CMS plans to fine Health First Health Plans $43,546 for failing to properly administer Medicare’s Part D transition supply policy, according to an April 29 notice from the agency.
The insurer, part of the Rockledge, Fla.-based health system, had a systemic error in its claims adjudication system affecting enrollees who had a break in coverage and then re-enrolled. Under federal rules, Part D plans must provide a one-time temporary supply of medication to enrollees within their first 90 days under a new plan, even if the drug is subject to formulary restrictions or prior authorization requirements.
Health First’s system was applying enrollees’ prior enrollment effective dates rather than their most recent ones, so it didn’t recognize that returning enrollees were entitled to coverage. As a result, affected members either experienced delays, had to pay out of pocket, or didn’t receive their medications at all. CMS conducted its audit of the company’s Medicare operations June 9 to 20, 2025. Health First can appeal the fine until June 29.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
