Medicare: 5 Compliance Trends to Look for in Plan Year 2025

In 2024, the Center for Medicare and Medicaid Services (CMS) introduced changes to the rules it sets for Medicare Supplement, Medicare Advantage, and Part D insurance carriers and agencies, and 2025 promises more of the same.

By examining some of the final rules of 2024, we can project what to expect for the 2025 season. Now’s the time for insurance carriers and agencies that sell Medicare-adjacent properties to ramp up their sales forces.

Changes to Medicare billing requirements

Medicare’s final rule for 2024 tightened several billing rules, and, as implementation rolls out for new standards, we expect the 2025 Medicare season will see more of the same emphasis on tightening control over Medicare Advantage and Part D spending.

While Medicare has released its reimbursement rates for the upcoming season, and reimbursements are notably higher for Medicare Advantage plans, they’re also tightening standardization and transparency.

Medicare’s final rule for 2024 increased scrutiny of Medicare Advantage plan scoring. We project that carriers can anticipate even more aggressive coverage disclosure requirements and more data gathering in the coming year as Medicare judges the coverage provided under private plans.

Another big change is that CMS expanded its ability to recoup overpayments made to both carriers and agencies. Carriers and agencies alike can expect more pushback on claims, with CMS taking in more data for each claim and auditing far more of the claims made by private insurers.

Carriers will also need to stay on their toes to keep up with new standardized coding practices that CMS is using to enforce uniformity and ensure the program isn’t being overbilled for reimbursements.

For Medicare Part D, a new rule also locks Part D providers into a $2,000 out-of-pocket limit. For carriers, changing pricing models can necessitate some changes to the coverage they can provide.

Timely access and prior authorizations

Medicare has been aiming for more health access for people of different demographic or geographic limitations, and that’s led to several regulations about access in the last few years.

Probably the most impactful regulatory change is new expectations for prior authorizations. Prior authorizations, which are standard in private, traditional health insurance, are requirements that patients apply to their health insurance carrier prior to getting medical treatment. This practice has come under fire in state legislatures for the healthcare market at large, and is facing scrutiny from CMS.

Prior authorization can help consumers avoid unnecessary medical procedures or tests, and it can help carriers keep costs low. But it can also delay necessary treatments, and, when a carrier doesn’t have objective standards, prior authorizations can become occasions of disparate outcomes for consumers.

One medical association reported 97 percent of physicians said prior authorizations have adverse effects on their patient outcomes and serve to delay vital care.

So, to that end, CMS has implemented rules that’ll go into full effect in 2026 to create more uniform standards for carriers and streamline their prior authorizations processes.

Among the changes we can anticipate proactive carriers making this plan year (although many prior authorization rules won’t be in full effect until 2026):

• More detailed explanations of the prior authorization process for consumers, including reasons for denials.
• Tighter turnaround times for the process, including a mandated timeline of seven days or fewer for standard authorizations, 72 hours for urgent authorizations, and 24 hours or less for emergency authorizations.
• More physicians and hospitals with “gold-standard” relationships and track records whose treatments and tests don’t require preauthorization.
• APIs! CMS said that, while they aren’t currently mandating carriers to adopt API technology to make prior authorizations a more automatic and streamlined process, they’’re currently strongly suggesting

Marketing protections in Part D and Advantage plans

Medicare Advantage and Part D plans are administered by private companies and reimbursed by CMS’s Medicare program. However, some regulators are uncomfortable with the association of the word “Medicare” with private carrier plans.

One of the things private carriers and agencies must be sensitive to is that new regulations have tightened their ability to use “Medicare” in advertising these plans. Marketing and advertising materials can’t refer to services as simply “Medicare,” but must always emphasize Medicare Part D or Medicare Advantage. The point is to make it very clear that these plans aren’t part of Original Medicare and will have the networks and other restrictions associated with nonfederal healthcare insurance.

Of course, 2025 may see updates to the standard disclosure that all marketing and ads will need to include. In 2024, CMS implemented new requirements that carriers and agencies disclose how many different kinds of plans a particular carrier offered in an area, and we may see more of those kinds of disclosure changes in the next year when Medicare finalizes the 2025 rules.

Medicare Advantage plan marketing also can’t advertise Advantage plans generically; they must advertise specific Advantage plans or else they can’t refer to Medicare. These kinds of marketing and advertising rules can certainly complicate business during healthcare enrollment season, and we anticipate seeing more carriers tighten their advertising compliance reviews and require producers to submit more materials for review.

Another requirement to keep an eye on is the requirement that agencies and carriers retain call records of all marketing-oriented calls, which includes everything from the pre-sales process up through the plan enrollment calls. Current standards require those selling Medicare-adjacent plans to keep records and recordings of calls for up to ten years.

Behavioral health access

CMS and individual states have renewed their focus on providing access to behavioral and mental health services, and carriers that take a proactive approach to expanding their networks of service providers will be well-positioned to meet increasing scrutiny.

In addition to covering at least 20 outpatient mental health visits and 20 outpatient substance use disorder visits per year, Medicare Advantage plans must also provide access to a range of other mental health and substance use disorder services, including:

• Inpatient hospital care
• Partial hospitalization programs
• Intensive outpatient programs
• Group therapy
• Medication management
• Case management

Changing MedSup plans

Most regulatory trends affect Advantage and Part D the most, but Medicare Supplement providers are also subject to the winds of change. Some states are adopting rules that allow seniors to switch Medicare Supplement plans, even without underwriting, as long as the coverage is the same kind of plan (Supplement Plan G users can switch to another Plan G) or a less robust coverage.

For Advantage and Part D providers, changing plans each year isn’t uncommon, but Supplement plan carriers and agencies will need to adjust their practices in states where this is now allowed.

This change will undoubtedly necessitate keeping more people on staff equipped with Medicare Supplement know-how. And all of these changes may mean having more requirements for producers, either in terms of state-mandated CE, or in terms of carrier training requirements.

AgentSync and Medicare enrollment 2025

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