CMS final rule on broker comp, health equity could shake up Medicare Advantage

Centers for Medicare & Medicaid Services finalized a host of actions ranging from broker compensation, health equity, mental health, supplemental benefits and biosimiliars, in the Contract Year 2025 Medicare Advantage and Part D final rule Thursday night.

Technical experts and industry execs warned the changes will be consequential for MA plans.

"Yesterday's 2025 Final Rule was one of the more impactful that I can recall in my two-plus decades in the industry," said Sean Libby, president at BeneLynk. "It is clear that MA plans need a roadmap for health related social needs and health equity."

"It is difficult to put words to the extent and impact of changes codified today," said Melissa Newton Smith, senior advisor for Oliver Wyman. "Every MA leadership team needs to be thoughtfully redesigning your stars and quality approach in order to earn quality bonus payments in 2025."

"The primary winners are behavioral health providers, namely Arcadia Healthcare and Universal Health Systems," said global strategy firm Capstone in a new analysis.

The rule restricts "excessive compensation" for brokers that cause individuals to choose some MA plans over others based on a broker's financial interests. Brokers will now be paid a fixed amount, regardless of the plan an individual selects, beginning during the next annual enrollment period.

CMS raised the fixed broker fee by $100 after initially proposing a $31 increase.

Current CMS language suggests broker commission caps will not apply to major players like eHealth, GoHealth and SelectQuote, according to Capstone's analysis.

“We are thrilled CMS embraced our proposal to cap total broker payment,” said Ceci Connolly, ACHP president and CEO. “This commonsense policy change eliminates those perverse financial incentives and levels the playing field for health competition.”

Contracts between MA organizations and third party marketing organizations are now "generally" prohibited. These orgs created an incentive for brokers to not be objective when evaluating plans. The rule also limits how these third party organizations can collect and share data.

"New protections include a prohibition on middlemen selling seniors’ personal information over and over again which had led to incessant marketing and phone calls to seniors, as documented by Finance Committee investigations,” said Sen. Ron Wyden in a statement. “The final rule also includes policies I’ve pushed for to make sure MA plans provide access to mental health professionals who actually take patients – taking a step to rein in ghost networks."

As for behavioral health, CMS is expanding network requirements and established a new benefit category for mental health counselors (MHCs) and marriage and family therapists (MFTs). Further, a provider category called outpatient behavior health will include MHCs, MFTs, opioid treatment providers, mental health centers, addiction medicine physicians, nurse practitioners and physician assistants.

MA plans like UnitedHealthcare, Humana, Elevance Health and Aetna will likely deal with increased admin burden as a result of the behavioral health changes, said Capstone.

CMS is also trying to increase utilization of supplemental benefits in MA plans, so tax dollars aren't funding unused benefits. MA plans will be required to better market benefits available to enrollees by issuing a "Mid-Year Enrollee Notification" between June 30 and July 31.

Premier Inc. was "encouraged" by the behavioral health policy changes but criticized CMS for not instituting a better mechanism for monitoring and enforcement.

Last year, prior authorization was the primary focus of the final rule. Now, CMS is calling for plans to update utilization management committees with a person that has expertise in health equity. It also wants an annual report on health equity analysis of prior-auth policies. Those results should be posted online.

"The goal of the health equity analysis is to create additional transparency and identify disproportionate impacts of UM policies and procedures on enrollees who receive the Part D low-income subsidy, who are dually eligible, or who have a disability," said a CMS fact sheet.

Healthcare consultant Dwight Pattison said star rating changes include colorectal cancer screening measures and two new measures on substance use, among many other changes.

Thursday's rule drop also limits out-of-network cost sharing for MA D-SNP preferred provider organizations starting in 2026, lowers the look-alike threshold and streamlines the risk adjustment data validation (RADV) appeals process. Medicare's current quarterly special enrollment period will be replaced by a one-time-per month period for dually eligible individuals.

Part D sponsors will have the ability to make midyear substitutions of biosimilars as formulary maintenance changes or interchangeable biological products. Premier Inc. approved of the changes but warned of vertically-integrated payers putting profits over lower drug prices.