By Fortune – April 22, 2024

It may be months before the calendar flips to 2025, but not for Medicare. The Centers for Medicare & Medicaid Services (CMS), which runs the program, just announced two major changes for 2025 you’ll want to know about. Next year, Medicare will also dramatically alter the maximum amount beneficiaries will need to pay out-of-pocket for their covered medications. Read the article.

Background

On April 4, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises the Medicare Advantage Program, Medicare Prescription Drug Benefit Program (Medicare Part D), Medicare Cost Plan Program, Programs of All-Inclusive Care for the Elderly (PACE), and Health Information Technology Standards and Implementation Specifications.

Additionally, this final rule addresses several key provisions that remain from the CY 2024 Medicare Advantage and Part D proposed rule, CMS-4201-P, published on December 14, 2022. Together, the changes in this final rule build on existing Biden-Harris Administration policies to strengthen protections and guardrails, promote healthy competition, and ensure Medicare Advantage and Part D plans best meet the needs of enrollees. In addition, these policies promote access to behavioral health care providers, promote equity in coverage, and improve supplemental benefits. 

This fact sheet discusses the major provisions of the 2025 final rule which can be downloaded here: https://www.federalregister.gov/public-inspection/2024-07105/medicare-program-medicare-advantage-and-the-medicare-prescription-drug-benefit-program-for-contract

Many individuals with Medicare rely on agents and brokers to help navigate complex Medicare choices as they comparison shop for coverage options. The Medicare statute requires that CMS must establish guidelines to ensure that the use of compensation creates incentives for agents and brokers to enroll individuals in the Medicare Advantage or Part D plan intended to best meet the prospective enrollee’s health care needs. However, excessive compensation, and other bonus arrangements, offered by plans to agents and brokers can result in individuals being steered to some Medicare Advantage and Part D plans over others based on the agent or broker’s financial interests, rather than the prospective enrollee’s health care needs. 

CMS is cracking down on that. Specifically, CMS is finalizing requirements that redefine “compensation” to set a clear, fixed amount that agents and brokers can be paid regardless of the plan the individual enrolls in, addressing loopholes that result in commissions above this amount that create anti-competitive and anti-consumer steering incentives. The provisions of this final rule, which are applicable beginning with the upcoming Annual Enrollment Period, ensure that agent and broker compensation reflect only the legitimate activities required of agents and brokers, by broadening the scope of the regulatory definition of “compensation,” so that it is inclusive of all activities associated with the sales to/enrollment of an individual into a Medicare Advantage or Part D plan.

In response to feedback from stakeholders, CMS is increasing the final national agent/broker fixed compensation amount for initial enrollments into a Medicare Advantage or Part D plan by $100, which is an amount higher than what was proposed ($31). CMS believes this increase will provide agents and brokers with sufficient funds to serve individuals with Medicare. This increase will eliminate variability in payments and improve the predictability of compensation for agents and brokers. This increase will be added to agent and broker compensation payments for the Annual Election Period in Fall 2024 and applied to all enrollments effective in CY2025 and future contract years. 

Additionally, the final rule generally prohibits contract terms between Medicare Advantage organizations/Part D sponsors and middleman Third Party Marketing Organizations (TPMOs), such as field marketing organizations, which may directly or indirectly create an incentive to inhibit an agent or broker’s ability to objectively assess and recommend the plan that is best suited to a potential enrollee’s needs. In the final rule, CMS provides several examples of contract terms that will be impermissible under this prohibition, including provisions offering volume-based bonuses for enrollment into certain plans.

These final policies advance the goals of President Biden’s historic Competition Council and Executive Order signed in July 2021, by helping to ensure a robust and competitive Medicare Advantage marketplace.

The Centers for Medicare & Medicaid Services (CMS) finalized the Calendar Year (CY) 2025 Rate Announcement for the Medicare Advantage (MA) and Medicare Part D Prescription Drug (Part D) Programs that updates payment policies for these programs and ensures payment accuracy.

