Medicare Advantage and Part D plans – How Verisk can help

By Mark Popolizio, J.D., Shawn Johnson, J.D.

July 21, 2025 / 11 min read

In our recent updates, we examined several different aspects related to the Centers for Medicare and Medicaid Services’ (CMS’s) conditional payment recovery process for those beneficiaries enrolled in Medicare Parts A and B,^[1]including the connection between Section 111 reporting and CMS recovery, how CMS’s recovery process works, and Treasury collection actions.

In this article, the focus shifts to Medicare Part C (Medicare Advantage) and Medicare Part D (Prescription Drugs). Importantly, as we will learn below, Medicare Advantage and Part D recovery claims differ significantly from CMS’s recovery process. It is critical that insurers understand these differences as part of their overall Medicare best practices to minimize potential liability, including avoiding possible “double damages” actions.

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Toward this objective, this article highlights key points regarding the Medicare Advantage and Part D programs, their recovery process, and how Verisk can help, as follows:

1. Medicare Advantage Plans (MAPs) are private Medicare insurance plans. More than 50% of all Medicare beneficiaries nationally are enrolled in a MAP.

Part C of the Medicare program is known as “Medicare Advantage.” Under Part C, Medicare beneficiaries receive their Medicare benefits through Medicare-approved private insurers referred to as Medicare Advantage Plans (“MAPs” or “MA Plans”), instead of Original Medicare (Parts A and B).^[2]In general, MAPs provide the benefits typically provided through Original Medicare, with some MAPs offering additional benefits not covered under Original Medicare.^[3]In addition, Medicare prescription drug coverage (Medicare Part D) is included as part of most MAPs.^[4]

MAP enrollment has steadily increased over the past several years. Based on recent CMS data, 51% of all Medicare beneficiaries are now enrolled in a private Medicare Part C plan.^[5]By state, CMS’s data reflects that MAP enrollees now account for more than half of all Medicare beneficiaries in 26 states, with four states (AL, MI, MN, RI) having MAP enrollment rates of 60% or greater.^[6]MAP enrollment in California is 52% and New York is 53%, while Texas’s MAP enrollment is 54% per CMS's data.^[7]Meanwhile, Puerto Rico’s MAP enrollment rate is noted as 86%.^[8]When looking at these figures, it is interesting to consider that MAP enrollment did not exceed 50% in any state only a decade ago.^[9]

Currently, there are approximately 3,719 different MAP plans available nationally.^[10]Overall, MAP enrollment continues to be concentrated in two providers: UnitedHealthcare and Humana. These two firms account for nearly half (47%) of all MAP enrollment nationwide, and at least 75% of MAP enrollment in more than a quarter of all U.S. counties.^[11]More specifically, UnitedHealth insures 29% (or 9.4 million) of total Medicare Advantage enrollees, while Humana insures 18% (or 6.0 million).^[12] Following these two firms are BlueCross/BlueShield (BC/BS) and CVS Health. BC/BS provides coverage for 14% (or 4.6 million) of all Medicare Advantage enrollees, while CVS Health insurers 12% (or 4.1 million).^[13]In addition to these firms, other MAP providers, with their respective market share and enrollment figures, are noted as follows: Kaiser Permanente 6% (1.9 million); Centene 3% (1.1 million); and Cigna 2% (0.6 million).^[14]All other insurers provide coverage for 16% (or 5.1 million) Medicare Advantage enrollees.^[15]

