Regulators will enhance Medicare Advantage marketing, prior authorization and network adequacy standards for 2025, the Centers for Medicare and Medicaid Services said in a final rule Thursday.
The agency set fixed compensation for agents and brokers to prohibit them from steering patients to plans that don't best suit their health needs. But CMS increased the pay cap for initial enrollments into plans by $100, versus the $31 proposed in November.
Related: Marketing limits could shake up Medicare Advantage market
The regulation also prohibits beneficiary information from being shared between marketers without the individual’s consent.
The agency is requiring more transparency into whether prior authorization affects health equity, as well. Under the rule, Medicare Advantage carriers will need to staff utilization management committees with at least one health equity expert, perform analyses and publicly release their results on plan websites.
Medicare Advantage plans covered 33.8 million people as of March 1, up 6.4% from a year ago, according to recent CMS data. CMS touted the new policies as a way to improve the Medicare Advantage program and protect those consumers. They will kick in with the upcoming annual open enrollment period, CMS said in a fact sheet.
“In my travels around the country, I always hear from Medicare enrollees that Medicare can be confusing and access to accurate, unbiased, actionable information is vital — whether it’s about enrollment or how to access services,” Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, said in a news release.
In recent years, CMS sought to rein in Medicare Advantage marketing tactics, put limits on prior authorizations and modify the star ratings program.
The stronger marketing policies build on President Joe Biden’s campaign to curb Medicare Advantage advertising as consumer complaints rise. Medicare Advantage insurers and online brokers are also the target of an ongoing Senate investigation.
The final regulation also follows CMS’ rate announcement Monday that will cut Medicare Advantage payments 0.16% in 2025.
As part of the rule released Thursday, the agency finalized a plan to allow members dually eligible for Medicare and Medicaid and those who qualify for Part D low-income subsidies to sign up for a new, integrated special needs plan monthly, rather than quarterly.
The final rule also required Medicare Advantage carriers to:
- Collect and publicly report how their preapproval requirements impact people with disabilities, those who are enrolled in special needs plans or low-income members who receive subsidies for Medicare Part D drug coverage.
- Include marriage and family therapists, mental health counselors, addiction medicine clinicians and opioid-use providers in their networks.
- Provide personalized notifications to members midyear about unused supplemental benefits and how to access the benefits.
- Put independent contractors in charge of reviewing members’ appeals for longer nursing home, outpatient or home healthcare services.
- Limit the amount of information they can ask for when challenging risk-adjustment audits.
The rule also grants more flexibility to carriers by lifting a requirement that they notify regulators about formulary changes between biologic drugs and their generic equivalents.
The insurance industry appeared pleased with the regulation immediately following its release.
"We are thrilled CMS embraced our proposal to cap total broker payment,” Ceci Connolly, Alliance of Community Health Plans president and CEO, said in a news release. “This commonsense policy change eliminates those perverse financial incentives and levels the playing field for health competition.”
In comments on the proposal, large health insurers wrote it lacked clarity on how third-party marketing organizations could be reimbursed. Nonprofit insurers supported the proposal as they said it could promote competition in Medicare Advantage.
Better Medicare Alliance President and CEO Mary Beth Donahue said in a news release the organization supports marketing and prior authorization efforts that modernize the Medicare Advantage program.