Medicare emphasizes compliance for violative plans

August 1, 2006

WASHINGTON, D.C.-While continuing to tout the success of using private plans to provide prescription drug benefits to millions of seniors, the Centers for Medicare and Medicaid Services (CMS) also is waving a big stick. The agency announced in June that it has taken more than 1,000 compliance actions to resolve beneficiary complaints and ensure adequate service, part of its campaign to demonstrate that CMS can police this huge new program.

WASHINGTON, D.C.-While continuing to tout the success of using private plans to provide prescription drug benefits to millions of seniors, the Centers for Medicare and Medicaid Services (CMS) also is waving a big stick. The agency announced in June that it has taken more than 1,000 compliance actions to resolve beneficiary complaints and ensure adequate service, part of its campaign to demonstrate that CMS can police this huge new program.

Most CMS enforcement actions request prescription drug plans (PDPs) and Medicare Advantage drug plans (MA-PDs) to provide more accurate information and improve service for patients. In the program's first six months, the agency issued:

CMS also took action in 75 situations to temporarily restrict plan marketing activities. Such cases most often arose from a plan posting incorrect information about drug prices and formularies or imposing inappropriate utilization curbs on a covered drug.

Overall, CMS said its complaint rate for MA-PDs averaged 1.6 per 1,000 beneficiaries-compared with 2.5 per 1,000 beneficiaries for stand-alone PDPs. Most complaints have been about enrollment or disenrollment problems, difficulties obtaining needed drugs and unhappiness about the cost of drugs or incorrect co-pays at the pharmacy counter.

At the same time, MA plans have been the target of more serious CMS enforcement action in two cases. The agency has imposed a corrective action plan on one MA-PD that had problems assuring access to medicines for new enrollees during the transitional coverage period. CMS is reportedly looking to terminate America's Health Choice of Florida because of continued marketing violations.