2. MAPs have recovery rights – including the right to sue for “double damages” in some jurisdictions.

Under specific MAP statutes and regulations, MAPs may seek recovery from their enrollees and insurers.^[16]The bigger question, however, is whether MAPs can also sue for “double damages” under the Medicare Secondary Payer statute’s private cause of action (PCA) statute.^[17]If so, then MAPs can sue insurers (and potentially other parties) for “double damages” if they fail to address MAP recovery claims properly—just like the federal government can for traditional Medicare conditional payment claims. On this question, significantly, three United States Circuit Court of Appeals have ruled that the MSP’s PCA statute applies to MAPs. Specifically, the Third, Eleventh, and Second Circuits have ruled that MAPs can in fact sue insurers for “double damages” under the PCA statute. See, In re Avandia, 685 F.3d 353 (3rd Cir. 2012), Humana v. Western Heritage Insurance Co., 832 F.3d 1229 (11^th Cir. 2016), and Aetna Life Insurance Company v. Big Y Foods, Inc., 52 F.4^th (2^nd Cir. 2022).^[18]Of note, the 11^th and 2^nd Circuit Courts also levied “double damages” against the defendant insurers as part of their rulings. In addition to the above U.S. Circuit Court decisions, several United States District Courts have also ruled that MAPs can bring “double damages” claims as outlined in the endnote to this sentence.^[19]

3. Medicare Part D provides prescription drug coverage for Medicare beneficiaries through private insurers. Approximately 80% of all Medicare beneficiaries have Part D coverage.

Medicare Part D is the Medicare program’s voluntary outpatient prescription drug benefit available to Medicare beneficiaries. Similar to Medicare Advantage, Part D benefits are provided through private plans that contract with the federal government.^[20]Beneficiaries can choose to enroll in either a stand-alone prescription drug plan (“PDP”) to supplement Original Medicare, or a Medicare Advantage plan that provides all Medicare-covered benefits, including prescription drugs (“MA-PD”).^[21]The Congressional Budget Office estimates that spending on Part D benefits will total approximately $137 billion dollars in 2025.^[22]

Recent CMS data reflects that 54 million of the 68 million Medicare beneficiaries were enrolled in a Medicare Part D plan, with 58% enrolled in a MA-PD and 42% in a stand-alone PDP.^[23] In 2025, it is reported that there are 464 stand-alone prescription drug plans (PDPs) which is a noted 35% decrease from 2024, and the fewest number of available PDPs since the Part D program started in 2006.^[24]On this note, the number of firms sponsoring stand-alone PDPs is decreased from 11 firms in 2024 to 7 firms in 2025, which is also the smallest number since the Part D benefit was launched in 2006.^[25] Notwithstanding this reduction, beneficiaries in each state still have a choice of at least a dozen stand-alone PDPs.^[26]While the availability of stand-alone PDPs has decreased, there has been an increase in Medicare Advantage drug plans with more Medicare beneficiaries now receiving Part D coverage through Medicare Advantage plans.^[27]

4. Federal statutes, regulations, and CMS policy guidance indicate that Part D plans also have recovery rights.

Certain federal statutes and regulations reference that Part D plans have the same recovery rights as Medicare Advantage Plans (MAPs). For example, 42 U.S.C. § 1395w-102(4) states, in part, that the recovery rights afforded to MAPs “apply in the same manner” to Part D. Likewise, 42 CFR § 423.462 provides that the same “Medicare secondary payer procedures” that apply to Medicare Advantage Plans under § 422.108 also apply to Part D plans. Further, under 42 CFR § 422.108, MAPs may seek reimbursement from insurers and other parties in workers’ compensation, liability, and no-fault cases. This regulation further gives MAPs the same recovery rights as traditional Medicare under the MSP. In addition, CMS in a 2011 policy memo states, in part, that Part D plans “have the same MSP rights and responsibilities as Medicare Advantage Plans, including collection of mistaken primary payment from insurers, group health plans, employer sponsors, enrollees, and other entities.”^[28] Further, in 2018, CMS added language to its Medicare Prescription Drug Benefit Manual including, in part, that “Part D sponsors will have the same responsibilities under MSP requirements as [Medicare Advantage] plans, including collection of mistaken primary payment from insurers, group health plans, employer sponsors, enrollees, and other entities; and the relationship between MSP rules and State laws. Part D sponsors must properly apply MSP requirements and regulations to their payments (e.g. working aged, worker’s compensation).”^[29]

