14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training

Why This Topic Matters on the AHIP Exam

Every Medicare Advantage Organization and Part D Sponsor is legally required, under 42 CFR Section 422.503(b)(4)(vi) and Section 423.504(b)(4)(vi), to operate an "effective compliance program." AHIP tests two things from this requirement: whether you can name and describe the seven core elements CMS mandates, and whether you understand the non-discrimination training obligation that sits alongside them. Because Module 5 is 20% of the final and this is the backbone requirement underneath everything else in the module (FWA reporting, corrective action, sanctions), expect at least one or two direct "which of the following is one of the seven core elements" questions.

The Seven Core Elements of an Effective Compliance Program

CMS requires every Sponsor's compliance program to include, at minimum, these seven elements, drawn from Chapter 21 of the Medicare Managed Care Manual and Chapter 9 of the Prescription Drug Benefit Manual:

A useful memory device is Policies, Officer, Training, Communication, Discipline, Monitoring, Response. If an exam option lists something that isn't one of these seven, such as "annual sales bonus structure" or "marketing budget approval," it is a distractor, not a core element.

FWA Training Requirement Details

Two specific numbers show up often on the exam: FWA and general compliance training must occur within 90 days of initial hire and at least annually thereafter. There is one narrow training exception: FDRs who already meet FWA training and education requirements through accreditation as a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier, or through enrollment in Medicare Part A or Part B, are deemed to have satisfied the FWA training obligation without repeating it separately.

Non-Discrimination Training

Alongside the seven core elements, Sponsors must also train employees and FDRs on non-discrimination obligations, most directly grounded in Section 1557 of the Affordable Care Act (ACA), which prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in any health program receiving federal funds, squarely including Medicare Advantage and Part D. In practice, this means:

• Marketing and enrollment materials cannot be designed, targeted, or withheld in a way that discourages enrollment by any protected group, such as steering healthier populations away from a plan or avoiding outreach in areas with higher disability populations;
• Materials must be available in accessible formats, including large print and audio, and in languages spoken by a threshold share of the plan's service-area population, with required taglines in the top languages spoken locally;
• Agents may not make assumptions about a beneficiary's needs, cognitive capacity, or preferences based on protected characteristics during a sales appointment.

A 2026 Update Worth Knowing: OIG's Modernized Compliance Guidance

In 2025, the HHS Office of Inspector General released its first major update to Medicare Advantage compliance program guidance in more than two decades, consolidating over 25 years of audit and enforcement experience into a single modernized framework. It does not replace the seven core elements, which remain the regulatory floor, but it sharpens what CMS and the OIG expect a "good" compliance program to actually do. It flags risk areas including access-to-care monitoring, such as quarterly provider-directory checks and prior-authorization turnaround times, marketing and broker-payment oversight, overreliance on artificial intelligence tools in risk-adjustment coding as a new enforcement priority, Star Ratings data integrity, and continued responsibility for vendor (FDR) conduct even when work is outsourced. Expect the exam to frame this as "which of the following is a growing compliance risk area" rather than asking you to recite the guidance verbatim.

Exam Scenario

A Sponsor's compliance officer wants to know which core element requires the plan to investigate a reported issue and fix the underlying cause, not just discipline the one employee involved. The answer is element seven, Procedures for Prompt Response to Compliance Issues, which is exactly what feeds into the corrective action plan process covered next in 14.3.

Key Takeaways

• CMS requires seven core compliance elements for every MA/PDP Sponsor: written policies, a compliance officer and committee with board oversight, training, communication lines, disciplinary standards, monitoring and auditing, and prompt-response procedures.
• FWA training must occur within 90 days of hire and annually thereafter, with a narrow exception for DMEPOS-accredited suppliers and Medicare Part A/B enrollees.
• Non-discrimination training, grounded in ACA Section 1557, prohibits marketing, enrollment, or communication practices that disadvantage beneficiaries by race, color, national origin, sex, age, or disability.
• OIG's 2025 modernized compliance guidance flags AI overreliance in risk adjustment as a new enforcement risk area, alongside access-to-care and marketing oversight.
• "Prompt response to compliance issues," element seven, is the regulatory hook for corrective action plans.