Agility has breaking news about the 2025 Final Medicare Advantage rules released by the Centers for Medicare and Medicaid Services (CMS). The rules are 438 pages long, but we have included a summary below.
Vaccine Cost-Sharing Changes
CMS is removing cost sharing for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) covered under Part D, including applying the Medicare Part D deductible. These vaccines would be at no cost to Medicare beneficiaries.
Insulin Cost-Sharing Changes
CMS announces that the Medicare Part D deductible will not apply to covered insulin products. In 2025, the “statutorily defined maximum applicable” copay will be $35 for a one-month supply of each covered insulin product for a Medicare enrollee prior to the enrollee reaching the annual out-of-pocket maximum.
CMS is working to finalize this maximum copay amount for insulin products covered under a prescription drug plan (PDP) or a Medicare Advantage prescription drug (MA-PD) for future years. Medicare plan enrollees not reaching the annual out-of-pocket threshold will pay the “covered insulin product applicable cost-sharing amount” that is the lesser of:
- $35.
- An amount equal to 25 percent of the maximum fair price established for the covered insulin product by Part E of Title XI or
- An amount equal to 25 percent of the negotiated price, as defined in § 423.100, of the covered insulin product under the PDP or MA-PD plan.
Medicare Prescription Payment Plan
Every MAPD and PDP plan sponsor must provide their members with the option to choose a Prescription Payment Plan in a plan year that caps their cost-sharing under the plan in monthly amounts. Specifically, CMS adds a new § 423.137 establishing:
- Requirements for the Medicare Prescription Payment Plan,
- Adding several new Part D required materials and content at § 423.2267,
- Adding Medicare Prescription Payment Plan information to the list of required content for Part D sponsor websites at § 423.2265,
- And add the Medicare Prescription Payment Plan to the list of Part D requirements waived for the Limited Income Newly Eligible Transition (LI NET) program at § 423.2536.
CMS is codifying the requirements in the Final CY 2025 Part D Redesign Program Instructions for the treatment for Medical Loss Ratio (MLR) purposes of Medicare Prescription Payment Plan unsettled balances for 2026 and subsequent years.
CMS is finalizing all requirements for 2026 and future years with:
- Modified timing and content requirements for the renewal notice at § 423.137(d)(10)(iv)
- Modified the requirements for the telephonic notice of election approval at § 423.137(d)(10)(ii)
- Modified the requirements for voluntary termination effective date at § 423.137(f)(2)(i)(A)(1)
- Modified timing requirements for the involuntary termination notice at § 423.137(f)(2)(ii)(D)(1)
- Modified § 423.137(i)(2) to state that Part D plan sponsors should require long-term care pharmacies to provide the “Medicare Prescription Payment Plan Likely to Benefit Notice” to the Part D enrollee (or their authorized representative) at the time of the pharmacy’s typical enrollee cost-sharing billing process
- Modified § 423.137(m)(1) to exempt dual eligible special needs plans (D-SNPs) from specific general outreach and education requirements
- Modified § 423.137(j)(7) to remove the requirements for Part D sponsors to ensure that pharmacies are prepared to provide information regarding out-of-pocket (OOP) costs for the Medicare Prescription Payment Plan to a participant at the point of sale.
Improving Experiences for Dually Eligible Enrollees
CMS wants to integrate the care dual-eligible enrollees receive from their Medicare and Medicaid managed care plans. They want these plans to develop policies that integrate care with delivery systems and financing approaches that:
- Maximize patient-centered coordination of Medicare and Medicaid services,
- Lessen cost-shifting incentives between the two programs,
- Creates a seamless experience for dually eligible individuals.
CMS is finalizing new Federal requirements for applicable integrated D-SNP plans to:
- Have integrated member identification (ID) cards serving as the ID cards for both the Medicare and Medicaid plans the enrollee is enrolled in,
- Conduct an integrated health risk assessment (HRA) for Medicare and Medicaid rather than separate HRAs for each program.
CMS is finalizing provisions to codify timeframes for special needs plans to conduct HRAs and individualized care plans (ICPs), prioritizing the involvement of enrollee or the enrollee’s representative, as applicable, in developing the ICPs.
Timely Submission Requirements for Prescription Drug Event (PDE) Records
All MAPD and PDP plan sponsors must file their PDE event records within a specified timeline called the General PDE Submission Timeliness Requirements. CMS requires that initial PDE records be due within 30 calendar days following the date the claim is received by the MAPD or Part D sponsor (or its contracted first tier, downstream, or related entity).
Adjustment and deletion of PDE records are due within 90 calendar days of discovering an issue requiring a change to the PDE. Resolution of rejected PDE records is due within 90 calendar days of receiving notice that CMS rejected the record.
In addition, CMS proposes regulatory changes at § 423.325(b) to establish a distinct PDE submission timeliness requirement for selected drugs, in which CMS requires a Part D sponsor to submit initial PDE records for drugs chosen (as described in section 1192(c) of the Act) within 7 calendar days from the date the Part D sponsor (or its contracted first tier, downstream, or related entity) receives the claim.
Medicare Transaction Facilitator Requirements for Network Pharmacy Agreements
CMS requires MAPD and Part D sponsors to include a provision in their participation agreement with contracting pharmacies requiring these pharmacies to honor the negotiated pricing agreements the Medicare Drug Price Negotiation Program executes. The pharmacies will also certify the accuracy and completeness of their enrollment information in the Medicare Transaction Facilitator Data Module (MF DM).
CMS believes this requirement facilitates Medicare enrollees’ access to selected covered Part D drugs, promotes access to negotiated prices under the Negotiation Program for beneficiaries and pharmacies, and helps ensure accurate Part D claims information and payment.
Clarifying MA Organization Determinations to Enhance Enrollee Protections in Inpatient Settings
CMS clarifies the definition of “organization determination, including Medicare Advantage (MA) plan decisions made concurrent to the enrollee’s receipt of services. CMS finalizes existing guidance requiring plans to give a provider notice of a coverage decision, in addition to the enrollee, whenever the provider submits a request on behalf of an enrollee.
CMS also finalized a rule saying an enrollee’s liability to pay for services cannot be determined until an MA organization has made a claims payment determination. Finally, CMS finalized its restriction on plans’ ability to use information gathered after the inpatient admission has taken place when reviewing the appropriateness of the admission itself.
Risk Adjustment Data Updates
CMS finalized a series of provisions related to risk adjustment data updates.
- Technical change to the definition of Hierarchical Condition Categories (HCCs) to remove the reference to a specific version of the ICD while maintaining a reference to the ICD in general, to keep the HCC definition in § 422.2 current as newer versions of the ICD become available and are adopted by the Secretary,
- Substituting the terms ‘‘disease codes’’ with ‘‘diagnosis codes’’ and ‘‘disease groupings’’ with ‘‘diagnosis groupings’’ to be consistent with ICD terminology.
- Codifying the longstanding practice of requiring the collection and mandatory submission of risk adjustment data by PACE organizations (at § 460.180(b)) and Cost plans (at § 417.486(a)).
It’s also important to note what CMS decided NOT to do:
- No coverage for GLP-1’s to treat obesity.
- No rules to regulate AI prior authorization before authorization.
- No new definitions of marketing and strengthening provider directory requirements.
There’s a great deal to read and understand in these new rules for Medicare Advantage, and Agility is here to help you gain this understanding sooner rather than later. Contact Agility at (866) 590-9771 or email [email protected] to ask your questions about the 2025 CMS Medicare Advantage Rules to our team of CMS compliance resources. Agility can also add you to our free weekly email list for tips and vital information!
