Disasters and Emergencies

Clever Care Health Plan has established disaster and emergency procedures in accordance with applicable federal and state requirements to help ensure members maintain access to covered health care services and prescription drugs during declared disasters and emergencies. These accommodations apply when a disaster or emergency declaration affects access to health care services or pharmacies.

Coverage During a Declared Disaster or Emergency

If the President of the United States, a state Governor, or the U.S. Secretary of Health and Human Services declares a disaster, emergency, or public health emergency that affects access to care, Clever Care will take appropriate steps to help members access covered services.

During a declared disaster or emergency, Clever Care may:

• Allow members to receive covered Medicare Part A, Part B, and supplemental Part C services from out-of-network providers when network providers are unavailable.
• Apply in-network cost sharing for covered services received from out-of-network providers when members cannot reasonably access network providers.
• Waive prior authorization requirements and referral requirements when necessary to ensure timely access to medically necessary care.
• Provide access to covered Part D drugs at out-of-network pharmacies when network pharmacies are unavailable.
• Lift Part D “refill-too-soon” edits when necessary to help members access needed medications.
• Allow affected members to obtain an extended-day supply of covered medications, when requested and available.
• Waive the 30-day advance notice requirement for plan changes that improve or preserve access to benefits during the disaster or emergency.

Access to Medical Care During a Disaster

If you cannot access a network provider because of a declared disaster or emergency, you remain entitled to receive covered services.

When access to network providers is disrupted, Clever Care will allow covered services to be obtained from out-of-network providers at in-network cost sharing, consistent with applicable Medicare requirements. This includes situations where travel restrictions, evacuations, facility closures, or other disaster-related circumstances prevent reasonable access to network providers.

Payment for Services Furnished by Non-Contracted Providers

During a declared disaster or emergency, Clever Care will cover Medicare Part A, Part B, and supplemental Part C benefits furnished by non-contracted providers to members in affected service areas when access to contracted providers is unavailable or significantly disrupted.

Non-contracted providers furnishing covered services to affected members may submit claims to Clever Care for payment. Claims will be processed in accordance with applicable Medicare requirements and CMS disaster guidance. Members will not be charged more than the applicable in-network cost-sharing amount for covered services received under these disaster accommodations.

Access to Prescription Drugs During a Disaster

If you cannot access a network pharmacy because of a declared disaster or emergency, you may be able to obtain covered Part D prescription drugs at an out-of-network pharmacy.

Clever Care will also take steps to help ensure continued access to prescription medications by:

• Allowing covered prescriptions to be filled at out-of-network pharmacies when network pharmacies are unavailable.
• Temporarily lifting refill-too-soon edits when appropriate.
• Allowing extended-day supplies when available and clinically appropriate.

These accommodations will be administered in accordance with applicable Medicare Part D requirements and CMS guidance.

Section 1135 Waiver Information

When the U.S. Secretary of Health and Human Services declares a public health emergency under Section 319 of the Public Health Service Act and a Presidential disaster or emergency declaration is also in effect, the Secretary may exercise authority under Section 1135 of the Social Security Act.

Under this authority, CMS may authorize flexibilities that help ensure continued access to needed health care services during the emergency.

Duration of Disaster Accommodations

Disaster and emergency accommodations remain available for affected members throughout the applicable disaster or emergency period and in accordance with CMS guidance.

Clever Care will continue these accommodations until the applicable declaration ends or until otherwise directed by CMS or other applicable regulatory authorities.

How Clever Care Monitors Disaster Declarations

Clever Care monitors information from:

• The Centers for Medicare & Medicaid Services (CMS)
• The U.S. Department of Health and Human Services (HHS)
• The Federal Emergency Management Agency (FEMA)
• State and local emergency management authorities

For Presidential major disaster declarations, Clever Care monitors FEMA disaster declarations and incident periods at fema.gov/disaster/declarations.

Our Response Process

When a disaster, emergency, or public health emergency is declared:

1. The Compliance Department notifies appropriate business areas of applicable requirements and guidance.
2. Clever Care monitors CMS, HHS, and other governmental communications for updated instructions and timelines.
3. Disaster-related coverage information is posted to the Clever Care website, as appropriate.
4. Operational teams implement actions necessary to support member access to covered services and medications.

Proactive Access Measures

In certain circumstances, Clever Care may implement operational measures to help preserve access to prescription drugs and covered services, even before a formal disaster declaration is issued, when disruption to member access is anticipated.