CMS Removes Sanctions Against Aetna

CMS Removes Sanctions Against Aetna

The Center for Medicare and Medicaid Services (CMS) released Aetna from its enrollment and marketing sanction last month, in June 2011. These sanctions were put in place in April 2010 in response to numerous complaints from providers and beneficiaries. The complaints included limited access to medications; failure to make prescriptions available under CMS transition fill requirements; improper and unapproved requirements for prior authorization and step therapy; and failure to follow expedited appeal timeframes. (See our article Medicare Issues Sanction Notice to Aetna Insurance Company).

Aetna contacted CMS in March of this year to report that they had corrected all of their deficient areas. After a period of close inspection, CMS lifted the sanctions (see their letter dated 6/13/11 (PDF)).

Aetna is now permitted to market and advertise their 2011 Medicare Part C and D products. They may also accept enrollments from beneficiaries who are in valid special election periods (see our section on special election periods for more info).

The earliest effective date for a new enrollment is 7/1/2011. In the immediate future, however, CMS will not assign beneficiaries with the low-income subsidy (LIS) to Aetna, though LIS beneficiaries can choose to enroll in an Aetna plan.

CMS will continue to closely monitor Aetna’s performance. If the issues that gave rise to the company’s sanction do recur, CMS will consider taking additional compliance and enforcement actions. CMS also requests that providers and/or beneficiaries report any significant issues they see associated with Aetna, or any other of their Medicare Advantage or prescription drug plans. People can do so by contacting their CMS Regional Office.

CMS also recently lifted sanctions on Arcadian. In California, this company offers Medicare Advantage prescription drug (MA-PD) plans called Arcadian Community Care Plus in Santa Barbara, San Luis Obispo, Tulare and Shasta counties. With the sanction lifted, Arcadian can now market and advertise their 2011 plans, and can also accept enrollments from beneficiaries with valid election periods starting as early as 8/1/2011. Arcadian had been sanctioned for issues related to marketing violations by agents and brokers, including prohibited marketing practices, resulting in delays in access to care.

There are still many plan sponsors who have not yet had their sanctions lifted. In California, these sanctioned sponsors are not allowed to market to or enroll new beneficiaries into the following plans:

  • Health Net Healthy Heart (HMO in many counties)
  • Health Net Seniority Plus Green (HMO in many counties)
  • Health Net Violet (HMO in many counties)
  • Health Net Orange Option 1 (stand alone Part D plan statewide)
  • Health Net Orange Option 2 (stand alone Part D plan statewide)
  • Today’s Options Premiere 450A (PFFS in many counties)
  • Today’s Options Premiere 800 (PFFS in many counties)
  • Today’s Options Premiere 850E (PFFS in many counties)
  • Today’s Options Premiere 850F (PFFS in many counties)
Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.