Documents and Tools

You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year.

• Annual Enrollment Period from October 15 to December 7.
• Open Enrollment Period every year from January 1 to   March 31.
• Special Enrollment Period vary based on your situation, such as moving out of the plan’s service area, you have Medi-Cal Visit meidcare.gov for a full list.

Refer to Chapter 10 of your Evidence of Coverage for a complete description of the rights and responsibilities upon disenrollment.

Clever Care is committed to protecting the health care rights of members, including the right to file a grievance. A complaint/grievance is a formal way of telling us that you are unhappy about the quality of care you’ve received, waiting times and the customer service you receive. The grievance process is fundamental to ensuring our members receive needed health care services.

If you have any grievance, please help us to make it right. We want to do the right thing for you and improve for future.

Grievance and Appeal Form

You need to file your grievance within 60 days of the occurrence. If you have a good reason for being late in filing a complaint/grievance, let us know and we will consider whether to extend the timeline for filing a complaint/grievance. 

How to file a complaint/grievance:
Call Customer Service at 1-833-283-9888 (TTY: 711). We will do everything we can to resolve your concern.
Fax your complaint/grievance to us at 1-657-276-4715.

Mail your complaint/grievance to:

Clever Care
Attn: Grievance and Appeals
660 W. Huntington Dr. Suite 200
Arcadia CA 91007-3424

Chapter 9 in your Evidence of Coverage includes the process and more information on how to file a complaint/grievance. Or you can visit Medicare.gov.

For process, status questions, or to obtain an aggregate number of Clever Care of Golden State grievances, appeals and exceptions, please call Customer Service at 1-833-823-9888 (TTY: 711).

Prior Authorization is a decision made by the plan regarding certain medical services that require pre-approval or prior to arrangement for health care services.  You, your representative, or your network Primary Care Provider (PCP), or the provider that delivers or intends to deliver services to you, may request a Prior Authorization by filing out a Request for Prior Authorization form. 

• You may request a prior authorization over the phone by calling us at 1-833-388-8168 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, and 8 a.m. to 8 p.m., weekdays, from April 1 through September 30.
• Fax the completed form to 1-657-276-4719, or
• Mail to:

Clever Care
Attn: Utilization Management
660 W. Huntington Dr. Suite 200
Arcadia CA 91007-3424

Medical item or service decisions will be made no later than 72 hours after receipt for requests meeting the definition of Expedited (fast decision) and no later than 14 calendar days for requests meeting the definition for Standard.

For Part B drug determination, the turn-around time for a request is 72 hours for a standard review and 24 hours for an expedited review.

If you do not get a referral, Clever Care may not cover the service. For more information, call Customer Service or refer to Chapter 9 of your Evidence of Coverage.

An advance directive (also known as a living will) is a way to make sure that your designated medical power of attorney is able to communicate your medial wishes if you cannot speak for yourself.

Together, with your doctor, you can create an advance directive that will instruct providers to withhold or withdraw life sustaining treatment in the event of a terminal condition or permanent unconscious condition.

When you have completed your advance directive, ask your doctor to put the form in your file. It is also a good idea to let your loved ones and your Medical Power of Attorney (if designated) know you have an advance directive. 

You may change your advance directive at any time. Call us if you have any questions or want help.

Advance Directive form

Appointing a Representative – Instructions & Form

People who want to represent a member can be appointed or authorized by the member.

A member can authorize anyone (like a relative, friend, advocate, an attorney, or a doctor) to act as his or her representative and file a grievance, appeal, or organization determination on his or her behalf.

A representative (or surrogate) can also be authorized by the court or act on behalf of the member in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute.

How to authorize a representative:

• The member must sign, date, and complete a representative form.
• The person acting on behalf of the member must sign, date and complete the same form.
• Print and complete the Appointment of Representative form. If a member is incapacitated or legally incompetent a surrogate is not required to submit an Appointment of Representative Form. The surrogate will need to give Clever Care Medicare Advantage copies of the legal papers supporting his or her status as the member’s authorized representative.

Clever Care Medicare Advantage requires a copy of the completed and signed Appointment of Representative Form to process a grievance, appeal or organization determination filed by the member’s representative. The form will be valid during the entire grievance, appeal or organization determination process. The Appointment of Representative Form is valid for one year from the date indicated on the form. A member can revoke the authorization at any time.

Appointment of Representative form

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

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, but or prior to the issuance of, an 1135 waiver by the Secretary, the 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).
• Waive in full, requirements for authorization and pre-notification referrals where
• Temporarily reduce plan-approved out-of-network cost-sharing amounts to in-network cost sharing
• Waive the 30-day notification requirement to enrollees as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the enrollee; and
• 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
• 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

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 an 1135 waiver is issued, CMS will identify consequent requirements and responsibilities to the 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 the Clever Care and seek reimbursement from the Clever Care for those health care services, retrospectively.

Procedure:

1. In the event of a Presidential major disaster, emergency declaration, or public health emergency the Compliance Department will distribute notification to all business
2. 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 additionalguidance and requirements, including timeframes associated with those requirements during such disasters and
3. Plan will disclose policies about providing benefits during disasters on the Plan
4. Each business area will ensure appropriate action is taken, in accordance with state and federal laws and related
5. Access to Part C Provider Network: Typically, the source that declared the disaster will clarify when the disaster or emergency is If, however, the disaster or emergency time frame has not been closed 30 days from 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.
6. Access under Part D: In the event of a Presidential major disaster, emergency declaration, or public health emergency in which the underlying circumstances are reasonably expected to result in a disruption in access to covered Part D drugs, then Clever Care will lift the “refill-too-soon” edits. Clever Care may exercise some operational discretion as to how these edits are lifted during a disaster or emergency as long as access to Part D drugs is at the point-of-sale. For instance, Clever Care may implement an edit that is readily resolvable at the point-of-sale through the use of 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.
• 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 (http://www.fema.gov/news/disasters.fema). In circumstances in which the incident period has not officially closed 30 days from the initial Presidential declaration, Clever Care may consider extending the implementation of the edits but is not required to do 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.

In the absence of a Presidential major disaster or emergency declaration or a public health emergency, Clever Care may consider lifting the edits, for instance, in advance of an impending disaster; if the Clever Care determines it appropriate to do so 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.