CMS to sanction Aetna for Part D drug mishaps

The Centers for Medicare and Medicaid Services (CMS) will impose an intermediate sanction, effective April 21, to stop Hartford, Conn.-based Aetna Inc. from marketing to or enrolling new Medicare Part D beneficiaries in its plans. Aetna, is the fourth major insurer to receive such a sanction in the last two years, reports the Philadelphia Inquirer. Further, the announcement came less than a month after CMS canceled another drug benefit contract with Fox Insurance Company.

The sanction will remain in effect until Aetna resolves problems with the administration of the Part D drug benefit in its national standalone prescription drug plan (PDP) and its 25 Medicare Advantage prescription drug (MA-PD) contracts. Some 600,000 Medicare beneficiaries are enrolled in the PDP, and an additional 400,000 are enrolled in the MA-PD plans. These existing enrollees shouldn't be impacted by the sanction, says CMS.

Aetna's mistakes include: not ensuring that existing beneficiaries could continue to receive drugs they received in 2009 that were not on the plans' 2010 formularies; improperly processing coverage determinations and expedited appeal requests when delays could result in harm or death to beneficiaries; applying prior authorization and step-therapy drug requirements that weren't approved by Medicare; and failing to act timely to ensure that enrollees are eligible for the Part D low-income subsidy. If Aetna doesn't comply with these Medicare requirements, the company could face fines or even contract termination, says CMS, which sent a warning letter to the insurer on April 5.

"Compliance problems are unacceptable to Aetna; the issues raised to us by CMS have our utmost attention," says Aetna President Mark Bertolini. "We are working with CMS to resolve these matters, and we also will be doing proactive outreach to impacted members to resolve these issues."

Most analysts don't expect the sanction to hurt Aetna too badly as long as the problems are resolved when the next open-enrollment period begins this fall, reports the Wall Street Journal.

To learn more about the sanction:
- read this Philadelphia Inquirer article
- read this Wall Street Journal article
- read the CMS press release or letter to Aetna
- read Aetna's statement

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