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Medicare Suspends Marketing and Enrollment for Fox Insurance Program Drug Plan

Posted Mar 01 2010 5:31pm

This is interesting from reading the press release as it states patients were not getting their drugs on time or having other issues and imposing therapy image authorization requirements not approved by CMS, and missing appeals deadlines.  Authorization requirements sounds like some additional algorithmic formulas were used here to “score” patients, as well all know that happens today with computer formulas. 

Are We Ever Going to Get Some Algorithm Centric Laws Passed for Healthcare!

The map below shows in which states they operate.  I assume current enrollees are fine, but nobody new can be enrolled for the Part D Drug Plan.  BD

Press Release:

The Centers for Medicare & Medicaid Services (CMS) today directed Fox Insurance Company of New York to immediately suspend marketing and enrollment of new members in the organization’s Medicare Part D prescription drug plans. CMS imposed this immediate sanction because the Fox drug plan has not been able to meet the prescription drug needs of some of its newest members, actions which could pose serious threats to their health and safety.

These beneficiaries, many of whom qualify for the low-income subsidy under Part D, are primarily located in 21 states.

“Current Fox drug plan members who are having difficulty in getting their prescriptions filled should contact 1-800-MEDICARE or their local state health insurance assistance program for help,” said Jonathan Blum, acting director of CMS’ Center for Drug and Health Plan Choices.

The plan has failed to fully meet its obligations to Medicare beneficiaries, particularly new enrollees, by failing to provide timely access to Part D drugs by imposing prior authorization and step therapy requirements that were not approved by CMS, not meeting the necessary appeals deadlines, and not meeting the requirements to transition new enrollees to the covered drugs.

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These failures could result in improper delays in therapies and/or preventing access to medically necessary drugs and therapies. Threats to enrollee health and safety relate to Fox’s non-Medicare compliant coverage determinations involving protected class drugs and other needed drugs for the treatment of cancer, HIV/AIDS and seizure disorders; as well as drugs for diabetes and respiratory disease.

Fox’ problems were raised to CMS by both plan members and their physicians. CMS will closely monitor the plan to determine that corrective actions have been taken.   If Fox is not in compliance to Medicare requirements, penalties that range from fines to the possibility of termination of the Fox contract with Medicare could be imposed.

CMS encourages plan members who may have concerns with their Part D coverage to contact 1-800-MEDICARE (1-800-633-4227) or the state health insurance assistance program (SHIP) to help get them resolved.

NOTE:   The Fox plan is available in:  Arkansas, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Louisiana, Maryland, Missouri, North Carolina, New Jersey, New York, Nevada, Ohio, Pennsylvania, South Carolina, Texas and West Virginia.

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