CMS Issues Intermediate Sanction Notice to Aetna
On April 5, the Centers for Medicare & Medicaid Services (CMS) issued a notice to Aetna Inc. of its intent to impose an intermediate sanction to prevent the insurance company from marketing to and enrolling new Medicare beneficiaries. The sanction goes into effect April 21, and will remain in effect until CMS determines Aetna has corrected its alleged deficiencies for the long term.
Medicare issued the intermediate sanction because it says the plan has failed to fully meet its obligations to Medicare beneficiaries, according to a CMS press release. CMS says the problems include the following:
- Failing to meet Medicare’s transition requirements by ensuring that existing beneficiaries were able to continue to receive drugs they had been receiving in 2009 that were not on the plans’ formularies in 2010;
- Improperly processing coverage determinations and expedited appeal requests in cases where delays would jeopardize the life or health of the enrollee;
- Applying prior authorization (PA) and step therapy (ST) drug requirements that had not been approved by Medicare; and
- Failing to take timely and proper steps to ensure that enrollees are eligible for the Part D low-income subsidy (LIS).
The agency became aware of Aetna’s problems through both plan members and their physicians. CMS says it will closely monitor the plan to determine that corrective actions have been taken and these deficiencies are not likely to recur. If Aetna fails to meet Medicare requirements, penalties that range from fines to the possibility of termination of Aetna’s contracts with Medicare could be imposed.
According to CMS, the approximately one million enrollees in the Aetna plans across the country should not be impacted by the sanction.
“Current Aetna health and drug plan members who are having difficulty in getting their prescriptions filled should contact 1-800-MEDICARE or their local state health insurance assistance program for help,” said Jonathan Blum, acting director of CMS’ Center for Drug and Health Plan Choices.
Read the letter CMS sent to Aetna.
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