Last week Medicare issued an intermediate sanction notice to Aetna Insurance Company prohibiting any marketing or enrollment of new beneficiaries into their national Part D prescription drug stand-alone plan and their 25 Medicare Advantage Prescription Drug plans (MA-PDs) as of April 21, 2010.
This sanction is in response to growing provider and beneficiary complaints of not being able to access their medications and having unnecessary obstacles and illegitimate denials for drugs for which they are entitled.
The Centers for Medicare and Medicaid Services says the sanctions will stay in place until Aetna adequately demonstrates they have corrected these problems and that they will not re-occur. Aetna currently has 400,000 beneficiaries enrolled in their MA-PD plans, and 600,000 enrolled in their stand-alone PDP plan.
Some of the obligations Aetna plans have failed to fulfill for their Medicare beneficiary enrollees as listed in CMS’ press release include:
- 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).
If the situation fails to improve for Aetna’s enrollees, CMS has warned that Aetna Insurance Company could incur penalties and even termination of their Medicare contracts.
In addition to Aetna, CHA has reports of potential problems with WellCare Part D plans – such as encountering prior authorization (PA) requests for certain drugs where in the past there had been none. If you or your clients encounter any such problems with WellCare or Aetna plans, please contact us and let us know.