CMS finalizes rule for 2025 Medicare Advantage, prescription drug plans

The Centers for Medicare & Medicaid Services April 4 finalized changes to the Medicare Advantage and prescription drug programs for contract year 2025 intended to improve access to behavioral health care; cap and standardize MA plan compensation to brokers, including prohibiting volume-based bonuses for enrollment into certain plans; limit the distribution of personal beneficiary data by third-party marketing organizations; ensure that MA plans offer appropriate supplemental benefits; streamline enrollment for individuals dually eligible for Medicare and Medicaid; and annually review MA utilization management policies for health equity considerations.

Among other changes, the final rule streamlines the appeals process for enrollees if their MA plan terminates coverage for certain post-acute care services; standardizes the appeals process for MA Risk Adjustment Data Validation audit findings; limits out-of-network patient cost-sharing for certain plans serving dually eligible enrollees; and gives Part D plans more flexibility to substitute biosimilars for reference drug products.

For more on the rule, see the CMS fact sheet. AHA members will receive a Special Bulletin with further details from the final rule.