CMS finalizes 2025 Medicare Advantage rule: 11 key updates

CMS issued its final 2025 Medicare Advantage and Part D rule April 4, setting new standards around marketing, broker payments, and prior authorization.

Here are 11 things to know about CMS' final rule: 

1. CMS set a fixed amount that agents and brokers can be compensated by MA plans, regardless of the plan a beneficiary enrolls in. The agency increased the final fixed amount by $100, compared to the proposed $31.
   
   
2. Personal beneficiary data collected by a third-party marketing organization for marketing or enrollment purposes may only be shared with another TPMO when prior written consent is given by the enrollee.
   
   
3. Insurers are generally prohibited from paying TPMOs volume-based bonuses for steering a certain number of enrollees to health plans. 
   
   
4. CMS is adding behavioral network adequacy evaluation standards to include providers specializing in mental health and addiction issues.
   
   
5. Plans are required to issue a mid-year notice to enrollees, informing them of any supplemental benefits they have access to in their plan that they have not used.
   
   
6. MA plans must analyze their utilization management policies and procedures from a health equity perspective, including having one member of the UM committee with expertise in health equity and an annual health equity analysis of prior authorization policies.
   
   
7. There are new restrictions on the marketing of supplemental benefits for chronically ill enrollees, requiring plans to disclose that these benefits are only available to beneficiaries with certain diagnoses, not all Medicare beneficiaries. 
   
   
8. Independent contractors will review untimely fast-track appeals of an MA plan’s decision to terminate services in a skilled nursing or outpatient rehab facility, and for home health services.
   
   
9. The rule reduces the number of plans able to enroll beneficiaries dually eligible for Medicare and Medicaid outside of the open enrollment period. This will crack down on year-round aggressive marketing of D-SNP plans, CMS said. 
   
   
10. MA plans will be limited in how much information they can request from CMS when appealing risk adjustment data validation audits.
    
    
11. Part D sponsors will have more flexibility around formulary substitutions of biosimilars with interchangeable generic products.

Read the full rule here.