The intermediate sanction, which prevents Aetna from marketing to and enrolling new beneficiaries, goes into effect on April 21 and will remain in effect until Aetna demonstrates to CMS that it has corrected its deficiencies and they are not likely to recur, according to the release. CMS’s actions should not impact the approximately one million enrollees in the Aetna plans across the country.
CMS issued the intermediate sanction because the plan has failed to fully meet its obligations to Medicare beneficiaries, according to the release. These 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 and step therapy 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.
CMS 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, according to the release.
Read the CMS release on Aetna’s intermediate sanction.
