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.
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.
‘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:
- 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.