HHS Finalizes Rule Expanding Access to Care and Increasing Protections for Medicare Part D Plans

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare and Medicaid Services (CMS), is finalizing policies to ensure Medicare Advantage and Medicare Part D prescription drug plans best meet the needs of people with Medicare. 

The 2025 Medicare Advantage and Part D final rule establishes a set amount a plan can compensate an agent or broker to protect Medicare Advantage and Part D plan enrollees and prospective enrollees from anti-competitive steering, and to help these individuals find the plan that best suits their needs rather than being steered into options based on financial incentives to agents and brokers from insurance plans. CMS is also requiring that Medicare Advantage plans include an expert in health equity on their utilization management committees and for the committees to conduct an annual health equity analysis of the plans’ prior authorization policies and procedures. 

The final rule also promotes access to behavioral health providers and services for people with a Medicare Advantage plan to help ensure they can receive essential treatments for mental health and substance use disorders. It expands network adequacy evaluation requirements to a new outpatient behavioral health specialty type, which includes marriage and family therapists and mental health counselors who are now able to bill under Original Medicare, as well as addiction medicine clinicians, opioid treatment providers and other behavioral health practitioners providing psychotherapy or medication for substance use disorder. 

Additionally, the rule finalizes new guardrails for certain types of supplemental benefits, available only to chronically ill enrollees, to ensure these supplemental benefits offered by a Medicare Advantage plan meet the health needs of people with Medicare by being supported by evidence. The rule also requires Medicare Advantage plans to send a mid-year, personalized communication to their enrollees about accessing unused supplemental benefits. These actions ensure that the large federal investment of over $65 billion per year of taxpayer dollars in supplemental benefits will meet enrollee needs and will not be used just for marketing.