In this episode, Meliza Weiner, BESLER’s Senior Manager of Revenue Cycle & Clinical Review Nurse, provides us with a glimpse into BESLER’s next free live webinar, Medicare Advantage: Key Trends in 2025, presented live on Wednesday, January 29, at 1 PM ET.
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Learn how to listen to The Hospital Finance Podcast® on your mobile device.Highlights of this episode include:
- What to expect in the upcoming webinar
- Medicare Advantage plans overview
- What the enrollment trajectory looks like
- Updates from CMS for 2025 in regard to Medicare Advantage
- Tips for providers
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Meliza Weiner, BESLER’s Senior Manager of Revenue Cycle and Clinical Review Nurse. In this episode, Meliza will provide us with a glimpse into BESLER’s next free live webinar, Medicare Advantage: Key Trends in 2025, that she’s presenting live on Wednesday, January 29, at 1 PM Eastern Time. Welcome back and thank you for joining us, Meliza.
Meliza Weiner: Thank you so much, Kelly, for having me back.
Kelly: All right. Well, let’s go ahead and jump in. So can you provide us with a brief overview of what people can expect in your upcoming webinar?
Meliza: Of course. Well, so the upcoming webinar will focus on Medicare Advantage and the emerging trends that will occur this year in 2025. It will cover a basic overview of Medicare as well as an overview of Medicare Advantage. It will also cover and maybe list out some advantages and disadvantages of all the different MA plans, look at the transfer rule and its impact to Medicare Advantage plans, and then cover some statistics, specifically enrollment projection in Medicare Advantage, as well as any available plans that are still there or that have exited, as well as taking a look at the updates for that CMS-4205-F, the Medicare Advantage and Part D Final Rule, and take away some pointers for providers. So basically, the objective, really, Kelly, is to maybe have an understanding, if not a lot of knowledge, about Medicare Advantage and its emerging trends that’s going to happen this year, and the importance of the updates within the Medicare Advantage and the Part D Final Rule.
Kelly: Sounds like it’s going to be a very informative webinar indeed. So, most are familiar with Medicare Advantage plans, but could you provide a brief overview of what they are?
Meliza: Sure. Well, it’s important to understand, first, what I consider as this ever nonstop, evolving, redesigning, or what we call reforming environment of healthcare options that are available. But we need to understand, first, what Medicare Advantage is. Medicare Advantage plans, which is also known as Medicare Part C, basically is another option to what we used to know as original Medicare or traditional Medicare by combining hospital coverage and medical coverage and sometimes Part D, which is prescription drug plan, into one convenient plan. So, these plans are expected to include services like dental, vision, and hearing care, which are often overlooked in standard traditional original Medicare. But many of these Medicare Advantage plans include more than that. They’re more comprehensive. Beneficiaries can expect basically an array of plans that accommodate various healthcare needs, having access to comprehensive care that is designed for their lifestyle. What really is important to remember is that each plan has unique features. Now, with these unique features, you’re going to have varying costs, different provider networks. So that’s something they need to think about with Medicare Advantage plans. And additionally, these are plans that also offer additional benefits that Medicare doesn’t typically offer, like wellness programs, transportation services, bathroom safety equipment like those safety grips in the bathtubs, even telehealth options, which does make it a bit easier to manage health at home.
Some plans offer non-skilled home services and home-based palliative care services, which typically Medicare does not offer. Now, one thing I want to mention, I thought was interesting, is that they are offering discounted pet support medications, caregiver support reimbursement, and, of course, vaccines. So, I see this, that Medicare Advantage plans are showing some improvements and recognizing that the importance of promoting better health is looking at a holistic approach, which is what CMS and Medicare itself want the Medicare Advantage plans to do for all of their beneficiaries.
Kelly: Wow, that’s a lot of great information. Thank you for sharing it with us. So, Meliza, what does the enrollment trajectory look like?
Meliza: Well, interesting that you ask that question. Medicare Advantage enrollment has always been growing. Typically, if everybody’s following it or whoever is following it, it’s growing yearly. And now they’re projecting it to grow in 2025. And we’re just starting. It’s only January. But the Trustees’ Report for 2024 projected that there’s going to be an increase. We’re looking at 35.7 million, which is basically a 51% representation of enrollment in Medicare that’s going to move into Medicare Advantage. Compared to 2024, which is only 50%, we’re looking at probably 51% for 2025. The Congressional Budget Office projects that the share of all Medicare beneficiaries that are enrolled in Medicare Advantage plan will rise to at least 64% in 2033. Now, I think one of the contributing factors to this is that there are no companies that are joining the Medicare Advantage arena, and there are existing companies that are expanding their benefits. So, a lot of people are switching over. And despite there is only just eight firms that you can choose from, there are 42 plans and still over 3,000-plus varieties of those plans that are available to Medicare Advantage enrollees.
Now, one thing though to keep in mind is that these companies can decide if a plan will be available to everyone with Medicare in a specific state or only in certain counties in that state. So, insurance companies that offer Medicare Advantage plans may also offer more than one plan in one area and not in another. So, this is something that enrollees need to think about. Each year, these companies can decide to join or leave Medicare.
Kelly: Wow, that’s substantial and a lot to think about. So ,what are some of the updates from CMS for 2025 in regards to Medicare Advantage?
