Member Emergency Preparedness Plan

CHG members impacted by the federal, state or county declared state of emergency will continue to have access to medically necessary services by:

• Contacting Member Services staff, who are available 24/7 and can coordinate with members, network providers, and subcontractors to ensure member has access to medically needed emergency care: 1-800-224-7766 (TTY users please call 1-855-266-4584 or 711)

• Contacting our Behavioral Health Services, available 24/7, who provide free access to resources, materials, and counseling services through its dedicated hotline: CHG’s Behavioral Health Services Department at 1-800-404-3332 or the County of San Diego Access & Crisis Line at 1-888-724-7240

• Extending filing deadlines for Grievances and requests for Appeals

• Coordinating, transferring, and referring members to alternate sources of care when Providers are closed, unable to meet the demands of a medical surge, or otherwise affected by an emergency

• Authorizing Members to replace durable medical equipment (DME) or medical supplies Out-of-Network

• Relaxing time limits for prior authorization, precertification, or referrals and not require prior authorization for emergency room care outlined in Utilization Management. Policy No. 7251.8a “Review of Requests for Health Care Services”

• CHG Care Managers conducting outreach to members in care and disease management programs in mandatory evacuation areas to ensure continuity of care

• CHG working with members who have been displaced may see appropriate out-of-network providers at in-network benefit levels and may replace medical equipment and supplies as needed

• CHG extending filing deadlines for claims and pay emergency room clean claims within 45 calendar days outlined in Claims; Policy No. 8811a “Emergent Care Claim Payment Criteria”

• For Cal-MediConnect members CHG allows immediate refill of prescriptions for members eligible under our prescription program (Cal MediConnect). “MedImpact Medicare Part D Emergency Preparedness Program Description”

• Members who may have lost or misplaced their identification card can print a new card from our website at www.chgsd.com. 

 **Effective January 1, 2022 pursuant to Governor’s executive order N-01019, Medi-Cal pharmacy benefits were transitioned from managed care plans (such as Community Health Group) to DHCS and the Medi-Cal Rx program. 

Overview of CMS Guidance

  • CMS’ Emergency Preparedness guidance is defined within the 2010 Part C and D Call Letter, Medicare Managed Care Manual (Chapter 4), and the Medicare Prescription Drug Benefit Manual (Chapter 5). Requirements regarding pharmacy and provider access during a federal disaster or other public health emergency declaration are as follows:
  • We advise Medicare Advantage Organizations (MAOs), Cost Plans, and Part D sponsors to consult the U.S. Department of Homeland Security's Federal Emergency Management Agency’s (FEMA) website (https://www.fema.gov/declaration-process) for information about the disaster or emergency declaration process and the distinction between types of declarations.
  • Organizations should also consult the Department of Health and Human Services (DHHS) o (http://www.phe.gov/preparedness/pages/default.aspx) or Centers for Medicare & Medicaid Services (CMS) (http://www.cms.gov)
  • Websites for any detailed guidance that may be posted. 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 absent an 1135 waiver by the Secretary, Cost Plans, MAOs and Part D sponsors are expected to:
  • Lift their “refill-too-soon” edits when these circumstances create a disruption in access to covered Part D drugs.
  • Plans 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 provided at the point of sale.

What if you need after-hours care?

After-hours care is when you need medical attention after your doctor's office is closed. If you need after-hours care, you can call:

  • CHG’s Telephone Advice Nurse Line. (TAN) 1-800-647-6966
  • Community Health Group 1-800-224-7766 or TTY 1-855-266-4584
  • Go to nearest urgent care center
  •  911 or go to the nearest hospital emergency room if you believe it is an emergency

Preparedness Resources

CHG members who need help during a major disaster should call the Member Services Department at 1-800-224-7766 (TTY users please call 1-855-266-4584 or 711). 

CHG encourages members to download and print the Member Preparedness Manual on the CHG website as a hard copy reference for key contact information in case of an emergency.