CMS Enforcement Actions: What Two New CMPs Reveal About Operational Risk in Part D and PACE

Recent CMS enforcement actions related to Part D and PACE highlight a consistent and important trend: compliance risk is driven by how operations perform—not just how policies are written.

On April 29, 2026, the Centers for Medicare & Medicaid Services (CMS) issued two civil money penalties (CMPs) involving:

• Health First Health Plans (Part D formulary and benefit administration)

• Collabria Care (PACE program deficiencies)

  
  

While the penalty amounts are relatively modest, these findings provide clear insight into where CMS is focusing enforcement—and where plans and providers should be audit-ready.

CMS publishes ongoing enforcement activity, including recent actions, on its enforcement page: https://www.cms.gov/medicare/audits-compliance/part-c-d/part-c-and-part-d-enforcement-actions

Health First: Part D Operational Failures

CMS identified issues in formulary and benefit administration, specifically related to transition supply processing. System logic errors resulted in:

• Improper rejection of transition fills

• Delayed or denied access to medications

• Increased member cost burden

What this signals: Even minor system configuration issues can lead to systemic compliance failures—particularly in high-impact areas like pharmacy access and transition supplies.

Collabria Care: PACE Execution Gaps

CMS identified multiple deficiencies in Collabria Care’s PACE program, including:

• Failure to deliver approved services as scheduled

• Gaps in tracking participants across care settings

• IDT recommendations not consistently implemented

• Medication timing issues

• Delays in scheduling services

Why this matters: PACE compliance depends on care coordination and execution. CMS expects organizations to demonstrate that care decisions are implemented, tracked, and documented in a timely manner.

CMS Enforcement Actions: Key Themes for Part D and PACE

Across both cases, CMS enforcement actions reinforce three critical themes:

1. Execution Matters More Than Policy

CMS is evaluating whether compliance programs work in practice—across systems, workflows, and vendors—not just on paper.

2. Data, Monitoring, and Follow-Through Are Critical

Organizations must demonstrate:

• Accurate system performance

• Effective tracking and escalation

• Consistent follow-through on required actions

  
  

3. Member Impact Drives Enforcement

Delays in care, medication access issues, and service gaps—especially for vulnerable populations—remain top enforcement priorities.

What Plans and Providers Should Do Now

These CMS enforcement actions present a clear opportunity to reassess risk:

Part D Sponsors

• Validate transition supply logic across enrollment scenarios

• Test claims adjudication and system configurations

• Review formulary and benefit administration processes

PACE Organizations

• Strengthen IDT documentation-to-execution workflows

• Improve service tracking and coordination across settings

• Monitor timeliness of care delivery and medication administration

All Organizations

• Conduct mock audits aligned to CMS protocols

• Use data to validate operational performance—not just policy design

• Identify and address “silent failures” proactively

How Rebellis Can Help

At Rebellis, we work with plans and providers to strengthen audit readiness and compliance program effectiveness in today’s enforcement environment.

Our approach includes:

• Compliance Program Effectiveness (CPE) audits

• Mock audits aligned to CMS expectations

• Targeted material and operational reviews

We focus on testing how compliance performs in real-world scenarios—helping organizations identify gaps before they become enforcement findings.

Pharmacy & Part D Support

For Part D sponsors, these CMS enforcement actions also highlight the importance of:

• Transition supply accuracy

• Claims adjudication and system logic

• Formulary and benefit administration controls

Rebellis provides pharmacy-focused compliance support to validate these high-risk areas and ensure alignment with CMS requirements.

Bottom Line

These recent CMS enforcement actions make one thing clear: Compliance programs must be operationally effective—not just well-designed.

Now is the time to test, validate, and strengthen execution—before CMS does.

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