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CMS imposes sanctions on Capital BlueCross Medicare plans

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The Centers for Medicare & Medicaid Services have imposed sanctions on some Medicare Parts C and D plans offered by Capital BlueCross, suspending Medicare enrollment and advertising immediately.

In a letter dated May 28, CMS said it "identified multiple, serious violations of Part C and Part D organization/coverage determination, appeal, and grievance requirements that resulted in CBC ’s enrollees experiencing inappropriate denials or delays of medications at the point of sale and within enrollees’ coverage determinations or appeals. Additionally, enrollees experienced inappropriate out of pocket cost for covered Medicare services and medications."

"These failures pose a serious threat to the health and safety of enrollees," the letter said. "Many of these issues stem from a complete ineffective monitoring and oversight of CBC’s Pharmacy Benefit Manager (PBM), which is responsible for CBC’s coverage determinations. Additionally, CBC’s lack of internal controls and  of consistent procedures resulted in a breakdown in other processes with Part D redeterminations, Part C organization determinations, Part C reconsiderations and grievances."

According to CMS, it conducted an audit of CBC's Medicare operations from April 7-18 of this year and found that CBC's failures in the noted areas "were widespread and systemic."

CBC has seven days to submit a corrective action plan to CMS, and CMS said the sanctions will remain in effect until the agency is satisfied that the deficiencies have been corrected and are not likely to recur.

CBC, a nonprofit insurer, is based in Susquehanna Township, Dauphin County. 

“The membership of current enrollees in our Medicare products is not affected by this action,” CBC spokesman Joe Butera said in an emailed statement after business hours Friday. “We take these matters very seriously and a focused team is working on this important matter. Much work has already been done to remediate some of the audit findings we had expected. We will continue to work to make improvements as expeditiously as possible, putting all the necessary resources of our company behind this effort to help ensure we can meet the needs of our Medicare members and deliver quality and effective coverage. Capital BlueCross continues to be focused on serving our customers and community with excellence as we have for more than 75 years.”

Editor's Note: This item was modified from its previous version to add a comment from Capital Blue Cross.

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