Insurance Company Ejected From Medicare Program For Denying Medication To Seniors

Medicare Part D Company Ejected From Program For First Time


Ryan Grim | Huffington Post | Updated: 03- 9-10 05:06 PM

For the first time since the program was enacted, an insurer is being ejected from the Medicare Part D program for denying medication to seniors and otherwise failing to live up to Medicare obligations, the Centers for Medicare & Medicaid Services (CMS) announced Tuesday.

The timing of the decision gives a boost to Democratic reform efforts, as the party can point to the behavior of the Fox Insurance Company of New York as the type that would be reined in by tough regulation of the industry.

"Just as insurance companies have been unjustly hiking premiums for Americans, we see another instance of an insurer putting their profit margins ahead of the health of their customers," said Rep. Pete Stark, Chair of the House Ways and Means Health Subcommittee. "We were able to shut this bad actor down because CMS exercised their oversight over Medicare Part D plans. We need health care reform to extend this oversight over the insurance companies that cover all Americans." A call to Fox was not returned.

In February, the insurer was told that it must suspend marketing and enrollment of new members for denying access to medication. CMS asked other Fox customers to alert it to ongoing problems and apparently found them sufficient enough to expel the company from the program. Fox has more than 100,000 customers. They will have the opportunity to be moved onto the rolls of other companies.

From the Dept. Health & Human Services - http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3634&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date">CMS Release - Among the audit findings CMS found include:

· Failing to provide access to Medicare prescription drugs benefits by imposing unapproved prior authorization and step therapy criteria that made it more difficult for beneficiaries to get drugs that are protected by law.

· Not meeting the plan's appeals deadlines,

· Not complying with Medicare regulations requiring enrollees to be transitioned to new drugs at the beginning of the new plan year.

· Failing to notify enrollees about prior authorization and step therapy determinations as required by Medicare.

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