Senior Whole Health Plan Overview

FEBRUARY 2020

SWH Vision & MissionVisionBe a national leader in integrated health care that is simple, comprehensive, humane and respectful.

MissionMaximize the quality of life, health, security and independence of our members.

Senior Whole Health (SWH) is committed to conducting business operations honestly and ethically with members,provider suppliers and governmental agencies.

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Senior Whole Health

Offers a Medicare Advantage Special Needs Plan (SNP), a Senior Whole Health Nursing Home Certifiable Plan (HMO SNP) and a Senior Care Options Plan (SCO).

Medicare Advantage SNP members and Nursing Home Certifiable HMO SNP members qualify for and receive Medicare and Medicaid benefits. SCO plan members are 65 or older and qualify for Medicaid but receive both Medicare and Medicaid benefits supported by the state of Massachusetts.

Is designed to meet the needs of our members, SWH is a Fully Integrated Special Needs Plan (FISNP)

Coordinates members’ Medicare, MassHealth (Medicaid) and Medicare Part D Prescription Drug benefits as a single integrated benefit for ALL members.

Provides all members with the same comprehensive benefits despite the type of plan.

Accepts full risk for all Medicare and Medicaid benefits including long- term care.

A Unique Health Plan

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Quick Facts

SWH has been enrolling members in Massachusetts since August 2004 • Current membership: Over 15,000 members

Our service area includes Eastern, Central & Western MA• Bristol, Essex, Hampden, Middlesex, Norfolk,

Plymouth, Suffolk, and Worcester Counties

Independent & local• Cambridge, MA• Bridgewater, MA

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Eligibility

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Be 65 years old or older

Have Medicare & MassHealth Standard (dual eligible) or at least have MassHealth Standard

Live in the Senior Whole Health service area

TO BE ELIGIBLE, INDIVIDUALS MUST:

Rating Categories for Member:

Community Well, Nursing Home Certifiable, Chronically Mentally Ill, Alzheimer's/Dementia and Institutional

(exclusion: individuals with end-stage renal disease)

Why Members Join Senior Whole Health?

No out of pocket expenses

Medication—no prescription copays and pharmacists on staff to help

Healthy You Card—a pre-paid over-the-counter card helps them pay for certain health-related items

Enhanced vision benefits —routine eye exams plus $305 towards frames

Enhanced dental—cleanings, checkups, implants, x-rays, fillings, full and partial dentures & more!

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Transportation—to and from doctor’s appointments (no PT-1 form)

Gym benefits—free YMCA membership (or $55 per month allowable reimbursement)

Podiatry—enhanced benefit for routine foot care

Acupuncture benefit—40 visits per year for pain management (under MassHealth benefit), anxiety and smoking cessation

Challenges of Dual Eligibles

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This results in: Fragmented care and unnecessary hospital, outpatient and radiology services

Revenue “gaming” between nursing homes and hospitals

Difficulty in receiving most appropriate and least restrictive services

Common characteristics of dual-eligible beneficiaries include:• Diagnosis of multiple chronic conditions

while taking multiple medications from different providers

• English is not their primary speaking language

• Lower education levels

• Non-medical issues that impact their medical care

• Limited or no coordination of care or benefits

• Aged 65 or older

The SWH Model of Care

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SWH’s Model of Care has goals and objectives for the targeted population and a specialized provider network; uses nationally-recognized clinical practice guidelines; conducts health risk assessments to identify the special needs of beneficiaries; and coordinates and manages services for these vulnerable beneficiaries.

SWH’s Model of Care provides the structure for care management processes and systems that enables us to provide coordinated care for individuals with special needs.

Key Operational Benefit

Medicare, Medicaid & Part D consolidation: One Plan/One Card

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Results in reduced administrative burden• Single payment source (one stop shop)

• No deductibles, copays or coinsurance to collect

• No referrals required to in-network providers

• No PT-1 forms required for transportation

• Access to SWH pharmacist for assistance with medication management

Please be sure to go to our website at www.seniorwholehealth.com for updates, forms, resources, the Provider Manual and more!

Provider Portal

Step 1

Register for an account

1. Access portal via the following URL: https://swhiweb.seniorwholehealth.com/providerportal/

2. Click on ‘Register Account’

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3. Enter a Senior Whole Health (SWH) Claim ID billed in the past 2 months. This is required information.

4. Enter the amount paid for the SWH Claim ID you provide. This is required information.

Please note: If there is no match for the NPI/TIN/Claim/Paid Amount, you will not be able to proceed. In addition, you must build a unique account for each NPI you are affiliated with.

Step 2

Complete registration form

1. Enter your personal information on the registration form. Please do not fill out this section for someone else.

2. Provider NPI is required; TIN is only required for those records that are pay to entities.

Provider Portal (continue)

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Login Information/Terms of Service Agreement

1. Create an original username and password for your account

2. Choose your personal security questions and choose your answers

3. Id you agree to the Terms of Service, please click “I AGREE”

4. Click “NEXT”

Step 3

Confirm Registration Summary & Validate Email

1. Review and confirm all of your information on the Registration Confirmation Summary page

2. Check your email for a verification code

3. Enter the Verification Code into the field next to “VERIFICATION CODE”

4. Click “SUBMIT”

Accessing Member Eligibility

Accessing Member Eligibility

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Fill out all necessary information to access your patient information:

You will need at least three (3) of the following: Last Name, Date of Birth, Member ID, Medicare ID, Medicaid ID

Accessing Claims

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1. On the left side of the Home Screen, click on the link that says Claim Center.

2. You may search using the following criteria:Institute/Professional Claims, date range, status and Provider NPI OR by Claims ID number. Fill our the required information and click Search.

3. You’ll see all the claims that fulfill your search criteria. The display will show claim ID, service dates, patient, service provider and status. You may click on the claim ID for more details.

How To Refer Potential Members To SWH?

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Marketing Outreach Department1-888-566-3526 TTY 711

Need brochures in your practice?Contact your Provider Relations Account Manager or call the Provider Relations line:

1-855-838-7999

Legal

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