2025 Medicare Advantage and Part D Final Rule: What Professionals Need to Know
6 min read
Every year, the Centers for Medicare & Medicaid Services (CMS) issues a final rule describing changes to Medicare Advantage (Part C) and the Medicare prescription drug program (Part D). This 2025 final rule analysis aims to help:
- Professionals in the aging network who work with plans to provide Medicare Advantage supplemental benefits
- Those who provide enrollment counseling to Medicare beneficiaries and individuals dually eligible for both Medicare and Medicaid
Which changes to Medicare Advantage supplemental benefits are relevant to the aging network?
Midyear notice of unused supplemental benefits
The number of aging network providers with experience contracting with Medicare Advantage plans to provide supplemental benefits to Medicare Advantage enrollees is growing. The final rule requires plans to notify enrollees in June or July each year if the enrollee has not used most of their supplemental benefits by June of that year.1 CMS will require this change starting in January 2026.2
CMS hopes this notification will increase uptake of supplemental benefits. It’s possible that greater enrollee demand for these benefits could create more opportunities for the aging network to partner with Medicare Advantage plans to deliver these benefits.
CMS stated: “it is unclear whether plans are actively encouraging utilization of these benefits by their enrollees…One purpose of the Mid-Year Notice is to address concerns that some MA plans may be using supplemental benefits primarily as marketing tools to steer enrollment.”2
Evidentiary basis for SSBCI
The final rule also requires Parts C and D sponsors to have the ability to demonstrate to CMS, should the agency request it, that plan Supplemental Benefits for Chronically Ill enrollees (SSBCI) are relevant to the chronic conditions they’re associated with.3 CMS will require plans to demonstrate that SSBCI have a reasonable expectation of improving the health or overall function of the enrollee with a chronic condition.4 This change may impact the types of supplemental benefits the aging network contracts with plans to provide. The rationale for the provision: to ensure SSBCI are evidence-based and benefits are provided fairly.5
Making SSBCI marketing clearer
The final rule also will require plans to include an SSBCI marketing and communications disclaimer saying that a supplemental benefit is only available if the individual:
- Has a particular chronic condition
- Meets Medicare’s definition of a “chronically ill enrollee” and
- Is deemed eligible for the benefit by the plan3
If the number of qualifying conditions for the SSBCI are five or fewer, the plan would have to list all relevant conditions on the disclaimer.6 If the number of conditions is more than five, then the Medicare Advantage organization must list the top five conditions (as determined by the Medicare Advantage organization).6 CMS goes further than the proposed rule by having plans take steps to avoid giving the impression that the five conditions listed are the only ones relevant to the SSBCI.7 With accessibility in mind, CMS finalizes a provision from the proposed rule requiring that fonts and font sizes are readable and that the pacing of spoken words in ads are not too fast.8
What are key substance use disorder and mental health services changes?
CMS has been expanding access in recent years to more mental health care and substance use treatment services and expanding the pool of providers who can bill Medicare. In the final rule, CMS continues this practice by requiring plans to include a new facility-specialty provider category for outpatient mental health and substance use disorder treatment,9 emphasizing that the outpatient category would cover “the range of enrollees’ behavioral health needs.”10
Also, CMS says the billing category can include outpatient providers such as marriage and family therapists, licensed counselors, the community mental health center workforce, and clinicians working at outpatient mental health and substance use treatment facilities.9
CMS will in 2025 implement this Medicare Advantage network adequacy standard. The provision could be another important one of the final rule for the aging network to note given that this change may create new partnership opportunities and a broader referral network.11
How does the final rule make plan materials more accessible?
Plans will be required by September 2025 to include a disclaimer tagline on all materials about the availability of auxiliary aids and services as well as the availability of language assistance services provided in English and at least the next 15-most spoken languages.12
Does the final rule discuss changes to how beneficiaries enroll in plans?
