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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One Response to “CMS Issues Intermediate Sanction Notice to Aetna”

  1. mini lipski says:

    work for acs inc an outsourcing company that has a contract with Aetna. They hired us off the streets to apply the step therapy and precertification guidelines they established for 2010. I knew this was wrong from the very start of the job. So many medicare members that have been on life sustaining medications for years, go to the pharmacy to pick up their meds, are told when they get there that they are not covered. Many are on a fixed income, have trouble getting out to the pharmacy because of age and illness have to pay out of pocket for their pills or breathing treatments. Then, their doctor or nurse has to call us and practically beg for their patients medicine, taking time away from helping people in their office, and causing frustration and worry for both the patients, and the caretakers. T;h;is was a bait and switch tactic by Aetna to profit from the most vulnerable and helpless people. It is my wish that Aetna loses the government contract with medicare to punish them for the greed and downright hell that they have put people through since the start of the year. They do not care about the elderly or any other customers they have. They are in the game for only one reason___Profit!!!!!!!!!

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