Inside CMS’ latest final rule for MA and Part D plans

CMS on Thursday released a final rule for Medicare Advantage (MA) and Part D plans for 2025, which will enhance standards for marketing, prior authorization, and network adequacy.

Policy primer: A guide to MA plan types and how they impact care

New standards increase consumer protections

As of March 1, MA plans covered 33.8 million people, a 6.4% increase from a year before. According to CMS, the new policies in the final rule will improve the MA program and offer greater protections to consumers.

In the final rule, CMS set a cap on the compensation amount MA or Part D plans can pay agents or brokers to prevent them from guiding patients to plans that don’t best suit their needs. The compensation cap is set to increase to $100 from the initially proposed $31.

“We are thrilled CMS embraced our proposal to cap total broker payment,” said Ceci Connolly, president and CEO of the Alliance of Community Health Plans. “This commonsense policy change eliminates those perverse financial incentives and levels the playing field for health competition.”

The final rule also generally prohibits contract terms between MA organizations or Part D sponsors and third-party marketing organizations that could directly or indirectly prevent agents or brokers from objectively assessing and recommending the most suitable plan for potential enrollees. CMS provides several examples of impermissible contract terms, including provisions that offer volume-based bonuses for enrollment in certain plans.

CMS is also requiring MA plans to have health equity experts on their utilization management committees. These committees are required to conduct an annual health equity analysis of their plans’ prior authorization policies and procedures. According to CMS, this analysis will help identify any disproportionate delay or denials for enrollees who have limited income and resources or a disability.

“CMS is continuing its commitment to ensuring that Medicare Advantage and Part D prescription drug plans remain strong, stable, and affordable for people with Medicare,” said CMS Administrator Chiquita Brooks-LaSure. “This final rule builds on Biden-Harris Administration efforts to strengthen consumer protections so that people with Medicare can more easily choose the Medicare coverage options that are right for them.”

Additional changes to improve access

The final rule also aims to increase access to behavioral health providers and services by expanding network adequacy evaluation requirements to include a new outpatient behavioral health specialty. This specialty includes marriage and family therapists, mental health counselors, and addiction medicine clinicians.

To ensure that enrollees are aware of supplemental benefits in their MA plans, plans are required to send out a “Mid-Year Enrollee Notification of Unused Supplemental Benefits” between June 30 and July 31 of every plan year. The notifications must be tailored to each enrollee and include the scope of the benefit, cost-sharing, instructions on how to access the benefit, and more.

Finally, the rule allows Part D plans greater flexibility to substitute lower cost biosimilar biological products so that enrollees will have access to equally effective, but potentially more affordable, treatments more quickly.

“In my travels around the country, I always hear from Medicare enrollees that Medicare can be confusing and access to accurate, unbiased, actionable information is vital — whether it’s about enrollment or how to access services,” said Meena Seshamani, CMS deputy administrator and director of the Center for Medicare. “This final rule builds on the bold actions we took last year to improve access to care and address predatory marketing, strengthening the Medicare program and improving the lives of the people we serve.”

(BERRYMAN/TEPPER, MODERN HEALTHCARE, 4/4; AHA NEWS, 4/1; CMS)