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CMS Notice of Enrollment Suspension for Medicare AdvantagePrescription Drug Contract Number H4005 - Triple-S Advantage

Category: Medicare Plan Providers
Published on 2021-09-03 13:25:03

On September 2, 2021, the Centers for Medicare & Medicaid Services (CMS) provided notice to Triple-S Advantage, Inc. (“Triple-S”) that CMS has made a determination to prohibit the enrollment of new beneficiaries under the Medicare AdvantagePrescription Drug (MA-PD) contract H4005 for contract year (CY) 2022.

As a result of this determination, Triple-S will be prohibited from accepting any MA-PD plan enrollments for 2022; this prohibition is effective for any enrollments beginning January 1, 2022, through December 1, 2022. This action will include the removal of H4005 from the list of MAPD plans from which beneficiaries may make an election during the CY 2022 Annual Election Period (AEP), which runs between October 15, 2021, and December 7, 2021. However, Triple-S may continue to accept and process enrollments that become effective on or before December 1, 2021.

During CY 2022, all individual market plans offered under H4005 will be precluded from accepting any new enrollees, including those beneficiaries already enrolled in a Triple-S MA-PD plan who may want to elect a different plan offered under the same contract. Pursuant to sections 1857(i) and 1860D-22(b) of the Act, if Triple-S has employer group plans, it may apply for an employer group waiver in order to continue to enroll members into their existing employer group plans, although CMS will not permit Triple-S to add new employer group plans to contract H4005 for CY 2022.

Triple-S must ensure that its marketing and communications materials and activities are not misleading to beneficiaries, and therefore must accurately reflect the fact that the plans under H4005 are not available for enrollment during 2022. Enforcement actions, as described in 42 C.F.R. Parts 422 and 423 Subparts K and O, may be imposed if CMS finds that Triple-S has engaged in activities that could mislead or confuse Medicare beneficiaries or misrepresent the plan. See 42 C.F.R.§§ 422.2262 and 423.2262.

If Triple-S submits a CY 2021 report in 2022 for H4005 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, 2023. In such an instance, CMS would allow Triple-S to offer plans under H4005 to beneficiaries during the CY 2023 AEP, which will be held between October 15, 2022, and December 7, 2022. In the event that the CY 2021 MLR report for H4005 again shows an MLR below 85%, enrollment under that contract will remain closed during CY 2023. Furthermore, CMS reminds Triple-S that if it fails to report an MLR of at least 85% for five consecutive years for H4005, 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).

Read the CMS sanction notice:

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