Hey Medicare Nation!
CMS Imposes a Civil Money Penalty against HUMANA!
CMS conducted an “Audit” of Humana’s Medicare Operations from June 3, 2019, through June 21, 2019.
Humana failed to comply with Medicare requirements related to Part D formulary and benefit administration and coverage determinations, appeals, and grievances in violation of 42 C.F.R. Part 423, Subparts C and M.
Humana’s failures in these areas were systemic and adversely affected or had a substantial likelihood of adversely affecting, enrollees.
CMS provided notice to Humana’s CEO, Mr. Bruce Broussard, on February 28, 2020, that CMS imposed a Civil Money Penalty in the amount of ……..
Humana failed to properly administer the CMS “transition” policy. This means if you are enrolling in a new plan, and you take a prescription that is NOT on the new plan’s formulary (drug list), the plan MUST allow you to “transition” by allowing you a 31 day supply of your prescription drug.
This allows you time to speak with your doctor to see if there is an alternative prescription drug on the new plan …… or……
you can request a “Formulary Exception.”
This means your doctor is requiring you to take this medication because it is the one that is stabilizing or correcting your condition and that you need to continue to take it.
If the drug is NOT on the new plan’s formulary and they Approve the formulary exception, you WILL be charged a higher amount for taking a drug that is not on their formulary.
Humana has the right to appeal the decision by requesting a hearing.
The notice is signed by John Scott, Acting Director of the Medicare Parts C and D Oversight and Enforcement Group.
NEXT CMS Penalty is given notice to………
SOLIS Health Plans out of Miami, Florida
On December 4, 2019, CMS gave notice to Mr. Daniel Hernandez – CEO of Solis Health Plans.
CMS imposed a CIVIL MONEY PENALTY of
CMS stated in their summary that Agents employed by SOLIS engaged in an aggressive marketing campaign that was conducted by a contractor provider clinic.
Solis Agents conducted a marketing presentation in a secluded area and enroll patients upon the conclusion of the presentation.
CMS determined that Solis violated the communication and marketing requirements, which had a substantial likelihood of adversely affecting its enrollees.
Solis Failed to oversee and manage the marketing process to ensure its agents and brokers did not engage in inappropriate marketing practices including “misleading” beneficiaries.
Solis may request a hearing to appeal CMS’s determination.
Both notices are signed by John Scott, acting director of the Medicare parts C and D Oversight and Enforcement Group.
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