Part C and Part D Enforcement Measures
CMS possesses the power to initiate enforcement measures or contractual actions in cases where it finds that a Medicare Plan Sponsor:
- Significantly breaches program and/or contract obligations,
- Operates its CMS contract in a manner incongruent with the efficient and effective management of Medicare Part C and Part D program stipulations, or
- Ceases to substantially adhere to the pertinent conditions of the Medicare Part C and D program.
Enforcement and contractual actions may involve:
- Imposition of civil money penalties (CMP)
- Implementation of intermediate sanctions (such as marketing, enrollment, or payment suspension), and
- Contract terminations.
Navigating the complex landscape of Medicare plans can be daunting, especially when it comes to understanding enforcement actions related to Medicare Part C and Part D. These actions, designed to ensure compliance and protect beneficiaries, can significantly impact plan availability and accessibility.
In this article, we delve into the intricacies of Medicare Part C & Part D Enforcement Actions, providing clarity on how these actions affect plan information, enrollment options, and search results within the Medicare Plan Finder (MPF). Whether you’re a Medicare beneficiary, a State Health Insurance Assistance Program (SHIP) counselor, or simply someone seeking to understand these critical aspects of Medicare administration, this guide aims to equip you with the knowledge needed to navigate Medicare enrollment with confidence and understanding.
Here’s a breakdown of the various features related to Medicare Part C & Part D enforcement actions, intended to assist SHIP counselors and other Medicare helpers in explaining these actions within the Medicare Plan Finder (MPF):
1. Identification of Plan Status
- Suppressed Information – Indicates if a plan’s details are being withheld.
- Sanctioned Plan – Indicates if a plan is under a sanction that prohibits marketing activities and/or enrollment.
2. Displayed Values
- All values under question (e.g., drug pricing, plan benefits, star ratings) will appear as “N/A”.
- For drugs not covered, the default or pharmacy cash price will be displayed.
3. User Experience for Current Enrollees
- Current enrollees will continue to view their plans normally.
- The plan displays as usual in Plan Finder search results.
4. Enrollment Actions
- The enrollment button is disabled and replaced with a message prompting users to contact the plan for enrollment.
- Sanctioned plans are not visible in Plan Finder search results.
5. Sanctioned Plan Details
- A link to sanctioned plans will be available at the bottom of the search results page.
- Sanctioned plan results will only show plan contact information and links to sanction letters.
6. Excluded Plans
Excluded plans do not appear in Plan Finder search results.
Understanding Plan Suppression and Sanctions in Medicare Plan Finder (MPF)
When enforcement actions are in place, they affect how plans are displayed in the Medicare Plan Finder (MPF). Here’s how different enforcement statuses impact the information available to users:
🔶 Suppressed Plan Data
Certain plan values such as drug pricing, benefit details, or star ratings will appear as “N/A”.
If a drug is not covered, default pharmacy cash prices will be displayed instead.
Despite the suppression, the plan may still appear in search results, but key information is limited.
Enrollment is disabled, and users will see a message saying, “Contact plan to enroll.”
Current enrollees will continue to see this as their plan in MPF.
🔶 Marketing & Enrollment Sanctions
Plans that are under marketing sanctions are removed from MPF search results.
A link at the bottom of the results page will redirect users to a list of sanctioned plans.
Sanctioned plan listings will not show plan details—only contact info and links to CMS sanction letters.
Enrollment is not allowed for these plans while sanctions are active.
Current members are unaffected and will continue to see their plan in their MPF profile.
🔶 Excluded Plans
Plans that are excluded due to serious violations or compliance failures will not appear at all in MPF results.
These are not available for new enrollment under any circumstances while excluded.
What This Means for People With Medicare
If you or someone you assist notices missing plan data or receives a message about contacting the plan directly, this could indicate an enforcement action is in effect. Here’s what you should do:
Don’t panic. Current coverage continues unaffected unless notified otherwise.
Check for other plan options if enrollment is blocked.
Review CMS Sanction Letters linked from the MPF to understand the nature of the issue.
Consult a licensed agent or SHIP counselor for help finding compliant plans that meet your needs.
In Summary
Understanding Medicare Part C and Part D Enforcement Actions is crucial for beneficiaries navigating the complexities of Medicare plans. The enforcement measures outlined by CMS serve to maintain program integrity and protect beneficiaries’ interests. Through the imposition of civil money penalties, intermediate sanctions, or even contract terminations, CMS ensures compliance with program obligations.
This guide aims to shed light on how these enforcement actions impact plan availability and accessibility, providing clarity for Medicare beneficiaries, SHIP counselors, and anyone seeking to understand Medicare administration. By familiarizing oneself with the identification of plan status, suppressed information, and sanctioned plan details within the Medicare Plan Finder, individuals can navigate enrollment confidently, armed with the knowledge needed to make informed decisions.
DISCLAIMER: Please verify the information provided here with the primary source to ensure accuracy. We strive to present information correctly. It is advisable to confirm details directly from the primary source for accuracy and reliability.
