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I am currently a member of a CMS sanctioned Medicare Part D plan, how do these sanctions affect me?

Category: Medicare Plan Providers
Updated: Nov, 13 2022

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?

A case-by-case 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 sanction. To learn more, 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?

No. Information for 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 Plan Finder, Drug Finder, and Formulary Browser tools.

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).

MA-Finder showing an example of a CMS sanctioned plan

Please note: 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.

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  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.