It is our mission to maximize the quality of life, health, security and independence of our Senior Care Options (SCO), Medicare Advantage Special Needs (HMO SNP) and Nursing Home Certifiable (HMO SNP) members. It is critical to that mission that we provide members with top quality care and service. Our Quality Improvement Team monitors nationally established indicators of business performance and compares them to benchmarks to identify opportunities for improvement.
As opportunities are identified, projects are proposed, prioritized, implemented and managed to attain the desired improvements. As the programs take effect, quality metrics continue to be monitored to make sure the desired performance is achieved. Over time, current projects are sustained, and new opportunities are identified and prioritized.
Using this approach, Senior Whole Health continuously works to improve the care and programs we offer to seniors in Massachusetts.
SWH Medicare HMO and Medicaid HMO is accredited by the National Committee for Quality Assurance (NCQA) which is a testament to the quality we provide for our members. This accreditation was based on our superior service and clinical quality that meet or exceed NCQA’s rigorous requirements for consumer protection and quality improvement.
When your providers make recommendations about the types of services and treatments you may need, they use a set of clinical practice guidelines. Clinical practice guidelines are based on clinical research and are recommended for optimal outcomes. You can view the clinical practice guidelines your provider uses by clicking on the following link:
Shared Decision Making Tools
Your doctor should work with you to decide the best care for your situation. Senior Whole Health has created a set of tools to help your doctor include you in these decisions. To review these tools, click on the link below.
The member rights include the right:
- To receive information about SWH’s services, practitioners and providers, enrollment, informational or instructional materials, grievance and appeal rights and member’s rights and responsibilities annually in a manner appropriate to their condition and ability to understand;
- To receive reasonable accommodations if required;
- To be treated with respect and recognition of their dignity and their right to privacy;
- To participate with practitioners in making decisions about their healthcare including the right to refuse treatment;
- To participate in a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage;
- To voice complaints or appeals about SWH or the care provided;
- To make recommendations regarding SWH’s member rights and responsibility policy;
- To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation;
- To request and receive a copy of his or her medical record and request that the record be amended or corrected;
- To not be balanced billed by a provider for any service;
- To receive services in a culturally competent manner and non-discriminatory manner;
- To receive updates and/or changes to the rights and responsibilities at least annually;
- To annually receive the Evidence of Coverage; and
- To exercise their member rights without negative consequences.
Member responsibilities include the responsibility to:
- Provide, to the extent possible, information that SWH and its practitioners and providers need in order to care for a member
- Follow the plans and instructions for care that the member has agreed upon with the practitioner or provider
- Understand a member’s health problems and participate in developing mutually agreed upon treatment goals and care plans
- Get familiar with the covered services and the rules a member must follow to obtain the covered services
- Inform SWH if there is any other health insurance coverage or prescription drug coverage in addition to the SWH plan
- Tell the member’s doctor and other healthcare providers that the member is enrolled in a SWH plan
- Help doctors and other providers help the member by giving the doctors and providers information, asking questions, and following through on the care plan
- Be considerate by respecting the rights of other patients and acting in a way that is respectful of a healthcare practitioner or provider and the staff
- Pay what any healthcare bills that are owed
- Tell SWH if there is a change of residence
- Call Member Services at 1-888-794-7268 (TTY 711) from 8 a.m. to 8 p.m., 7 days a week. for help when there are questions or concerns.
Senior Whole Health and its FDRs shall comply with applicable statutory, regulatory, other requirements, sub-regulatory guidance, and contractual commitments related to the delivery of covered CMS services, which include, but are not limited to, federal and state False Claims Acts, Anti-Kickback statutes, prohibitions on inducements to beneficiaries, Health Insurance Portability and Accountability Act (HIPAA), and other applicable statutes. Read the full SWH Fraud, Waste and Abuse Policy here.
Reporting suspected fraud, waste and abuse is easy— and it’s important.
Molina AlertLine: 1-866-606-3889 (TTY 711)
Other ways to report suspected fraud:
Office of Inspector General (OIG)
To report suspected cases of fraud, waste, or abuse in Federal Health and Human Services (HHS) programs, you may fill out the online OIG Hotline form. You can also call, mail or fax using the information below:
Office of Inspector General
U.S. Department of Health & Human Services
P.O. Box 23489
Washington, DC 20026
Phone: 1-800-HHS-TIPS (8477)
Centers for Medicare and Medicaid Services
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Phone: 1-800-368-1019, 1-800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html