Medicare Blog | Medicare News | Medicare Information

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?

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