MAPD - Medicare Advantage 2025

What does Medicare Advantage plans in 2025 hold for your health coverage? The upcoming CMS rules for MAPD Medicare Advantage plans in 2025 will reinforce beneficiary rights, broker accountability, and access to behavioral health—potentially transforming your health care experience.

This guide demystifies the latest Medicare reforms, providing you with the crucial insights needed to navigate your coverage options and secure optimal care.


Key Takeaways

  • The 2025 Proposed Rule for Medicare Advantage and Part D introduces key provisions aimed at protecting beneficiaries, expanding access to behavioral health services, and urging health equity in Utilization Management while mandating public reporting of health equity analysis.


  • Operational changes may include revisions to star ratings, agent and broker compensation limits, and standardized national compensation amounts, emphasizing transparency and objective plan recommendations for better healthcare outcomes.


  • The rule proposes to bolster support for dual eligibles and low-income subsidy recipients, providing more frequent enrollment opportunities and streamlining access to Medicaid benefits to improve the Medicare experience for vulnerable populations.

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Understanding the 2025 Proposed Rule for Medicare Advantage and Part D

The CMS has introduced the 2025 Proposed Rule for Medicare Advantage and Part D, a significant initiative aimed at elevating the healthcare experience for Medicare beneficiaries. This rule includes the following key provisions:

  • Prioritizing beneficiary protections


  • Imposing restrictions on agent and broker arrangements


  • Expanding access to behavioral health providers


  • Incorporating health equity components into Utilization Management functions


The ultimate objective of this rule is to ensure the judicious use of taxpayer funds by Medicare Advantage plans and the effective fulfillment of enrollees’ health or overall function needs.


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These modifications aim not just to safeguard beneficiaries but also to boost competition in the Medicare Advantage and Part D market.

Encouraging competition could potentially lower costs and broaden access to care for low-income beneficiaries, marking a pivotal stride towards democratizing healthcare access and affordability through cost sharing.


Star Ratings Revisions

One of the key revisions proposed by the CMS is related to the star ratings for Medicare Advantage plans. Under the new rule, MA plans that fail to submit complete data for partially favorable or unfavorable reconsiderations to Independent Review Entities (IREs) will automatically receive a 1-star rating for timeliness and quality of appeals processes.

This measure is aimed at ensuring that MA plans provide timely and appropriate access to medically necessary services.

The American Hospital Association (AHA) supports this proposal, stressing the importance of proper appeals handling. The AHA has expressed concerns that some Medicare Advantage plans manage appeals in a way that could shield denials from Independent Review Entity (IRE) oversight, potentially distorting MA plan star ratings on appeals measures.

Hence, this measure is not only a step towards accountability but also towards transparency.


Operational Changes

Beyond revising the star ratings, the CMS has proposed operational modifications to the Medicare Advantage program and the Medicare Cost Plan Program. The objective of these changes is to sync agent and broker incentives with the goal of enrolling individuals in the Medicare Advantage plan most suited to their healthcare needs.

The proposal plans to prohibit certain contract terms for agents and brokers, such as those that may prevent objective plan recommendations or have incentives tied to enrollment rates.

The potential implications of these operational changes are significant. By aligning agent and broker incentives with the beneficiaries’ needs, the proposed rule could lead to more suitable plan selections and improved healthcare outcomes.

However, it is also important to note that raising the national Medicare Advantage compensation amount could result in higher overall Medicare spending due to increased administrative costs for plans paying higher agent/broker fees.


Enhancing Behavioral Health Services in Medicare Advantage

The 2025 proposed rule also targets improvements in behavioral health services within Medicare Advantage. The CMS is suggesting updates to network adequacy standards with the intention of boosting Medicare Advantage beneficiaries’ access to behavioral health services.


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‘Outpatient Behavioral Health’ has been proposed as a new facility-specialty type subject to time-and-distance requirements for network adequacy. This new category may include a variety of providers such as:

  • MFTs


  • MHCs


  • Opioid treatment providers


  • Community Mental Health Centers


  • Addiction medicine physicians


In addition, the CMS proposes that Medicare Advantage plans can receive a 10% credit towards network adequacy standards by including telehealth providers for Outpatient Behavioral Health services.

