Medicare Advantage final rule addresses competition and marketing practices
In addition, the Medicare Advantage final rule requires plans to review prior authorization policies with a health equity perspective.
Source: CMS Logo
- CMS has finalized policies to promote competition in Medicare Advantage and Part D plans, boost access to behavioral healthcare services, and reduce deceptive marketing practices.
The Contract Year (CY) 2025 Medicare Advantage and Part D final rule included guardrails about plan compensation to agents and brokers who help beneficiaries navigate coverage options. Excessive compensation from plans may result in beneficiaries being steered to certain Medicare Advantage or Part D plans based on financial incentives instead of beneficiary health needs.
CMS finalized requirements that redefine compensation to set a fixed amount that agents and brokers can receive regardless of the plan a beneficiary enrolls in, aiming to address the anti-competitive and anti-consumer loopholes. The agency is increasing the national agent/broker fixed compensation for initial enrollments into a Medicare Advantage or Part D plan by $100.
Additionally, CMS is prohibiting contract terms between Medicare Advantage organizations and Part D sponsors and third-party marketing organizations (TPMOs), such as including provisions offering volume-based bonuses for enrollment.
TPMOs also have sold personal beneficiary data, resulting in deceptive marketing tactics for Medicare Advantage and Part D plans. In the final rule, CMS has codified the requirement that personal beneficiary data collected by a TPMO for marketing or enrollment may only be shared with another TPMO with prior express written consent from the individual.
The rule will improve access to behavioral health providers by adding network adequacy evaluation standards for a new facility-specialty provider category, Outpatient Behavioral Health.
Specialists in the category include marriage and family therapists, mental health counselors, opioid treatment program providers, community mental health centers, addiction medicine physicians, and other providers who regularly furnish addiction medicine and behavioral health counseling covered by Medicare.
Medicare Advantage plans must verify that providers they add to their network have furnished or will furnish behavioral healthcare services to at least 20 patients within one year. Medicare Advantage networks must also include one or more telehealth providers in the Outpatient Behavioral Health category.
The final rule included policies addressing supplemental benefits, including requiring Medicare Advantage plans to conduct outreach efforts to notify beneficiaries of the supplemental benefits available to them. Plans must issue a mid-year enrollee notification of unused supplemental benefits annually between June 30 and July 31 that informs beneficiaries of unused benefits and how to access the benefits.
In addition, Medicare Advantage plans must demonstrate that special supplemental benefits for the chronically ill (SSBCI) meet the legal threshold of improving chronically ill beneficiaries’ health or overall function.
CMS finalized a policy requiring plans to analyze their utilization management policies and procedures from a health equity perspective. At least one member of the utilization management committee must have expertise in health equity, and the committee must conduct plan-level annual health equity analyses of prior authorization policies used by plans. The results of the analyses must be publicly available on the plan’s website.
The health equity requirements aim to identify disproportionate impacts of utilization management policies and procedures on beneficiaries receiving the Part D low-income subsidy, dual eligibles, and those with disabilities.
The rule also updates policies regarding dual eligible special needs plans out-of-network cost-sharing, the Medicare Advantage Risk Adjustment Data Validation (RADV) appeals process, and the Medicare Part D medication therapy management program. The full rule can be found here.
