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CMS Bans Aetna From Enrolling New Medicare Beneficiaries

Les Masterson, for HealthLeaders Media, April 9, 2010

CMS issued an immediate sanction notice to Aetna after the insurer "continued to improperly administer the Medicare drug benefit in the plan's national standalone prescription drug plan and its 25 Medicare Advantage prescription drug contracts," according to CMS.

The immediate sanction prevents Aetna from marketing to and enrolling new beneficiaries effective April 21. The sanction will remain in place until Aetna "demonstrates to CMS that it has corrected its deficiencies and they are not likely to recur."

There are about 1 million Medicare Advantage and Part D members enrolled in Aetna plans, but CMS said the sanction will not impact them.

CMS said the problems were raised by members and physicians and if they are not corrected, the federal government may levy fines or terminate Aetna's contract with Medicare.

The specific issues raised by CMS are:

  • "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 and step therapy drug requirements that had not been approved by Medicare.

  • "Failing to take timely and proper steps to ensure that enrollees are eligible for the Part D low-income subsidy."

After the announcement, Aetna released a statement that said the company is cooperating with CMS and working to resolve the issues.

"Compliance problems are unacceptable to Aetna; the issues raised to us by CMS have our utmost attention," said Aetna President Mark T. Bertolini. "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."


Les Masterson is an editor for HealthLeaders Media.

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