Summit County’s largest Medicare managed-care plan is in trouble with the federal government for mishandling consumer appeals and grievances.
The Centers for Medicare and Medicaid Services (CMS) suspended all new enrollment and marketing for SummaCare Inc.’s Medicare managed-care plans this week because of “multiple, serious violations.”
In a 10-page letter to the Akron-based insurer, CMS indicated that the violations “resulted in enrollees experiencing delays or denials and increased out-of-pocket costs for medical services and prescription drugs.”
“These failures pose a serious threat to the health and safety of enrollees,” concluded CMS, the federal agency that oversees Medicare.
The sanctions resulted from a routine CMS audit of SummaCare’s Medicare operations from June 2 to June 13.
SummaCare’s Medicare managed-care plans enroll about 16,500 Summit County residents and more than 33,000 in 41 counties in the northern half of Ohio.
CMS said the federal action does not affect coverage or benefits for current enrollees. SummaCare, however, is required to notify all enrollees about the sanction.
Enrollees directly affected by the problems that prompted the sanctions against SummaCare might be eligible for a special election period to switch to another plan, CMS said.
Except in special circumstances, consumers typically can’t switch plans until the annual open enrollment period, Oct. 15 through Dec. 7.
“CMS is being vigilant in making sure that beneficiaries receive the benefits they have earned and deserve,” spokeswoman Elizabeth Schinderle said Friday. “CMS is taking action against an insurance company that delayed or denied beneficiaries’ access to prescription drugs and Medicare-covered services and inappropriately charged additional costs for Medicare-covered services and prescription drugs.”
SummaCare has been one of the highest rated plans on Medicare’s quality rating scale, earning 4.5 out of five stars. The rating system considers patient experience and complaints, as well as drug pricing and patient safety for the prescription drug plans and efforts to manage chronic illnesses and promote preventive care for the managed-care plans.
Robert Thomas, 66, of Akron, was surprised to hear SummaCare is having problems.
Thomas said he never has had difficulties getting his medications or medical care for his kidney failure covered while he has been enrolled in a SummaCare Medicare managed-care plan for more than a decade.
“I like them,” he said. “I’ve never had any problems.”
The federal government said many of the current issues stem from “ineffective monitoring and oversight” by SummaCare of its pharmacy benefits manager, which is responsible for determining whether the plan covers prescription drugs. The Centers for Medicare and Medicaid Services also blamed the violations on SummaCare’s “lack of internal controls and consistent procedures,” resulting in a breakdown of the proper processes for reviewing appeals.
A total of 38 violations related to coverage determination and appeals were discovered. Problems ranged from failing to fully investigate consumer grievances to not including adequate reasons in letters denying coverage of prescription drugs.
SummaCare has until Monday to submit a plan to CMS to correct the problems.
The insurer then is required to hire an independent auditor to confirm the corrective action plan is being followed before the Medicare program will consider lifting the enrollment and marketing bans.
SummaCare also has the option of providing a written rebuttal to the allegations by Thursday or requesting a hearing to review the case.
Insurer pledges changes
In a prepared statement, SummaCare Chief Executive Marty Hauser said the insurer already has started corrective actions.
“We are obviously extremely disappointed in the results of the recent CMS audit,” he said. “We pledge to our valued members that we will resolve any and all deficiencies cited by CMS. ... CMS has consistently recognized SummaCare as one of the top-performing plans in the country, so while these sanctions at this time are certainly concerning, they’re also correctable.”
SummaCare’s Medicare plans combine optional Part C coverage that provides help paying for doctor visits, hospital stays and other medical services with Part D benefits that cover prescription drugs.
These plans are available to everyone covered by Medicare, the federal health insurance program for people 65 and older and some younger disabled Americans.
The federal government contracts with private insurance companies to provide drug and/or medical coverage to Medicare recipients who sign up for the plans. Everyone but the poorest enrollees pays a portion of the monthly premium if one is charged to consumers; the government picks up the rest of the cost.
The Medicare plans are separate from SummaCare’s commercial plans offered through employers and individual plans sold through the federal health insurance marketplace or brokers.
Consumers with questions can call the Medicare program at 1-800-633-4227 or SummaCare at 330-996-8885.
Cheryl Powell can be reached at 330-996-3902 or cpowell@thebeaconjournal.com. Follow Powell on Twitter at twitter.com/CherylPowellABJ.