CMS has issued more than two dozen fines against Medicare Advantage, Part D and special needs plans since January 2025, largely because of inadequate benefits administration or claims processing errors that caused enrollees to overpay for medical services and prescription drugs.
Five recent Medicare fining events from CMS:
1. In May, CMS fined 13 health plans a combined $1.5 million for MA and Part D violations related to cost-sharing rules and claims processing errors.
2. In April, CMS fined a Providence PACE organization (formerly Collabria Care) $48,833 for service delivery failures at the Napa, Calif.-based organization, and Health First Health Plans $43,546 for failures to properly administer Medicare’s Part D transition supply policy.
3. In April 2025, three PACE organizations were each fined $47,596 for failing to meet essential program requirements, including inadequate service provision, poor tracking and documentation of services, and failure to ensure recommended services were either provided or properly documented with valid reasons for non-provision.
4. In April 2025, CMS fined seven health plans a total of $434,652 for Part D violations related to formulary and benefit administration, and coverage determinations and appeals processes, which the agency said caused delayed medication access and improper denials.
5. In January 2025, CMS fined seven plans a combined $2.49 million for Part C and Part D violations related to out-of-pocket limits, cost-sharing and low-income subsidy requirements. Violations stemmed from 2021 plan year conduct, with audits conducted throughout 2023.
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