Meliza: So, if someone is going to take a look at this, Kelly, and they go into CMS.gov, they will see a lot of updates. And I’ll just briefly highlight some of them. I think the first one, and I think that’s very important to mention, is about the premiums. The average premium for Medicare Advantage plan, which also includes Medicare Advantage plans with prescription drug coverage, is expected to decrease from $18.23 in 2024 to $17 in 2025 monthly. So, it’s going to decrease by $1.23 per month. And, the special needs plan, there’s going to be more available. And what basically that means is people with special needs, there’s going to be more offering for them. Anybody with specific health conditions like your end-stage renal disease, certain healthcare needs or institutions that are needed, or also those who have Medicaid, they’re looking at the offering will grow by 9% between what occurred in 2024 to now in 2025. The other thing also is that the number of Medicare Advantage plans offering that are targeted to offer supplemental benefits for the chronically ill will grow from 105 organizations offering it to 111 organizations offering it. Another thing that I want to highlight also is the lower average of total Part D premiums in 2025. It is going to decrease from $53.95 to $46.50. And anybody who’s in traditional Medicare and only takes part in a Part D plan total premium, it’s projected that premium is going to decrease also by $1.63.
Out-of-pocket costs – this is another big one – for prescription drugs will be capped at just $2,000. And they have the option to spread their prescription drug costs throughout the year. They don’t have to pay upfront at the beginning of the year. There’s also going to be improved access to outpatient behavioral health providers and services. And the one thing that caught my attention when I saw this is the increase in prior authorization transparency. What basically this is telling us is that Medicare is saying that Medicare Advantage plans must include an expert in health equity on the utilization management committees that are required to oversee all of the prior authorization and utilization management policy, and ensure that they are compliant with all of the CMS rules. They’re basically looking to identify any inconsistent delay or denial of access to needed care for those enrollees that have a disability or limited income and resources. And one last thing I want to highlight is improved coordination for people with Medicare and Medicaid. Basically, they want to simplify the process and the written material so that dually eligible employees– I mean, eligible enrollees rely on to access services. There’s going to be less confusion.
Kelly: Wow, that is a lot of information and bound to be confusing for a lot of people. But thank you for providing all that for us. So, Meliza, any tips for providers?
Meliza: Oh, there are a lot of tips. I think one of the tips that I like to give all the time is for providers to stay on track, stay focused, and be agile because of this changing landscape of healthcare. Stay abreast of any developments. Providers really need to particularly pay attention to contracts, especially when they’re in writing and negotiating the contracts. Oftentimes, Medicare Advantage contracts are seen as a last resort or an effort in which they just make it as an addendum that gets attached to a commercial contract that an organization currently has. So, it’s more like an afterthought, if you will. There is not much attention to it. They need to take a look at the details, look at the fine print, because these contracts need to be scrutinized and evaluated. You have to understand that Medicare Advantage plans must follow Medicare rules. So, the little one-offs and tweaking to make it vague can sometimes hurt you right away or maybe later. These plans that are under Medicare are actually under the Medicare guidance and they get payment through Medicare. So, in essence, the plan must follow Medicare rules, with big emphasis on the payment methodology rules. Seeing the language itself must be examined. Sometimes you have to mirror that language that Medicare has because a payment methodology versus an actual rate is going to be different.
There is going to be a difference in timely filing, with prompt payment and with add-on payments. And between traditional original Medicare and Medicare Advantage plan, the aim is to help the beneficiaries be healthier. So, for providers and plans, it would be prudent to work as partners. Create awareness, education, maybe through marketing of services and offerings. Another tip that I like to give all the time is also it is important to look at the coding aspects, especially when it comes to ones that are falling under any new breakthrough diagnosis that are coming out, any new treatments, and most importantly, virus-related services. We went through COVID, which everybody’s aware of. Now I don’t know. We’re in a new variant now. Every year there’s a new variant for COVID. And let’s not forget the emerging of what used to be eradicated. Measles is now making a comeback. So those types of diagnosis and services that we don’t typically see, now they’re coming back. They need to pay particular attention to how that is coded, following up on positive test requirements. This is not just good for additional DRG, which is a definite plus, but it’s also good in using correct diagnosis codes and CPT codes for stays, for visits, for testing and supplies, because it ensures compliance. Keep in mind, Medicare organizations are subjected to audits as well.
These audits, which are typically conducted by the OIG, is not to punish. Although, Kelly, sometimes it feels like it is, but it determines the health status of their beneficiaries and their enrollees and the Medicare Advantage organization’s compliance with its participation in the CMS Risk Adjustment Program. So today, audits conducted demonstrated numerous misquoted diagnosis, resulting in net overpayments valued in the millions. So again, it’s just about being mindful and, importantly, being compliant.
Kelly: Wow, thank you for all those great tips, Meliza. That was awesome. And thank you so much for joining us and for sharing this great sneak peek into the upcoming live webinar, Medicare Advantage: Key Trends in 2025, that you’re presenting live on Wednesday, January 29, at 1 PM Eastern Time. And as a bonus, you can earn CPE. Thanks again, Meliza.
Meliza: Thank you so much, Kelly.
Kelly: And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…
[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.
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