How do I?

How do I enroll in Senior Whole Health?
How often can I change my health plan?

You can change health plans only at certain times during the year. From October 15 through December 7, you can join, switch or drop a Medicare health or prescription drug plan for any reason. When you do, your new plan is effective on January 1 of the following year.

Dual-eligible members may also change plans during the Special Election Period (SEP). The SEP starts the month you become dually eligible and lasts as long as you receive Medicaid benefits. You may use the SEP one time each quarter for the first three (3) quarters of the year:

  • January – March
  • April – June
  • July – September

When you change plans using the SEP, your enrollment status is effective the first day of the month following receipt of the request. It is considered used during the month it is requested.

For more information on ending your membership with Senior Whole Health, enrolling in another Medicare Advantage plan or enrolling in Original Medicare, please review your Evidence of Coverage

Can Senior Whole Health end my enrollment?
  • Yes, in certain situations we will end your enrollment. This is called involuntary disenrollment and will occur if any of the following happen:
  • You no longer have Medicare Part A and part B.
  • You’re no longer eligible for Medicaid. (Disenrollment occurs if you do not regain and do not expect to regain Medicaid coverage within one month.)
  • You move out of our service area.
  • You are away from our service area for more than six months.
  • You become incarcerated.
  • You’re not a US citizen or lawfully present in the US.
  • You lie about or withhold information about other insurance you have.
  • You intentionally give us incorrect information concerning your eligibility when you enroll. (We must get permission from Medicare before we can disenroll you for this reason.)
  • You continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you or other members of our plan. (We must get permission from Medicare before we can disenroll you for this reason.)
  • You let someone else use your membership care to get medical care. (We must get permission from Medicare before we can disenroll you for this reason.)
  • If we end your membership for this reason, Medicare may have your case investigated by the Inspector General.
  • You are required to pay the extra Part D amount because of your income and you do not pay it. (Medicare will disenroll you in this case.)
    We cannot ask you to leave our plan for any reason related to your health.
How do I get care or treatment that requires prior authorization?

Your provider will contact Senior Whole Health to request prior authorization.

What is an Organization Determination?

An organization decision, or coverage decision, is a decision we make about your medical benefits and coverage or about the amount we will pay for medical services. Whenever we decide what services and the quantity of services we will cover, we are making an organizational decision.

How do I request an Organizational Determination?

You, your doctor, or someone else you appoint to act on your behalf may request an organizational determination.

Senior Whole Health Medicare Advantage Special Needs (SNP), Nursing Home Certifiable (HMO SNP) or Senior Care Options (SCO) members can make a request by:

  • Faxing your completed form to 1-617-494-5554
  • Writing to us at:

Senior Whole Health
Attention:  Utilization Management Department
58 Charles Street
Cambridge, MA 02141

How do I appoint someone to make the request for me?

You may appoint an individual to act as your representative using the Appointment of Representative Form

You can also get this form by calling Member Services at 1-888-794-7268 (TTY 711) from 8 a.m. to 8 p.m., 7 days a week.

How long will it take to get a decision?

When we give you our decision, we will use the standard timeframe unless we have agreed to give you a fast decision.

  • A standard decision means we will give you an answer within 14 days after we receive your request.
  • A fast decision means we will answer within 72 hours.

To get a fast organizational decision, you must meet two requirements: ◦

  • The request must be for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
  • Using the standard timeframe could cause serious harm to your health or your ability to function.

If your doctor tells us that your health requires a fast decision, we will automatically agree.

If you ask for a fast decision on your own, without your doctor’s support, we will decide whether your health requires a fast decision. If we say no, we will make a decision within the standard timeframe.

If we deny your request for services or treatment, you have the right to ask us to reconsider, and perhaps change this decision by making an appeal. Refer to the appeals section for more information on filing an appeal.

 

Coverage decisions: Getting prescription drugs

Coverage decisions involving prescriptions include:

  • Asking us to cover a drug not on our formulary, called a formulary exception
  • Asking us to waive a requirement (prior authorization, step therapy or quantity limits), called a formulary exception
  • Asking us for prior approval for a drug on the formulary, called prior authorization

 

How do I ask for a formulary exception?

When asking for a formulary exception, your doctor or prescriber must tell us the medical reason for the exception.

You may request a coverage decision about drugs by phone or in writing.

  • To request by phone, call the Senior Whole Health Pharmacy department at
  • To request in writing, send a letter or complete the CMS Coverage Determination Request Form and return it to us:
    • By mail to: Senior Whole Health of Massachusetts

Attn: Pharmacy Department

58 Charles St.

Cambridge, MA 02141

  • By fax to: 1-888-251-7823
How long will it take to get a decision?

When we give you our decision, we will use the standard timeframe unless we have agreed to give you a fast decision.

  • A standard decision means we will give you an answer within 72 hours after we receive your request.
  • A fast decision means we will answer within 24 hours.

