As Medicare open enrollment begins for 2025, major reductions in Medicare Advantage (MA) plan offerings are expected to lead to major shifts in patient enrollment in plans. Existing enrollees will need to decide whether to explore alternative plans or switch to traditional Medicare. It’s imperative that providers keep a close track on enrollment trends for the upcoming year as the shift in enrollment may have an impact on their value-based arrangements with MA plans. For patients seeking to retain their provider, it’s important they are supported in analyzing the plan offerings and ensuring their provider is accepting that insurance.

1. Reduction in Medicare Advantage Plan Offerings
   It is expected that approximately 1.5 million people will see their MA plans eliminated and 3.5 million will lose Medicare Part D policies. Disruption in plan availability will require proactive support for patients to ensure they receive adequate coverage and maintain care continuity. Patients will have the option of moving to Traditional Medicare and be responsible for associated premium increases or shop around for a new Medicare Advantage plan. Providers and Health plans must be closely aligned on robust provider marketing and retention programs. Providers will be challenged to hold onto patients in their best plans and should review their contracts with MA plans to ensure adequate coverage and monitor enrollment, especially for those taking risk in value-based care arrangements. Enrollment changes can significantly impact provider reimbursement and risk score for enrollees moving between plans, especially those in large IPAs with value-based contracts.
2. Non-Premium Cost Increase
   Maximum out of pocket spending is expected to increase for patients. Healthpilot estimates total average maximum out of pocket spending will increase by $450 to around $5929. These changes can impact patient affordability and adherence to treatment plans. Providers can help to educate their patients about what services may lead to higher costs and when possible, tailor treatment plans to help minimize out of pocket expenses.
3. Shifts in Part D Benefits
   There will be an estimated 25% reduction in standalone plans, causing increases in drug deductibles out of pocket expenses for medications. As part of the Inflation reduction act, out of pocket expenses for Part D medication cap at $2000 in 2025. There is also a new option to pay off one’s total drug bill in monthly installments. Plans may reduce the formulary in their Part D design and providers will need to educate patients appropriately. Providers should anticipate changes in medication access for patients, requiring more proactive management of medication regiment.
4. Hospital Network Transitions
   More hospitals are opting out of some Medicare Advantage health plans, resulting in a shift to out of network status. This can pose challenges for patients remaining within the same plans and visiting hospitals that have shifted out of network, for instance they may face higher out of pocket costs. Hospitals who plan to terminate MA plans should engage with patients who decide to return to traditional Medicare to simplify access to care and mitigate financial impact. Patients will need support to proactively evaluate whether their current plan and preferred hospitals and specialists are still within their network coverage and to decide whether to switch to a new MA plan or traditional Medicare to avoid increased out of pocket expenses.
   Providers in value-based arrangements should analyze their contracts to understand the impact of patients switching plans on their panel size, revenue and performance opportunities. For instance, hospitals shifting to out of network status can lead to higher costs for ED and inpatient utilization. Providers should analyze historical utilization of the hospitals that have shifted out of network for their new panels and create strategies to ensure continuity of care for patients and strengthen care coordination with remaining in-network providers.
5. Benefit Changes
   Prior Auth Requirements are changing and there will be a reduction in additional benefits (dental, vision, transportation, OTC, hearing, etc.) offered by Medicare Advantage plans. An increasing number of services will be requiring prior authorization which is expected to create additional administrative burden for providers. Providers should streamline their practice’s prior authorization workflow to minimize delays for patients. Some helpful strategies to streamline prior authorization include having dedicated staff, using electronic prior authorization requests as opposed to manual requests, standardizing workflow to ensure what staff need to submit a prior authorization request, and create a cheat sheet for staff to use for common procedures and prescriptions requiring a prior auth.

COPE Health Solutions has supported numerous healthcare organizations across the country in successfully navigating changes to value-based contracts and insurance plans. COPE Heath Solutions can offer guidance to organizations navigating strategies to best analyze the impact of Medicare Advantage changes to value-based contracts. Our initiatives can be tailored to your organizational needs to support efforts to streamline enrollment, minimizing procedural barriers and improving member experiences.

If you are interested in a free assessment to learn more about the impact to your local region, please reach out to us at info@copehealthsolutions.com or 213-259-0245 to learn how CHS can help your organization succeed in Medicare Advantage or any other form of value-based payment for Medicare, Medicaid or commercial lines of business.

Literary Reference:

https://www.wsj.com/health/healthcare/medicare-plans-are-making-big-changes-for-2025-heres-how-to-navigate-them-5c81fd05?st=zBukqS