Medicare Advantage now covers more than half of beneficiaries, but federal enforcement, mostly with relatively small penalties, may not be enough to ensure accountability across the rapidly expanding system, a new study finds.
Study: Federal Enforcement Action Against Medicare Advantage Plans. Image credit: dailyplus/Shutterstock.com
Recent research published in JAMA Internal Medicine Highlights opportunities to strengthen federal enforcement of private Medicare plans. The researchers analyzed enforcement actions in more than 1,100 contracts over 10 years and found that penalties vary from year to year and remain relatively modest.
Approximately 42% of contracts Cited at least once, Questions have been raised about whether current enforcement is strong and consistent enough to deter non-compliance and protect beneficiaries. this may be related to Patients navigate care decisions. Increasing these efforts could also help ensure safer and more reliable coverage for millions of older adults.
Medicare Advantage Oversight Faces Enforcement Questions
Enrollment in privately managed Medicare plans has grown rapidly and now covers more than half of those enrolled in Medicare and accounts for billions of dollars in government health spending each year. As these plans play an increasing role in care delivery, strong oversight remains essential, with regulators relying on audits, routine oversight, and enforcement actions to ensure compliance and protect enrollees.
However, questions remain about the scope, consistency, and intensity of these enforcement efforts. Previous reports have highlighted concerns such as access barriers, administrative burden, and potentially misleading marketing practices, but evidence regarding enforcement patterns remains limited. Addressing these gaps may help provide more effective monitoring and strengthen programs.
Investigate fines, suspensions, and dismissals with cross-sectional analysis
In this cross-sectional study, researchers analyzed enforcement actions issued by the Centers for Medicare and Medicaid Services (CMS) against Medicare Advantage contracts between 2010 and 2023. Using a new dataset obtained through a Freedom of Information Act request, they examined 1,173 health maintenance organization and preferred provider organization contracts and 844 enforcement actions. The team defined enforcement actions as civil monetary penalties, suspension of registration and marketing, and termination, and evaluated their frequency, distribution, and average amount per registrant. Data analysis was conducted between May 2025 and January 2026.
To enhance their analysis, researchers linked enforcement records with multiple CMS datasets including star ratings, plan benefit files, and beneficiary-level data. This approach allowed us to assess contract characteristics such as plan structure, premiums, and quality performance, along with enrollee demographics such as age, gender, race, ethnicity, and Medicaid dual eligibility. We also categorized referral sources such as program audits, financial audits, and complaints to better understand the causes of enforcement actions.
The team adjusted the penalties to 2023 values using the Consumer Price Index and assumed that the penalties would be distributed equally among contracts within the same organization. We then summarized trends over time, compared enforcement patterns across contract types, and assessed variation in enforcement actions across plan characteristics and beneficiary populations. This comprehensive framework allowed researchers to examine both the scale and context of regulatory enforcement in Medicare Advantage.
Coverage patterns vary depending on plan quality and enrollee demographics
The analysis found that most regulatory actions are monetary in nature, with civil penalties accounting for 87% of all actions and affecting 38% of contracts. In contrast, suspensions (12%) and terminations were rare. Overall, 42% of contracts received at least one enforcement action, while 58% received no enforcement action. This indicates that enforcement is concentrated in a subset of plans. Program audits serve as the primary trigger and are responsible for 65% of actions, highlighting their central role in identifying non-compliance.
Enforcement activities varied significantly over time and were often tailored to audit cycles, reflecting the cyclical structure of CMS program audits. Fines (calculated per registrant) dominated each year, reaching a high of approximately $6.50 in 2019, but remaining below $3.00 in all other years. Despite their frequency, the amounts of these penalties were limited, ranging from approximately $0.12 to a maximum of $6.50, and were small compared to overall plan returns reported in other analyses. Suspensions and firings are rare, but are usually related to more serious or persistent problems, such as poor quality ratings or financial instability. Notably, approximately one-fifth of contracts were subject to repeated enforcement, suggesting continued compliance challenges within specific plans.
Clear differences also emerged based on contract and registrant characteristics. Terminated contracts had the lowest quality ratings and lowest premium levels of all groups. These plans also enroll relatively high percentages of Hispanic beneficiaries. In contrast, suspended contracts had a higher proportion of individuals eligible for both Medicare and Medicaid and a higher proportion of black enrollees. Although these associations do not imply causation, they highlight important differences in the contexts in which coercion occurs.
Enhanced auditing and transparency can improve plan compliance
This study shows that Medicare Advantage plan enforcement has varied over time and relies primarily on modest penalties. As the program grows, these findings highlight opportunities to improve oversight in a more effective and forward-looking manner. Expanding program audits and recalibrating penalties could increase accountability without adding unnecessary burdens.
Greater transparency around enforcement actions and their incorporation into quality indicators could further promote compliance and support informed beneficiary decisions. Targeted approaches, such as risk-based audits and graduated sanctions for repeat violations, can improve overall plan responsiveness. Future research will be important to identify which oversight strategies most effectively promote compliance, improve quality of care, and ensure equitable protection of beneficiaries.
This study has some limitations. Enforcement datasets obtained through Freedom of Information Act requests may be incomplete or contain inaccuracies. Estimates of penalties can be inaccurate because penalties are not always accurately attributed to individual contracts. Additionally, some categories of enforcement actions were not captured in the dataset, and the study’s observational design means that the differences identified across contracts and populations cannot be interpreted as causal.
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Reference magazines:
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Chen, Z., Trivedi, A. N., Luke-Lee, H., Ma, J., and Myers, D. J. (2026). Federal enforcement actions against Medicare Advantage plans. JAMA Internal Medicine Toi:10.1001/jamainternmed.2026.1237. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2848051
