Readiness: A Year-Round Effort

A solid, compliant sponsor isn’t perfect, but they know how to react swiftly when the unexpected arises, and it will come up year-round. Take it from recent enforcement notices issued by the Centers for Medicare & Medicaid Services (CMS).

Within a matter of days, the agency first imposed and then lifted an immediate suspension of enrollment and marketing sanction on a Prescription Drug Plan (PDP) sponsor new to the market. Operated by a highly reputable organization with over 100 years in the finance and insurance industries, the enrollment and marketing freeze was imposed due to the sponsor not providing CMS with evidence of a valid license within the state of Florida. The sponsor had disclosed to the agency that the state had recently informed them an amendment was required for their license to be complete. Therefore, based on what was in effect with the state, the sponsor was not in compliance with the Part D regulation 42 C.F.R. § 423.401(a) which requires each PDP sponsor have a license under state law as a risk bearing entity eligible to offer health insurance or health benefits coverage.

The issue was quickly remedied when the Office of Insurance Regulation provided notice to CMS it had approved the additional line of business on the sponsor’s license. As a result, CMS lifted the sanction. The requirement to be properly organized and licensed under state law is confirmed upon submission of a Part D application, unless a waiver is requested and approved. That should generally be the end of it, but in this sponsor’s case, there was more to come.

As illustrated by this recent enforcement action, things you think are in place might not be, and no checklist can prepare you for those instances. Those most successful in administering government programs are honest about what they know, unafraid to pick up the phone and verify, and driven to implement effective corrections.