CY2025 Medicare Advantage and Part D final rule

On April 4, the Centers for Medicare & Medicaid Services (CMS) released the CY2025 Medicare Advantage and Part D final rule. The rule makes several changes to improve access to timely care supported by the AOA, including:

Adding network adequacy evaluation standards for an “Outpatient Behavioral Health” new facility-specialty provider category;
Requiring MA utilization management (UM) committees to have at least one member with health equity expertise on the committee and requiring the UM committees to conduct plan-level annual health equity analysis of prior authorization policies used by the plan, with the results posted publicly; and
Requiring MA plans to engage in mid-year outreach efforts to ensure that enrollees are aware of supplemental benefits offered by the plan that have not yet been accessed in the plan year;

However, despite strong AOA opposition, CMS finalized provisions permitting Part D sponsors to treat formulary substitutions of biosimilars for their reference products as “maintenance changes” that do not require prior approval by CMS. The rule also allows plan sponsors to immediately substitute new interchangeable biologic products with notification to enrollees after making the change.