Slide 1: CMS’s Oversight of Medicare Health Plans

April 9, 2024

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Note: this slide and all slides going forward include a logo of a “CMS” graphic with “CENTERS FOR MEIDCARE & MEDICAID SERVICES” under it.
Slide 2: Medicare Oversight and Enforcement Group (MOEG)
•	Part of the Centers for Medicare & Medicaid Services
•	Audits Medicare health plans to make sure beneficiaries receive items, services, and prescription drugs.
•	Penalizes Medicare health plans that violate Medicare’s rules.

Note: the following footnote appears on this slide and all slides going forward. INFORMATION NOT RELEASEABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may contain confidential and privileged information or otherwise protected by law. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Any unauthorized review, use, disclosure or distribution is prohibited and may result in prosecution to the full extent of the law.
Slide 3: CMS Audits Plans
•	Audits determine if Medicare health plans are:
o	Planning Care
o	Providing Access to Care
•	Includes reviewing prior authorization.
o	Coordinating Care
Slide 4: CMS Requires Plans to Fix Problems
•	Plans and CMS create a workplan to fix problems.
•	Plans work on the problems in the workplan.
•	CMS monitors plans’ progress
•	Plans are re-audited to make sure the problems are fixed.
•	Plans continue working on the problems if they aren’t fixed.
•	CMS is satisfied when the re-audits show the problems are fixed.
Slide 5: CMS can Penalize Plans
•	CMS can penalize plans that delay or do not provide care to beneficiaries.
•	Penalties include:
o	Financial Penalties
•	Can be large when many beneficiaries are impacted.
o	Stopping Enrollment
•	Until the problems are corrected
o	Terminating a Plan’s Contract