Beginning in 2025, CMS will give Part D Extra Help (Low-Income Subsidy or LIS) enrollees and dually-eligible beneficiaries eligible for both Medicare and Medicaid the option to participate in a Special Enrollment Period (SEP), which will go from being available on a quarterly basis to a monthly basis. LIS enrollees and duals would have a monthly option to leave their combined Medicare Advantage prescription drug plan (MA-PD) and switch to traditional fee-for-service Medicare along with a standalone prescription drug plan (PDP) or move from one PDP to another.13 An LIS enrollee or dually eligible individual could not, however, use the SEP to enroll in an MA-PD.14 In explaining its rationale for the provision, CMS notes that “enrollment counselors such as State Health Insurance Assistance Programs (SHIPs) and state ombudsman programs have also noted that the once-per-quarter rule is complicated and makes it difficult to determine the enrollment options available to dually eligible individuals.”15Dual-Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans designed to meet the needs of the Medicare/Medicaid dually eligible population. CMS finalized the integrated care SEP so that these individuals may only use the SEP to enroll into a meaningfully integrated D-SNP plan.16
Does the rule make improvements to integrated plans for individuals enrolled in both Medicare and Medicaid?
In the final rule, CMS focuses on eliminating D-SNP enrollee choice overload and ensuring meaningful Medicare-Medicaid integration. To address the “overwhelming marketing” of “increasingly complex” duals plans, in January 2027, CMS will limit the number of certain types of integrated plans available via the same Medicare Advantage sponsor, plan, or affiliate.17
The agency will also eliminate the number of duals plans that do not offer meaningful Medicare and Medicaid integration due to service area and enrollment misalignment.18 Beginning in plan year 2027, CMS will only contract with one full-benefit D-SNP offered by a Medicare Advantage plan in each Medicaid Managed Care Organization (MCO) service area.19
To ensure that more meaningfully-integrated MA plans are available, and reduce confusion and misunderstanding, CMS will contract with increasingly fewer non-SNP Medicare Advantage plans in 2025 and 2026.20 CMS says it hopes doing so will make it harder to plans to confuse or mislead enrollees.
Bringing integrated plans to Medicare Plan Finder
CMS also plans to make it easier for dually eligible individuals to search for integrated plans on Medicare Plan Finder (MPF).21 CMS indicates that it is “working on this for contract year 2025 and intend[s] to include a limited number of specific Medicaid covered benefits on MPF when those services are available to enrollees through the D-SNP or the affiliated Medicaid MCO.”22
Sources
1. CMS. “Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program for Contract Year 2024.” Page 30562. April 23, 2024. 23 Found on the internet at https://www.federalregister.gov/documents/2024/04/23/2024-07105/medicare-program-changes-to-the-medicare-advantage-and-the-medicare-prescription-drug-benefit
2. Page 30565
3. Page 30554
4. CMS says in the final rule, “that MA plans will be required to document and submit to CMS upon request each determination that an enrollee is not eligible to receive an SSBCI.” Pages 30554 and 30555.
5. Page 30555
6. Page 30608
7. Page 30613
8. Pages 30609 and 30615
9. Page 30490
10. Page 30492
11. Matthew Hubbard. Updated Medicare Reimbursement Rule Addresses Health-Related Social Needs and Care Coordination. Dec. 11, 2023. Found on the internet at https://www.ncoa.org/article/updated-medicare-reimbursement-rule-addresses-health-related-social-needs-and-care-coordination
12. Pages 30529 and 30530
13. Pages 30677 and 30678
14. Page 30677
15. Page 30680
16. CMS will ensure that the SEP can only be used to enroll in the following meaningfully-integrated D-SNP categories: fully integrated dual eligible special needs plans (FIDE SNPs), highly integrated dual eligible special needs plans (HIDE SNPs), or applicable integrated plans (AIPs). Pages 30675 and 30682
17. Pages 30678 and 30679
18. Page 30678
19. Page 30679
20. Page 30708
21. Page 30702
22. Pages 30702 and 30703