Regarding Part D recovery, in the authors’ experience, Part D plans, in general, have not been as active in pursuing reimbursement in comparison to MAPs. Further, unlike in the MAP context, we have not seen the type of litigation and judicial activity (at least thus far) regarding Part D recovery issues. In this regard, an interesting question is whether the courts would find that Part D plans also have “double damages” rights under the MSP’s private cause of action statute. To the authors’ knowledge, this precise issue has not yet been directly litigated, although the 3^rd Circuit as part of its decision in Avandia, finding that MAPs could sue insurers for double damages, indicated that its ruling would also apply to Part D recovery claims.^[30]

5. The MAP and Part D recovery process is different from CMS’s recovery process.

How MAP and Part D plans pursue recovery differs from how CMS processes its recovery claims. By way of a quick refresher, as discussed in our recent articles noted above, CMS uses two contractors, the Benefits Coordination & Recovery Center (BCRC) and the Commercial Repayment Center (CRC) to process its Part A and B recovery claims and can refer delinquent debts to the United States Department of Treasury for collection.

However, importantly, CMS’s process only relates to CMS’s recovery regarding Part A and B claims. CMS’s process does not apply in the MAP or Part D context. In other words, CMS, BCRC, CRC, and Treasury are not involved regarding MAP and Part D recovery. Rather, parties must deal directly with the individual MAP or Part D plan(s) (or their recovery vendors) to obtain any claimed recovery amount and address any related recovery claims.^[31]In this regard, it important to note that there is no standardized process for MAP or Part D recovery. Each MAP and Part D plan handles recovery differently using their own internal recovery process, while some MAPs contract with third-party vendors to handle recovery on their behalf.

In terms of determining MAP and/or Part D enrollment, CMS’s Section 111 Query Process can be helpful. Specifically, under the Query Process system, CMS provides information regarding a claimant’s MAP and/or Part D enrollment status, including, in pertinent part, the contract number, contract name, plan number, coordination of benefits (COB) address, and entitlement dates for the past three years (up to 12 instances) of MAP and/or Part D coverage.^[32]Thus, checking the Query results is a good first step to determine a claimant’s MAP and/or Part D beneficiary status. From there, insurers can use this data, if they elect, to contact the identified plan(s) to proactively address potential MAP and/or Part D recovery claims or otherwise determine how these potential claims should be addressed and resolved.

Importantly, keep in mind, that, in general, most beneficiaries can switch their Medicare plans during the Open Enrollment Period and during the Medicare Advantage Open Enrollment Period.^[33] Medicare beneficiaries may also be able to switch Medicare plans during Special Enrollment Periods depending on certain life events.^[34]During these periods, Medicare beneficiaries may be able to switch between traditional Medicare (Parts A and B) and a MAP, between MAPs, and between Part D plans. In the MSP context, this means that a claimant may have received Medicare benefits from different Medicare entities throughout the life of a claim, and each of those entities may have a right to recover. For this reason, it may be helpful to use the Section 111 Query Process to identify a claimant’s Medicare enrollment status and monitor the Query results throughout the course of the claim to determine if the claimant has switched plans. While the Query does not provide lien amounts, it does provide the information needed to contact the identified plans to obtain any claimed recovery amounts.

How Verisk can help

Verisk offers several different Medicare recovery services that can help you address CMS conditional payment claims, including our standard Medicare Advantage and Part D recovery services. We also offer our popular CP Link® program which provides a proactive approach to Medicare recovery claims that leverages your Section 111 data to initiate the conditional payment process. CP Link helps speed up the conditional payment process by identifying potential conditional payment claims through Section 111 data, helps reduce adjuster time, and facilitates a holistic compliance approach to address conditional payment claims. In addition, our PAID Act Add-on for CP Link utilizes the PAID Act data as the industry’s first and only automated, customizable solution for identifying and resolving Part C and D liens—ensuring full-spectrum compliance and risk mitigation.

