Charles Baker, VP, Compliance Solutions and Tammy Hall, Senior Consultant, Compliance Solutions

Medicare Advantage (MA) plans offering supplemental benefits have reported enrollee underutilization of many of these benefits. Supplemental benefits may include hearing, dental, vision, fitness programs, over-the-counter drugs, transportation for medical appointments, and other services that address social determinants of health, including food and housing assistance.

In an effort to address underutilization, CMS introduced a new requirement in its 2025 Final Rule designed to ensure enrollees are fully aware of all available supplemental benefits they’re entitled to, thereby promoting better health outcomes and overall well-being. The new requirement is an effort to help Medicare Advantage plans act as better stewards of rebate dollars for supplemental benefits and overall care coordination.

The Final Rule also includes several strict requirements focused on strengthening data accuracy requirements, enhancing oversight and monitoring, reporting and corrective actions, improving data collection methods, collecting health equity data, provider data accuracy, and enhancing penalties for misreporting data requirements.

New Supplemental Benefits Notification Requirements

Medicare Advantage plans will need to:

  • Identify Unutilized Supplemental Benefits by developing a system to effectively track, review and report each enrollee’s use of all available supplemental benefits.
  • Develop Personalized Notifications by creating tailored communications to enrollees that highlight specific benefits available that have not been used —and provide detailed information on how to access benefits.
  • Mid-year Notifications must list any available supplemental benefits not used within the first six months of the year.
  • Promote Awareness and Accessibility, including resources and contact information to help enrollees understand how to access supplemental benefits.

New Data Integrity and Data Validation Requirements

The following strict new 2025 data integrity requirements will have significant impacts on Medicare Advantage plans:

  • Increased Accountability and Compliance Requirements, including enhanced data accuracy standards and increased regular audits and monitoring
  • Financial and Operational Implications which may lead to potential penalties for non-compliance and increased administrative costs
  • Improved Data Quality and Reporting through standardized data submission formats and enhanced health equity data collection
  • Provider Data Accuracy achieved through accurate provider directories
  • Strategic and Competitive Advantages realized by improved plan quality and performance

Implementing Final Rule Changes: Challenges and Considerations

There are several challenges to consider related to executing required changes:

  •  Administrative Burden and Operational Complexity. Plans will need to develop and/or invest in systems and processes to track all supplemental benefits utilization and generate detailed personalized enrollee notifications. MA plans will also need to invest ways to meet the strict data integrity requirements to include testing of systems and processes prior to implementation. Plans should consider generating reports on each month, and compliance departments should add these requirements to monitoring and auditing workplans.
  • Communication Effectiveness. The success of the notifications will depend on the clarity and comprehensiveness of the information provided. Notifications should be easy to understand, actionable and sent out as soon after June 30 as possible. The timing of the notifications may increase the potential chances of utilization before the end of the year.
  • Follow-up Support. Providing the required notifications may not be enough; plans should consider creating a follow-up process to further promote utilization and offer support to assist enrollees in accessing and using supplemental benefits.

2025 Final Rule Financial Implications

There are significant financial implications to consider, which may include:

  • Administrative and Compliance Costs
    • Investments in data management systems to comply with stricter standards
    • Staff training to handle new requirements
    • Notification costs that may include increased postage, printing or digital communication platforms
    • Increased time for regular audits and monitoring
  • Potential Penalties
    • Non-compliance penalties related to new requirements
    • Exclusion from the Medicare program

The new notification, data integrity, and data validation requirements represent CMS’s forward-thinking approach to enhancing the value and impact of Medicare Advantage plans. As plans begin to adopt these changes, ongoing evaluation and adjustment will be critical to effectively achieving these goals. MA plans must strategically invest in these areas to ensure compliance, optimize financial performance, and enhance their competitive position in the market.

Contact ATTAC Consulting Group to learn how our Compliance Solutions experts can guide your plan to meet CMS’s 2025 Final Rule requirements.