The Centers for Medicare & Medicaid Services (CMS) late Thursday released the 2025 final rule, codifying many of the provisions it proposed in the fall.
The 1,327 page final rule, which is scheduled to be published in the Federal Register on April 23, makes significant changes to Medicare Advantage (MA) marketing, agent and broker compensation, prior authorization, supplemental benefits, and the Risk Adjustment Data Validation (RADV) appeal process.
CMS said in an announcement that the new policies will promote competition, increase access to care, and protect individuals from inappropriate marketing and prior authorization. “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 Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare, CMS, in a statement. “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.”
Here is an overview of some of the major changes announced on Thursday:
Agent and broker compensation
CMS aims to crack down on commissions, bonuses, gifts, and prizes that some insurers offer to brokers or agents to steer consumers to their MA or Part D plans even if they may not meet the prospective enrollee’s health care needs.
To level the playing field, the final rule sets clear, fixed amounts that insurers pay agents and brokers regardless of the plan the individual enrolls in, beginning with the upcoming Annual Enrollment Period. CMS will eliminate separate administrative payments and base compensation on fair market value, but for 2025, the base rate per enrollee will increase by $100 per enrollee for new enrollments. MA organizations will be allowed to compensate brokers for enrollments in a renewal year at 50 percent of the fair market value.
Agents and brokers are currently paid $611 for each MA initial enrollment and $306 for a MA renewal enrollment. If the fair market value increases in 2025 to 2.5 percent, then the flat payment (including the $100 one-time increase) would be $726 for initial enrollment and $313 for renewals. In 2026, under the same percentage increase, broker/agent payment would be $744 for initial enrollment and $372 for renewals.
Third-party marketing restrictions
CMS is also placing restrictions on third-party marketing organizations (TPMOs). In some cases, TPMOs have been selling and reselling beneficiary contact information to bypass existing CMS rules that prohibit cold calling so they can aggressively market MA and Part D plans. Beneficiaries aren’t aware that by placing a call or clicking on a web link they are unwittingly agreeing and providing consent for TPMOs to collect and sell their information for future marketing activities.
To prevent this in the future, CMS will prohibit TPMOs from collecting personal data unless the beneficiary provides prior express written consent. In addition, the TPMO must obtain this written consent through a transparent, and prominently placed, disclosure from the individual to share the information and be contacted for marketing or enrollment purposes. The agency said the provision is meant to address complaints that individuals have been receiving unwanted phone calls and emails from brokers or agents trying to enroll them in MA and Part D plans.
Access to behavioral health care providers
To beef up network adequacy standards and ensure that MA enrollees have access to behavioral health providers, CMS is adding a new facility-specialty provider category called “outpatient behavioral health” that will include marriage and family therapists, mental health counselors, opioid treatment program providers, community mental health centers, addiction medicine physicians, and other providers, like nurse practitioners, physician assistants, and clinical nurse specialists, who regularly offer addiction medicine and behavioral health counseling or therapy services covered by Medicare. MA plans must independently verify that the new provider they add to their network has provided services to at least 20 patients within a 12-month period using reliable information such as the MA plan’s claims data, prescription drug claims data, or electronic health records. The MA’s contract network of providers must include one or more telehealth providers of that specialty type.
Changes to supplemental benefits: Notification and marketing
To ensure MA enrollees are aware of supplemental benefits that are available to them, CMS requires plans to notify members mid-way through the plan year to list any supplemental benefit they have not yet accessed. The personalized notification must include the scope of the benefit, cost-sharing, instructions on how to access the benefit, any network application information for each available benefit, and a customer service number to call for more information.
In addition, CMS will now require MA plans to demonstrate that special supplemental benefits for the chronically ill (SSBCI) they offer meet the threshold of having a reasonable expectation that they will improve the health or overall function of chronically ill members. This means MA plans must establish and maintain information from relevant research studies or other data to demonstrate that an SSBCI meets these requirements.
