Navigating Healthcare Regulations: Seven Medicare Advantage Strategies for Success in 2025
In the ever-evolving landscape of healthcare regulation, knowledge is power. ZeOmega’s subject matter experts are here to gather the latest need-to-knows and share best practices. With a meticulous eye for detail and a deep understanding of CMS mandates, we offer you not just insights but a steadfast foundation upon which to build your strategies for continued success.
CMS Releases 2025 Final Rule and Rate Announcement
This month, CMS released both the 2025 Final Rule and Rate Announcement. With a combined total of over 1400 pages of legalese, these documents are not light reading. Not to worry, though. In this blog, we’ll cover all the key takeaways, policy change rationales, and actionable recommendations.
1. Agents, Brokers, and Third-Party Marketing Organizations (TPMOs)
Summary: The final rule creates agent and broker compensation guardrails, including an increase cap of $100 for new Medicare Advantage and Part D enrollments across all plans. Additionally, CMS prohibits TPMOs from sharing member information without express written consent. These new policies become effective in October 2024.
Rationale: The top concern for beneficiaries is ensuring enrollment in plans that best suit their unique health needs. Certain incentives and marketing practices can result in unfair steering, favoring some plans over others that may not be in the consumer’s best interest.
Recommendation: Medicare Advantage Organizations (MAOs) should review current contractual compensation terms and broker certification policies to ensure compliance. Additionally, competitive analysis of benefit packages, maintaining Star ratings, and targeted marketing campaigns remain priorities for attracting membership.
2. Access to Behavioral Health Services
Summary: CMS has included new network adequacy requirements for Outpatient Behavioral Health and added covered benefits for family/marriage therapy and mental health counseling. The new policy also requires proof that clinicians have or will provide qualifying services to at least 20 members over 12 months. Networks with at least one telehealth provider receive a 10% credit on time and distance requirements.
Rationale: Recognizing the importance of mental health and substance abuse support for whole-person care, CMS is using these policy updates to ensure beneficiaries have reasonable and timely access to these services.
Recommendation: Review network adequacy reports focusing on time and distance requirements. Identify areas out of compliance and opportunities to contract with providers and facilities to increase the availability of services.
Source: CMS 2025 Final Rule Note: Time is in minutes, and distance is in miles.
3. Notification of Unused Supplemental Benefits
Summary: MAOs are required to personally notify members of unused supplemental benefits like dental, fitness, vision, etc., annually between June 30 and July 31 each benefit year.
Rationale: Millions of federal dollars are paid out in rebates to MAOs to support supplemental benefits and address social risks. CMS wants to ensure members are aware of the benefits personally available to them and how to use them.
Recommendation: Automate letter workflows. Jiva’s automated send letter functionality allows users to configure identification rules and templates to run on a defined schedule.
4. Utilization Management and Health Equity
Summary: MAOs are to have at least one health equity expert on their utilization management (UM) committee. Additionally, plans must conduct an annual health equity review of prior authorization policies and procedures and publish findings on their website.
Rationale: This policy supports CMS’ advancement of health equity and promotes transparency on how low-income subsidy (LIS) qualifying, dually eligible, and disabled members' prior authorization requests are impacted.
Recommendation: Add additional parameters to prior authorization reporting and visualizations to identify and monitor equitable determinations. Jiva’s UM reports and data views allow users to add parameters or create visualizations for tracking health equity performance.
5. Dual Eligible Special Needs Plans (D-SNP)
Summary: The final rule changes the special enrollment period (SEP) for dually eligible members from quarterly to monthly and creates a new integrated care SEP to encourage alignment with affiliated Medicaid managed care plans. Additionally, CMS limited the number of benefit packages MAOs can offer within the same area as affiliated Medicaid managed care plans. Beginning in 2026, CMS imposed cost-sharing limits for out-of-network preferred provider organizations applicable to Part A and B benefits. Lastly, thresholds for D-SNP lookalike plans will decrease from 80% to 60% by 2026.
