On November 6, the Centers for Medicare & Medicaid Services (CMS) released the 2025 Medicare Advantage (MA) Proposed Rule to protect Medicare beneficiaries from predatory marketing, promote competition and increase access to mental healthcare services. While many in the industry look to this annual announcement with great anticipation of tactical proposals, CMS’ 2025 proposals are far more strategic than tactical. CMS’ most impactful proposals for 2025 include:
- Strategic redesign of Dual Eligible Special Needs Plans (D-SNP)
- Protection of beneficiaries from anti-competitive sales and marketing activities
- Expanded access to high-impact supplemental benefits
- Expanded access to mental and behavioral healthcare services
Proposed Changes to Star Ratings
With almost $13 billion at stake in MA based on Star Ratings performance, Stars is generally the first thing plans look for in every new CMS proposal. Proposed 2025 Star Ratings changes include:
- The retirement of Medication Therapy Management (MTM) Comprehensive Medication Review (CMR) Completion measure to Display for Measurement Year (MY) 2025 and MY2026 if previous proposal to adjust measure specifications is codified.
- An indication that the Initiation and Engagement of Substance Use Disorder Treatment (IET) measure has been submitted to Measures Application Partnership (MAP) and Adult Immunization Status, Depression Screening & Follow-up, Social Needs Screening measures will be submitted to MAP as precursors to potential addition of these measures to Star Ratings.
- A requirement that medication adherence rate disputes be submitted to CMS prior to the Plan Preview period.
- Revision of data completeness issues and calculation of scaled reductions for Appeals measures.
- Codification of calculations of the Categorical Adjustment Index (CAI) and Health Equity Index (HEI) resulting from contract consolidations.
- Granting authority to the CMS Administrator to modify Quality Bonus Payment (QBP) assignment after a QBP appeals decision has been made.
Though not explicitly addressed in the Proposed Rule, CMS’ also confirmed that all December 2022 Stars proposals which were not finalized in the April 2023 Final Rule remain under consideration and will be decided concurrently as these proposals are finalized.
Proposed Operational Changes
CMS also proposed an array of operational changes, some of which will seismically impact member acquisition, retention and ultimately Stars performance.
- Elimination of payments to agents/brokers for administrative activities such as Health Risk Assessment (HRA) completions, appointment scheduling.
- Requirement that plans send a mid-year outreach informing all enrollees of their unused supplemental benefits.
- Application of Network Adequacy standards to certain types of mental health and behavioral health specialties.
- Adjustment of formulary change procedures to increase and accelerate in-year uptake of biosimilars.
- Adjustment of Multi-Language Insert requirements from the 15 most common languages nationally to the 15 most common languages in members’ state.
- Requirement for Special Supplemental Benefits for the Chronically Ill (SSBCI) in bids to be supported by a bibliography of evidence.
- Requirement for plans to follow written policies to determine SSBCI eligibility, requiring documentation of SSBCI denials rather than approvals.
Proposed Changes for D-SNPs
Though the Stars and operational proposals have the nearest-term tactical impact, the array of D-SNP proposals are far more strategic and impactful over the longer-term. The D-SNP proposals essentially redesign D-SNP structure and operations, and for many plans will be existential to their longer-term viability. CMS’ proposed D-SNP changes include:
- Expanded policies to increase enrollment in aligned/integrated Medicare and Medicaid plans.
- Revision of quarterly special enrollment periods (SEP) for duals/low-income subsidy-eligibles to a monthly SEP for enrollment in a prescription drug plan (PDP) and creation of a new SEP to allow duals to elect an integrated D-SNP on a monthly basis.
- Reduction of the D-SNP look-alike threshold to 70% to determine 2026 MA plan non-renewals and to 60% to determine 2027 non-renewals.
- Required disenrollment by 2030 of duals not enrolled in the affiliated Managed Care Organization.
Recognizing the seismic impact these D-SNP proposals will have amidst the recent proliferation of D-SNP plans and products, CMS explicitly states their intention and awareness that should proposals be finalized as presented, their intention is that these proposals will:
- Strengthen incentives for MA sponsors to also compete for Medicaid managed care contracts.
- Reduce the number of D-SNP options available in market.
- Result in denials of D-SNP applications since CMS is not obligated to accept any and every MA plan bid.
- Restructure and reduce the number of D-SNP’s a Medicare Advantage Organization (MAO) may offer in a service area.
- In states with few or no integrated D-SNPs, result in duals being unable to change MA-PD plans outside of the Annual Enrollment Period, Open Enrollment Period, or other available SEPs, which limits their ability to change plans as their needs change.
The combination of these proposals with the codified changes to risk adjustment and Stars in 2024, to the codified changes in 2024 Medicare covered services and eligible providers, and previous proposals will alter the strategy, structure and operations for most MA plans in the coming years.
With almost 50% of Medicare beneficiaries impacted by these proposals and every plan impacted, we encourage leadership in every MA plan to read these proposals and carefully evaluate their impact on each contract and plan benefit package. For some plans, these D-SNP proposals will literally put them out of business. For others, the proposals will so dramatically alter your strategy that you may need to start planning immediately to adapt.
Feedback is due to CMS by January 5, 2024, and will shape the entire future of Medicare Advantage. CMS estimates that no more than 2,000 people will read this Proposed Rule. If only 2,000 read the proposals, and only a few dozen provide comments to CMS, every plan, vendor and provider's future will be shaped by the few who elect to craft a thoughtful response. For comparison, the 2024 Proposed changes to the Physician Fee Schedule generated 20,000 official comments to CMS! Every single plan will be impacted differently by these proposals, so aggregated feedback from trade groups may not serve your needs.
Please let us know if you need help understanding the impact of these proposals to your plan or crafting thoughtful feedback for CMS. CMS reads and considers all feedback received from MAOs, and your feedback will shape the industry we all love and the experiences of our families, friends and neighbors. Our team has extensive experience supporting plans to achieve success during periods of change. If you need help, email me at firstname.lastname@example.org for more information.
Melissa is a well-known thought leader and healthcare strategist with proven success developing enterprise-wide solutions to improve Star Ratings, HEDIS scores, quality performance, health outcomes, and the member experience. As Chief Consulting Officer, she helps clients evaluate market dynamics and opportunities, optimize distribution channels, and fulfill strategic planning needs.