The Centers for Medicare & Medicaid Services has issued an intermediate sanction against the Aetna Insurance Company for what CMS officials said are violations in administering the Medicare drug benefit.
According to CMS officials, the sanction would become effective April 21 and would prevent Aetna from marketing to and enrolling new beneficiaries until it corrects the violations and "they are not likely to recur."
CMS said Aetna "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."
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, Aetna's violations include:
- failing to meet Medicare's transition requirements by ensuring that existing beneficiaries were able to continue receiving 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 officials said they were made aware of Aetna's problems by both plan members and their physicians. CMS officials said they will be closely monitoring Aetna.
Aetna President Mark T. Bertolini said the company 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," Bertolini said. "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. "