Disaster and Emergency Policy
Gold Kidney Health Plan will take action to assure continued health plan benefit coverage in the event of the declaration of a disaster and will lift the “refill-too-soon” edits on Part D drugs to facilitate beneficiary access. “Disasters” include a:
- Presidential emergency declaration
- Declaration of emergency or disaster by a Governor
- Presidential (major) disaster declaration
- Public health emergency announcement by the Secretary of Health and Human Services
Activities to Ensure Access in times of a disaster
Gold Kidney Health Plan will identify ways to facilitate member access to care. These actions may include:
- Allowing Coverage of Medicare Parts A, B, and Supplemental plan benefits to be supplied at non-contracted facilities.
- Waving in full or in part applicable requirements for authorization of pre-notification.
- Temporarily extend the same cost sharing rates at non-contracted facilities so they are the same as they would at plan-contracted facilities.
- All changes to benefits, cost sharing and access that help the member get the care they need will be effective right away without the 30-day notice requirement.
- Gold Kidney will also consider other disaster related exceptions when required policy, contract, or other rules cannot be not met as a result of this disaster, such as when a member is in need of non-emergency care after being displaced from their home and is not able to obtain care from a network health care provider.
- Waive the early refill edit on prescription refills.
If Gold Kidney Health Plan is unable to resume normal operations by the end of the public health emergency or state of disaster, we will notify the Centers for Medicare & Medicaid Services (CMS).
- In the event of a Presidential major disaster, emergency declaration, or public health emergency, the Compliance Department will distribute notification to all business areas.
- The Compliance Department will monitor the Department of Health and Human Services (DHHS) website (Link 1) and the CMS website (Link 2) for additional guidance and requirements, including timeframes associated with those requirements during such disasters and emergencies.
- Plan will disclose policies about providing benefits during disasters on the Plan 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 over. 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 Gold Kidney will resume normal operations 30 days from the initial declaration. If Gold Kidney is unable to resume normal operations after 30 days, Gold Kidney will notify CMS.
- 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 Gold Kidney will lift the “refill-too-soon” edits. Gold Kidney 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, Gold Kidney may implement an edit that is readily resolvable at the point-of-sale through the use of a pharmacist override code.
Gold Kidney 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, Gold Kidney will monitor FEMA’s website, for the closure of disaster incident periods listed in the Disaster Federal Register Notice section (Refer to the link below). In circumstances in which the incident period has not officially closed 30 days from the initial Presidential declaration, Gold Kidney may consider extending the implementation of the edits but is not required to do so. If Gold Kidney chooses to remove the edits, Gold Kidney 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, Gold Kidney may consider lifting the edits, for instance, in advance of an impending disaster, if Gold Kidney determines it appropriate to do so to ensure pharmacy access.
Gold Kidney 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.