Aetna’s marketing and enrollment of new Medicare customers will come to a halt April 21, after the discovery of compliance issues by the Centers for Medicare & Medicaid Services. The CMS announced it would impose an intermediate sanction against the Connecticut-based health insurer to ensure its Medicare beneficiaries continue to have access to recommendation drugs meeting Medicare needs.
Problems regarding Aetna were brought to the attention of CMS by plan members and physicians. CMS later found that the insurer continued to improperly administer the Medicare benefit in the plan’s national stand-alone prescription drug plan (PDP) and its 25 Medicare Advantage prescription drug (MA-PD) contracts.
According to the CMS, about 400,000 Medicare beneficiaries are enrolled in the MA-PD plans and another 600,000 are enrolled in Aetna’s PDP. Among the specific issues the CMS identified were Aetna applying prior authorization and step therapy drug requirements that are unapproved by Medicare, and improperly processing coverage determinations and expedited appeal requests in cases where delays would jeopardize the life or health of the enrollee.
The CMS also found that Aetna failed to meet Medicare transition requirements by ensuring that existing beneficiaries were able to continue receiving drugs in 2009 that were not on the plans’ formularies this year. The insurer said the pending suspension does not affect current health insurance and Medicare enrollees and that it will work to resolve the issues highlighted by CMS as soon as possible.
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