CMS Drops Fox Insurance from Medicare Part D

Les Masterson, for HealthLeaders Media , March 10, 2010

Saying the health insurer was jeopardizing "the health and safety" of Medicare Part D enrollees, CMS terminated its contract with Fox Insurance Company on Tuesday.

The decision comes less than two weeks after CMS told Fox it could not enroll new members or market its Part D offering because CMS alleged the insurer was not following "Medicare's rules for providing prescription drug coverage to its enrollees." On Tuesday, CMS said a further investigation found persistent problems that placed obstacles in front of enrollees "in getting needed and, in many cases, life-sustaining medications," according to CMS.

In fact, CMS said Fox required enrollees to "have unnecessary and invasive medical procedures before they were able to obtain drugs."

"Fox committed a series of violations, including improperly denying its enrollees coverage of critical HIV, cancer, and seizure medications," said CMS.

CMS reportedly found that Fox:

  • Failed 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."
  • Did not meet "the plan's appeals deadlines."
  • Didn't comply "with Medicare regulations requiring enrollees to be transitioned to new drugs at the beginning of the new plan year."
  • Failed "to notify enrollees about prior authorization and step therapy determinations as required by Medicare."

"The immediate termination of Fox as a Medicare prescription drug plan demonstrates our commitment to protecting the health of some of their most vulnerable enrollees from getting necessary drugs, in some cases life-sustaining medicines. CMS' immediate action was essential to protect members' health and safety—an integral part of our contract with all Medicare beneficiaries," said Jonathan Blum, acting director of CMS' Center for Drug and Health Plan Choices.

The more than 123,000 Medicare Part D beneficiaries with Fox Insurance, who are spread across 21 states, will be covered under LI-NET, which is run by Medicare and administered by Humana, until May 1. Fox enrollees will have until that time to choose a new prescription drug plan or Medicare will enroll them into a new plan.

Les Masterson is an editor for HealthLeaders Media.

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