CMS Proposals Address Anti-Competitive Practices in Medicare Advantage

CMS has proposed provisions to improve protections for Medicare Advantage beneficiaries, prevent anti-competitive practices, and strengthen access to behavioral healthcare services.

The Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program proposed rule includes new guardrails for plan compensation to agents and brokers. Beneficiaries may use agents and brokers to help them choose a new plan. In return, agents and brokers receive compensation from the plans.

Although intended to help people navigate their plan options, agents and brokers may steer beneficiaries toward plans that provide significant compensation rather than those that meet the beneficiary’s health needs.

CMS proposed redefining “compensation” and setting a fixed amount that agents and brokers can be paid regardless of the plan the beneficiary chooses. This will expand the regulatory definition to include all activities associated with enrollment in a Medicare Advantage or Part D plan.

The agency has proposed a national agent/broker fixed compensation of $632. According to a fact sheet, the fixed rate will help eliminate payment variability and improve the predictability of compensation for agents and brokers.

CMS also proposed prohibiting contract terms between Medicare Advantage organizations and marketing intermediaries that tend to result in volume-based bonuses for enrollment into certain plans.

“CMS continues to improve the Medicare Advantage and Part D prescription drug programs and maintain high-quality health care coverage choices for all Medicare enrollees,” CMS Administrator Chiquita Brooks-LaSure said in a press release.

“People with Medicare deserve to have accurate and unbiased information when they make important decisions about their health coverage. Today’s proposals further our efforts to curb predatory marketing and inappropriate steering that distorts healthy competition among plans.” 

In addition to addressing steering incentives, the proposed rule aims to improve access to behavioral healthcare services for Medicare Advantage beneficiaries. Previous regulations have established Medicare benefit categories for services provided by marriage and family therapists and mental health counselors. The 2024 Physician Fee Schedule also states that addiction or drug and alcohol counselors can enroll in Medicare.

To ensure Medicare Advantage beneficiaries have access to these behavioral healthcare providers, the proposed rule would add a new category of facility specialty called Outpatient Behavioral Health, for which CMS sets plan network adequacy standards. This category would include marriage and family therapists, mental health counselors, opioid treatment program providers, community mental health centers, and addiction medicine physicians.

The Outpatient Behavioral Health facility specialty would be added to the list of specialty types that receive a 10 percent credit if the Medicare Advantage plan’s contracted provider network includes one or more telehealth providers of that specialty type.

The proposed rule also would require Medicare Advantage plans to engage in outreach efforts informing beneficiaries about the supplemental benefits available to them. Additionally, plans must demonstrate that supplemental benefits for the chronically ill (SSCBI) items and services are reasonably expected to improve the health of chronically ill beneficiaries.

Other adjustments included in the rule are related to utilization management procedures, dually eligible managed care beneficiaries, and the risk adjustment data validation (RADV) appeals process. The full proposed rule can be found here.