The Centers for Medicare & Medicaid Services (CMS) late Monday released the 2025 Medicare Advantage (MA) proposed rule, which revises provisions of the MA program, including cracking down on payments to brokers or agents for enrolling beneficiaries in certain plans, improving supplemental benefits, increasing access to behavioral health care providers, and promoting equity in coverage
The 486-page proposed rule, which is scheduled to be published in the Federal Register on November 15, curtails excessive compensation to agents and brokers who steer prospective enrollees to specific plans. CMS said these new guardrails aim to “protect people with Medicare and promote a competitive marketplace.”
“People with Medicare deserve to have accurate and unbiased information when they make important decisions about their health coverage," CMS Administrator Chiquita Brooks-LaSure said in the announcement. “Today’s proposals further our efforts to curb predatory marketing and inappropriate steering that distorts healthy competition among plans.”
Proposed marketing changes
The 2025 proposal builds on the 2024 MA final rule, which banned misleading television ads and strengthened accountability for plans to monitor agent and broker activities. Testimony during a recent Senate Finance Committee hearing revealed that most enrollees rely on the advice of a broker to choose an MA plan but some larger firms and third-party marketing organizations leverage their influence and pay big bucks to agents or brokers who get enrollees to sign up for their plans.
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CMS said it is concerned that some MA plans compensate agents and brokers in a way that may circumvent existing payment rules and inappropriately steer individuals to enroll in plans that don’t meet their needs. These financial incentives include excessive broker and agent compensation and other bonus arrangements often paid by large plans for steering beneficiaries to some plans over others instead of recommending plans on the prospective enrollee’s best interest.
As a result, CMS proposes to redefine “compensation” to set a clear, fixed amount of $632 (compared to the existing national compensation cap of no more than $601) that national agents and brokers can be paid regardless of the plan the beneficiary enrolls in. The proposal ensures that agent and broker compensation reflect only the legitimate activities associated with the sales and enrollment of a beneficiary into an MA plan or Part D plan. The fixed amount would eliminate the current variability in payments and improve the predictability of compensation for agents and brokers.
Furthermore, the proposed rule generally prohibits contract terms between MA plan organizations and marketing middlemen, such as field marketing organizations, that result in volume-based bonuses for enrollment into certain plans, which may interfere with the ability of agents or brokers to assist the enrollee in finding the plan that is best suited to their needs.
Proposed changes to supplemental benefits and how plans market them
CMS said 99 percent of MA plans offer at least one supplemental benefit (the average is 23 supplemental benefits) and the most frequently offered benefits are vision, hearing, fitness, and dental. Some of the benefits address unmet social determinants of health needs, such as food insecurity or inadequate access to transportation. However, in many cases plans report that few enrollees use these benefits.
To ensure the benefits effectively reach enrollees and meet their needs (and not used as a marketing ploy to attract enrollees to plans), CMS wants to require MA plans to send a personalized notification to their enrollees mid-year to let them know of any unused supplemental benefits available to them. The notification would 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 if additional help is needed.
CMS also proposes additional requirements to ensure that benefits offered as special supplemental benefits for the chronically ill (SSBCI) are backed by evidence. By the time they submit bids, plans must demonstrate that the SSBCI items and services meet the legal threshold of having a reasonable expectation of improving the health or overall function of chronically ill enrollees and are supported by research. CMS proposes MA plans establish and maintain bibliographies of relevant research studies or other data to demonstrate that an SSBCI meets these requirements. The agency also wants to update SSBCI marketing requirements to prevent misleading marketing related to these benefits that makes it appear that the benefits are available to everyone.
Proposed changes to prior authorization to ensure health equity
CMS said it is concerned that certain prior authorization policies may have a disproportionate impact on underserved populations and may delay or deny access to certain services. To provide additional safeguards, CMS wants to require that MA plans include an expert in health equity on their utilization management (UM) committees and that the committees conduct an annual health equity analysis of the plans’ prior authorization policies and procedures. This analysis would examine the impact of prior authorization on enrollees with one or more of the following social risk factors—eligibility for Part D low-income subsidies, dual eligibility for Medicare and Medicaid, or having a disability—compared to enrollees without these risk factors. The results of the analysis must be made publicly available on plan websites. “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, are dually eligible, or have a disability,” CMS said.
Proposed changes to improve access to behavioral health care providers
CMS wants to update network adequacy standards to improve access to behavioral health care services. The Consolidated Appropriations Act, 2023 established a new statutory Medicare benefit category for services furnished by marriage and family therapists (MFTs) and mental health counselors (MHCs). In the recently published 2024 Physician Fee Schedule Final Rule, CMS also finalized that addiction or drug and alcohol counselors, who otherwise meet the statutory requirements of MHCs, are able to enroll in Medicare. An estimated 400,000 MFTs and MHCs will be eligible to enroll in Medicare, and enrolled MFTs and MHCs can bill Medicare for services starting January 1, 2024. Most of these providers practice within outpatient behavioral health facilities, such as mental health centers, substance use treatment centers, and hospitals. To help ensure that people with MA plans have access to behavioral health providers, including these newly enrolled providers, CMS proposes to add a range of behavioral health providers under one category called “Outpatient Behavioral Health.” Specialists under this category will include MFTs and MHCs, Opioid Treatment Program providers, Community Mental Health Centers, addiction medicine physicians, and other providers who furnish addiction medicine and behavioral health counseling or therapy services in Medicare today.
CMS also wants to add the Outpatient Behavioral Health facility specialty to the list of the specialty types that will receive a 10 percent credit if the MA plan organization’s contracted network of providers includes one or more telehealth providers of that specialty type who provide additional telehealth benefits for covered services.
Proposed changes to RADV appeals process
The proposed rule also addresses operational constraints within existing Risk Adjustment Data Validation (RADV) appeal regulations. CMS proposes that MA plan organization may request only a medical record review determination appeal or payment error calculation appeal for purposes of reconsideration, and not both at the same time.
CMS suggests that organizations that request a medical record review determination appeal may only request a payment error calculation appeal after the completion of the medical record review determination administrative RADV appeal process. In addition, the proposed rule clarifies that a revised audit report containing a recalculated payment error calculation will not be issued by the Secretary at each level of appeal but instead will be issued when a medical record review determination appeal or a payment error calculation appeal is final. The proposal also includes a requirement 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 plan’s or CMS’s timely request for review (whichever is later), the hearing officer’s decision becomes final.
Other proposed changes
The rule also proposes changes to:
- Allow MA plan beneficiaries to access the Quality Improvement Organization’s fast-track appeals process.
- Allow Part D plans more flexibility to quickly substitute lower cost biosimilar biological products
- Increase the percentage of dually eligible managed care enrollees who receive integrated Medicare and Medicaid services by revising the current quarterly special enrollment period to monthly opportunities.
- Limit out-of-network cost sharing for D-SNP preferred provider organizations (PPOs) for specific services, beginning in 2026. The proposed rule would 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.
- Lower the D-SNP look-alike threshold from 80 percent to 70 percent in 2025 and to 60 percent in 2026.
Comments on the proposed rule must be submitted by January 5, 2024. For information on submitting comments, see the proposed rule in the Federal Register.