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What CMS’ 2024 Audit Report Means for Medicare Advantage & Part D Plans — And How to Prepare Now

CMS’ 2024 Part C & Part D Program Audit and Enforcement Report is out—and it’s full of critical insights every Medicare Advantage (MA) and Part D sponsor should be watching closely.


Covering 39 program audits across 494 contracts, the report spans nearly 88% of the MA population and almost 70% of all Medicare beneficiaries. With 19 full-scope and 20 focused audits, CMS’ oversight is more expansive—and targeted—than ever.


Key Takeaways for Health Plans:


1. First Year Look at New Utilization Management (UM) Rules-CMS evaluated MA plans’ compliance with the new UM requirements under CMS-4201-F. While initial findings showed general compliance, CMS cautioned against broad conclusions due to the early implementation stage.

2. Recurring Compliance Failures-CMS identified familiar trouble spots, including:

  • Formulary Administration – Denials due to unapproved edits or eligibility issues.

  • Coverage Determinations (CDAG/ODAG) – Misclassified requests and system misconfigurations.

  • Care Coordination (SNPCC/MMPCC) – Missing links between health risk assessments (HRAs) and individualized care plans.

3. Civil Money Penalties (CMPs)-CMS issued 14 CMPs totaling $2.9 million, with notable plans including Molina, Centene, Humana, and Elevance. Violations ranged from inappropriate cost-sharing to misclassified Part D requests.

4. Intermediate Sanctions-Plans were sanctioned for failing to meet Medical Loss Ratio (MLR) and D-SNP integration requirements. Consequences included enrollment suspensions—a major growth barrier.

5. CMS Enforcement Focus - Plans were reminded of their obligation to:

  • Correct eligibility file errors

  • Issue timely and complete refunds

  • Oversee delegated entities

  • Monitor MOOP limits and PDE record accuracy


What’s Next?

With CMS expanding its audit scope and sharpening enforcement, health plans must take a proactive stance—especially ahead of the next audit cycle.


Let’s talk about how Rebellis Group can help you strengthen compliance, avoid penalties, and stay audit ready.


 
 
 
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