The Rate Announcement complements policies in the CY 2025 MA and Part D proposed rule that would strengthen protections for the millions of people who rely on MA and Medicare Part D prescription drug coverage, which will be finalized in the coming days.  Under this CY 2025 Rate Announcement,  payments from the government to MA plans are expected to increase on average by 3.70 percent, or over $16 billion, from 2024 to 2025. The federal government is projected to pay between $500 and $600 billion in Medicare Advantage payments to private health plans in 2025.

The CMS prior authorization rule significantly impacts insurers by mandating more efficient and transparent prior authorization processes, particularly for Medicare and Medicaid plans. This rule compels insurers to adopt standardized electronic communication methods, enhancing administrative efficiency and patient care coordination.

While it may initially increase compliance costs due to necessary IT upgrades and procedural changes, it aims to reduce inappropriate denials and appeals, thereby potentially lowering long-term operational costs. Insurers will need to adjust their prior authorization criteria and reporting practices, ensuring better patient outcomes and higher satisfaction, which could ultimately lead to cost savings and improved service quality.

Here's how this rule generally affects insurers:

Increased Administrative Efficiency: The rule aims to standardize and streamline the prior authorization process. Insurers are expected to adopt more efficient electronic communication methods, which can reduce administrative burden and costs over time.

Enhanced Transparency: Insurers are required to be more transparent about their prior authorization requirements and policies. This can involve publicly disclosing the rationales for denials and providing specific information about the services that require prior authorization.

Improved Patient Care Coordination: By requiring insurers to expedite the prior authorization process, the rule intends to minimize delays in patient care. This may lead to better coordination and continuity of care.

Potential for Increased Compliance Costs: Implementing standardized electronic processes and adhering to new transparency requirements may initially increase operational costs for insurers. This includes costs related to upgrading IT systems, training staff, and modifying existing procedures.

Impact on Clinical Decision-Making: Insurers may need to adjust their criteria for prior authorization to align with the new rules. This could affect how they manage approvals for certain treatments or medications.

Data Reporting Requirements: Insurers might be required to report on their prior authorization activities, including denial rates and the average time taken to respond to requests. This adds an additional layer of data management and reporting.

Potential Reduction in Denials and Appeals: The standardization and transparency required by the rule could lead to a decrease in inappropriate denials, thereby reducing the volume of appeals insurers need to process.

Quality of Care and Patient Satisfaction: Improved and quicker prior authorization processes can lead to better patient outcomes and higher patient satisfaction, which is beneficial for insurers in terms of reputation and patient trust.

Adaptation to Technology Standards: Insurers will need to ensure that their electronic communications meet the technical standards set by CMS, which may require significant IT infrastructure adjustments.

Long-Term Cost Savings: While there might be initial costs associated with complying with the new rule, in the long run, the efficiencies gained could lead to cost savings for insurers.

Insurers must stay informed and adapt to these changes to remain compliant with CMS regulations while continuing to provide effective services to their beneficiaries.

You can view the details here.

CMS has proposed new regulations that will impact agent and broker compensation – as well as potentially disrupt the FMO support model. Time is running out for your voice to be heard and influence the final rule!

Precision Senior Marketing is actively engaging with CMS, and subsequently lawmakers in DC, to influence the final language of the proposed rule. The first and primary method to influence the final rule is through the comment letter process. Comment letters on this proposed rule are due to CMS no later than January 5^th at 5PM ET.

As a critical stakeholder, we encourage you to write your own letter to CMS explaining the significant value that Agents and FMOs provide to American seniors in MA distribution and post-enrollment support. Your efforts here can play a vital role in shaping the final rule that CMS will enact. To help you draft an effective 1-page comment letter, we have provided detailed guidance on yourFMO.com.

NOTE: CMS discounts form / templatized letters – so to ensure the greatest impact of your submission, we have provided bullets for you to consider to include or summarize, in your words, for your own unique letter. This should allow you to craft an impactful letter in as little as 10 minutes.

Will you join us in the effort to protect agents, brokers, and FMOs – and educate Washington on the vital role we play in ensuring consumers are placed in the right plan for their healthcare needs?

