CMS issued nearly $2.5 million in fines on Jan. 17 across multiple health plans for Medicare contract violations related to Part C maximum out-of-pocket limits and cost-sharing requirements, and Part D coordination of benefits and low-income subsidy requirements.
All the reported issues occurred in 2021, and audits took place throughout 2023. Civil money penalties have been imposed to address these deficiencies, and the plans were required to refund affected members. Insurers can request a hearing to appeal the fines. Further noncompliance could lead to stricter enforcement actions, including contract termination.
Seven fines:
- Centene was fined $2 million for violating Part C requirements by charging enrollees more than the annual maximum out-of-pocket limits, potentially increasing their financial burden.
- Elevance Health was fined $149,060 for failing to comply with Part C requirements by overcharging enrollees for medical services and exceeding maximum out-of-pocket limits, potentially increasing enrollees' financial burden.
- Health Alliance Medical Plans and its parent, Carle Health, were fined $101,500 for violating Part C requirements by charging enrollees more than the annual maximum out-of-pocket limits, potentially increasing their financial burden.
- Humana was fined $99,064 for violating Medicare Part D requirements by failing to reprocess prescription drug claims based on enrollees' low-income subsidy levels within the required timeframe, potentially increasing their out-of-pocket costs.
- Molina Healthcare was fined $67,976 for failing to reprocess Part D prescription drug claims based on enrollees' low-income subsidy levels within 45 days and for charging Part C enrollees more than the maximum out-of-pocket limits, potentially increasing their out-of-pocket costs.
- Baylor Scott & White's health plan was fined $37,816 for violating Medicare Part C requirements by overcharging enrollees for medical services and exceeding maximum out-of-pocket limits, potentially increasing their financial burden.
- Medco Containment Life, a Cigna subsidiary, was fined $32,364 for violating Part D requirements by failing to reprocess prescription drug claims based on enrollees' low-income subsidy levels within the required timeframe, potentially increasing enrollees' out-of-pocket costs.