Rationale: CMS recognizes the administrative hurdles and complex health challenges dually eligible members face. The new policies seek to promote integrated care that addresses these complexities and reduces barriers. Additionally, these updates improve the healthcare experience for D-SNP members by reducing surprise costs and ensuring these members receive high-quality, coordinated care.
Recommendation: Organizations should prepare for D-SNP membership to grow by scaling programs and implementing tools to efficiently manage care coordination. ZeOmega’s SDOH Social Care solution allows users to understand social risks within communities and develop targeted initiatives to improve health outcomes. Additionally, Jiva’s Long-Term Services and Supports (LTSS) solution provides essential reporting, state and community interfaces, holistic case management, compliant workflows, and integrated care plans.
6. Risk Adjustment
Summary: CMS will continue to phase in the V28 Hierarchical Condition Category (HCC) model with a 67% blend in risk score calculations for 2025. The Part D model has also been updated to reflect benefit redesign considerations required under the Inflation Reduction Act (IRA). Risk score trends projected using the blended calculation are expected to increase by 3.87% on average. Furthermore, MAOs who wish to appeal Risk Adjustment Data Validation (RADV) medical record reviews and ultimately payment calculations must now follow a three-step appeals process outlined in the final rule.
Rationale: The V28 HCC model accounts for updated calibration data, restructuring of HCCs based on ICD-10 codes, and reevaluation of conditions with high coding variation between Medicare Fee-For-Service (FFS) and MA. The Part D, or RxHCC model updates are required due to increased plan liability set forth by the IRA which impacts bid development accuracy. Projected risk score trends for 2025 are based on coding patterns, demographics, and blended HCC model calculations.
Recommendation: By now plans should understand the differences between the V24 and V28 HCC models and how the transition will impact payments. Identification of common coding errors, compliance reviews resulting in deleted HCCs, and educational training will need to remain a focus for risk adjustment teams. MAOs should implement HCC reconciliation tools like the Jiva Risk Adjustment Navigator to maximize recapture rates and identify risk score discrepancies. Risk adjustment teams will need to evaluate required changes to internal appeals processes and conduct training to educate internal stakeholders on the new requirements.
7. Quality and Star Ratings
Summary: CMS codified proposed changes to the Star Ratings methodology introduced in the 2025 Advance Notice which included additions, removals, and adjustments across several measures. Also included were clarifications on the Health Equity Index calculations for consolidated contracts and permissible bases for rating appeals. Lastly, CMS continues to expand the Universal Foundation of measures and intends to continue applying the measure set across its programs.
Rationale: CMS continuously evaluates measures and completeness of submission data to determine what, if any, changes are required to promote care quality. As announced in the previous Advanced Notice, the Health Equity Index has been added to the Quality Bonus Payment calculation incentivizing plans to promote equitable care and is effective for scoring year 2027. Furthermore, in alignment with efforts to reduce provider burden, the Universal Foundation is intended to establish consistency across government programs.
Recommendation: Quality teams should closely review all program changes and update Healthcare Effectiveness Data and Information Set (HEDIS) and Pharmacy Quality Alliance (PQA) measure identification logic and chart chase lists accordingly. Using tools like the Jiva Care Quality Navigator, MAOs should closely monitor provider performance, stratify quality program data to monitor care equity and identify strategies to mitigate care barriers.
We’re Here to Help
With regulations evolving rapidly, staying informed is key to success. As your organization delves into the intricacies of the 2025 Final Rule and Rate Announcement, remember that proactive adaptation is the cornerstone of progress. Whether it's ensuring compliance with D-SNP regulations or improving Star Ratings, ZeOmega stands ready to support your journey. Take charge of your strategies, leverage our recommendations, and propel your organization towards a future of excellence in Medicare Advantage.
Connect with ZeOmega to learn more.
