2025 Medicare Advantage and Part D Final Rule Seeks to Protect Patients

Last week, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), finalized policies that continue to strengthen enrollee protections and guardrails to ensure Medicare Advantage (MA) and Medicare Part D prescription drug plans best meet the needs of people with Medicare. This final rule also promotes healthy competition, increases access to care, and protects enrollees from harmful marketing by limiting the distribution of personal beneficiary data by Third-party marketing organizations and ensures that MA organizations analyze their utilization management (UM) policies and procedures from a health equity perspective. The Medicare statute requires that CMS establish guidelines to ensure that the use of compensation creates incentives for agents and brokers to enroll individuals in the MA or Part D plan intended to best meet the prospective enrollee’s health care needs. However, excessive compensation, and other bonus arrangements offered by plans to agents and brokers can result in individuals being steered to some MA and Part D plans over others based on the agent or broker’s financial interests, rather than the prospective enrollee’s healthcare needs. Additionally, the final rule generally prohibits contract terms between MA organizations/Part D sponsors and middleman Third Party Marketing Organizations (TPMOs), such as field marketing organizations, which may directly or indirectly create an incentive to inhibit an agent or broker’s ability to objectively assess and recommend the plan that is best suited to a potential enrollee’s needs. For more, see the final rule.

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