In this episode, Sandy and Elizabeth break down the latest CMS updates shaping the Medicare Advantage landscape, diving into the Advance Notice, RADV audit enforcement, emerging enrollment trends, and sweeping Special Needs Plan (SNP) regulatory changes.

We unpack CMS’s recent memo outlining its refined RADV audit strategy, including expanded audit cadence, updated sampling methodologies, extended medical record submission timelines, and the agency’s approach to balancing accelerated oversight with operational realities for plans and providers.

The conversation then turns to Medicare Advantage enrollment trends, including signs of market flattening, the expansion of SNPs, and potential shifts toward Medigap coverage.

Finally, we explore major policy developments affecting D-SNPs, C-SNPs, and I-SNPs, with a focus on CMS’s push toward deeper Medicare–Medicaid integration for dually eligible beneficiaries.

Whether you’re a health plan executive, legal or compliance professional, policy analyst, or advisor, this episode provides timely insights into where CMS is headed—and what these changes mean for strategy, operations, and risk in the year ahead.

In our Year in Review episode, hosts Elizabeth Lippincott and Sandy Durkin distill a turbulent 2025 into the developments that mattered most for Medicare Plans.

You’ll hear a clear breakdown of the year’s biggest compliance and enforcement stories—from DOJ’s kickback allegations against major MA players to CMS’s aggressive expansion of RADV audits, followed by a late‑year court decision that vacated CMS’s extrapolation rule on procedural grounds. We also cover regulatory highlights and the operational realities behind plan exits and non‑renewals, including run‑out obligations and audit exposure that linger long after a contract ends.

The episode closes with what leaders should do now: tighten documentation and vendor oversight, align risk adjustment with care management, and prepare for continued regulatory scrutiny—because stability comes from readiness, not predictability.

In this episode of Health Law Simplified, hosts Sandy and Elizabeth unpack a pivotal federal court ruling that vacates a key CMS rule governing RADV audits in Medicare Advantage. Learn why the court struck down CMS’s extrapolation methodology and elimination of the Fee-for-Service Adjuster, and what this means for MA plans, compliance teams, and future rulemaking. We explore the procedural missteps that led to the ruling, its alignment with broader judicial scrutiny of CMS, and the potential ripple effects across the industry. Plus, hear practical insights on how MA organizations can respond and prepare for what’s next.

This episode of Health Law Simplified explores the recent wave of insurer exits from the Medicare Advantage market, examining why major carriers are leaving and the financial, regulatory, and operational challenges involved. Sandy and Elizabeth discuss the strategic consequences of non-renewal, including CMS contracting bars, notification requirements, run-out responsibilities, audits, and legal risks, while offering practical advice for organizations considering an exit and highlighting the impact on employees, members, and the broader healthcare landscape.

In this episode of Health Law Simplified, hosts Sandy Durkin and Elizabeth Lippincott welcome Charles Baker, Vice President of Compliance Solutions at ATTAC Consulting, for a deep dive into the evolving landscape of Medicare Advantage compliance. From the operational impact of RADV audits and the philosophical roots of risk adjustment to the implications of the No UPCODE Act and the future of in-home HRA assessments, Charles shares his unique perspective shaped by years in social work, academia, and health plan leadership. Tune in for a candid conversation on how managed care organizations can align regulatory demands with meaningful patient care.

In this episode of Health Law Simplified, we unpack a major shift in Medicare Advantage oversight: CMS’s sweeping expansion of its Risk Adjustment Data Validation (RADV) audit program. Beginning immediately, CMS will significantly expand its oversight by auditing all 550 eligible Medicare Advantage contracts each year – an ambitious leap from the previous annual review of just 60 plans. Hosts Sandy Durkin and Elizabeth Lippincott explore why CMS is cracking down, how it's scaling up with new technology and a 50-fold increase in medical coders, and what this means for health plans and providers. They break down the legal and financial implications of extrapolated audit findings, including the risk of large recoupments, and talk about their expectations for the extrapolation methodology for targeted audits.  This episode offers critical insights and practical steps to prepare for one of the most consequential oversight changes Medicare Advantage plans have seen.

This episode of Health Law Simplified unpacks the U.S. Department of Justice’s False Claims Act lawsuit against major Medicare Advantage insurers and brokerages. The DOJ alleges illegal kickbacks and discriminatory practices targeting disabled beneficiaries. The episode also explores CMS’s 2025 Final Rule on broker compensation, its legal challenges, and the broader implications for compliance, marketing ethics, and regulatory enforcement in the Medicare Advantage space.

In this episode, Elizabeth and Sandy delve into the latest updates in the Medicare Advantage and Part D landscape. Our word of the year, "stability," sets the tone as we explore the implications of the CMS final rule for 2026, which finalizes several Biden-era proposals. We discuss the key changes in the rule, including new guardrails for supplemental benefits and the Medicare Prescription Payment Plan, and highlight what was notably left out of the rule. Additionally, we cover the CMS rate announcement and the rebranding of the health equity incentive program to "Excellent Health Outcomes for All (EHO4all)," set to be implemented for the 2027 Star Ratings. Lastly, we examine the recent developments in the risk adjustment litigation against UnitedHealth Group, focusing on the special master's report and its potential impact on MA plans.

We talk with Molly Turco, who served as Senior Policy Advisor on Medicare Advantage (MA) and Medicare Part D at the Center for Medicare at the Centers for Medicare & Medicaid Services until leaving the agency in January. Molly unpacks updates in MA policy and reimbursement, including the v28 risk adjustment model and prior authorization. 

Join us as we walk through the 2022 Inflation Reduction Act’s changes to Medicare Part D and Medicare Advantage. Learn about how those changes are impacting the senior health plan market today.