Enforcement gaps in Medicare Advantage raise questions about plan accountability

By Pooja Toshniwal PahariaReviewed by Lauren HardakerMay 7 2026

As Medicare Advantage now covers more than half of beneficiaries, new research reveals that federal enforcement, dominated by relatively small financial penalties, may be falling short of ensuring accountability across a rapidly expanding system. 

Study: Federal Enforcement Actions Against Medicare Advantage Plans. Image credit: everydayplus/Shutterstock.com

A recent study published in JAMA Internal Medicine highlights opportunities to strengthen federal enforcement of private Medicare plans. Researchers analyzed more than a decade of enforcement actions across more than 1,100 contracts and found that penalties varied year to year and remained relatively modest.

About 42 % of contracts were cited at least once, raising questions about whether current enforcement is strong and consistent enough to deter nonadherence and protect beneficiaries. This may be relevant to patients navigating care decisions. Strengthening these efforts could also help ensure safer, more reliable coverage for millions of older adults.

Medicare Advantage oversight faces questions on enforcement strength

Enrollment in privately administered Medicare plans has grown rapidly, now covering over half of the people enrolled in Medicare and accounting for billions in government healthcare spending each year. As these plans play a growing role in care delivery, strong oversight remains essential, with regulators relying on audits, routine monitoring, and enforcement actions to ensure compliance and protect enrollees.

However, questions remain about the scope, consistency, and strength of these enforcement efforts. While prior reports have highlighted concerns such as access barriers, administrative burden, and potentially misleading marketing practices, evidence on enforcement patterns remains limited. Addressing these gaps could help inform more effective oversight and strengthen the program.

Cross-sectional analysis examines penalties, suspensions, and terminations

In this cross-sectional study, researchers analyzed enforcement actions issued by the Centers for Medicare & Medicaid Services (CMS) against Medicare Advantage contracts between 2010 and 2023. They examined 1,173 health maintenance organization and preferred provider organization contracts alongside 844 enforcement actions, drawing on a novel dataset obtained through a Freedom of Information Act request. The team defined enforcement actions as civil monetary penalties, enrollment and marketing suspensions, and contract terminations, and evaluated their frequency, distribution, and average monetary value per enrollee. Data analysis was conducted between May 2025 and January 2026.

To strengthen the analysis, researchers linked enforcement records with multiple CMS datasets, including star ratings, plan benefit files, and beneficiary-level data. This approach enabled them to assess contract characteristics, such as plan structure, premiums, and quality performance, alongside enrollee demographics, including age, sex, race, and ethnicity, and dual eligibility for Medicaid. They also categorized referral sources, such as program audits, financial audits, and grievances, to better understand the origins of enforcement actions.

The team adjusted monetary penalties to 2023 values using the Consumer Price Index and assumed equal distribution of penalties across contracts within the same organization. They then summarized trends over time, compared enforcement patterns across contract types, and evaluated variation in enforcement actions across plan characteristics and beneficiary populations. This comprehensive framework allowed the researchers to examine both the scale and context of regulatory enforcement in Medicare Advantage.

Enforcement patterns vary by plan quality and enrollee demographics

The analysis showed that most regulatory measures were financial in nature, with civil monetary penalties accounting for 87 % of all actions and affecting 38 % of contracts. In contrast, enrollment suspensions (12 %) and contract terminations were uncommon. Overall, 42 % of contracts received at least one enforcement action, while 58 % had none, indicating that enforcement was concentrated among a subset of plans. Program audits served as the primary trigger, responsible for 65 % of actions, underscoring their central role in identifying nonadherence.

Enforcement activity fluctuated considerably over time and often aligned with audit cycles, reflecting the cyclical structure of CMS program audits. Monetary penalties (calculated per enrollee) dominated each year, reaching their highest level in 2019 at roughly $6.50 and staying below $3.00 in all other years. Despite their frequency, the size of these penalties remained limited, varying from about $0.12 up to $6.50, and were small relative to overall plan revenues reported in other analyses. Suspensions and terminations were rare but typically linked to more serious or persistent issues, such as low-quality ratings or financial instability. Notably, about one-fifth of contracts experienced repeated enforcement actions, suggesting ongoing compliance challenges within certain plans.

Clear differences also emerged across contract and enrollee characteristics. Terminated contracts showed the lowest quality ratings and the lowest premium levels among all groups. These plans also enrolled a relatively higher proportion of Hispanic beneficiaries. In contrast, suspended contracts had a larger share of individuals eligible for both Medicare and Medicaid and a higher proportion of Black enrollees. These associations do not imply causation but highlight important differences in the contexts in which enforcement occurs.

Stronger audits and transparency could improve plan compliance

The study shows that enforcement of Medicare Advantage plans has varied over time and relied largely on modest financial penalties. As the program grows, these findings highlight an opportunity to refine oversight in more effective, forward-looking ways. Expanding program audits and recalibrating penalties could strengthen accountability without adding unnecessary burden.

Greater transparency around enforcement actions and their inclusion in quality metrics may further encourage compliance and support informed beneficiary decisions. Targeted approaches, such as risk-based audits and graduated sanctions for repeat violations, could improve responsiveness across plans. Future research will be important to identify which oversight strategies most effectively promote compliance, improve care quality, and ensure equitable protection for beneficiaries.

The study has several limitations. The enforcement dataset, obtained through a Freedom of Information Act request, may be incomplete or contain inaccuracies. Monetary penalty estimates may be imprecise because penalties could not always be attributed exactly to individual contracts. In addition, some categories of enforcement actions were not captured in the dataset, and the study’s observational design means that identified differences across contracts and populations cannot be interpreted as causal.

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