This post is part of a series sponsored by AgentSync.
In 2024, the Centers for Medicare & Medicaid Services (CMS) implemented changes to the rules it sets for Medicare Supplement, Medicare Advantage, and Part D insurers and agents, with similar changes planned for 2025.
By looking at some of the final rules for 2024, we can get a sense of what to expect for the 2025 season. Now is the time for insurance companies and agents selling Medicare-related properties to beef up their sales forces.
Changes to Medicare billing requirements
Medicare’s 2024 final rule tightened some billing rules, and the 2025 Medicare season is expected to similarly focus on strengthening controls over Medicare Advantage and Part D spending as implementation of the new standards progresses.
Medicare has announced its reimbursement rates for the coming season, and while they are significantly higher for Medicare Advantage plans, they also include greater standardization and transparency.
Medicare’s 2024 final rule increased scrutiny of the scoring of Medicare Advantage plans, and insurers can expect more aggressive coverage disclosure requirements and increased data collection next year as Medicare determines the coverage offered by private plans.
Another big change is that CMS has expanded the ability of both insurers and agents to recover overpayments. As CMS gets more data on each claim and audits far more claims made by private insurers, insurers and agents are expected to become even more resistant to claims.
Insurers also need to stay vigilant and keep up with new standardized coding practices that CMS is using to enforce uniformity and ensure programs are not overcharging for reimbursement.
For Medicare Part D, the new rules also lock in Part D providers. Out-of-pocket maximum is $2,000For carriers, the change in pricing model is likely to necessitate some changes to the coverage they can offer.
Timely access and prior approval
Medicare aims to make health care services available to people with different demographic or geographic limitations, and several regulations regarding access to health care services have been introduced in recent years.
Perhaps the most impactful regulatory change is the new expectation of prior authorization. Prior authorization is standard in private traditional health insurance, a requirement that patients apply for a treatment with their health insurer before receiving it. The practice has come under criticism from state legislatures across the health care marketplace and is facing scrutiny from CMS.
Prior authorization helps consumers avoid unnecessary medical procedures and tests and helps insurance companies keep costs low. But it can also delay needed treatment. If insurance companies don’t have objective standards, prior authorization could lead to disparate outcomes for consumers.
One medical association reported: 97 percent of doctors They said prior authorization would harm patient outcomes and delay important treatments.
As a result, CMS has implemented rules, which will be fully effective in 2026, to create more uniform standards for carriers and streamline the pre-approval process.
Some of the changes insurers who are proactive with their plans this year can expect include (although many of the pre-authorization rules won’t be fully implemented until 2026):
- A more detailed explanation of the pre-approval process for consumers, including reasons for denial.
- The process will be faster, with mandated timelines of within seven days for standard approval, 72 hours for emergency approval, and 24 hours for urgent approval.
- An increasing number of doctors and hospitals have “gold standard” relationships and track records and offer procedures and tests that do not require prior authorization.
- APIs! While CMS is not currently mandating that insurers adopt API technology to make prior authorizations more automated and streamlined, the agency is currently Strongly suggest
Marketing Protections in Part D and Advantage Plans
Medicare Advantage and Part D plans are administered by private companies and reimbursed by CMS’s Medicare program, although some regulators are uncomfortable with the word “Medicare” being associated with private insurer plans.
One thing private insurers and agents must be aware of is that new regulations have tightened their authority to use “Medicare” in advertising for these plans. Marketing and advertising materials cannot simply call the services “Medicare” and must always emphasize Medicare. Part D or Medicare advantage. It’s important to clarify that these plans are not part of Original Medicare and have the network and other restrictions associated with non-federal health insurance.
Of course, 2025 could see updates to the standard disclosures that must be included in all marketing and advertising. In 2024, CMS introduced a new requirement for carriers and agencies to disclose how many plan types a particular carrier offers in a given region. We could see more changes to these types of disclosures next year when Medicare finalizes its 2025 rules.
Marketing for Medicare Advantage plans also cannot promote Advantage plans generally; you cannot mention Medicare unless you are promoting a specific Advantage plan. These types of marketing and advertising rules can definitely complicate business during health insurance enrollment season. We also expect to see more insurers tightening advertising compliance reviews and requiring producers to submit materials for review.
Another requirement worth noting is the requirement that agents and insurers keep records of marketing-related calls, including everything from pre-sales processes to enrollment calls. Current standards require that agents who sell Medicare-related plans keep call logs and recordings for up to 10 years.
Access to Behavioral Health
CMS and states have placed a renewed emphasis on providing access to behavioral and mental health services, and insurers that take a proactive approach to expanding their networks of service providers will be well positioned to navigate increased scrutiny.
Medicare Advantage plans must cover at least 20 outpatient mental health visits and 20 outpatient substance use disorder visits per year, as well as provide access to a variety of other mental health and substance use disorder services, including:
- Inpatient treatment
- Partial Hospitalization Programs
- Intensive Outpatient Programs
- Group Therapy
- Medication Management
- Case Management
MedSup Plan Changes
Regulatory developments will most significantly affect Advantage and Part D, but Medicare Supplement providers are also being subject to change. Some states have adopted rules that allow seniors to switch Medicare Supplement plans without underwriting review, as long as they are the same type of plan (a Supplement Plan G user can switch to another Plan G) or have less robust coverage.
While it is not unusual for Advantage and Part D providers to change plans annually, Supplement plan insurers and agents will need to adjust their practices in states where this is currently permitted.
The changes will no doubt require more staff to be on hand with Medicare supplement know-how. And all of these changes may mean putting more requirements on producers in terms of: State-mandated CE, or in terms of career training requirements.
AgentSync and Medicare Enrollment 2025
It’s not Medicare season yet, but fall enrollment is coming up soon.
You don’t have to wait until your distribution partners are bombarded with questions and the phones are ringing off the hook to get the partnership channel transparency you need. AgentSync simplifies licensing, appointments, onboarding and offboarding of producers for the upcoming sales cycle.
To learn more about how AgentSync can help make Medicare enrollment season compliant, efficient, and less confusing, see below. How a major Medicare distributor upgraded its technology Use AgentSync.
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