Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and
business strategies about Medicare Advantage plans, product design, marketing,
enrollment, market expansions, CMS audits, and countless federal initiatives in
MA and Medicaid managed care.
By James
Gutman, Managing Editor
July 30, 2015 Volume
21 Issue 15
CMS this month cited six Medicare
Advantage sponsors for failing to furnish correct and/or timely benefit and
cost information for their MA plans for the 2015 contract year (CY). The agency
notified the plans involved that it will impose civil money penalties (CMPs)
that range from a low of $34,445 for Health Alliance Medical Plans to a high of
$349,075 for Health Net of Arizona.
The CMPs, which the sponsors may
request a hearing to contest, come despite acknowledgments by the agency that
in one case the plan had self-disclosed the problem to CMS and in two other
cases the MA sponsors had mailed “errata sheets” to plan members shortly before
the end of the Annual Election Period (AEP) last fall. The enforcement actions
seem to suggest CMS is taking an increasingly tough stance against what it
considers unclear and/or inaccurate benefit information furnished to MA
enrollees in the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
documents that plan sponsors must send to members by Sept. 30 each year. There
weren’t any CMS enforcement actions such as fines related to the required
beneficiary notices for 2014, although there were five such actions in 2013.
“CMS is imposing penalties against
these plan sponsors because we identified substantial violations of the
disclosure and information dissemination requirements,” the agency tells MAN.
“More specifically, the plan sponsors did not provide timely and/or accurate
benefit information…to their enrollees for the 2015 Medicare Open Enrollment
Period. As a result, these violations had the substantial likelihood of
adversely affecting one or more enrollees.”
In some of the CMP notices, the agency
pointed out that it was not the first time the plan sponsors had failed in this
regard. In the July 13 letter to Health Net, for instance, Gerard Mulcahy,
director of CMS’s Medicare Parts C and D Oversight and Enforcement Group, wrote
that “in 2014 Health Net AZ received a notice of non-compliance for failing to
accurately describe benefits and/or cost sharing information to its enrollees
in its CY 2014 ANOC/EOC documents.”
For 2015, the letter said, “Health Net
AZ reported to CMS that 13,963 of its enrollees received inaccurate information
about their 2015 benefits in Health Net AZ’s CY 2015 ANOC documents.”
Specifically, according to CMS, 4,865 members received an ANOC that didn’t
include cost-sharing amounts for days 1-5 of inpatient hospital stays. Those
amounts climbed from $320 per day to $345 per day for 2015, the agency said. In
another MA contract, CMS added, “9,098 enrollees received an ANOC that
incorrectly stated its network included pharmacies with preferred cost sharing,
when the plan does not offer preferred cost sharing.”
Health Net did not mail the errata
sheets about this inaccurate information until Nov. 24, 2014, which was too
late for enrollees to “use the information to make a fully informed decision”
about their Medicare plan options for 2015, the letter asserted. The AEP now
ends Dec. 7 each year.
United Didn’t Include Some Benefit
Changes
In the July 14 letter to
UnitedHealthcare, CMS said it would impose a $149,150 CMP in light of the
company self-disclosing to the agency that 5,966 of its members received
“untimely information about their 2015 benefits” in the ANOC documents.
Specifically, according to the letter, United said one of its Plan Benefit
Packages (PBPs) was not included in the ANOC file sent to its “print vendor for
fulfillment.”
This was important, CMS explained,
since a plan-year benefit comparison of 2014 to 2015 showed several “changes
that had the potential to negatively affect beneficiaries.” Among those were a
$12.80 hike in the monthly plan premium, higher cost-sharing amounts for Part D
prescription drugs and increased annual deductibles. United did not mail the
ANOC for this PBP until the week of May 4, 2015, well after the AEP had ended,
CMS wrote in the letter.
In the letter to Indiana University
Health Plans, Inc., which stands to be assessed a $101,675 CMP, CMS said IUHP
reported to the agency that 4,067 of its enrollees received inaccurate
information about their 2015 benefits. Those members, Mulcahy’s letter
reported, received an EOC “that incorrectly stated that enrollees could use
out-of-network providers when outside the service area” in a point-of-service
option. IUHP’s Select Plus plan does not offer this option “except in limited
circumstances (i.e., emergencies, urgently needed care, and out-of-area
dialysis services),” the letter said.
IUHP did not mail errata sheets
correcting the inaccurate information until Dec. 23, according to CMS. And
“this is the third year [in a row] in which IUHP has provided inaccurate
information to its enrollees,” the agency noted, pointing to a notice of
non-compliance and warning letter sent for CYs 2013 and 2014.
In the letter to Health Alliance parent
The Carle Foundation, CMS said 2,364 of its enrollees received inaccurate
information about 2015 benefits, most of them because an ANOC did not include
copayment amounts for out-of-network skilled nursing facility benefits, for
which costs “significantly increased” for 2015. Health Alliance did not mail
the errata sheet until Dec. 5, 2014, two days before the end of the AEP, CMS
said.
In another Health Alliance contract,
the agency added, 203 enrollees received ANOC/EOC documents containing
“numerous inaccuracies, many of which incorrectly conveyed lower-cost sharing
and more extensive benefits under the plan.” The sponsor did not mail the
errata sheets about these till Nov. 12, which CMS considered too late for
making “a fully informed decision.”
The $52,045 CMP that Fallon Community
Health Plan stands to be assessed stems from 1,487 of its enrollees receiving
EOC documents stating that the 2015 monthly premium is $129, when it actually
is $176, according to CMS. The agency’s letter said Fallon did not mail errata
sheets correcting this information until Jan. 23, 2015, and that Fallon in 2014
had received a notice of non-compliance for failing to describe benefits and/or
cost-sharing information accurately in 2014 ANOC/EOC documents.
ATRIO Health Plan in Oregon also was
cited as a repeat offender. Its $69,405 CMP for 2015, CMS said, stems from
2,149 of its enrollees receiving inaccurate benefits information. In one
contract, this involved understating by one day the time for which members must
make copayments for a hospital stay, while in another contract it involved
understating the maximum out-of-pocket amount for hospitalizations, according
to the agency. ATRIO did not send errata sheets correcting these inaccuracies
until after the AEP had ended, CMS noted.
View the CMS letters by visiting the
July 30 From the Editor entry at MAN's subscriber-only web page: www.aishealth.com/newsletters/medicareadvantagenews.
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