After being notified by plan members and their physicians, the Centers for Medicare & Medicaid Services (CMS) issued a notice to Aetna Insurance Co. of its intent to impose an intermediate sanction to ensure that Medicare beneficiaries continue to have access to prescription drugs under Medicare’s requirements.

Aetna was served with the intermediate sanction notice because it allegedly 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, according to CMS. Approximately 400,000 Medicare beneficiaries are enrolled in the organization’s MA-PD plans and another 600,000 are enrolled in the Aetna PDP.

Aetna released a statement on April 9, 2010. “Compliance problems are unacceptable to Aetna; the issues raised to us by CMS have our utmost attention,” said Aetna President Mark 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.” 

The suspension does not affect current Aetna Medicare enrollees. The intermediate sanction, which will prevent Aetna from marketing to and enrolling new beneficiaries, will be effective April 21. It will remain in effect until Aetna demonstrates to CMS that it has corrected its deficiencies, and they are not likely to recur. Medicare’s actions should not impact the approximately 1 million enrollees in the Aetna plans across the country.

Medicare issued the intermediate sanction because the plan has failed to fully meet its obligations to Medicare beneficiaries. CMS says, more specifically those obligations include, but are not limited to:

• 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

CMS will closely monitor the plan to determine that corrective actions have been taken and these deficiencies are not likely to recur. 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.

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