CMS Finalizes Medicare Advantage Policy and Payment Rules
Medicare Advantage (MA) plans can expect an average 3.7 percent increase in 2025, an increase that plans argue is largely offset by acuity (i.e., risk score) growth. Based on plan-specific dynamics, some plans will receive more and others less in 2025 than the 3.7 percent average. The Centers for Medicare and Medicaid Services (CMS) indicates that it does not expect beneficiary premiums or benefits to be negatively impacted by these changes. The payment rule can be viewed here; a CMS fact sheet is available here.
The final policy rule, which is scheduled for publication in the Federal Register on April 23rd, includes provisions enhancing MA enrollees’ right to appeal coverage terminations to a Quality Improvement Organization (QIO) even in cases where the appeal request is untimely or the person is no longer in a skilled nursing facility (SNF) or receiving home health services. This creates parity to the rights available in traditional Medicare. The final rule also includes a special exception to network adequacy requirements for facility-based institutional special needs plans, requires plans to review their prior authorization policies and procedures to ensure that they do not impose unnecessary barriers to care for certain populations, and seeks greater plan transparency and accountability for the supplemental benefits that plans offer to beneficiaries, ensuring that they are clear on which benefits are available to them and how to access them. A fact sheet on the policy rule is available here.