On April 4 the Centers for Medicare & Medicaid Services (CMS) posted the 2025 Medicare Advantage and Part D final rule, which aims to strengthen protections and guardrails, promote healthy competition, and ensure Medicare Advantage and Part D plans best meet the needs of enrollees. Several highlights of the rule include the following updates:
- Developing new guardrails for plan compensation to agents and brokers to stop anti-competitive steering
- Limiting the distribution of personal beneficiary data by third-party marketing organizations
- Improving access to behavioral health care providers by adding network adequacy evaluation standards for new “Outpatient Behavioral Health” facility-specialty providers
- Implementing mid-year notifications of available supplemental benefits for enrollees
- Developing new standards for supplemental benefits for the chronically ill
- Providing annual health equity analysis of utilization management policies and procedures
- Enhancing enrollee rights to appeal a Medicare Advantage plan’s decision to terminate coverage for non-hospital provider services
- Increasing the percentage of dually eligible managed care enrollees who receive Medicare & Medicaid services from the same organization
- Limiting out-of-network cost sharing for certain preferred provider organizations (PPOs)
- Developing contracting standards for dual eligible special needs plan look-alikes
- Standardizing the Medicare Advantage risk adjustment data validation appeals process
- Adding flexibility to more quickly substitute lower cost biosimilar biological products for their reference products
- Improving targeting criteria for the Medicare Part D Medication Therapy Management (MTM) program
Questions about the Medicare Advantage and Part D final rule may be directed to coding@aasm.org.
