On September 9, 2020, the Centers for Medicare & Medicaid Services (CMS) provided notice to Blue Cross of Idaho Care Plus, Inc. (“Blue Cross of Idaho”) that CMS has made a determination to prohibit the enrollment of new beneficiaries under the Medicare Advantage-Prescription Drug (MA-PD) contract H1302 for contract year (CY) 2020.
As a result of this determination, Blue Cross of Idaho will be prohibited from accepting any MA-PD plan enrollments for 2021; this prohibition would be effective for any enrollments beginning January 1, 2021, through December 1, 2021. This action will include the removal of H1302 from the list of MA-PD plans from which beneficiaries may make an election during the CY 2021 Annual Election Period (AEP), which runs between October 15, 2020, and December 7, 2020. However, Blue Cross of Idaho may continue to accept and process enrollments that become effective on or before December 1, 2020
Current members of Medicare plans under this contract (H1302) are not
by the sanctions and may remain with their 2020 Medicare plan
into 2021. However, during CY 2021, all individual market plans offered under H1302 will be precluded from accepting any new enrollees, including those beneficiaries already enrolled in a Blue Cross of Idaho MA-PD plan who may want to elect a different plan offered under the same contract.
If Blue Cross of Idaho submits a CY 2020 report in 2021 for H1302 that demonstrates it has achieved an MLR of at least 85%, CMS will allow the sponsor to resume accepting enrollments that become effective on or after January 1, 2022. In such an instance, CMS would allow Blue Cross of Idaho to offer plans under H1302 to beneficiaries during the CY 2022 AEP, which will be held between October 15, 2021, and December 7, 2021. In the event that the CY 2020 MLR report for H1302 again shows an MLR below 85%, enrollment under that contract will remain closed during CY 2022. Furthermore, CMS reminds Blue Cross of Idaho that if it fails to report an MLR of at least 85% for five consecutive years for H1302, CMS must terminate that contract.
The Social Security Act requires Medicare Advantage organizations to maintain a medical loss ratio (MLR) of at least 85%. The statute further provides, that when an organization fails for three consecutive years to meet the 85% threshold, CMS must suspend that organization’s ability to accept new enrollments in the plans it offers under the non-compliant contract for the contract year following submission of the report (i.e., the second contract year after the third consecutive year in which the organization failed to meet the minimum MLR).
Blue Cross of Idaho has reported to CMS the following MLRs for MA-PD contract H1302: 79.5% for CY 2017, 84.8% for CY 2018, and 82.9% for CY 2019. Based on this plan sponsor-reported information, CMS has determined that Blue Cross of Idaho has failed to meet the 85% MLR threshold for three consecutive years.
Read the CMS sanction notice: