In the event of a disaster or emergency, Medicare Advantage plans (MA plans) must ensure that members in affected areas can continue to access care and prescription drugs. These special rules are triggered by a formal declaration of emergency or disaster by a federal or state government. The Centers for Medicare and Medicaid (CMS) created a current emergencies page to assist beneficiaries.
Additionally, the Secretary of the Department of Health and Human Services (HHS) can declare a Public Health Emergency that can also allow for the waiver or modification of Medicare Advantage requirements.
Surviving a disaster can be overwhelming and disorienting. That’s even more the case when you are dependent on life-sustaining medication and care.
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If you depend on a Medicare Advantage plan, you might be worried that you’ll owe steep out-of-pocket costs if you have to see doctors or seek care at a hospital outside of your plan’s network. Fortunately, the rules require MA plans to waive a number of their usual requirements and restrictions, allowing you to get the medical support you need, at no extra cost, during a disaster.
These special rules are in effect for a limited time following a disaster declaration. The specific duration can vary, but generally, the changes last for at least 30 days. You may still be displaced or impacted by a disaster when these special rules expire. Getting in touch with your MA plan provider as soon as possible can get you the needed assistance and limit your out-of-pocket expenses.
Older people who rely on original Medicare don’t have any portability issues to worry about; their coverage has no geographic or network limitations and is accepted nationwide.
Here’s a breakdown of the key rules for using Medicare Advantage during a disaster:
Access to medical care during a disaster
During a declared disaster or emergency, your Medicare Advantage plan must allow you to get care from other health care providers at Medicare-certified facilities, even if they aren’t in your plan’s network and your health care need isn’t an emergency. If you have problems finding a provider, contact your plan for help
It’s a good idea to become familiar with your plan rules during an emergency or disaster before something actually happens. They may be able to recommend providers and locate pharmacies outside of your immediate area, and save you some time. You can usually find your plan’s contact information on your plan membership card, or you can also call 1-800-MEDICARE (1-800-633-4227) for assistance.
If you need regular care from a specialist, it would be to your advantage to put a list of providers, in and out of network, in surrounding communities. Pre-planning can help you address your medical needs more quickly. Don’t overlook that access to the internet and phone service can be disrupted by inclement weather. Having a list that includes addresses and directions at the ready can move things along.
- Out-of-Network Care: Your plan must allow you to receive care from out-of-network providers at Medicare-certified facilities, even for non-emergency services, if you can’t reasonably get to an in-network provider.
- Cost-Sharing: The plan must charge you the same cost-sharing amounts for copays, deductibles, etc., for out-of-network care as you would pay for in-network care. If you pay more, you should save your receipts and contact your plan for a refund.
- Referrals: Gatekeeper referrals, such as needing a referral from a primary care physician to see a specialist, must be waived. Your plan has to suspend these requirements.
- Authorization: The plan may suspend rules that require you to get prior authorization for certain services if failing to do so would increase your costs or limit your access to care.
Prescription drug access in a disaster
There are a few ways you can get a refill of your prescription medications in an emergency. If possible, move most prescriptions from one in-network pharmacy to another, and back to your regular pharmacy when the emergency or disaster ends. Be prepared to tell the new pharmacy the name of your regular pharmacy, such as the location or phone number, and the drugs you need refilled.
If your only option is to buy your drugs at an out-of-network pharmacy, you’ll probably have to pay full cost for the drugs. If you do pay full costs, save your receipts so you can submit them to your plan for a refund. One downside: you won’t get a refund for any out-of-network cost-sharing amount.
Contact your plan if you need help finding the closest in-network pharmacy or on how to submit a claim. You can also call 1-800-MEDICARE (1-800-633-4227) to get your plan’s contact information. TTY users should call 1-877-486-2048.
- Refills: Your plan must lift “refill-too-soon” restrictions, allowing you to get an early refill of your prescription drugs.
- Out-of-Network Pharmacies: You must have access to covered prescription drugs at out-of-network pharmacies if it’s not reasonable for you to get to an in-network pharmacy.
- Extended Supply: You can request to get an extended day supply, usually a 60- or 90-day supply, of your prescription drugs.
- Lost or Damaged Drugs: Your plan must help you replace lost or damaged prescription drugs.
Special Enrollment Period (SEP)
If you missed an enrollment period, such as the annual Medicare open enrollment period, due to a declared disaster or emergency, you may be eligible for a Special Enrollment Period (SEP). This allows you to enroll in, disenroll from, or switch Medicare plans.
This SEP is available to individuals who live in or relied on a helper who:
- Reside, or resided at the start of the incident period, in an area for which the Federal Emergency Management Agency (FEMA) has declared an emergency or a major disaster
- Had another enrollment period at the time of the incident period, the AEP or other special enrollment opportunity, and
- Did not enroll or make a change during that other enrollment period
I want to emphasize that the SEP is available to Medicare beneficiaries who don’t live in the affected areas but rely on help making health care decisions from friends or family members who live in the affected areas. You don’t have to be directly impacted by the emergency or disaster to use the SEP.
CMS will establish a special enrollment opportunity for individuals affected by a weather-related emergency or major disaster who need to enroll in, disenroll from, or switch Medicare health or prescription drug plans, and missed other enrollment periods. This opportunity will be available in areas for which FEMA has declared an emergency or a major disaster. It is available as of the start of the incident period and runs for four full calendar months. Enrollments are effective on the first of the month after the plan
For those signing up for the first time: If you sign up for Part A or Part B during a SEP because of a natural disaster or emergency, you’ll have two months to switch to a Medicare Advantage Plan and/or a Medicare Part D drug plan. Your coverage will start the first day of the month after the plan receives your request to join.
You can submit your enrollment request through 1-800-MEDICARE, your agent/broker, or by contacting the Medicare Advantage or Part D prescription drug plan directly.
Have a medical disaster plan
It’s important to know the types of disasters that could happen in your community to be better prepared. Sign up for alerts and warnings so you are aware of local plans for evacuations and shelter resources.
Get and emergency kit together; consider the items you use every day and which ones you may need to add to your kit.
Compile a list of your prescription medicines. Include information about your diagnosis, dosage, frequency and any allergies. Pack an extra stash of nonprescription drugs, such as pain and fever relievers, antihistamines and antidiarrheal medicines. Last but not least, don’t forget extra hearing-aid batteries.
If you need assistance about your original Medicare or Medicare Advantage plan, you can contact 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week with any questions. TTY users should call 1-877-486-2048.