YourMiHealthAgenc
Expert
Hello,
I wanted to start a thread with what peoples expectations are on what will happen with the MAPD/Medicare market with the recent proposed updates. I have read so many different interpretations and expect that things will change a few more times before it is truly "final." Nevertheless, here are some of our thoughts. . . What are yours?
Final Medicare Marketing Rule
Short-Term Health Plan Rule
I wanted to start a thread with what peoples expectations are on what will happen with the MAPD/Medicare market with the recent proposed updates. I have read so many different interpretations and expect that things will change a few more times before it is truly "final." Nevertheless, here are some of our thoughts. . . What are yours?
Final Medicare Marketing Rule
- Agent and Broker Compensation: Standardizes compensation to prevent steering enrollees towards specific plans based on commissions. Increases base compensation for agents and brokers by $100 (previously proposed increase was $31) first year with a $50 renewal. Prohibits contract terms that incentivize biased recommendations. A fixed amount will be paid to agents and brokers regardless of the plan an enrollee chooses. It aims to eliminates bias caused by commissions that were previously tied to specific plans. This will be up to the carrier to decide to pay this increase.
- Prohibition on Biased Contracts: The rule prohibits contract terms between Medicare Advantage plans and marketing organizations that create incentives for agents/brokers to favor certain plans over others.
- Personal Beneficiary Data: Limits sharing of personal data by third-party marketing organizations. Requires explicit consent for data sharing between organizations.
- Will impact lead generators.
- Access to Behavioral Health Care: Establishes network adequacy standards for a new "Outpatient Behavioral Health" category, encompassing various providers. Requires plans to include telehealth providers for behavioral health services.
- Transparency of Supplemental Benefits: Requires plans to notify enrollees about unused supplemental benefits in mid-year. Standardizes information provided about available benefits. This might get changed to quarterly.
- New Standards for Supplemental Benefits for Chronically Ill: Requires plans to demonstrate the effectiveness of these benefits with research. Updates marketing and communication requirements to prevent misleading information.
- Health Equity Analysis of Utilization Management: Requires plans to analyze utilization management practices for potential bias against underserved populations. Mandates public reporting of these analyses.
- Appeals Process for Termination of Services: Expands enrollee rights to appeal termination decisions through a faster review process.
- Increasing Integration for Dually Eligible Individuals: Encourages enrollment in Medicare Advantage plans affiliated with Medicaid managed care plans. Limits enrollment in certain plans for individuals not enrolled in affiliated Medicaid plans (reduces aggressive marketing tactics). Creates a new monthly enrollment period for switching to standalone prescription drug plans and DSNP MAPD plans (previously quarterly).
- Medicare Advantage D-SNP PPO Out-of-Network Cost Sharing: Limits out-of-network cost-sharing for specific services starting in 2026 (reduces cost-shifting to Medicaid, impact figures not yet available).
- Contracting Standards for Dual Eligible Special Needs Plan Look-Alikes: Lowers the D-SNP look-alike threshold from 80% to 70% in 2025 and to 60% in 2026 (to ensure plans meet D-SNP requirements).
- Standardization of Medicare Advantage Risk Adjustment Appeals Process: Streamlines the appeals process for disagreements over payment calculations.
- Increased Flexibility for Biosimilar Substitution in Part D Plans: Allows for faster substitution of biosimilar drugs for more affordable options. Provides enrollees with earlier access to cost-effective alternatives.
- Improved Targeting for Medicare Part D Medication Therapy Management: Expands access to medication management services for enrollees with specific chronic conditions (including HIV/AIDS) and high medication costs (threshold set at $1,623 for annual cost in 2025).
Short-Term Health Plan Rule
- Beginning September 1, 2024, short-term products are restricted to a term of no more than 3 months with an option one month renewal or extension, for a maximum duration of no more than 4 months.
- At this point, you would need to move them to another plan and do the same thing as long as healthy. (This is added interpretation)
- The regulation prohibits policy stacking by the same underwriter or another affiliate under same control group within a rolling 12-month period beginning on the effective date of initial enrollment.
- A new short-term consumer notice must be displayed in 14-point font type on first page of the policy certificate and application. It also must be prominently displayed in all print and electronic marketing materials, including websites.
- More to come…..