By combining automation with our experienced team, we consistently deliver extraordinary savings for our customers. For example, in 2024, our Medicare Advantage services delivered over $1.7 million in savings for our customers, while our CP Link program achieved over $160 million in conditional payment services.

Please do not hesitate to contact the authors if you have any questions regarding CMS’s conditional payment process, MAP and Part D recovery, or Verisk’s Medicare recovery services.

[1] In general, Parts A and B are known as “Original Medicare.” Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). See, Medicare and You Handbook 2025, at p.10.

[2] See, Understanding Medicare Advantage Plans, at p. 2 and Medicare and You Handbook 2025, at p.10.

[3] See, Understanding Medicare Advantage Plans, at p. 4 and Medicare and You Handbook 2025, at p. 10 and 12.

[4] See, Understanding Medicare Advantage Plans, at p. 4 and Medicare and You Handbook 2025, at p. 10 and 12.

[5] Medicare Enrollment Dashboard | CMS Data, (Last Data Available, March 2025). On this point, it is interesting to consider that in 2007, only 8 million of all Medicare beneficiaries were enrolled in a MAP. However, 10 years later this figure had more than doubled to 18 million beneficiaries, while MAP enrollment hit 28 million beneficiaries in 2022 and then increased to 31 million beneficiaries by 2023. Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2024: Enrollment Update and Key Trends, KFF (August 8, 2024).

[6] Medicare Enrollment Dashboard | CMS Data, (Last Data Available, March 2025).

[7] Medicare Enrollment Dashboard | CMS Data, (Last Data Available, March 2025).

[8] Medicare Enrollment Dashboard | CMS Data, (Last Data Available, March 2025).

[9] Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2024: Enrollment Update and Key Trends, KFF (August 8, 2024).

[10] Jeannie Fuglesten Biniek, Meredith Freed, Anthony Damico, and Tricia Neuman, 2025 Medicare Advantage Plan Choices are Stable, Following Years of Steady Growth, KFF (October 15, 2024). While MAP enrollment continues to grow, it is noted that, in 2025, the total number of available MAPs declined slightly from 3,959 in 2024 to 3,719 (a 6% decrease). Id.

[11] Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2024: Enrollment Update and Key Trends, KFF (August 8, 2024).

[12] Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2024: Enrollment Update and Key Trends, KFF (August 8, 2024).

[13] Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2024: Enrollment Update and Key Trends, KFF (August 8, 2024).

[14] Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2024: Enrollment Update and Key Trends, KFF (August 8, 2024).

[15] Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2024: Enrollment Update and Key Trends, KFF (August 8, 2024).

[16] The statutes on this point are 42 U.S.C. §1395mm(e)(4) and 42 U.S.C. § 1395w-22(a)(4) as follows:

42 U.S.C. §1395mm(e)(4) is entitled “Payments to health maintenance organizations and competitive medical plans” and states as follows: “Notwithstanding any other provision of law, the eligible organization may (in the case of the provision of services to a member enrolled under this section for an illness or injury for which the member is entitled to benefits under a workmen’s compensation law or plan of the United States or a State, under an automobile or liability insurance policy or plan, including a self-insured plan, or under no fault insurance) charge or authorize the provider of such services to charge, in accordance with the charges allowed under such law or policy— (A) the insurance carrier, employer, or other entity which under such law, plan, or policy is to pay for the provision of such services, or (B) such member to the extent that the member has been paid under such law, plan, or policy for such services.” Id.

Similar provisions are contained in 42 U.S.C. § 1395w-22(a)(4). This section is entitled “Organization as secondary payer” and provides that: “Notwithstanding any other provision of law, a Medicare+Choice organization [now called Medicare Advantage] may (in the case of the provision of items and services to an individual under a Medicare+Choice plan under circumstances in which payment under this subchapter is made secondary pursuant to section 1395y(b)(2) of this title) charge or authorize the provider of such services to charge, in accordance with the charges allowed under a law, plan, or policy described in such section— (A) the insurance carrier, employer, or other entity which under such law, plan, or policy is to pay for the provision of such services, or (B) such individual to the extent that the individual has been paid under such law, plan, or policy for such services.” Id.

