This post is part of a series sponsored by AgentSync.
In 2024, the Center for Medicare and Medicaid Services (CMS) introduced changes to the rules it sets for Medicare Supplement, Medicare Advantage, and Part D insurance carriers and agencies, and 2025 promises more of the same.
By examining some of the 2024 final rules, we can predict what to expect for the 2025 season. Now is the time for insurance carriers and agencies that sell Medicare-adjacent properties to bolster their sales force.
Changes in Medicare Billing Requirements
The 2024 Medicare final rule strengthened several billing rules, and with the implementation of new standards, we expect the same focus on tightening controls on Medicare Advantage and Part D spending will continue in the 2025 Medicare season.
While Medicare has released its reimbursement rates for the upcoming season and reimbursements for Medicare Advantage plans are significantly higher, they are also tightening standardization and transparency.
The 2024 Medicare final rule increased scrutiny of Medicare Advantage plan evaluations. We expect that carriers can expect even stricter coverage disclosure requirements and increased data collection in the coming year as Medicare assesses coverage under private plans.
Another big change is that CMS has expanded its ability to recover overpayments to both carriers and agencies. Both carriers and agencies can expect to see a steeper decline in claims as CMS collects more data for each claim and reviews far more claims from private insurers.
Carriers must also stay current to keep up with new standardized coding practices that CMS is using to enforce uniformity and ensure the program is not overcharged for reimbursements.
For Medicare Part D, a new rule also imposes a $2,000 out-of-pocket limit on Part D providers. For wireless providers, changing pricing models may require some changes to the coverage they offer.
Medicare strives to improve access to health care for people with different demographic or geographic limitations, and this has led to several access regulations in recent years.
Perhaps the most impactful regulatory change is new expectations for prior approvals. Prior authorizations, which are standard in private, traditional health insurance, are requirements that patients must apply to their health insurance company before receiving medical treatment. This practice has come under fire in state legislatures covering the entire healthcare market and is being closely scrutinized by CMS.
Prior authorization can help consumers avoid unnecessary medical procedures or tests, and it can help carriers keep costs down. But it can also lead to a delay in necessary treatments, and if a carrier does not have objective standards, prior authorizations can lead to different outcomes for consumers.
A medical association reported that 97 percent of physicians said prior authorizations had a negative impact on their patients’ outcomes and caused vital treatments to be delayed.
To that end, CMS has implemented rules that will be fully effective in 2026 to create more consistent standards for carriers and streamline their pre-approval processes.
Among the changes proactive airlines can expect this plan year (although many prior approval rules won’t take full effect until 2026):
- More detailed explanations of the consumer pre-approval process, including reasons for denial.
- Faster turnaround times for the process, including a mandated time frame of seven days or less for standard authorizations, 72 hours for urgent authorizations, and 24 hours or less for emergency authorizations.
- More doctors and hospitals with “gold standard” relationships and track records whose treatments and tests do not require prior authorization.
- APIs! CMS said that while they are not currently requiring carriers to adopt API technology to make prior authorizations a more automated and efficient process, they are currently strongly suggesting it
Marketing protection in Part D and Advantage plans
Medicare Advantage and Part D plans are administered by private companies and reimbursed through CMS’s Medicare program. But some regulators are unhappy with the association of the word “Medicare” with private carrier plans.
Among other things, private carriers and agencies need to be aware that new regulations have tightened their ability to use “Medicare” when advertising these plans. Marketing and promotional materials must not simply refer to services as “Medicare” but must always highlight Medicare Part D or Medicare Advantage. The point is to make it clear that these plans are not part of Original Medicare and have the network and other limitations associated with non-government health insurance.
Of course, there may be updates to the standard disclosure in 2025, which must include all marketing and advertising content. In 2024, CMS implemented new requirements that require carriers and agencies to disclose how many different types of plans a given carrier offers in an area. Next year, as Medicare finalizes the 2025 rules, we may see more disclosure changes like this.
With Medicare Advantage plan marketing, Advantage plans also cannot be advertised broadly. They must promote certain Advantage plans or they cannot qualify for Medicare. Such marketing and advertising rules can certainly make business difficult during health care enrollment season, and we expect more carriers to tighten their advertising compliance reviews and require manufacturers to submit more materials for review.
Another requirement to keep in mind is the requirement that agencies and carriers retain call recordings of all marketing-oriented calls, which includes everything from the pre-sales process to plan enrollment calls. Current standards require those selling Medicare-adjacent plans to retain recordings and recordings of calls for up to 10 years.
Access to behavioral health
CMS and individual states have renewed their focus on providing access to behavioral and mental health services, and providers that take a proactive approach to expanding their networks of providers will be well positioned to withstand increasing scrutiny.
In addition to covering at least 20 mental health outpatient visits and 20 substance use disorder outpatient visits per year, Medicare Advantage plans must also provide access to a range of other mental health and substance use disorder services, including:
- Inpatient hospital care
- Partial hospitalization programs
- Intensive outpatient programs
- Group therapy
- Medication management
- Case management
Change MedSup plans
Most regulatory trends impact Advantage and Part D the most, but Medicare supplement providers are also exposed to the winds of change. Some states are adopting rules that allow seniors to switch Medicare supplement plans even without purchasing insurance, as long as it is the same plan type (Supplement Plan G users can switch to a different Plan G) or has less robust coverage.
It is not uncommon for Advantage and Part D providers to change their plans each year, but supplemental plan providers and agencies must adjust their practices in states that now allow this.
This change will undoubtedly require more staff to be equipped with Medicare Supplement expertise. And all of these changes may result in higher demands being placed on manufacturers, either in terms of government-mandated CE or in terms of training requirements for carriers.
AgentSync and Medicare Enrollment 2025
It’s not quite Medicare season yet, but fall enrollment is moving very quickly.
Don’t wait for your channel partners to bombard you with questions and the phones to ring to get the partnership channel visibility you need. Let AgentSync help you simplify your producer licensing, scheduling, onboarding and offboarding for your upcoming sales cycle.
To learn more about how AgentSync can help you make the Medicare enrollment season compliant, efficient, and less crazy, check out how a leading Medicare distributor updated their technology with AgentSync.
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2024-05-28 04:38:11
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