Disasters and Emergencies

Clever Care of Golden State, Inc. (“Clever Care”) has established a Disaster and Emergency Declaration policy in line with state and federal laws and related regulations.

Coverage During Declared Disasters and Emergencies

When a Presidential emergency or major disaster declaration, a Governor’s declaration, or a public health emergency announcement by the HHS Secretary occurs, Clever Care will:

• Allow Part A/B and supplemental Part C benefits at specified non-contracted facilities
• Fully waive authorization and referral pre-notification requirements
• Temporarily reduce out-of-network cost-sharing to in-network levels
• Waive the 30-day enrollee notification requirement when all changes benefit the enrollee
• Provide access to Part D drugs at out-of-network pharmacies when network pharmacies are unavailable
• Lift “refill-too-soon” edits for Part D drug access at point of sale
• Allow affected enrollees to obtain the maximum extended-day supply, if requested and available

Section 1135 Waiver Information

If the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act alongside a Presidential disaster/emergency declaration, the Secretary may exercise waiver authority under Section 1135 of the Social Security Act. Under this authority, CMS may authorize Medicare Administrative Contractors to pay for Part C services furnished to Clever Care enrollees and seek retrospective reimbursement from Clever Care.

Procedure

• The Compliance Department distributes notifications to all business areas upon a major disaster, emergency, or public health emergency declaration.
• The Compliance Department monitors the DHHS and CMS websites for additional guidance, requirements, and timeframes.
• The Plan discloses disaster-related benefit policies on its website.
• Each business area ensures appropriate action aligned with state and federal laws.

Access to Part C Provider Network

The declaring source typically clarifies when the disaster or emergency is effective. If the timeframe hasn’t closed within 30 days and CMS hasn’t indicated an end date, Clever Care resumes normal operations 30 days from the initial declaration.

Access Under Part D

During a Presidential disaster/emergency declaration or public health emergency reasonably expected to disrupt access to covered Part D drugs, Clever Care lifts “refill-too-soon” edits. Edits remain lifted until the public health emergency terminates or the declared disaster/emergency ends.

FEMA Monitoring for Major Disasters

For Presidential major disasters, Clever Care monitors FEMA’s website for closure of disaster incident periods at fema.gov/disaster/declarations.

Proactive Access (When No Declaration Is in Effect)

Without a formal declaration, Clever Care may lift edits proactively if deemed appropriate to ensure pharmacy access. The plan ensures enrollees have adequate access to Part D drugs at out-of-network pharmacies during any federal disaster or public health emergency declaration where enrollees are evacuated or displaced.

This page was last updated on May 26, 2026.