NEW! CMS Enforcement Actions – April 2025 Update

In April 2025, the Centers for Medicare & Medicaid Services (CMS) issued a significant round of enforcement actions impacting a wide range of Medicare Advantage (MA), Prescription Drug (Part D), and Program of All-Inclusive Care for the Elderly (PACE) organizations. A total of 11 plans were sanctioned, including 10 civil monetary penalties (CMPs) and one enrollment suspension.

These enforcement actions signal CMS’ continued push for higher standards in compliance, service delivery, and operational integrity.

Key Themes from April’s Enforcement Actions

1. Formulary and Benefits Administration Deficiencies Five organizations were penalized for issues tied to formulary management, including benefit design flaws, drug coverage inconsistencies, and system configuration errors. These findings highlight ongoing challenges in ensuring members receive timely and accurate access to covered medications.

2. PACE Program Integrity Concerns Three PACE organizations were sanctioned for failing to deliver core services or maintain adequate documentation. CMS is clearly increasing its oversight of PACE programs, focusing on service delivery, transparency, and documentation rigor.

3. CDAG (Coverage Determinations, Appeals & Grievances) Failures Several plans were cited for deficiencies in handling prior authorizations and appeals. CMS identified problems with timeliness, notification accuracy, and denial justification—areas that have become frequent drivers of enforcement.

4. Administrative and Oversight Weaknesses Breakdowns in contract oversight, compliance program execution, and systemic administration errors in Parts C and D led to additional citations. Plans are expected to maintain robust, proactive governance over internal and delegated entities.

5. Financial Solvency The enrollment suspension issued to Eternal Health highlights CMS’s ongoing expectation that sponsors demonstrate financial stability and meet both federal and state solvency requirements.

A Clear Message: Compliance Shortcomings Will Be Penalized

CMS is sending a strong and consistent message: recurring compliance failures—particularly those related to drug coverage, appeals, and service delivery—will not be tolerated. These April enforcement actions should serve as both a warning and a compliance checklist for all plan sponsors.

Now Is the Time for Proactive Compliance

If your organization needs help reviewing processes, identifying gaps, or building a stronger compliance program, we’re here to support you.

Don’t wait for CMS to come knocking—reach out to us today.