Enforcement set the tone six weeks before AEP: CMS barred one Medicare Advantage contract from 2027 enrollment and froze another, DOJ settlements on upcoding passed $1 billion, and UnitedHealthcare dropped prior authorization on about 1,700 codes.
National headlines
1. CMS sanctions pull two Medicare Advantage insurers off the 2027 AEP shelf
What happened: In a notice dated September 3, CMS suspended new enrollment in MMM Healthcare's MA-PD contract H7522 in Puerto Rico for January 1 through December 31, 2027, because the contract fell below the 85% medical loss ratio minimum for three consecutive years: 72.9% in 2023, 75.4% in 2024 and 74.1% in 2025. Its plans are removed from the list beneficiaries can elect during AEP; existing members keep coverage, and enrollment can resume for 2028 if the 2026 MLR reaches 85%. Separately, CMS froze enrollment on August 27 in eternalHealth's two MA-PD plans, about 10,000 members in Massachusetts and Arizona, after the state placed the insurer under administrative supervision.
Why it matters: An enrollment sanction does not show up as a plan exit in the landscape files, but it has the same effect on new sales: the plan stays in the market for its current members and disappears from the shopping list. The MLR sanction is also mechanical. Three years under 85% triggers it, which makes it predictable for any contract running thin on medical spend.
Strategic implication: Check your county footprint for sanctioned contracts before AEP scripts lock. In a sanctioned competitor's service area, new-to-Medicare and switching volume has one fewer destination, and current members who want to leave during AEP have to go somewhere else. For your own book, confirm where each contract sits against the 85% floor on a three-year basis, not just the current year.
eternalHealth's sanction took effect August 27 and was reported September 1. Becker's September 4 roundup of eight recent suspensions and terminations covers both actions.
On this site: Competitor vulnerability · Carrier & plan intelligence
2. DOJ Medicare Advantage upcoding settlements pass $1 billion
What happened: The Justice Department has secured about $1.1 billion from two Medicare Advantage risk-adjustment cases. The Villages Health agreed on August 27 to pay $541.5 million over diagnosis codes added through retrospective amendments and coding 'sprints', with a sample review showing unsupported codes rising from 28.6% in 2020 to 50.7% in 2024. Kaiser Permanente paid $556 million in January over data-mining queries that prompted post-visit addenda and diagnosis-submission targets tied to incentives.
Why it matters: Both cases target practices that are common across the industry: chart review, retrospective addenda and coding programs with financial targets. The Villages Health is now owned by Humana's CenterWell, so the exposure follows the asset to its buyer. Settlement size at this level changes how compliance, provider-partner and M&A diligence teams should weigh coding programs.
Strategic implication: Audit retrospective diagnosis capture, especially addenda made long after the visit and any incentives tied to risk-score outcomes, in both your own programs and your value-based provider partners. For strategy teams, revenue that depends on retrospective coding lift should be treated as at risk in 2027 planning.
The Villages Health settlement was announced August 27, outside the window; Becker's August 31 roundup put it next to the Kaiser case.
On this site: Policy impact · Regulatory library
3. UnitedHealthcare removes prior authorization from about 1,700 codes, including Medicare Advantage and D-SNP
What happened: UnitedHealthcare is removing prior authorization from roughly 1,700 codes starting in October 2026, about 30% of its preapproval requirements. The cut covers more than 800 commercial codes, about 940 ACA codes, about 120 Medicare Advantage and dual special needs plan codes, and 3 to more than 600 Medicaid codes depending on the state. Affected categories include oncology, cardiology, musculoskeletal procedures, genetic and lab testing, therapy, home health and durable medical equipment.
Why it matters: The Medicare cut is smaller than the commercial one, but it comes from the largest MA carrier just as CMS moves prior-authorization metrics to public websites. Providers and brokers will compare carriers on this, and a large competitor has just changed the baseline.
Strategic implication: Benchmark your MA and D-SNP prior-authorization lists against UnitedHealthcare's in shared counties, starting with the service categories above. Where you still require authorization on the same codes, decide whether that is a deliberate utilization control you can defend to providers, or an item to cut before it becomes a broker talking point.
On this site: MA and D-SNP lens · What's changed
4. OIG finds Part D paid $587.7 million for drugs that had become over-the-counter
What happened: An HHS OIG audit released August 31 found Part D paid $587.7 million from 2021 to 2023 for five drugs that should have been ineligible after switching to over-the-counter status: $184 million in 2021, $194.5 million in 2022 and $209.1 million in 2023. Generic versions of Voltaren topical accounted for $562.1 million across 15.8 million prescriptions. OIG attributed the problem to CMS updating its formulary reference file from outdated FDA data and to the absence of timeframes for sponsors to stop paying. CMS agreed to set that guidance.
Why it matters: The dollars were paid by sponsors, so the audit points at formulary and claims operations as well as CMS. Once CMS issues timeframes, OTC switches become an explicit sponsor compliance obligation. The improper payments also rose every year of the audit period.
Strategic implication: Have pharmacy operations confirm how quickly OTC switches, including the generic equivalents, are removed from covered-drug logic, and treat the coming CMS guidance as a new audit item. For product teams, the Voltaren case is a reminder to review OTC benefit design and Part D coverage together.
Activity date is the OIG report release; reporting date is September 2.
On this site: Spend intelligence
5. Mass General Brigham drops Dana-Farber from its Medicare Advantage network two weeks before AEP
What happened: Mass General Brigham's Medicare Advantage plan, which covers about 20,500 members, will remove Dana-Farber Cancer Institute from its network on October 1, 2026, following the split between the two institutions. Members being treated at Dana-Farber must switch plans or oncologists. Only a fraction of the plan's members are in active treatment there.
Why it matters: A provider-sponsored plan is using its network to steer oncology volume, and the members affected are high-cost and very visible. The timing lets affected members act at AEP, and cancer-center access is the kind of network story that brokers and local media pick up.
Strategic implication: In Greater Boston, competing plans that keep Dana-Farber in network have a specific, time-limited message for affected members. More broadly, monitor provider-sponsored plans for network changes that follow a health-system realignment, because those moves are made for system reasons and often land close to AEP.
Healthcare Dive (September 8) and Becker's (September 9) followed outside the window.
On this site: Compare markets
Compiled September 28, 2026. Covers material national developments from August 31-September 6, 2026, with clearly labeled exceptions where background is needed to read a development inside the window.
Provided for general informational and educational purposes only. It is not legal, financial, insurance or regulatory advice and should not be relied on as such; consult qualified professionals before acting on anything here. © 2026 medicareinsights.org.