital bed, wheelchairs, oxygen, and walkers.

    Prior authorization may be required for some equipment.

    Meals provided at home or in congregate settings, such as senior centers for individuals unable to prepare meals or have them prepared.

    Prior authorization required.

    Services provided in your home. These services may be provided by licensed staff or unlicensed staff. Includes nursing, home health aide, occupational, physical and speech therapies. 

    Prior authorization required.

    Checking, setting up and giving help for social problems to keep you in your home. Services are performed by a qualified social worker and provided within a plan of care.

    Prior authorization required.

    Products needed to take care of a medical condition. Usually these products are not re-usable by other people. New York Medicaid allows us to pay for compression and support stockings only when they are used venous or lymphatic impairment.

    Prior authorization required.

    Includes non-emergency transportation to and from a medical appointment. To schedule transportation, call 1-855-558-1638 and follow the prompts. Transportation must be scheduled at least 3 (three) days before your appointment. You can schedule your transportation up to 30 days in advance. 

    Prior authorization required.

    Includes assessment of nutritional needs, development and evaluation of treatment plans, nutrition education and counseling. Includes cultural considerations.

    Prior authorization required.

    A nursing home is a place for people who don't need to be in a hospital but can't be cared for at home. Most nursing homes have nursing aides and skilled nurses on hand 24 hours a day.
    Some nursing homes are set up like a hospital. The staff provides medical care, as well as physical, speech and occupational therapy. There might be a nurses' station on each floor. Other nursing homes try to be more like home. They try to have a neighborhood feel. Often, they don't have a fixed day-to-day schedule, and kitchens might be open to residents. Staff members are encouraged to develop relationships with residents. 

    Some nursing homes have special care units for people with serious memory problems such as Alzheimer's disease. Nursing homes are not only for the elderly, but for anyone who requires 24-hour care. For SWH of NY to pay for nursing home care, you must be eligible to receive the nursing home care from Medicaid in New York.

    Prior authorization required.

    Vision services include: 

    Annual preventive eye exams 
    Medically necessary eye exams
    Eyeglasses provided by network optometrists (must be medically necessary)
      ̶  Limited to one pair of glasses every 2 (two) years unless your prescription changes

    For members who require both distance and reading correction, you may get one pair of each every 2 (two) years

    Prior authorization required.

    Shoes, shoe modifications or shoe additions which are used to correct, accommodate, or prevent a physical deformity or range of motion malfunction in a diseased or injured part of the ankle or foot. 

    Prior authorization required.

    Covered services include: 

    Physical and occupational therapy 
    Speech language therapy 
    Cardiac rehabilitative therapy 
    Social and psychological therapy
    Comprehensive Outpatient Rehabilitation Facility (CORF) services

    Prior authorization required.

    Service to help you stay at home instead of going to a nursing home. Personal care includes services such as housekeeping, meal preparation, bathing, toileting, and grooming. 

    Prior authorization required.

    An electronic device that sends an alert if you are not safe or have fallen and cannot get up by yourself. 

    Prior authorization required. 

    Care for your feet by a podiatrist (foot doctor). Foot care including initial examination, nail trimming and callous removal when medically necessary.

    Prior authorization required.

    Must be provided by a registered professional nurse (RN) or licensed practical nurse (LPN) possessing a license and current registration from the NYS Education Department. Services may be provided through an approved certified home health agency, licensed home care agency or private practitioner.

    Prior authorization required.

    Prosthetics are man-made body parts (other than dental) used to replace your missing body part(s).

    Orthotics are special inserts for your shoes.

    Prior authorization required.

    We will coordinate with your health care professionals on required medical equipment, supplies, respiratory therapy, and oxygen.

    Prior authorization required.

    Social day care is set up as a safe place you can go to receive care and meet with others. Social day care services include time with other adults, supervision, personal care, and help with your nutrition. Some social day care facilities have more services and may include help for your caregiver, help with living skills, care coordination, and transportation.

    Assessment and Prior authorization required.

    Social supports are people and tools that help keep you in touch with other people.

    Environmental supports are changes to your home that increase your ability to do things on your own or increase your ability to help with your care. Social and environmental supports include services such as home maintenance tasks, homemaker/chore services, housing improvement, and respite care.

    Prior authorization required.

Getting Care

Primary and acute care services are not covered services in the Senior Whole Health of New York plan. Instead, these services are covered by your Medicaid or Medicare plan. This means you get to maintain your relationship with your current PCP to assure there is no disruption in medical care. If you need help finding a provider in your community, your Care Management Team can assist you.

    For services covered by Senior Whole Health of New York, you may choose any provider from our network of providers that offers the services you need. Read more about how to choose a doctor here. Look for a provider who: 
    Is accepting new patients 
    Is convenient (nearby, wheelchair accessible, etc.) 
    Speaks your language or has staff members who do 
    Understands your culture 

    If you plan to be away from home or outside our service area, please notify your Care Manager as early as possible so we can arrange any needed services. We’ll work with you and continue to provide non-emergency covered services to the extent they can be arranged with area providers. If you are out of the area and have an emergency, go to the nearest emergency facility. 

    When you need care right away, there are options. 

    Emergency services

    Emergencies are times when there could be serious danger or damage to your health if you don’t get care right away. If you have an emergency, call 911 or go to the nearest hospital emergency room (ER). 

    Call your PCP and Senior Whole Health of New York as soon as you can after you visit the ER. Your PCP can help with your follow-up care. 

    Urgent care

    An urgent medical condition is when care is needed for a sudden illness, injury, or condition that is not an emergency but needs to be treated in the next 24 to 48 hours. If you need help finding a nearby urgent care center, call Member Services at 1-877-353-0185, 24 hours a day for guidance. Our nurses can advise you on where to go when you need care. Call your PCP and Senior Whole Health of New York as soon as you can after you visit urgent care. Your PCP can help with your follow-up care. 

    Your PCP

    When you’re sick or hurt, always call your PCP first (unless it’s an emergency). Even if you call outside of their normal hours, someone from the office should be on call and able to help.