Part C Provider Network Access for residents in a declared Public Health Emergency Area

For enrollees residing in an emergency area, CMS expects plans to waive prior authorization and out-of-network requirements. For example, a Medicare Advantage enrollee affected by the disaster may go to a provider outside of the network without obtaining authorization from his or her plan. In addition, any cost-sharing for out-of-network or out-of-area access should be reduced to the in-network rate for beneficiaries affected by the disaster. To the extent possible, plans should conduct outreach to members in affected areas. Plans should be prepared to help beneficiaries access care and answer questions from out-of-network providers. Part C sponsors should also re-implement their network requirements when the emergencies end or in accordance with additional CMS guidance.

To effectuate these policies, CMS expects sponsors to continuously monitor the Federal Emergency Management Agency (FEMA) Website (http://www.fema.gov/news/disasters.fema) for issuance of Presidential major disaster declarations and the DHHS Website.

This news update was originally published on June 18, 2008.