Welcome Members

Member Resources

Supplemental Benefits

With Clever Care you are getting a quarterly allowance to pay for comprehensive dental procedures, including routine dental cleaning, exams, X-rays, fillings, crowns, and more!

 

How to access care

  • Find a participating dentist from the Liberty Dental network.
  • Call and make an appointment
  • Show your Clever Care ID card, it’s that easy!

 

Your dentist will submit a claim to Clever Care, and we will apply the available allowance balance to the claim. If any amount is unpaid (due to lack of allowance dollars), your dental provider will send you a bill.

 

Dental Benefits 

 

Need help?

For questions about our dental benefits, call Clever Care Customer Service at 1-833-388-8168 (TTY: 711).

How to access care

  • Find a participating independent or retail provider from the EyeMed network.
  • Call and make an appointment.
  • Show your Clever Care ID card, it’s that easy!

 

Using your allowance

Clever Care gives members $300, every two years, to help pay for eye glass frames, contacts, and more. Your eye care provider will walk you through all of the options and will submit the claim to Clever Care for payment.

 

We will apply the available allowance to the claim. If any amount is unpaid (due to lack of allowance dollars), your vision provider will send you a bill.

 

Vision Benefits

 

Need help?

For questions about our vision benefits, call Clever Care Customer Service at 1-833-388-8168 (TTY: 711).

Accessing care

Call NationsHearing at (866) 304-7557 Monday-Friday, 8:00 a.m. to 5:00 p.m. Pacific Time to scheduling a hearing either in-person or from your computer at home. Their trained representative will help you decide which provide to use.

 

Hearing Benefits

 

Clever Care gives members an annual allowance to pay for or help pay for hearing aids for both ears. You and your hearing provider will find the right hearing aid fit your needs. You get:

  • Hearing aids (available from all major manufacturers)
  • Three follow-up visits
  • Three-year manufacturer’s repair warranty
  • One-time replacement coverage for lost, stolen or damaged hearing aids1

1Deductibles may apply.

 

Need help?

For questions about our hearing benefits, call Clever Care Customer Service at 1-833-388-8168 (TTY: 711).

 

Clever Care members receive a pre-paid debit card that is replenished quarterly. It can be used to purchase eligible over-the-counter (OTC) items such as medications, health and wellness products, and first aid supplies.

 

OTC Medicare Catalog


How to purchase items

  • Visit NationsOTC.com and sign in using your 19-digit OTC card number; or
  • Go to a participating retail location (CVS, Walgreens, Rite Aid, Walmart, and more); or
  • Call 1-833-746-7682 Monday-Friday 5 a.m. and 5 p.m. (Pacific Time).

 

Only items listed in the OTC Medicare Catalog are covered. You may place as many orders as you need during the benefit year. After your order has been processed it will be fulfilled and shipped within 2-5 business days.

 

Reminders:

  • Your allowance amount will be added to your debit card the first month of each quarter.
  • Any unused balance will carry over to the next quarter.
  • You are responsible for paying costs over the allowance credit on your debit card.
  • At the end of the benefit year (December 31), any unused balance will expire.

 

Need help?

Call Clever Care Customer Service at 1-833-388-8168 (TTY: 711).

Part D/Pharmacy

At Clever Care, we put members’ health and safety first. As part of our Medicare Part D plan, Clever Care offers QA and UM programs at no extra cost to Part D members. These programs are designed to ensure the safe and appropriate use of prescription medications covered under Medicare Part D. The programs help identify potential risks and opportunities to improve your medication therapy.

 

Quality assurance (QA)

In this program, every time a prescription is dispensed, it is reviewed for:

  • Age/gender-related contraindications
  • Over-utilization (e.g., early refill) and underutilization
  • Clinically significant drug-drug interactions
  • Incorrect drug dosage or duration of drug therapy
  • Therapeutic duplication
  • Inappropriate or incorrect drug therapy
  • Patient-specific drug contraindications
  • Abuse or misuse

This program also periodically reviews claims data.

 

Utilization management (UM)

This program consists of three parts, and is designed to encourage the safe, appropriate, and cost-effective use of Medicare Part D prescription drugs.