The agency has also included SSBCI marketing and communications requirements to prevent MA plans from issuing misleading marketing and communications related to these benefits that may make it appear that the benefits are available to everyone.
Utilization management, prior authorization changes to ensure health equity
The final rule calls for MA organizations to analyze their utilization management (UM) policies and procedures from a health equity perspective. Organizations must ensure:
- At least one member of the UM committee has expertise in health equity
- The UM committee conducts plan-level annual health equity analysis of prior authorization policies and procedures used by the MA plan
- Makes the results of the analysis publicly available on the plan’s website
CMS said in a fact sheet that the goal of the health equity analysis is to create additional transparency and identify disproportionate impacts of UM policies and procedures on enrollees who receive the Part D low-income subsidy, who are dually eligible, or who have a disability.
Right to appeal a decision to terminate coverage of non-hospital provider services
CMS is revising regulations to ensure enrollees in MA have the same access to a quality improvement organization (QIO) review of a fast-track appeal as individuals in traditional Medicare.
The agency will now require the QIO, instead of the MA plan, to review untimely fast-track appeals of a MA plan’s decision to terminate services in a skilled nursing facility, comprehensive outpatient rehabilitation facility or by a home health agency. It also eliminates the provision requiring forfeiture of an enrollee’s right to appeal a termination of services from these providers when they leave the facility.
Enrollment options for dually eligible managed care individuals
CMS aims to improve the experiences and outcomes for dually eligible individuals by increasing the percentage of dually eligible MA enrollees who are in affiliated Medicaid managed care plans, as opposed to MA plans that differ from the enrollee’s Medicaid plan.
The final rule revises the current Part D quarterly special enrollment period (SEP) for dually eligible, and other Part D low-income subsidy enrolled individuals, to a once-per-month SEP to enroll in a standalone prescription drug plan and creates a new integrated care SEP to allow dually eligible individuals to elect an integrated dual eligible special needs plan (D-SNP) when the individual also receives Medicaid services through an affiliated managed care plan.
It also limits enrollment in certain D–SNPs to those individuals who are also enrolled in an affiliated Medicaid managed care organization (MCO) and limits the number of D–SNP plan benefit packages an MA organization, its parent organization, or entity that shares a parent organization with the MA organization, can offer in the same service area as an affiliated Medicaid MCO.
CMS said by reducing the number of plans that can enroll dually eligible individuals outside of the annual election period, the rule will also reduce aggressive, confusing marketing tactics toward dually eligible individuals throughout the year.
Limits to out-of-network cost sharing
The rule limits out-of-network cost sharing for MA D-SNP preferred provider organizations (PPOs) for specific services beginning in 2026. CMS said this will reduce cost-shifting to Medicaid, increase payments to safety net providers, expand dually eligible enrollees’ access to providers, and protect dually eligible enrollees from unaffordable costs.
Contracting standards for Dual Eligible Special Needs Plan Look-Alikes
The rule will lower the MA D-SNP look-alike threshold from 80 percent to 70 percent in 2025 and to 60 percent in 2026. This policy will help to address the continued spread of MA plans that are serving high percentages of dually eligible individuals without meeting the requirements to be a D-SNP and promoting full implementation of requirements for D-SNPs.
Changes to RADV appeals process
CMS finalized revisions to the Risk Adjustment Data Validation (RADV) appeal regulations.
MA organizations will no longer be able to request both a medical record review determination appeal and a payment error calculation appeal at the same time. Instead, they may only request a payment error calculation appeal after the completion of the medical record review determination administrative RADV appeal process.
The final rule also clarifies that a revised audit report containing a recalculated payment error calculation will be issued when a medical record review determination appeal or a payment error calculation appeal is final.
The rule also stipulates that if the CMS administrator does not decline to review or does not elect to review within 90 days of receipt of either the MA organizations’ or CMS’ timely request for review (whichever is later), the hearing officer’s decision becomes final.