At St. Luke’s Health Plan, compliance is a core part of how we serve our members, providers, partners and communities. Our Compliance Program promotes ethical conduct, regulatory compliance, accountability and transparency across all areas of the organization. The program applies to all employees, board members, contractors, vendors and First Tier, Downstream and Related Entities (FDRs).

As a Medicare Advantage and Prescription Drug Plan sponsor, St. Luke’s Health Plan operates in a highly regulated environment and complies with requirements established by the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG), the Idaho Department of Insurance and other regulatory agencies.

The Compliance Program helps ensure that we:

• Conduct business ethically and with integrity
• Follow all applicable federal and state laws and regulations
• Protect member information and privacy
• Prevent, detect, and address fraud, waste, and abuse (FWA)
• Foster a culture of accountability and transparency
• Deliver high-quality healthcare coverage and services to our members

St. Luke’s Health Plan’s Compliance Program is built on industry-leading guidance from CMS and the OIG and includes seven core elements:

1. Written Policies and Standards

We maintain policies, procedures, and Standards of Business Conduct that clearly communicate expectations regarding ethical behavior, regulatory compliance, privacy, conflicts of interest, reporting obligations and non-retaliation.

2. Compliance Leadership and Oversight

The Board of Directors, through its Audit, Risk, and Compliance Committee (ARCC), oversees the Compliance Program. The Compliance Officer leads day-to-day compliance activities and reports directly to senior leadership and the Board.

3. Training and Education

Employees, board members, contractors, and applicable FDRs receive compliance and fraud, waste and abuse training upon hire and annually thereafter. Training is regularly updated to reflect changing regulatory requirements.

4. Open Communication

We encourage employees, members, providers, and partners to raise concerns through multiple reporting channels, including anonymous reporting options. Good-faith reporting is protected by our non-retaliation policy.

5. Disciplinary Standards

The organization maintains clear and consistently applied disciplinary standards to reinforce accountability and compliance expectations.

6. Monitoring and Auditing

We conduct ongoing monitoring, auditing and risk assessments to identify potential compliance issues and ensure adherence to regulatory requirements. Oversight includes delegated entities and high-risk operational areas.

7. Prompt Response and Corrective Action

Potential compliance concerns are investigated promptly. When issues are identified, corrective actions are implemented, monitored and reported as appropriate.

Anyone may report a potential compliance concern, including employees, providers, vendors, FDRs and members. Reports can be made confidentially and, if desired, anonymously.

Compliance Hotline: 866-291-4324 (24/7 Support)

Online Reporting: View St. Luke's Health Plan compliance reports
All reports are reviewed by the Compliance Department and addressed in accordance with established investigation and resolution procedures. Individuals who report concerns in good faith are protected from retaliation.

St. Luke’s Health Plan is committed to preventing, detecting, and correcting fraud, waste and abuse. We use:

• Routine audits and monitoring
• Data analytics and trend analysis
• Exclusion screenings
• Training and awareness
• First tier, downstream and related entity (FDR) oversight
• Reporting and investigation processes

When potential fraud, waste, abuse or other compliance concerns are identified, the Health Plan conducts a thorough review to determine the nature and scope of the issue, implements appropriate corrective actions and monitors the effectiveness of remediation efforts. When required, matters may be reported to regulatory or law enforcement agencies in accordance with applicable laws and program requirements.

A strong compliance culture helps protect our members, employees, providers and business partners. Every individual associated with St. Luke’s Health Plan plays an important role in maintaining ethical business practices, regulatory compliance and trust in our organization.

When in doubt, ask questions, seek guidance and report concerns. Together, we help ensure St. Luke’s Health Plan operates with integrity, accountability and excellence.

If the Governor of Idaho, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in an area served by the Plan, you remain entitled to receive covered services under your Medicare Advantage plan.

When a disaster or emergency results in a disruption of access to health care, St. Luke's Health Plan will ensure continued access to covered benefits in accordance with Centers for Medicare & Medicaid Services (CMS) requirements. Disaster-related accommodations will remain in effect until the earlier of:

• Thirty (30) days after all applicable disaster or emergency declarations have ended and expired without renewal; or

• The date access to health care services is restored and there is no longer a disruption of access to care as defined by applicable CMS guidance.

If your usual network provider is unavailable because of a disaster or emergency, you may obtain covered medically necessary services from another available provider.

During a declared disaster or emergency that disrupts access to health care services in your plan’s service area, St. Luke's Health Plan may allow Medicare Advantage members to receive covered services from out-of-network providers at in-network cost-sharing amounts when access to network providers is unavailable.

Emergency services remain covered anywhere in the United States. If you believe you are experiencing a medical emergency, call 911 or go to the nearest emergency room.

If you are unable to use your usual network pharmacy during a disaster or emergency, you may be able to obtain covered prescription medications from another pharmacy, including an out-of-network pharmacy when permitted by CMS disaster guidance.

Medicare Advantage members needing assistance obtaining prescription medications should contact Customer Service for support.

During a declared disaster or emergency, St. Luke's Health Plan may implement temporary accommodations and flexibilities authorized by CMS to help ensure its Medicare Advantage members maintain access to medically necessary care. These accommodations may include adjustments to prior authorization, provider network, or pharmacy access requirements, as permitted by federal regulations and CMS guidance.

St. Luke's Health Plan may implement changes that benefit its Medicare Advantage members immediately when authorized by CMS and applicable Medicare Advantage requirements.

If you need help locating a provider, obtaining prescription medications, understanding your coverage, or accessing care during a disaster or emergency, please contact Customer Service at (833) 840-1214 (TTY users call 711). Calls to this number are free.

Hours are:

• Oct. 1 - March 31: Every day 8am to 8pm (MT)
• Apr. 1 - Sept. 30, Monday-Friday 8am to 8pm (MT).

If you are experiencing a life-threatening emergency, call 911 immediately.