This move not only promotes the use of modern technology in healthcare but also accommodates the ongoing shift towards remote healthcare services due to the COVID-19 pandemic.


Reimbursing MFT and MHC Services

One of the key components of the proposed rule is the introduction of a new Medicare benefit category for services by Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs), including behavioral health counseling. This change will significantly impact their reimbursement under Medicare Advantage plans.

MFTs and MHCs are eligible to provide services in various settings, such as private practice and outpatient behavioral health facilities, covered by Medicare Advantage.

However, it’s worth noting that MFT associates, interns, and students are not eligible to enroll as Medicare providers, and therefore cannot be reimbursed under Medicare Advantage plans.


Access to Opioid Treatment Programs and Addiction Medicine Physicians

Proposals from the CMS also include improving access to opioid treatment programs and addiction medicine physicians. Under the proposed rule, the ‘Outpatient Behavioral Health’ category for network adequacy standards in Medicare Advantage plans would encompass addiction medicine physicians and Opioid Treatment Program providers.

This inclusion is aimed at providing enrollees with increased access to a range of behavioral health services.

Furthermore, Medicare Advantage plans can gain a 10% credit towards meeting network adequacy requirements by incorporating telehealth providers from the Outpatient Behavioral Health specialty.

This provision potentially enhances the availability of telehealth options for addiction treatment, thereby extending the reach of these critical services.

Promoting Health Equity in Medicare Advantage Plans

The proposed rule also underscores the importance of promoting health equity in Medicare Advantage Plans. The new rule mandates that Medicare Advantage plans carry out an annual health equity analysis pertaining to their prior authorization policies and procedures.


Medicare advantage plans


The focus of this analysis is on the impact of prior authorization on enrollees who possess specific social risk factors.

Additionally, Utilization Management committees within Medicare Advantage organizations must include a member with expertise in health equity.

The results from the health equity analysis must be made publicly available on the Medicare Advantage plan’s website. This step is aimed at promoting transparency and accountability in efforts to reduce healthcare disparities.


Impact on Underserved Populations

The proposed health equity requirements bear significant implications for underserved populations within Medicare Advantage. With a growing number of beneficiaries of color opting for the Medicare Advantage program, it underscores its critical role in catering to the needs of these populations.

Moreover, Black and Latino beneficiaries in Medicare Advantage are more engaged with preventative healthcare services than their counterparts in FFS Medicare. Medicare Advantage enrollees also experience notably lower rates of avoidable hospitalizations and all-cause readmissions.

The proposal to include health equity experts on utilization management committees could further advance the identification and reduction of barriers to care for underserved populations within Medicare Advantage.


Public Reporting of Health Equity Analysis

The public reporting of health equity analysis by Medicare Advantage organizations is seen as a key step in maintaining transparency and accountability in efforts to reduce healthcare disparities.

By making these results publicly available, Medicare Advantage organizations are held accountable for their efforts to address health equity.

Moreover, the public reporting of these analyses provides valuable insights into the progress made towards achieving health equity. The Better Medicare Alliance suggests that the success of Medicare Advantage in addressing health disparities could provide lessons that might be applied to ensure continued progress toward greater health equity for all beneficiaries.



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Supporting Dual Eligibles and Low-Income Subsidy Recipients

The proposed rule bolsters support for dual eligibles and low-income subsidy recipients by providing more regular opportunities for enrollment and plan modifications.

It suggests a new Special Enrollment Period, permitting dual eligibles to enroll in an integrated Dual Eligible Special Needs Plan monthly. This is intended to enhance flexibility compared to the current quarterly SEP.


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In addition, beneficiaries who qualify for the Medicare Part D Low-Income Subsidy will now be able to adjust their Medicare Advantage or Medicare Part D coverage once per quarter.

This provision offers more frequent opportunities for plan changes tailored to their needs. As a result, these changes represent a significant step towards improving the Medicare experience for this vulnerable population.


Integrated Care SEP

The Integrated Care Special Enrollment Period (SEP) is proposed to enhance the integration of Medicare and Medicaid services for dual-eligible individuals. Under this new rule, dual-eligible beneficiaries will be able to enroll into D-SNPs on a monthly basis using the Integrated Care SEP.

This enhanced flexibility can lead to better integration of care for those who are dually eligible for Medicare and Medicaid.

