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.
on this site
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?
Maybe. 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?
Probably not. In previous years, information for sanctioned Medicare Part D and Medicare Advantage plans was not shown within the Medicare.gov Plan Finder site.
The Medicare.gov Plan Finder does show the name and contact information for sanctioned Medicare plans after you click on the "View sanctioned plans" link found at the bottom of the Medicare.gov plan summary page. However, the Medicare Plan Finder 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 November 20, 2023) - and you will need to visit the plan's website or contact the plan's Member Services directly to receive coverage information.
Viewing sanctioned Medicare plans on the on this site site
Alternatively, our on this site site shows all available information for sanctioned Medicare plans in our Medicare Part D and Medicare Advantage Plan Finders, 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.
In this 2021 example, the this site site 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: MA-Finder.com/2021/83713) - to provide basic users with basic information about this 2021 Medicare plan.
Please note: Sometimes Medicare plans are sanctioned for multiple years or before the annual Open Enrollment Period (AEP - starting October 15th and continuing through December 7th), so the formulary drug data or coverage data for these previously-sanctioned plans is not available to us - and consequently is also not available on our on this site site.