DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 MEDICARE PARTS C AND D OVERSIGHT AND ENFORCEMENT GROUP Date: March 1, 2017 To: All Medicare Advantage Organizations, Medicare Advantage – Prescription Drug Plans and Prescription Drug Plans From: Vikki Ahern, Director Medicare Parts C and D Oversight and Enforcement Group Subject: Civil Money Penalty Enforcement Actions for 2016 Program Audits The Centers for Medicare & Medicaid Services (CMS) has released the Civil Money Penalties (CMPs) imposed on Part C and Part D Sponsors for violations of Medicare Parts C and D requirements found during the sponsors’ 2016 Program Audit. These violations were related to failure to comply with one or more of the following Medicare requirements: Part D formulary benefit administration, or Part C or Part D organization/coverage determinations, appeals, and grievances. The circumstances that led to the failure and the impact (or the substantial likelihood of impact) on beneficiary access to medical services and prescription drugs were considered when determining if a CMP was warranted. A total of 17 Sponsors were issued a CMP between October 2016 and February 2017 based on findings from their 2016 program audit. These notices are posted on the Part C and Part D Enforcement Actions webpage at: https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-andAudits/PartCandPartDEnforcementActions-.html. The release of these actions furthers the goal of improving industry standards and providing continued transparency in CMS oversight activities. All audit related CMP notices will continue to be posted simultaneously to the CMS website within the first quarter of the next program audit year. This allows the public and sponsors to more easily compare all of the CMP audit violations imposed within the same program audit year. CMPs as a result of marketing violations or other ad hoc enforcement actions, sanctions, or terminations will continue to be posted to the CMS website within the normal timeframe after notification to the sponsor. When reviewing the published CMP data for actions imposed within the same program audit year, there are two important points to consider. First, a sponsor’s audit score does not necessarily correlate with the amount of the CMP or the determination to impose a CMP. A sponsor’s audit score is a reflection of the number of conditions of non-compliance discovered during the course of an audit (audit scores for 2016 Program Audits are listed in the attached Appendix). Conversely, CMPs are imposed when the conditions of non-compliance adversely affected enrollees or there was a substantial likelihood that enrollees were adversely affected. Even if a sponsor receives an above average audit score because they had fewer conditions of non-compliance, the scope of the issues and the types of violations may still result in a CMP. Second, the amount of the CMP does not automatically reflect the overall performance of sponsors. The majority of CMPs are assessed on the number of enrollees impacted by certain violations. In most instances, the amount of the CMP will be higher for larger sponsors with more enrollees or where a violation impacted a larger number of enrollees. Appendix: 2016 Program Audit Scores by Sponsor and CMP Indicator Sponsor # of Program Areas Audited Audit Score CMP Issued (Yes/No) 1 2 3 4 5 6 AvMed, Inc. Banner Health BCBS MN, MT, NE, ND, WY, Wellmark IA and SD Blue Cross & Blue Shield of Rhode Island Caidan Enterprises, Inc. Centene Corporation 4 5 3 4 5 5 1.59 1.35 0.31 0.65 0.90 1.60 Yes No No No Yes Yes 7 8 9 10 11 12 CommunityCare Managed Healthcare Plans of OK, Inc. Essence Group Holdings Corporation Fallon Community Health Plan FirstHealth of the Carolinas, Inc. Gateway Health Plan, LP Golden State Medicare Health Plan 4 4 5 3 5 3 1.06 0.76 1.35 1.11 0.65 1.20 Yes No Yes Yes No No 13 14 15 16 17 18 Hawaii Medical Service Association Health Care Service Corporation Health Partners Plans, Inc. Health Plan of San Mateo Healthfirst, Inc. HealthNow New York Inc. 5 5 5 5 5 4 1.35 1.15 1.55 1.80 1.50 1.24 No Yes Yes Yes Yes No 19 20 21 22 23 24 Independent Care Health Plan Inc. InterValley Health Plan Kinderhook Capital Fund III, L.P. Medstar Health, Inc. Ministry Health Care, Inc. Molina Healthcare, Inc., 3 4 3 3 5 5 2.10 0.71 1.70 2.00 1.10 1.65 Yes No No No No No 25 26 27 28 29 30 MVP Health Care, Inc. PH Holdings, LLC Premera Premier Health Partners Presbyterian Healthcare Services Samaritan Health Services 4 5 4 3 4 5 0.88 0.85 0.76 2.70 1.29 1.55 Yes Yes No No Yes No 31 32 33 34 35 36 SCAN Health Plan Spectrum Health System The New York State Catholic Health Plan, Inc. UnitedHealth Group, Inc. UPMC Health System WellCare Health Plans, Inc. 5 4 5 5 5 5 1.30 0.47 1.05 1.20 1.05 1.45 Yes No No Yes No Yes 37 Wisconsin Physicians Service Ins Corporation. 3 0.23 No