In early April, the Centers for Medicare and Medicaid Services (CMS) finalized the 2025 Medicare Advantage Rule. This legislation also included changes to Medicare Part D, which covers prescription medications. Many health care organizations were expecting updates surrounding prior authorization, which is a hot topic since proposed federal legislation could speed up the approval process for members. However, there are a range of policy modifications that health plans should be aware of.

One change that will take effect in 2025 will offer beneficiaries better data protection from third-party marketing organizations. CMS also settled on a higher fixed rate that Medicare Advantage plans can pay insurance brokers and agents.

In terms of benefit utilization, CMS is now requiring all health plans to notify their members of any unused supplemental benefits by mid-year. CMS is also mandating all Medicare Advantage plans to analyze their policies surrounding utilization management to be more mindful of health equity. In addition, all utilization management committees must now have at least one member who specializes in health equity.

Similar to prior authorizations, CMS has moved to fast-track the appeals process. This will impact Medicare Advantage plan termination decisions for skilled nursing, home health, and outpatient care. Since the acuity in some of these settings is high, this will help health care teams plan for next steps in a way that effectively manages overall costs.

Some 2025 updates apply directly to provider networks. CMS added network adequacy evaluation standards to a wider range of mental health organizations, including those that specialize in substance use and mental health treatment. This will aim to streamline the assessment process for all in the ever-growing behavioral health industry.

In order to effectively prepare for these policy changes in the next year, it’s recommended that health plans prepare their provider network. Potential action steps may include:

  • Developing verbiage to inform members of their remaining benefits along with how and where to best utilize them will help members get the most out of their plans and drive satisfaction rates higher.
  • Taking steps to focus more on health equity – both within your health plan and the providers you partner with.
    • Staying in communication with your members to learn their needs and help them set goals for their health.
    • Understanding what programming and coverage benefits they are most interested in.
    • Encouraging clinicians in your provider network to advocate for health equity by offering client-centered care.
  • Preparing all behavioral health treatment professionals in your provider network for more stringent network adequacy evaluations. This may include taking advantage of services such as contract management, rate negotiation, and provider data management.