Hospitals, payers get behind key points of CMS' Medicare Advantage proposed rule

Hospital and payer groups were broadly supportive of proposed changes to Medicare Advantage prior authorization and broker compensation regulations. 

CMS published its proposed Medicare Advantage rules for 2025 on Nov. 6. The agency pitched limiting plans' payments to brokers and prohibiting plans from paying value-based bonuses to third-party marketing organizations. 

CMS also proposed new requirements for plans to create utilization management review committees and have a health equity expert serve on these committees. 

In comments submitted to CMS Jan. 5, the American Hospital Association said it supported the addition of utilization management committees but proposed additional oversight of the committees. The AHA pitched requiring a member of the utilization management committee be a provider from an organization the payer contracts with and requiring the committee's reports to be publicly available. 

"It is especially critical to ensure that UM programs and other MA plan business practices do not create barriers for patients that could contribute to inequities in access to care or health outcomes," the association said in its comments. "At the same time, we recognize that an analysis of UM practices alone may not be sufficient to identify gaps in health equity due to unmet need, and we encourage CMS to continue advancing broader policy efforts to advance health equity goals." 

In a comment letter to CMS dated Jan. 3, the Alliance of Community Health Plans asked CMS to more clearly define the requirements for a health equity expert and requested the agency delay the date by which plans must publish their utilization reviews. 

Broker Payments 

Both the AHA and ACHP expressed support for caps on broker payments proposed by CMS. The proposed rule would cap compensation plans can pay brokers at $632, regardless of the plan a beneficiary enrolls in. This cap is currently $601, but plans can pay administrative fees and other payments on top of this cap to brokers. The new limit would encompass all payments that plans can pay brokers. 

"We are thrilled the administration recognized in this proposed regulation the urgency to address perverse financial incentives, protect consumers from nefarious marketing practices and safeguard the Medicare Trust Fund," ACHP President Ceci Connolly wrote to CMS. 

In comments submitted to CMS Jan. 5, the Better Medicare Alliance, a pro-MA group backed by large insurers, said the agency should regulate the actions of third-party marketing organizations rather than broker payments. 

"Failure to account for third-party marketing organizations to their full extent will not adequately address the concerns CMS raised and Better Medicare Alliance shares, including minimizing incentives to enroll beneficiaries in specific plans and ensuring beneficiaries are appropriately directed to a health plan that best meets their health care needs," the association wrote in its comments. 

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