For Agent Use Only. Not for the general public.

Preparing for the 2024 Annual Enrollment Period (AEP)

Preparing for the 2024 Annual Enrollment Period (AEP) in the Medicare market requires strategic planning and a proactive approach to effectively meet the needs of beneficiaries. As this critical period approaches, there are several key steps to consider in order to maximize your success and provide valuable services to your clients.

First and foremost, staying updated on changes to Medicare regulations, plan offerings, and industry trends is paramount. The healthcare landscape is constantly evolving, and being well-informed positions you as a reliable source of information for beneficiaries seeking the right coverage. Attend seminars, webinars, and training sessions provided by insurance carriers to ensure you're up-to-date with the latest developments.

Reviewing your marketing and outreach strategies is essential to engage potential clients during the AEP. Refresh your online presence by updating your website, social media profiles, and other digital channels. Consider creating informative content such as blog posts, videos, and downloadable guides that address common questions and concerns about Medicare plans. Tailoring your messaging to highlight the advantages of different plans can help beneficiaries make informed decisions.

Focusing on compliance is also crucial during the AEP. Familiarize yourself with the Medicare Marketing Guidelines issued by the Centers for Medicare & Medicaid Services (CMS). These guidelines outline the dos and don'ts of marketing Medicare plans. Ensuring that your marketing materials are accurate, transparent, and compliant will maintain your reputation and prevent potential legal issues.

Lastly, anticipate the surge in inquiries and be prepared to offer personalized assistance to beneficiaries. Consider implementing systems to manage incoming queries efficiently, whether through your website, email, or phone. Providing clear and concise information, as well as addressing concerns promptly, can set you apart as a trustworthy advisor. By offering exceptional customer service, you'll establish strong relationships with clients that extend beyond the AEP.

By strategically approaching this period, you'll not only serve your clients effectively but also position yourself as a knowledgeable and reliable Medicare advisor.

At PSM, we are committed to providing our agents with a range of resources and support to help them succeed. From personalized marketing materials to interactive sales strategies, our goal is to empower agents with the latest tools, technology and mentorship to achieve new levels of success this AEP.

AEP Resources:

Powerful Partnerships:

We are committed to providing our agents with a range of resources and support to help them succeed: Our powerful partnerships include:

Strong relationships with insurance carriers and industry experts to provide agents with access to the best products, tools, and support.

Capital infusion and acquisition strategies to help agents expand their business and reach their ultimate goals.

Dedicated service and mentorship from experienced professionals to help agents build a successful business.

Proprietary lead, training, marketing and enrollment platforms to streamline your sales process and business practices.

Compliance oversight to ensure agents are meeting regulatory requirements and operating ethically.

Succession planning and agency building support to help agents plan for the future and achieve long-term success.

AEP Helpful Guides:

We are here to support!

As a reminder, We pride ourselves on a "Do the Right Thing" approach and will go above and beyond to service the needs of our agents. We look forward to having a successful AEP and supporting you with products, technology and the personalized service you have come to expect from PSM. We appreciate the opportunity to earn your business and wish you the best!

The Inflation Reduction Act of 2022 was signed into law on August 16, 2022. The new law provides meaningful financial relief for millions of people with Medicare by improving access to affordable treatments and strengthening the Medicare Program both now and in the long run. The law makes improvements to Medicare by expanding benefits, lowering drug costs, keeping prescription drug premiums stable, and improving the strength of the Medicare program. The law also extends enhanced financial help to purchase HealthCare.gov and state-based Marketplace plans and expands access to Advisory Committee on Immunization Practices (ACIP) recommended vaccines for adults with Medicaid coverage.

