News Briefs: CMS Halts Enrollment in eternalHealth, Fines 10 Other Organizations

Apr 17
Apr 17, 2025

Via a slew of program audit notices issued this month, CMS placed Medicare Advantage startup eternalHealth, Inc. on an enrollment freeze and said it intends to fine 10 other organizations for program violations such as inappropriately rejecting covered Part D medications. Molina Healthcare, Inc. was asked to pay the largest of penalties, $285,000, after a program audit found the insurer did not properly administer Part D formulary and benefits to enrollees in contract H5649. According to an April 1 letter to the insurer, CMS found that “programming errors” resulted in inaccurate eligibility files sent to Molina’s PBM, which then inappropriately voided enrollees’ active coverage and rejected claims for enrollees who were still covered. The agency noted that such failures result in delayed access to medications, unnecessary out-of-pocket costs for medications, or beneficiaries never receiving medications. CMS is also seeking a civil monetary penalty of more than $20,000 from Centene Corp. for its failure to comply with Part D Coverage Determinations, Appeals, and Grievances, and a penalty of nearly $56,000 from Point32Health for Part D program violations in the areas of CDAG and formulary and benefits administration. The agency also issued penalty notices to three providers of Programs of All-Inclusive Care for the Elderly. Meanwhile, CMS informed Boston-based eternalHealth that it must stop enrolling and marketing to Medicare beneficiaries, mirroring a separate order from the Massachusetts Office of Consumer Affairs and Business Regulations after the insurer failed to meet state financial solvency requirements.
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Lauren Flynn Kelly

Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.