Member Resources

Know What to Expect After Applying

Congratulations on applying for a Highmark Wholecare health plan. Here are some things to look out for while you wait for your health care coverage to begin.

Confirmation Letter and Member Access Card

After applying, you’ll get a letter via U.S. Mail that tells you when you’re approved. Your letter will also include your Member Access card. You’ll need your card whenever you get care or a prescription filled.

Note, you can save a digital Member Access Card to your mobile device using our Wholecare member app. Visit the Apple App Store or visit the Google Play App Store to begin.

Member Packet

Your Member Packet includes plan documents, like your Evidence of Coverage (EOC). You can rely on your EOC to answer questions about your plan.

If you’d still like to learn more, you can visit our Frequently Asked Questions (FAQ) or call Member Services at 1-800-392-1147.

Healthy Food and Benefit Card

Your Healthy Food and Benefit Card helps you pay for your food each month. You’ll choose from hundreds of healthy items, like fresh produce.

Welcome Phone Call

Our Member Services Team will call to welcome you and also about scheduling a Health Risk Assessment (HRA) with your Primary Care Physician (PCP). Your HRA helps identify any areas you may need to work on to stay healthy.

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Take Next Steps After Applying

You can start preparing for your new health care coverage to begin as soon as you apply. Setting yourself up now means your health care coverage will be ready as soon as you need it.

Health Plan Steps

To save time when you need care, you can:

• Sign up for the Member Portal
• Choose a Primary Care Provider (PCP)
• Learn how to re-certify with Medicaid each year

Prescription Drug Steps

To get prescriptions covered and filled, you can:

• Find a pharmacy
• Search for a Medicare D-SNP Diamond and Ruby Drug 
• Learn about your medication benefits

Wholecare Steps

To make personalized care plans and attend community events, you can:

• Discover how Care Transitions can help
• Check out the Wholecare Resource Center
• Stop by a Wholecare Connection Center
  

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Browse Member Newsletters

As a Highmark Wholecare health plan member, you’ll receive a seasonal newsletter that’s full of helpful articles and tips. You’ll see topics like:

• Healthy recipes
• Safe exercises
• Health screening guides
• COVID and mental health
• Using your benefits

Read Medicare Member Newsletters

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Learn About Grievances and Appeals

If you feel an error was made about your coverage, or if you have a service complaint, you have the right to file your concerns. It’s important to know about steps you may need to take and deadlines for filing:

• Part D (Prescription Drug) Grievances and Appeals
• Pharmacy appeal (Part D Redetermination)
• Part C (Medical Services) Grievances and Appeals
• Appointed Representatives

Review Grievances and Appeals

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Review Member Rights and Responsibilities

Member Rights

As a Highmark Wholecare member, you have the right to:

1. Be treated with respect, recognizing your dignity and need for privacy, by Highmark Wholecare staff and network providers.
2. Get information in a way that you can easily understand and find help when you need it.
3. Get information that you can easily understand about Highmark Wholecare, its services and the doctors and other providers that treat you.
4. Pick the network health care providers that you want to treat you.
5. Get emergency services when you need them from any provider without Highmark Wholecare’s approval.
6. Get information that you can easily understand and talk to your providers about your treatment options, risks of treatment and tests that may be self-administered without any interference from Highmark Wholecare.
7. Make all decisions about your health care, including the right to refuse treatment. If you cannot make treatment decisions by yourself, you have the right to have someone else help you make decisions or make decisions for you.
8. Talk with providers in confidence and to have your health care information and records kept confidential.
9. See and get a copy of your medical records and to ask for changes or corrections to your records.
10. Ask for a second opinion.
11. File a Grievance if you disagree with Highmark Wholecare’s decision that a service is not medically necessary for you.
12. File a Complaint if you are unhappy about the care or treatment you have received.
13. Ask for a DHS Fair Hearing.
14. Be free from any form of restraint or seclusion used to force you to do something, to discipline you, to make it easier for the provider, or to punish you.
15. Get information about services that Highmark Wholecare or a provider does not cover because of moral or religious objections and about how to get those services.
16. Exercise your rights without it negatively affecting the way DHS, Highmark Wholecare, and network providers treat you.
17. Create an advance directive. See Section 6 on page 70 of the Member Handbook for more information.
18. Make recommendations about the rights and responsibilities of Highmark Wholecare’s members.

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Member Responsibilities

Members need to work with their health care service providers. Highmark Wholecare needs your help so that you get the services and supports you need.

These are the things you should do:

1. Provide, to the extent you can, information needed by your providers.
2. Follow instructions and guidelines given by your providers.
3. Be involved in decisions about your health care and treatment.
4. Work with your providers to create and carry out your treatment plans.
5. Tell your providers what you want and need.
6. Learn about Highmark Wholecare coverage, including all covered and non-covered benefits and limits.
7. Use only network providers unless Highmark Wholecare approves an out-of-network provider or you have Medicare.
8. Get a referral from your PCP to see certain specialists.
9. Respect other patients, provider staff, and provider workers.
10. Make a good-faith effort to pay your co-payments.
11. Report fraud and abuse to the DHS Fraud and Abuse Reporting Hotline.

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Understand Disenrollment

If you’re ending health care coverage with Highmark Wholecare, your Evidence of Coverage (EOC) booklet lists important dates and deadlines to know. Please carefully review your Diamond Plan EOC or check your Ruby Plan EOC before ending your membership.

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About Potential Contract Termination

We have a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either we or CMS can decide to end it. You will get 90 days advance notice in this situation. It is also possible for our contract to end at some other time during the year, too. In these situations we will try to tell you 90 days in advance, but your advance notice may be as little as 30 or fewer days if CMS must end our contract in the middle of the year.

If we leave the Medicare program or changes its service area so that it no longer includes the area where you live, we will tell you in writing. If this happens, your membership in Highmark Wholecare Medicare Assured will end, and you will have to change to another way of getting your Medicare benefits. Your choices for how to get your Medicare will always include Original Medicare and joining a Prescription Drug Plan to complement your Original Medicare coverage. Your choices may also include joining another Medicare Advantage Plan, or a Private Fee-for-Service plan, if these plans are available in your area and are accepting new members.

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