Disasters and Emergencies

Policy Overview

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

Coverage During Declared Disasters and Emergencies

In the event of a Presidential emergency declaration, a Presidential major disaster declaration, a declaration of emergency or disaster by a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services—prior to the issuance of a Section 1135 waiver by the Secretary—Clever Care will:

Allow Part A/B and supplemental Part C plan benefits to be furnished at specified non-contracted facilities, in accordance with 42 CFR 422.204(b)(3).
Fully waive requirements for authorization and referral pre-notification.
Temporarily reduce plan-approved out-of-network cost-sharing amounts to in-network cost sharing.
Waive the 30-day notification requirement to enrollees if all changes (such as reduced cost-sharing and waived authorization) benefit the enrollee.
Provide access to Part D drugs dispensed at out-of-network pharmacies when Part D drugs at a network pharmacy cannot be obtained, in accordance with Chapter 5 of the Medicare Prescription Drug Benefit Manual.
Lift the “refill-too-soon” edits to enable access to Part D drugs at the point of sale.
Allow affected enrollees to obtain the maximum extended-day supply, if requested and available at the time of the request.

Section 1135 Waiver Information

If, in addition to a Presidential declaration of a disaster or emergency under the Stafford Act or National Emergencies Act, the Secretary of Health and Human Services declares a public health emergency under Section 319 of the Public Health Service Act, the Secretary has the right to exercise his or her waiver authority under Section 1135 of the Social Security Act.

If a Section 1135 waiver is issued, CMS will identify consequent requirements and responsibilities for Clever Care Health Plan. Under the Secretary’s Section 1135 waiver authority, CMS may authorize Medicare Administrative Contractors to pay for Part C-covered services furnished to beneficiaries enrolled in Clever Care and seek reimbursement from Clever Care for those health care services retrospectively.

Procedure

In the event of a Presidential major disaster or emergency declaration, or a public health emergency, the Compliance Department will distribute notifications to all business areas.
The Compliance Department will monitor the Department of Health and Human Services (DHHS) website (http://www.dhhs.gov) and the CMS website (http://www.cms.hhs.gov) for additional guidance and requirements, including timeframes associated with those requirements during such disasters and emergencies.
The Plan will disclose policies about providing benefits during disasters on the Plan’s website.
Each business area will ensure appropriate action is taken in accordance with state and federal laws and related regulations.

Access to Part C Provider Network

Typically, the source that declared the disaster will clarify when the disaster or emergency is effective. However, if the disaster or emergency time frame has not been closed within 30 days of the initial declaration, and if CMS has not indicated an end date to the disaster or emergency, then Clever Care will resume normal operations 30 days from the initial declaration.

If Clever Care is unable to resume normal operations after 30 days, Clever Care will notify CMS.

Access Under Part D

In the event of a Presidential major disaster or emergency declaration, or a public health emergency in which the underlying circumstances are reasonably expected to result in a disruption in access to covered Part D drugs, Clever Care will lift the “refill-too-soon” edits.

Clever Care may exercise operational discretion as to how these edits are lifted during a disaster or emergency if access to Part D drugs is needed at the point of sale. For instance, Clever Care may implement an edit that is readily resolvable at the point of sale by a pharmacist override.

Clever Care will continue to lift edits until the termination of a public health emergency or the end of a declared disaster or emergency.

In the case of a public health emergency, it terminates when it no longer exists or upon the expiration of the 90-day period beginning from the initial declaration, whichever occurs first.

FEMA Monitoring for Major Disasters

For major disasters declared by the President, Clever Care will monitor FEMA’s website for the closure of disaster incident periods listed in the Disaster Federal Register Notice section (https://www.fema.gov/disaster/declarations).

In circumstances in which the incident period has not officially closed within 30 days of the initial Presidential declaration, Clever Care may consider extending the implementation of the edits but is not required to do so.

If Clever Care chooses to remove the edits, Clever Care will work closely with enrollees who indicate that they are still displaced or otherwise impacted by the disaster or emergency.

Proactive Access (When No Declaration Is in Effect)

In the absence of a Presidential major disaster or emergency declaration or a public health emergency, Clever Care may consider lifting the edits—for example, in advance of an impending disaster—if Clever Care determines it is appropriate to ensure pharmacy access.

Clever Care will ensure that enrollees have adequate access to covered Part D drugs dispensed at out-of-network pharmacies during any federal disaster declaration or other public health emergency declaration in which enrollees are evacuated or otherwise displaced from their place of residence and cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy.

Affected enrollees will be allowed to obtain the maximum extended-day supply, if requested and available at the time of refill.

Disasters and Emergencies

Policy Overview

Coverage During Declared Disasters and Emergencies

Section 1135 Waiver Information

Procedure

Access to Part C Provider Network

Access Under Part D

FEMA Monitoring for Major Disasters

Proactive Access (When No Declaration Is in Effect)

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