This law means millions of Americans across all 50 states, U.S. territories, and the District of Columbia will save money from meaningful benefits. The Inflation Reduction Act is accomplishing the following just one year after being enacted:

• Saving Affordable Care Act Marketplace consumers an average of more than $800 per year from continued expansion of financial assistance, based on national estimates.
• Driving the nation’s uninsured rate to historic lows.
• Lowering insulin costs for 4 million seniors and other Medicare beneficiaries with diabetes by capping a month’s supply of each covered insulin at $35.
• Providing ACIP-recommended adult vaccines at no cost to millions of people with Medicare.
• Lowering out-of-pocket costs for some people with Medicare for certain Part B drugs and biologicals with prices that have increased faster than the rate of inflation.
• Projecting savings for nearly 19 million seniors of an average of $400 per year when the $2,000 cap on out-of-pocket prescription drug costs goes into effect in 2025.

“Medicare beneficiaries were at the center of the conversation when CMS enacted new marketing rules earlier this year. But with these changes agents may find they will need to pivot from their familiar marketing approach.”

Good news: PSM anticipated these changes and activated a task force to study the published rules and clarify any implications for agents.

More good news: With AEP a few short weeks away, agents have the tools to ensure your marketing efforts and activities are compliant with the new rules. Let’s look at the rules changes.

July 7 marked 100 days until the start of Medicare's Annual Enrollment Period – affectionally known as AEP – and it's time to get excited! With new rules and regulations from CMS taking affect and new carrier products to learn and master, it's important that all of us to stay up to date and think through our collective strategies. According to recent statistics, more than 30 million Americans are enrolled in Medicare Advantage plans, making them eligible to sign up or renew their coverage during this AEP and start their new Medicare benefits on Jan. 1, 2024.

The best way to stay informed and prepared for the upcoming enrollment period is through research and leaning in to all the available resources at your fingertips. Make sure to review the new CMS rules and regulations as they are released and familiarize
yourself with the available products. Our CMS Task Force, led by our compliance and legal teams, is hard at work deciphering, analyzing and understanding processes for all of us to remain successful, while keeping compliant. As a reminder, our CMS FAQ webpage is your one-stop resource for rules interpretation, as well as for answers to question many colleagues have already submitted.

Get to know the Medicare products you are selling! Become knowledgeable about the benefits of the different plans available, rate changes heading into 2024, and competitiveness of the offerings in the areas you serve. Check out the new 2024 Medicare Advantage and Part D Rate Announcement Fact Sheet and the 2024 Medicare Advantage and Part D Final Rule – both available on the CMS.gov website.

Now is the time to reconnect with key clients ahead of the AEP 2024 selling season. Take
the opportunity to educate and reaffirm your relationships, while also establishing new ones. Aligned with new CMS marketing rules, this is also a great opportunity to follow best practices in informing clients of any new ancillary products that will be available when the enrollment period begins.

At the same time, now is also the time to start strategizing for how you’ll achieve your objectives this AEP, noting the important role this selling season plays in setting the tone for the new year. It starts with recruiting and certifications, and then fleshing out your game plan for how you’ll drive productivity throughout the AEP selling season.

Figure out which platforms you want to use, create and organize your promotional materials and plan out how you’ll drive activity. Doing this ahead of time will ensure that you are well prepared when the enrollment period begins. And don’t forget about our AEP Resource Page as your one-stop shop.

We are prepared to help you execute your AEP objectives

The complexity of the AEP process and the everchanging landscape of health care requires a comprehensive understanding of different types of plans and coverage options, timelines, and deadlines associated with AEP. Preparing your team for AEP is key! PSM’s approach - crafted and fine-tuned - takes a holistic approach to insurance distribution, one that allows us to create tailored partnership models with our agents and financial professionals and their affiliated companies to deliver what they and their clients need.

This includes a product portfolio of the nation’s best health and wealth solutions designed to meet the needs of consumers’ health and financial wellbeing, no matter where they are on their retirement journey.

The start of Medicare’s Annual Enrollment Period is just around the corner, and the time to prepare is now. Research the new rules and regulations, familiarize yourself with the different plans, and map out strategies that align with your goals. With the support and preparation from your PSM team, you will be ready and excited to help your clients make the best choices to live a happy, healthy retirement.

The AEP is right around the corner and there are some exciting opportunities on the horizon for 2024. Get prepared early to ensure a successful Annual Enrollment Period. We are here to help!