If you are
enrolled in a Medicare Part D plan or a Medicare Advantage plan sanctioned by the Centers for Medicare and Medicaid
Services (CMS), your Medicare plan coverage is not usually affected
by the sanctions, although you may receive a letter from your plan informing you of
the sanctions and your rights under the sanctions.
CMS continually monitors the quality of coverage provided by private Medicare plans and if a Medicare plan falls below CMS standards, the plan may be sanctioned and required to change internal practices or procedures before being allowed to market the plan again or enroll new members.
For example, CMS auditors may conclude that the Medicare Part D or Medicare Advantage plan substantially failed to comply with CMS requirements regarding:
- Medicare Part C and Medicare Part D coverage determinations, appeals and grievances (specifically, the Medicare plan was found to have improper reviews of their coverage requests, and inappropriate and untimely resolution of plan grievances);
- Medicare Part D formulary and benefit administration;
- Providing access to facilities and records; and
- Ensuring compliance program effectiveness.
You can read more about CMS sanctioned Medicare plans in our Q1News section here:
Question: If I am enrolled in a sanctioned Medicare Part D plan will CMS grant me a Special
Enrollment Period (SEP) so I can change to another Medicare plans?
SEP is available
to members of a sanctioned Medicare plan if they can show
that they were affected by plan practices that were at issue in the
, please speak with a Medicare representative (1-800-633-4227). Again, this SEP is not automatically granted and is considered on a case-by-case basis.
Question: Can I still review information about
sanctioned Medicare plans on the CMS Medicare.gov Plan Finder site?
sanctioned Medicare Part D and Medicare Advantage plans is not shown on the
Medicare.gov Plan Finder site.
The Medicare.gov Plan Finder does show sanctioned Medicare plans after you click on the "View sanctioned plans" link found at the bottom
of the plan summary page. However, Medicare only
shows basic plan contact information and a link to the sanctions letter
from CMS. Plan coverage information for current members of the
sanctioned Medicare plan is not provided (as of April 29, 2021).
However, our Q1Medicare.com
site shows all available information for sanctioned Medicare plans in our Medicare Part D and Medicare Advantage
, and Formulary
As an example, in September 2020, CMS sanctioned
the Idaho Medicare Advantage plan “Secure Blue no Rx (PPO) - H1302-004-0 and prohibited the Medicare Advantage plan from accepting plan enrollments "beginning January 1, 2021, through December 1, 2021". However, current plan members were not affected by the CMS sanctions and were allowed to remain with the Medicare plan into 2021 - and still would need information about their 2021 Medicare plan coverage.
To provide information about this 2021 Medicare plan, we displayed the “Secure Blue no Rx (PPO) - H1302-004-0” within our Medicare Advantage Plan Finder marked with a dark red rectangle and the text “Sanctioned Plan” (see: https://MA-Finder.com/2021/83713
Sometimes Medicare plans are sanctioned for several years or before the annual Open Enrollment Period (AEP - starting October 15th and continuing through December 7th), so the drug data or coverage data for these previously-sanctioned plans is not available to us - and consequently is also not available on our Q1Medicare.com site.