Medicare Slams Door on Enrollment and Marketing of
Aetna’s Drug and Advantage Plans
CMS says Aetna has failed to fully meet its
obligations to Medicare beneficiaries
April 9, 2010 – Last Monday, April 5, the Centers
for Medicare & Medicaid Services privately notified Aetna Insurance
Company of its intent to impose an intermediate sanction to prevent
Aetna from marketing to and enrolling new beneficiaries in its Medicare
Advantage and prescription drug plan. Today, Aetna announced is it will
cease enrollment and marketing due to the CMS action.
Senior citizens in 21 states enrolled in the Fox plan will be
provided access to drugs; need to choose new Medicare prescription
drug plan by May 1
March 11, 2010 – Fox Insurance Company of New York
this week became the first insurance company to be terminated from the
Medicare prescription drug program (Part D).
The sanctions relate to compliance with certain
Medicare Part D requirements, primarily those relating to changes in the
drugs covered by certain plans from 2009 to 2010, according to Aetna.
CMS also today released a news release about the
action, saying the sanctions were necessary to “ensure that Medicare
beneficiaries continue to have access to prescription drugs under
Medicare’s requirements.”
The CMS release stated, “The intermediate sanction,
which will prevent Aetna from marketing to and enrolling new
beneficiaries, will be effective April 21. It will remain in effect
until Aetna demonstrates to CMS that it has corrected its deficiencies
and they are not likely to recur.
“Medicare’s actions should not impact the
approximately one million enrollees in the Aetna plans across the
country.
“Aetna was served with the intermediate sanction
notice because it has continued to improperly administer the Medicare
drug benefit in the plan’s national standalone prescription drug plan
(PDP) and its 25 Medicare Advantage prescription drug (MA-PD)
contracts.”
Aetna’s statement said, “The suspension does not
affect current Aetna Medicare enrollees. Aetna is cooperating fully
with CMS on its review, and is working to resolve the issues CMS has
raised as soon as possible.”
“Compliance problems are unacceptable to Aetna; the
issues raised to us by CMS have our utmost attention,” said Aetna
President Mark T. Bertolini.
Aetna Faces Medicare Sanctions:
Kaiser Health News
Health insurer Aetna
announced Friday it will suspend "marketing to and enrollment of new
members to its Medicare plans for the elderly because of sanctions
imposed by the U.S. government,"
Reuters reports.
The suspension will effect "Aetna's Medicare
Advantage and standalone prescription drug plans, but … not … its
current Medicare enrollees" (Krauskopf, 4/9).
Wall Street Journal: The problems pointed out by the Centers for
Medicare and Medicaid Services involve "compliance problems related to
drug-plan requirements."
According to the Journal, "Aetna went from an open
formulary in 2009 to a closed formulary this year for many of its
Medicare plan benefit packages, spokesman Fred Laberge said. In an open
formulary, patients can be prescribed most any drug, while a closed
formulary restricts the choices of available medications. The issue
relates mostly to existing individual-plan members who were prescribed a
drug that was on the 2009 formulary but was no longer on the formulary
this year, he said.”
While CMS approved the health insurer's 2010
formulary, affected members may not have received a one-time, 30-day
transition supply of drugs, he said."
The company has said it will cooperate fully with
the CMS review and is working to resolve the problems as soon as
possible. "The company estimates some 20,000 current members may have
been affected by compliance problems related to transition" from an open
formulary in 2009 to a closed formulary for "many of its Medicare plan
benefits packages" (Wisenberg Brin, 4/9).
“Aetna takes our obligations to our Medicare
beneficiaries seriously, and our priority is to help ensure they have
access to high-quality care, excellent service and needed medications.
We are working with CMS to resolve these matters, and we also will be
doing proactive outreach to impacted members to resolve these issues.”
Approximately 400,000 Medicare beneficiaries are
enrolled in the organization’s MA-PD plans and another 600,000 are
enrolled in the Aetna PDP, according to CMS.
“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.
The news release further said, “Medicare issued the
intermediate sanction because the plan has failed to fully meet its
obligations to Medicare beneficiaries. More specifically those
obligations include, but are not limited to:
● 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).
CMS said the reports of problems were raised to CMS
by 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 and if Aetna is not in compliance to Medicare
requirements, penalties that range from fines to the possibility of
termination of Aetna’s contracts with Medicare could be imposed.
CMS encourages plan members who may have concerns
with their Part D coverage to contact 1-800-MEDICARE (1-800-633-4227) or
the state health insurance assistance program (SHIP) to help get them
resolved.
Just last month, Fox Insurance Company became the
first company kicked out of the drug program by CMS. (See link to report
in sidebar.)
Keep up with the latest news for senior citizens, baby
boomers
April 9, 2010 – Last Monday, April 5, the Centers
for Medicare & Medicaid Services privately notified Aetna Insurance
Company of its intent to impose an intermediate sanction to prevent
Aetna from marketing to and enrolling new beneficiaries in its Medicare
Advantage and prescription drug plan. Today, Aetna announced is it will
cease enrollment and marketing due to the CMS action.