Additional regulations for consideration are 42 C.F.R. § 422.108(f) and 42 C.F.R. § 417.528 (b) as follows:

42 C.F.R. § 422.108(f) states: “MSP rules and State laws. Consistent with § 422.402 concerning the Federal preemption of State law, the rules established under this section supersede any State laws, regulations, contract requirements, or other standards that would otherwise apply to MA plans. A State cannot take away an MA organization’s right under Federal law and the MSP regulations to bill, or to authorize providers and suppliers to bill, for services for which Medicare is not the primary payer. The MA organization will exercise the same rights to recover from a primary plan, entity, or individual that the Secretary exercises under the MSP regulations in subparts B through D of part 411 of this chapter.” Meanwhile, 42 C.F.R. § 417.528 (b) provides that: “Charge to other insurers or the enrollee. If a Medicare enrollee receives from an HMO or CMP covered services that are also covered under State or Federal worker’s compensation, automobile medical, or any no-fault insurance, or any liability insurance policy or plan, including a self-insured plan, the HMO or CMP may charge, or authorize a provider that furnished the service to charge— (1) The insurance carrier, employer, or other entity that is liable to pay for these services; or (2) The Medicare enrollee, to the extent that he or she has been paid by the carrier, employer, or other entity.” Id.

[17] The MSP’s private cause of action statute is codified at 42 U.S.C. 1395y(b)(3)(A) which states, in full, as follows: “There is established a private cause of action for damages (which shall be in an amount double the amount otherwise provided) in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement) in accordance with paragraphs (1) and (2)(A).” Id.

[18] By way of note, the 3rd Circuit has jurisdiction over federal cases originating in Delaware, New Jersey, Pennsylvania, and the U.S. Virgin Islands; the 11th Circuit has jurisdiction over federal cases originating in Alabama, Florida, and Georgia; while the Second Circuit has jurisdiction over federal cases originating in Connecticut, New York, and Vermont.

[19] On this point, the following United States District courts have ruled that MAPs can sue for “double damages:” California: MAO-MSO Recovery II, LLC v. Mercury Insurance, 2018 WL 3357493 (C.D. Calif. 2018); MAO-MSO Recovery II, LLC v. Farmers Insurance Exchange, 2018 WL 2106467 (C.D. Calif. 2018); Connecticut: Aetna v. Guerrera, 300 F.Supp.3d 367 (D. Conn 2018); Illinois: MAO-MSO Recovery II, LLC v. State Farm, 2018 WL 340021 (C.D. Ill. 2018); MSP Recovery Claims, Series 44 v. Zurich, 2023 WL 5227396 (N.D. Illinois 2023); Louisiana: Collins v. Wellcare Healthcare Plans, Inc., 73 F.Supp.3d 653 (E.D. La. 2014); Maryland: MAO-MSP Recovery II, LLC v. Government Employers Ins. Co., 2024 WL 2924063 (D. Maryland 2024); Massachusetts: MSP Recovery Claims Series LLC v. Plymouth Rock Assurance Corporation, 404 F.Supp.3d 470 (D. Massachusetts 2019); Ohio: MSP Recovery Claims, Series LLC v. Phoenix Insurance Company, 426 F.Supp. 3d 458 (N.D. Ohio, 2019); MSP Recovery Claims, Series LLC v. Grange Insurance Company, 2019 WL 6770729 (N.D. Ohio 2019); and MSP Recovery Claims, Series LLC v. Progressive Corporation, 2019 WL 5448356 (N.D. Ohio 2019); South Carolina: Humana Ins. Co. v. Bi-Lo, LLC, 2019 WL 4643582 (D. South Carolina 2019); Tennessee: Cariten Health Plan, Inc. v. Mid-Century Ins. Co., No.: 2015 WL 5449221(E.D. Tenn. 2015); Texas: Humana Ins. Co. v. Farmers Tex. Cnty. Mut. Ins. Co., 95 F.Supp.3d 983 (W.D. Tex. 2014) and Humana v. Shrader, 584 B.R. 658 (S.D. Tex. 2018); and Virginia: Humana Ins. Co. v. Paris Blank LLP, 187 F. Supp.3d 676 (E.D. Va. 2016).

