Benefits
As a member of SWH, we will work with you to design an individual plan of care that combines traditional health care services with social support services that will keep you healthy, independent and living at home.
The following diagram provides an overview of the benefits offered with the SWH (Medicare and Medicaid Advantage) and SWH Plus (Medicare and Medicaid Advantage Plus) plans:
Medicare Advantage Special Needs Program
Provides all the benefits of Medicare including:
Medicare Part D Prescription Drug Coverage
in combination with
Medicaid Advantage * | OR | Medicaid Advantage Plus *
(Please click on the links above to learn more about each program.)
* Based on a member’s eligibility and clinical status, SWH will determine the appropriateness of the Medicaid Advantage or Medicaid Advantage Plus program.
SWH (Medicare and Medicaid Advantage)
Enrollees in the SWH (Medicare and Medicaid Advantage) program will be eligible for:
- All Medicare services they would normally get under the CMS-approved standard uniform Medicare Advantage Product, and
- All the Medicaid services they would normally get under the State Medicaid Plan, either through a health plan’s Medicare and Medicaid Advantage products, or through Medicaid fee-for-service.
The SWH (Medicare and Medicaid Advantage) program includes certain Medicaid-covered services and benefits, and the cost of beneficiary cost sharing (co-pays and deductibles) and the supplemental premiums, if any, associated with the CMS approved standard uniform Medicare Advantage product.
SWH (Medicare and Medicaid Advantage) covered services include:
- Transportation (non-emergency medically related)
- Private-duty nursing services
- Dental services
- Home health services
- Inpatient mental health days in excess of Medicare's 190-day lifetime limit
Certain Medicaid services remain carved out of the Medicaid Advantage benefit package and will be covered through Medicaid fee-for-service.
Dual-eligible persons interested in participating in this program will enroll in the SWH’s Medicare and Medicaid Advantage products. Some Medicaid services will continue to be available to plan enrollees on fee-for-service basis.
For Medicaid Advantage, the responsibilities for plan qualification, plan oversight, and local Department of Social Services (LDSS) oversight lies with the New York State Department of Health.
As with Medicaid managed care, your local Department of Social Services will be responsible for determining your Medicaid eligibility, educating you about the availability of Medicaid Advantage plans within their jurisdiction, processing Medicaid Advantage enrollments and disenrollments, and updating recipients’ Medicaid status.
We know how complicated the choice of health services has become. That is why SWH is here to assist you with any questions about your options and our plan. Please feel free to contact us at 1-866-211-1777 for more information.
SWH Plus (Medicare and Medicaid Advantage Plus)
The SWH Plus (Medicare and Medicaid Advantage Plus) program is a coordinated plan of care and services for frail, and/or chronically ill individuals who can be maintained at home and who may otherwise reside in a nursing home, hospital or other long term-care facility.
With SWH Plus (Medicare and Medicaid Advantage Plus), SWH can deliver the highest quality long-term care services to the state’s most vulnerable individuals. Members and caregivers will greatly benefit from our vast network of providers, greater range of care options, and the unique blend of personalized, simplified coverage.
SWH Plus (Medicare and Medicaid Advantage Plus) offers comprehensive care, including preventive services, physician services, hospital care, pharmacy, support services to help keep our members living independently at home.
SWH Plus (Medicare and Medicaid Advantage Plus) has three main goals:
- To offer high quality care options to individuals who prefer to be maintained in their home.
- To enable members who have been institutionalized to return to the community.
- To enhance the communication process between and among providers of care. SWH strives to provide you with the most personalized health care experience through the provision of close case management and monitoring.
Medicaid Advantage Plus Benefits
- Transportation (non-emergency medically related)
- Private-duty nursing services
- Dental services
- Home health services
- Inpatient mental health days in excess of 190-day lifetime limit
- SNF days in excess of 100 days per benefit period
- Home delivered meals
- Congregate meals
- Adult day health care
- Social day care
- Personal care services
- Nutrition counseling
- Medical social services
- Social and environmental supports
- PERS (Personal Emergency Response System)
Participants in SWH Plus (Medicare and Medicaid Advantage Plus) must be medically eligible for medical and non-medical services over an extended period of time.
Medical eligibility for SWH’s Medicaid Advantage Plus program is determined through assessment, and by an individual’s primary care physician and the Department of Social Services.
SWH's Medicaid Advantage Plus is most appropriate for those individuals:
- With multiple complex care needs
- Needing medical and non-medical services over an extended period of time
- Living alone or without adequate support systems
- Needing a medical home base to optimize care provided by multiple physicians
- Who are interested in preventing or delaying nursing home placement
Since Medicaid regulations prohibit the duplication of services to individuals, those who are currently enrolled in a Managed Care Plan, Pre-paid Mental Health Plan (PMHP), Managed Long Term Care Program (MLTC), or Program of All-Inclusive Care for the Elderly (PACE) cannot join SWH unless they disenroll from their current program. Also, individuals participating in SWH may not receive Comprehensive Medicaid Case Management (CMCM) through a targeted case management program.
Local Department of Social Services and SWH
SWH and the member’s local Department of Social Services representative work together to coordinate information and jointly identify a plan of care that is comprehensive and detailed to each individual's needs.
This plan is available to anyone aged 65 or older and who has both NYS Medicaid and Medicare.
The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement, for more information contact the plan.
Last modified: 09/15/2010