Prior authorization (PA) A PA requirement means the member, or their doctor must get approval before your medication is covered at your pharmacy.

Step therapy (ST) A ST requirement means you must first try one drug to treat a medical condition before another drug will be covered for that same condition.

Quantity limits (QL) A Quantity Limit requirement limits the amount of a drug that will be covered with prior approval.

Together, these programs help us identify and work to resolve any health and safety risks that your medications could pose, and to help you get the most benefit from your Medicare Part D plan.

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program.

 

MTM is a service offered by Clever Care of Golden State at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit.  This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.

 

To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program.  Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.

 

You must meet ALL of the following criteria to qualify to participate  in Clever Care’s MTM program,

  1. Have at least 3 of the following conditions or diseases:
    • chronic heart failure, diabetes, dyslipidemia, hypertension, asthma, or chronic obstructive pulmonary disease, AND
  2. Take at least 8 covered Part D medications, AND
  3. Are likely to have medication costs of covered Part D medications greater than $4,376 per year.

 

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:

    1. Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, your caregiver, your pharmacist, and/or your doctor if we detect a potential problem.
    2. Comprehensive medication review: at least once per year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This review, or CMR, is provided to you confidentially via telephone by pharmacies operated by Tabula Rasa HealthCare. The CMR may also be provided in person or via telehealth at your provider’s office, pharmacy, or long-term care facility. If you or your caregiver are not able to participate in the CMR, this review may be completed directly with your provider. These services are provided on behalf of Clever Care Health Plan. This review requires about 30 minutes of your time. Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors. This summary includes:
      • Medication Action Plan (MAP): The action plan has steps you should take to help you get the best results from your medications.
      • Personal Medication List (PML): The medication list will help you keep track of your medications and how to use them the right way.
      1.  

 

The Personal Medication List can help you and your health care providers keep track of the medications you are taking.

 

If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please contact Customer Service 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.  Messages received on holidays or outside of our business hours will be returned within one business day.

Coverage Determination

A coverage determination is an initial coverage decision made by Clever Care regarding your Medicare Part D prescription drug. Coverage determinations you can request about your Part D drugs include:

  • You can ask whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the Plan’s List of Covered Drugs but requires our approval before it is covered.)
  • You can ask us to pay for a prescription drug you already bought.
  • You can ask us for an exception. (If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an “exception.”) Examples include:
    • Asking for coverage of a drug that is not on the drug list
    • Asking to pay a lower cost-sharing amount for a covered non-preferred drug
    • Asking us to remove the extra rules and restrictions on the Plan’s coverage for a drug such as:
      • Being required to use the generic version of a drug instead of the brand name drug
      • Getting plan approval in advance before we will agree to cover a drug for you
      • Quantity Limits

 

Important Information to Know About Asking for Exceptions

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

 

What to Do

You (or your representative or your doctor or other prescriber) may use the form below to submit your request for a Part D Coverage Determination.

 

Medicare Prescription Drug Determination Request Form

 

Please note: If you do not use this form, you will need to provide us the same information indicated in the form so we can process your request in a timely manner.

 

To start your Part D Coverage Determination request you (or your representative or your doctor or other prescriber) should contact Medimpact at (800) 926-3004 (TTY: 711).

  • You may Fax your request to: (858) 790-6060 (Attention: Medicare Reviews)
  • You may mail your request to:

MedImpact Healthcare Systems, Inc.
PO Box 509108
San Diego, CA 92150-9108

 

For additional assistance with making your Part D Coverage Determination request you may call our Customer Service Department.

 

Refer to your Evidence of Coverage, Chapter 9, Section 6 to find out more about the Part D Coverage Redetermination Process.

CMS created the “best available evidence” policy in 2006 requiring plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information was not accurate.

 

CMS continues to require Part D plans to rely on best available evidence and considers it best practice for the Part D plans to work with pharmacies to resolve these issues at point-of-sale when beneficiaries present with appropriate evidence of correct low-income status.

 

For more information call Customer Service or visit the CMS website

Provider Network

Members Rights

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

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

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