[20] An Overview of the Medicare Part D Prescription Drug Benefit, KFF (October 17, 2023).

[21] An Overview of the Medicare Part D Prescription Drug Benefit, KFF (October 17, 2023).

[22] Juliette Cubanski, A Current Snapshot of the Medicare Part D Prescription Drug Benefit, KFF (October 9, 2024).

[23] Medicare Enrollment Dashboard | CMS Data, (Last Data Available, March 2025).

[24] Juliette Cubanski, A Current Snapshot of the Medicare Part D Prescription Drug Benefit, KFF (October 9, 2024).

[25] Juliette Cubanski and Anthony Damico, Medicare Part D in 2025: A First Look at Prescription Drug Plan Availability, Premiums, and Cost Sharing, KFF (November 22, 2024).

[26] Juliette Cubanski, A Current Snapshot of the Medicare Part D Prescription Drug Benefit, KFF (October 9, 2024).

[27] Juliette Cubanski, A Current Snapshot of the Medicare Part D Prescription Drug Benefit, KFF (October 9, 2024).

[28] See, CMS memo, Medicare Secondary Payment Subrogation Rights, Medicare Advantage Organizations and Prescription Drug Plan Sponsors (December 5, 2011).

[29] See, CMS’s Prescription Drug Manual, Chapter 14, Coordination of Benefits (Revised, September 17, 2018). In addition, CMS added, in part, the following guidance to Part D providers: “Part D sponsors are responsible for identifying and recovering any Coordination of Benefits (e.g. where a Part D sponsor paid for a claim and another payer should have paid), MSP related mistaken payments and submitting associated adjustments to CMS. Recovery of payments when the sponsor determines no payment at all should have been made or the amount paid was more than it should have been should be sought from the responsible other party. Sponsors should implement processes to handle payment resolution in these situations directly with the primary payer or in limited cases with the beneficiary … [a] claim for a drug that should be paid as MSP may not be submitted or paid as a primary claim by the Medicare plan.” Id. Of note, this updated language supplemented existing manual provisions regarding Part D secondary payer concepts which stated, in part, that “Part D sponsors will have the same responsibilities under MSP requirements as [Medicare Advantage] plans, including collection of mistaken primary payment from insurers, group health plans, employer sponsors, enrollees, and other entities; and the relationship between MSP rules and State laws. Part D sponsors must properly apply MSP requirements and regulations to their payments (e.g. working aged, worker’s compensation).” Id.

[30] See, In re Avandia, 685 F.3d 353, at n.20. The court in this endnote stated “Our decision here unquestionably results in cost savings for the Medicare Trust Fund because our holding on the meaning of the private cause of action will apply equally to private entities that provide prescription drug benefits pursuant to Medicare Part D. See 42 U.S.C § 1395w-151(b) (requiring that provisions relating to the MA program and MAOs be read to include part D plans). Because Part D prescription drug plans explicitly share gains and losses with the federal government, 42 U.S.C. § 1395w-115(e), the Medicare Trust Fund unquestionably loses money if these private entities recover less from primary payers.” Id.

[31] https://www.cms.gov/medicare/coordination-benefits-recovery/overview/non-group-health-plan-recovery

[32] See CMS’s Section 111 NGHP User Guide, Chapter V, Appendix E (Version 7.3, August 7, 2023). In addition, CMS also provides the contract number, contract name, plan number, coordination of benefits (COB) address, and entitlement dates for the past three years (up to 12 instances) of Part C (Medicare Advantage) and the most recent Part A and Part B entitlement dates. Id.

[33] https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan

[34] Id.