The Center for Medicare and Medicaid Services (CMS) continues its efforts to make improvements to the Medicare Advantage program in its Contract Year 2025 Medicare Advantage (MA) and Part D final rule (CMS-4205-F), which will be published in the Federal Register on April 23, 2024. This is the rule that makes policy and technical changes to the program.

Some of the key provisions of the final rule include:

• Parity for fast-track appeals on coverage termination decisions in SNF and HH. CMS has made an important change for MA enrollees who have their skilled nursing facility or home health services terminated. Currently, these individuals must appeal quickly to receive a fast-track appeal from the MA plan or lose their right to a fast-track appeal of a plan’s decision to end their care. The final rule changes this so if an enrollee has a fast-track appeal right even if it is not a timely request is not submitted and that appeal would be reviewed by an independent review entity known as a Quality Improvement Organization(QIO). In addition, enrollees often don’t appeal because they can’t afford to pay privately for services if the appeal is unsuccessful and therefore, may leave the SNF or stop home health services. In the past, this action would prevent them from being eligible to receive a fast-track appeal. Under the new rule, this is no longer the case. These changes align this appeals process with traditional Medicare giving the beneficiary the same rights regardless of how they receive their Medicare benefits.
• Taking steps to limit anti-competitive practices.The final rule requires MA plan brokers are paid the same commissions regardless of the plan the beneficiary ultimately enrolls in and establishing that rate at $100 for initial enrollments. This eliminates the incentive for brokers to steer potential enrollees into certain plans who paid higher commissions or provided other incentives. MA enrollment has continued to consolidate into a few national plans in recent years and LeadingAge hopes this change will begin to level the playing field among all available plans. Our members report that typically they find the smaller, or more regional/local plans to be better partners often approving services for longer durations, being more likely to offer value-based payment arrangements, and are often easier to find a person with which to resolve issues. Market consolidation has had a negative impact on SNFs and HH agencies who must enter contract negotiations with no good financial choices – accept a bad contract where the reimbursement doesn’t cover their costs or forgo serving a significant portion of the population.
• Requires Analysis of Prior Authorizations and Equitable Access to Care. LeadingAge has been dogged in its advocacy for MA enrollees to have equitable access to Medicare benefits and reduce the excessive and unnecessary task of seeking prior authorizations and reauthorizations for care. MA plans have used prior authorizations as a tool to limit some of this access. In 2024, CMS took steps to clarify when plans can deploy this tool and what rules must be followed. In the final 2025 MA rule, we see CMS adding another layer of beneficiary protection by requiring the MA plans to include a health equity expert on their Utilization Management committees, conduct a plan-level health equity review of the impacts their prior authorization policies and procedures have on dual eligibles, those receiving low-income Part D subsidies and those with disabilities, and publicly display the results on their websites. We feel this is an important step and hope it achieves the intended goal. However,  we argued in our comment letter that this information would be better displayed in the Medicare Plan Finder information on plans than individual plan websites so beneficiaries can more easily compare plan performance as they are choosing a Medicare Advantage plan.
• Seeks increased accountability on supplemental benefits. In 2024, CMS began collecting data on supplemental benefits related to cost and utilization, which will provide important information about whether rebate dollars are actually being spent on the MA enrollees as intended . The 2025 final rule continues this accountability by requiring plans to notify beneficiaries mid-year about supplemental benefits still have available to them. It also requires plans to compile a bibliography of evidence on all  Supplemental Benefits for the Chronically Ill benefits they offer demonstrating how these benefits have a reasonable expectation of improving the recipients health or overall function.  Finally, CMS places limits how these benefits are marketed to ensure beneficiaries understand which benefits are actually available to them. Beginning October 1, 2024, MA plans and their brokers/agents will have to specify which benefits an enrollee will have access to.
• Facility-Based ISNP exception to network adequacy. The final rule will permit facility-based institutional special needs plans (ISNPs) an exception to network adequacy requirements if they can substantiate that the enrollees continue to have adequate access to basic benefits through either telehealth or out-of-network care at in-network cost sharing. CMS notes in its proposal that it will require the facility-based I-SNP to provide
  “evidence” to support its claim of an inability to contract with certain specialists. Acceptable “evidence”,  will include…

Unlike the 2024 rule, the 2025 policy rule changes will be felt by providers less directly.  The rule updates network adequacy standards for behavioral health services, making changes that aim to increase the percentage of the dual population enrolled in a single plan that provides both their Medicare and Medicaid benefits,