Auditing Medicare Advantage commissions against the CMS maximums

Medicare pays per enrollment, not as a percentage

Unlike life or property and casualty, Medicare Advantage and Part D commissions are flat dollar amounts per enrolled member, and CMS publishes a maximum each plan year. New enrollments can pay up to the full maximum; renewals up to half. Several states carry higher maximums than the national figure.

Because the amounts are published, a Medicare statement is one of the few places where you can say with certainty that a payment is short. There is no negotiated percentage to argue about — the line either matches the applicable maximum or it does not.

The 2026 and 2027 reference amounts

For plan year 2026, the Medicare Advantage maximum is $694 for a new enrollment and $347 for a renewal in most states, with higher amounts in Connecticut, Pennsylvania and the District of Columbia ($781 new / $391 renewal) and in California and New Jersey ($864 new / $432 renewal). Standalone Part D pays $114 new and $57 renewal. For plan year 2027 the national Medicare Advantage amounts are $725 new and $363 renewal.

Two things follow. First, the state matters — a California enrollment paid at the national amount is short by $170 on a single member. Second, the new-versus-renewal flag matters just as much: a new enrollment paid at the renewal amount is short by roughly half.

Where Medicare statements go wrong

The recurring failures are structural rather than random:

• New enrollment paid at the renewal rate — often an AEP enrollment coded as a plan change
• Wrong state amount applied, usually the national figure on a higher-maximum state
• Member enrolled but never appearing on any statement
• Part D paid at Medicare Advantage rates or the reverse on a statement that mixes both
• Partial-year proration applied where the full amount was due

Checking a mixed statement

Many carriers put ACA, Medicare Advantage and Part D lines on the same statement. Each needs a different basis: ACA on a flat per-member fee, Medicare per member against the published CMS maximum for the year and state (or your contracted share of it), Part D on its own maximum.

Commission Guardian prices each line on its own basis automatically — including when the product name on the statement reads something like "MAPD HMO H1234-002" — so a mixed statement is audited in one pass instead of being split by hand.