CMS publishes 2025 rule for Medicare Advantage and Medicare Part D

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Promoting competition, increasing access to behavioral health services, and consumer protections are part of the contract year 2025 rule for Medicare Advantage and Medicare Part D.

The U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) announced the rule with “bold action to expand enrollee protections,” including addressing “predatory” marketing of the Medicare Advantage and Part D programs.

“Competition within Medicare Advantage and Medicare Part D will provide consumers with meaningful choices among plans so they can select one that best meets their individual needs. Additional consumer protections will help people make the right decisions and get the coverage they want without hassles,” HHS Secretary Xavier Becerra said in a statement. He and CMS Administrator Chiquita Brooks-LaSure promoted the efforts of President Joe Biden and his administration to regulate the programs.

New regulations

• The rule sets the amount an insurance plan can compensate an agent or broker to guard enrollees and prospective enrollees against anticompetitive efforts to steer them to particular plans that may offer financial incentives to agents or brokers. The rule aims to assist enrollees in finding plans that best suit their needs, according to CMS.
• Third-party marketing organizations will need permission from Medicare enrollees to share personal beneficiary data collected when people enroll in programs.
• Medicare Advantage plans must include experts on health equity on utilization management committees, which must conduct annual health equity analyses on the plans’ prior authorization policies and procedures.
• The rule expands network adequacy evaluation requirements to a new outpatient behavioral health specialty type. This will include marriage and family therapists and mental health counselors who can bill under Original Medicare, as well as addiction medicine clinicians, opioid treatment providers, and other behavioral health practitioners providing psychotherapy or medication for substance use disorder. This provision intends to promote access to behavioral health resources.
• Medicare Advantage plans must send mid-year, personalized communications to enrollees about accessing unused supplemental benefits. CMS invests more than $65 billion a year in taxpayer dollars on those benefits, so notifying beneficiaries will help meet their needs.
• Medicare Part D plans will have greater flexibility to substitute lower-cost biosimilar biological products so enrollees gain faster access to equally effective, but potentially more affordable, drug treatment options, according to CMS.

Additional resources

CMS published a fact sheet with expanded details about the changes, available here. The rule is scheduled to be published April 24, but the draft version is available online here.

Meanwhile, political leaders traded verbal jabs about each other’s spending proposals and policies, including Medicare.

Last month, the Republican Study Committee, made up of conservative members of Congress, published its fiscal year 2025 budget titled “Fiscal Sanity to Save America.” Chair Rep. Kevin Hern (R-Oklahoma) said the federal debt is daunting, but not hopeless, if the nation adheres to conservative policies to lower spending, lower taxes, decrease the size and scope of the federal government, and spark economic growth, in ways that protect programs including Medicare.

The White House published a statement by Biden arguing the GOP plan would raise Medicare costs by eliminating Medicare’s ability to negotiate prescription drug prices and repealing caps on insulin prices and out-of-pocket spending. The Republican plan would transition Medicare to a system that would raise premiums for many seniors, according to the president.