5 Compliance Trends to Watch Out for in Plan Year 2025

In 2024, the Center for Medicare and Medicaid Services (CMS) made significant changes to the rules governing Medicare Supplement, Medicare Advantage, and Part D insurance carriers and agencies. As we look ahead to 2025, more changes are on the horizon that will impact how these insurance products are sold and managed.

One of the key changes for the upcoming season is the tightening of billing requirements for Medicare Advantage and Part D plans. CMS is increasing scrutiny on plan scoring and coverage disclosure, as well as expanding its ability to recoup overpayments from carriers and agencies. This means carriers will need to be more vigilant in their billing practices and ensure compliance with new standardized coding practices.

Another important development is the focus on timely access and prior authorizations. CMS is implementing new rules to create more uniform standards for carriers and streamline the prior authorization process. This includes tighter turnaround times for authorizations and more detailed explanations for consumers.

Marketing protections for Part D and Advantage plans are also being strengthened, with restrictions on how carriers can use the term “Medicare” in advertising. Carriers must now emphasize Medicare Part D or Medicare Advantage to make it clear that these plans are not part of Original Medicare.

Behavioral health access is also a priority, with Medicare Advantage plans required to provide a range of mental health and substance use disorder services. This includes coverage for inpatient hospital care, group therapy, and medication management.

Overall, the changes for the 2025 Medicare season are aimed at improving transparency, efficiency, and compliance for carriers and agencies. It’s important for insurance professionals to stay informed and adapt to these evolving regulations to ensure they are providing the best possible service to Medicare beneficiaries.