Furthermore, beneficiaries who qualify for the Medicare Part D Low-Income Subsidy will have increased opportunities to adjust their Medicare Advantage or Medicare Part D coverage more frequently via the Integrated Care SEP.

This provision is aimed at providing more flexibility and better access to care for these beneficiaries.


Streamlining Access to Medicaid Benefits

The proposed rule seeks to streamline access to Medicaid benefits for dually eligible individuals by possibly offering:

  • More frequent opportunities for enrollment and switching plans


  • Expanded access to integrated materials


  • Unified appeal processes


  • Continued Medicare services during an appeal


These measures are proposed to streamline the experience of dually eligible individuals.

Furthermore, allowing more frequent changes to Medicare Advantage and Part D coverage can improve the integration of care for those who are dually eligible for Medicare and Medicaid, thereby streamlining their access to Medicaid benefits.

These provisions could potentially improve the coordination of benefits and care for dually eligible individuals.


Other Notable Proposals in the 2025 Medicare Advantage Rule

There are several other notable proposals in the 2025 Medicare Advantage Rule. For instance, the CMS seeks to enhance data capabilities and transparency in Medicare Advantage.

This includes collecting more comprehensive data on Medicare Advantage, such as Medical Loss Ratios (MLRs), supplemental benefits costs and utilization, and race and ethnicity data. Enhancing transparency also includes the requirement for the public posting of prior authorization denials and approvals.


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Additionally, the CMS aims to improve risk adjustment data validation processes to ensure accuracy and fairness in the Medicare Advantage program.

In addition, the CMS aims to have detailed information on supplemental benefits by 2025, starting with the first collection in December 2024 for the plan year 2023. This will help to understand not only offerings, spending, enrollee usage, and plan-level utilization but also the prevalence of unused supplemental benefits.

These initiatives are all part of the CMS’s comprehensive data collection efforts to improve the Medicare Advantage program.


ePrescribing Standards Alignment

The 2025 proposed Medicare Advantage rule incorporates provisions aimed at aligning e-prescribing standards with existing Health and Human Services (HHS) guidelines.

This includes transitioning to the National Council for Prescription Drug Plans (NCPDP) SCRIPT standard version 2022011 and adopting the NCPDP Real-Time Prescription Benefit (RTPB) standard version 12. These changes aim to streamline the e-prescribing process under Part D.

Furthermore, changes to the ePrescribing standards also encompass modifications to the current regulatory text concerning HIPAA standards for eligibility transactions.

Provided that these provisions are adopted in a second final rule, the new e-prescribing standards will not be applied to coverage until January 1, 2025, or later.


Fast-Track Appeals Process Enhancements

The CMS included proposals for an independent fast-track appeals process for non-hospital services in the CY 2025 Medicare Advantage and Part D proposed rule. The aim of the fast-track appeals process enhancements is to improve beneficiary protections regarding the termination of coverage for non-hospital services.

Stakeholders were invited to submit comments on the proposals by January 5, 2024, indicating a period of public review and feedback on the suggested changes.


In conclusion, the 2025 Proposed Rule for Medicare Advantage and Part D represents a significant overhaul of the current system, aiming to improve beneficiary protections, restrict agent/broker arrangements, increase access to behavioral health services, and promote health equity.

The rule also introduces new measures to support dual eligibles and low-income subsidy recipients, as well as align e-prescribing standards and enhance the fast-track appeals process for non-hospital services.

As we move forward, these changes are expected to bring about significant improvements to the Medicare Advantage and Part D programs, benefiting millions of Medicare beneficiaries across the country.

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Frequently Asked Questions


What is the Medicare Advantage Rule 2025?

The Medicare Advantage Rule 2025 includes an independent, fast-track appeals process for non-hospital services, curbs inappropriate marketing practices, expands access to behavioral health services, promotes health equity, and advances Medicare-Medicaid integration.


What is the CMS 2024 Medicare Advantage proposed rule?

The CMS 2024 Medicare Advantage proposed rule includes changes such as closing loopholes for D-SNP look-alike plans, expanding language access, protecting beneficiaries from misleading marketing, and closing gaps in prescription drug coverage for Medicaid.

It also aims to increase access to coverage of Medicare Part D premiums.

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Compare Medicare Plans

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Speak with a licensed insurance agent

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