To get a fast coverage decision, you must meet two requirements: ◦

  • The request must be for a drug you have not yet received. (You cannot get a fast decision if your request is about payment for drug you have already received.)
  • Using the standard timeframe could cause serious harm to your health or your ability to function.
Grievances (complaints) and appeals

Although we strive to provide high quality health care for seniors in Massachusetts, we understand there may be times when you aren’t completely happy or satisfied. We try our best to deal with your concerns or issues as quickly as possible and to your satisfaction. You may use either our complaint (grievance) process or our appeal process, depending on what kind of problem you have.

There will be no change in your services or the way you are treated by Senior Whole Health staff or a healthcare provider because you file a complaint or an appeal. We will maintain your privacy. We will give you any help you may need to file a complaint or appeal. This includes providing Massachusetts seniors with interpreter services or help if you have vision and/or hearing problems. You may also choose someone (like a relative or friend or a provider) to act for you. To appoint an individual to act as your representative, fill out an Appointment of Representative Form.

How do I file a complaint?

You may file a complaint or someone else may file the complaint on your behalf.

To file the complaint:

  • Call Member Services at 1-888-794-7268 (TTY 711)
  • Fax your compliant to 617-494-5554
  • Write to:
    Senior Whole Health
    Attention: Quality Manager
    58 Charles Street
    Cambridge, MA 02141

You must submit your complaint within 60 days of the event or incident.

How long will it take to get a decision?

If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, you have the right to request a fast (expedited) review. A fast review means that we will notify you in writing of Senior Whole Health’s conclusion within 24 hours.

Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.

If your complaint is about the quality of care you receive, you may also make a complaint to the Quality Improvement Organization (QIP), called KEPRO, by calling 1-888-319-8452 (TTY 1-855-843-4776) Monday-Friday 9 a.m. to 5 p.m. 24-hour voicemail service is available.

You can make a complaint directly to KEPRO. You do not need to complain to us first. Or, if you wish, you can make your quality of care complaint to us and the QIP at the same time.

What is an appeal?

If we make an organizational determination about medical care or a coverage decision about a drug you need, and you disagree with our decision, you can appeal the decision. An appeal is a formal way of asking us to review and change an organizational decision we have made. When your appeal is about a Part D drug, we call it a “redetermination.”

Who can file an appeal or redetermination?

You, your doctor or another individual acting on your behalf may file an appeal. If someone other than you or your doctor is filing for you, the appeal must include an Appointment of Representative form authorizing this person to represent you.

How do I file an appeal for medical coverage?

Your appeal request must be made within 60 days of receiving the coverage decision.

You may file your appeal orally or in writing. To appeal a decision about medical coverage:

  • Call 1-888-794-7268 (TTY 711)
  • Fax to 1-855-838-7998
  • Write to us at:
    Senior Whole Health
    Attention: Quality Manager
    58 Charles Street
    Cambridge, MA 02141
How long will it take to get an appeal decision?

For appeals regarding coverage for services you have not yet received, the standard deadline for our decision is within 30 calendar days after we receive your appeal  We will give you our decision sooner if your health condition requires us to.

If your doctor tells us that your health requires a fast appeal, we will give you our answer within 72 hours after we receive your appeal. For appeals regarding coverage for services you have not yet received, the standard deadline for our decision is within 30 calendar days after we receive your appeal. We will give you our decision sooner if your health condition requires us to.

To get a fast appeal decision, you must meet two requirements: ◦

  • The request must be for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
  • Using the standard timeframe could cause serious harm to your health or your ability to function.

If your doctor tells us that your health requires a “fast decision,” we will automatically agree.

If you ask for a fast decision on your own, without your doctor’s support, we will decide whether your health requires a fast decision. If we say no, we will make a decision within the standard timeframe.

What if I disagree with your appeal decision?

Any time our appeal decision is to deny services, your case will automatically be sent on to the next level of appeal. An Independent Review Organization reviews our decision and decides whether the decision should be changed.

Review Chapter 8 or your Evidence of Coverage for more information about Level 2 appeals.

How do I file a redetermination (appeal) for a Part D drug?

You may call us, write us or fax us your request. You must make your request within 60 calendar days from the date of our coverage decision notice.

  1. To request by phone, call Member Services at 1-888-794-7268.
  2. To request in writing, complete the Request For Redetermination Of Medicare Prescription Drug Denial
    or send a letter to us by:
  • Fax to 1-888-251-7823
  • Mail to:
    Senior Whole Health
    Attn: Pharmacy Department
    58 Charles Street
    Cambridge, MA 02141 

You may also request a redetermination online using the Online request for Medicare Part D Redetermination.

 

How long will it take to get a decision on a Part D redetermination request?

For standard redetermination requests, we’ll give you an answer within 7 calendar days of the date we receive your appeal. If your health requires a fast appeal decision, we’ll answer your appeal within 72 hours. These timeframes are only for drugs you have not yet received.

 

 

 

 

 

 

 

 

 

 

For more information on these and other topics, refer to your

Senior Whole Health Evidence of Coverage

or call Member Services at 1-888-794-7268 (TTY 711) from 8 a.m. to 8 p.m., 7 days a week.