Streamlining and better access in the rest of the CMS 2025 final rule

In our last episode, we covered how the 2025 CMS final rule would affect your commissions and relationships with your upline. In this episode, we will dive into the rest of the final rule. Some of these efforts, like the rules surrounding prior authorizations and behavioral health, bolster efforts set in motion outside of CMS rulings, while others are quick fixes to make sure beneficiaries are getting the most out of their benefits—and maybe saving some money in the process. Let’s take a look.

More mental health care access

Across the board, behavioral health care access has been spotty at best. So much so that CMS is creating a new category of provider, named “Outpatient Behavioral Health,” which will encompass many of the mental health services beneficiaries might struggle to get or maintain access to, including marriage and family therapists and mental health counselors. These types of providers can be difficult to access for beneficiaries, as they often function within our facilities like mental health centers, substance use treatment centers, and hospitals. Medicare Advantage (MA) plans will be responsible for ensuring providers within this new category of care are capable of servicing at least 20 patients.

To further support beneficiary access to behavioral health support, providers falling within this category will qualify for a 10% credit towards meeting time distance standard requirements. MA plan networks must include at least one telehealth provider in this category who provides covered services.

Supplemental benefits notifications

CMS applauds MA plans’ efforts to help mitigate social issues working against the health of beneficiaries. Supplemental benefits, particularly those providing adequate food and transportation, help beneficiaries avoid emergent health situations. But they can only help if they are used, and some plans are reporting a swath of benefits being left on the table every year. To help remind beneficiaries of the 67 billion dollars of rebate funds estimated to be available in 2024 alone, MA plans must reach out to their beneficiaries sometime between June 30 and July 31 each plan year. This contact must be personalized to each beneficiary and detail every unused supplemental benefit so far that year. It also must include the scope of the benefit, any network or cost-sharing that might apply, instructions on how to use these benefits, and a customer service contact.

Utilization management committees clear up prior authorization processes

When prior authorization decisions are made, who sits down and makes the calls? A utilization management committee. MA plan committees must now include a health equity expert. With the help of this expert, the committee must complete an analysis of the policies and procedures the plan uses to make coverage decisions. The results must be made public on the plan’s website. This way, those who are affected by these decisions, particularly those with dual eligibility or who receive subsidies, can have more transparency.

The appeals process now mirrors traditional Medicare

If a prior authorization decision stands between beneficiaries and access to long term care like a skilled nursing facility, beneficiaries will now have the right to appeal that decision to the Quality Improvement Organization (QIO.) QIOs fast-track these appeals for those in traditional Medicare, but those with MA plans previous to this rule were restricted to the avenues provided by the plan. Now, the QIO can be involved more quickly. Additionally, MA plans can no longer require beneficiaries to waive their right to access the QIO if they leave a rehab center, skilled nursing facility, or home health agency.

More (and clearer) support for the chronically ill

Any time an MA plan submits something designed to support beneficiaries with chronic illness (SSBCI), they also must submit research that the supplemental benefit will improve the overall health or function of beneficiaries living with that illness. Marketing must clarify these benefits are for those with these conditions, not everyone.

Dual Eligible changes

CMS has made it clear: more beneficiaries who qualify for dual-eligible plans should be on dual-eligible plans. To make this dream come true, CMS is creating more opportunities for beneficiaries to change into these plans. Beneficiaries who are dually eligible or low-income subsidy eligible will have a monthly Special Enrollment Period (SEP) instead of the current quarterly one. This SEP will allow them to enroll in a standalone prescription drug plan or an integrated D-SNP if they qualify. Those who enroll in applicable D-SNPs must also be enrolled in a Medicaid-managed care organization. Carriers will now see a limit on the total number of D-SNP plans they can offer in one area.

D-SNPs will also see a limit on PPO cost sharing in 2026. The goal is to put more of the payment responsibility onto the MA plan instead of Medicaid and increase provider access for those enrolled.

Look-Alikes will dwindle

To reduce the number of plans functioning similarly to D-SNP plans without adhering to the same rules as D-SNPs, CMS will gradually lower the number of look-alike plans carriers are allowed to offer over the next two years. The look-alike numbers will dwindle to 70% in 2025 and 60% in 2026.

Part D Changes

Formularies will now be able to swap in biosimilars as a maintenance change. Approval from CMS will no longer be needed.

HIV/AIDS will be considered a core chronic disease. This will open drugs to treat HIV/AIDS up to more flexibilities.

Looking ahead

The themes here are clear: accessibility is king, and streamlining is a close second. Beneficiaries should have an easy time knowing what their benefits are, how to use them, and how to appeal the decision if they feel something is being kept from them. If a process is difficult, make it easier. Simplify, simplify. And as always, the best interest of the beneficiary comes first.