The federal government won’t allow Elevance Health to enroll beneficiaries into its Medicare Advantage plans beginning March 31 unless the organization takes corrective actions.
The Centers for Medicare & Medicaid Services (CMS) claims Elevance Health hasn’t complied with federal Medicare Advantage (MA) risk-adjustment data submission requirements for years. If the company doesn’t take immediate steps to comply, CMS will suspend Elevance Health’s enrollment and marketing activities beginning March 31.
In a 10-page notice dated February 27, CMS informed Elevance Health President of Medicare Programs Aimee Dailey that the sanctions will apply to 45 Medicare Advantage–Prescription Drug (MA-PD) contracts across the country. The sanctions are set to take effect March 31, unless Elevance completes required corrective actions within 30 days.
The suspensions would impact individuals who turn 65 as of March 31, have a qualifying life event, or want to switch plans or enroll in a special needs plan.
The company alerted the Securities and Exchange Commission (SEC) about the potential sanctions in a notice on Monday. Elevance said the suspension doesn’t impact the company’s current MA-PD members’ benefits or plans. According to Elevance, the company revised its risk-adjustment data submissions practices in April 2023 following the receipt of additional regulatory guidance.
“The company is engaging with CMS regarding the matters raised in the notice and is committed to working cooperatively with CMS to address its stated concerns,” Elevance said in the notice.
According to CMS, Elevance has failed since 2018 to properly correct and submit certain diagnosis codes used to calculate risk-adjusted payments for MA beneficiaries. Rather than use CMS’ required electronic systems—the Risk Adjustment Processing System (RAPS), Encounter Data Processing System (EDPS), or the Risk Adjustment Overpayment Reporting (RAOR) module—Elevance repeatedly sent data to CMS via encrypted USB flash drives, a method the agency explicitly rejects.
Despite receiving six written directives from CMS between 2019 and 2025 instructing the company to stop using nonapproved submission methods and follow federal standards, Elevance continued the practice as recently as October 10, 2025.
CMS noted that Elevance’s own retrospective medical record reviews uncovered diagnosis codes not supported by documentation, which meant the codes should have been deleted and any resulting overpayments returned within 60 days. Elevance, however, did not submit these corrections through the approved channels, resulting in continued reliance on inaccurate data.
The unsupported diagnosis codes span payment years 2016–2024 and relate to dates of service ranging from 2015 through April 2, 2023—a broad period affecting multiple plans and potentially thousands of beneficiaries, CMS said.
Elevance also continued to certify annually that its data submissions were accurate, complete, and truthful, despite documented knowledge that certain diagnosis codes were unverifiable. Federal regulations require MA organizations to affirm accuracy based on their "best knowledge, information, and belief."
What the sanctions mean
Under the sanctions:
- Elevance may not enroll new Medicare beneficiaries into the affected MA-PD plans.
- Elevance must suspend all marketing and communication activities to Medicare beneficiaries.
- The sanctions remain in place until CMS verifies that Elevance has corrected the deficiencies and implemented systems to prevent recurrence.
To avoid the sanctions, Elevance must
- Submit all required data corrections through RAPS, EDPS, or RAOR, and
- Send an attestation of completion by March 30, signed by its CEO or most senior official
If Elevance misses the deadline, sanctions will take effect, and the company must submit a detailed corrective action plan outlining timelines, compliance measures, and assurances of future adherence.
Elevance has two additional rights:
- A 10-day window (until March 10) to submit a written rebuttal to CMS
- A 15-day window (until March 16) to request a hearing before a CMS hearing officer
Neither action would delay the start date of the sanctions.