Now that we’ve had time to delve into the 1300+ pages of the 2025 Final Rule, the critical implementation phase begins. Many elements of this final rule were anticipated, and some were long overdue. This rule marks a significant shift towards expanding access, strengthening beneficiary protections, addressing social needs—not just identifying them—improving the quality of care and member experience, and shifting funds back into the Medicare Trust Funds.
Teams dedicated to Stars, HEDIS, Risk Adjustment, and the senior market are pivotal because of their commitment to enhancing beneficiary lives. Every year, we roll up our sleeves and dive into the work. That’s exactly what the mPulse teams have been doing since the release of the Final Notice. We initiated strategic discussions around these critical areas during the Proposed Rule and Advance Notice phases and have already made several updates to our solutions and products. These enhancements better equip our health plan clients to tackle these significant challenges effectively.
Whether these topics were new, codified, or have only now reached our ‘front door,’ we’ve outlined key areas and provided best practices, tips, and member engagement ideas as part of our health plan member engagement strategies. These are designed to help plans address these challenges head-on.
1. Medication Therapy Management (MTM)
Expanding MTM program eligibility criteria by:
- Adding HIV/AIDS to the core condition list
- Including all Part D maintenance drugs
- Revising the cost threshold calculations
mPulse’s Strategic Approach
Chapter 7 of the Prescription Drug Benefit Manual (specifically sections 30.3 & 30.7) mandates that CMS expects sponsors to implement procedures that actively drive participation and follow-up with beneficiaries who do not engage with initial offers. Sponsors are encouraged to adopt a multi-faceted approach to ensure comprehensive reach to all eligible patients.
Incorporating an omni-channel member engagement strategy is crucial to connect with all eligible members effectively. By anticipating members’ needs, you can remind them that the service is a covered benefit, assist them in preparing for the Comprehensive Medication Review (CMR), and reinforce the advantages of routine medication reviews.
Remember, introducing new channels or additional support to assist members in completing their CMR can be integrated into your Medication Therapy Management (MTM) program at any point during the year.
2. Mid-Year Enrollee Notification of Available Benefits
In addition to the new requirement to submit utilization and cost data in EDS, CMS will require plans to provide beneficiaries with a mid-year notification of all unused supplemental benefits.
Each notification must be personalized and include details about the unused benefit, including applicable cost-sharing details, information on how to access it, required network information, and a contract center number for additional assistance.
mPulse’s Strategic Approach
Getting the right benefits, supplemental and otherwise, into the hands of the right members can be challenging. We often cast a wide net and hope standard means of communication such as Evidence of Coverage (EOCs), Summaries of Benefits (SOBs), and landing pages are sufficient. However, actions taken by CMS in this area indicate that these methods are not enough, and many benefits are being underutilized or not used at all.
Member Engagement Ideas: Start engaging with your membership now, even without robust supplemental benefit utilization data. Utilize claims and encounter data to identify need-based populations who would benefit most from your supplemental offerings. Implementing these strategies now will be beneficial during the Annual Election Period (AEP) and Open Enrollment Period (OEP), when your members can be prompted to benefits that resonate with them both socially and clinically. If executed well, this approach could not only reduce the number of benefits notifications needed mid-year but also bolster your broader retention and satisfaction efforts.
3. Health Equity Index (HEI) and Reward
Data collection beginning with calendar years 2024 and 2025 will shape the 2027 Star Ratings and impact the 2028 payment year. Ratings and rewards will be determined by performance and enrollment thresholds within dual eligible, low-income, and disabled beneficiary populations.
mPulse’s Strategic Approach
With expanded LIS eligibility extended to individuals with incomes up to 150% of the federal poverty level (FPL) in 2024, some beneficiaries may not even know they qualify. Plans will want to make sure all of their eligible members have applied and qualified for subsidies. Not only should all beneficiaries have the protections available to them, but plans can’t afford to miss those HEI enrollment thresholds whenever and wherever possible.
There are a few steps to a successful approach:
- Use predictive models and analytics to identify members who may be eligible for but have yet to receive extra help.
- Develop an omnichannel engagement strategy to inform members of the income thresholds and provide them with information and support on applying.
- Be prepared to support members who may not qualify by offering additional plan, local, state, or federal resources. And help any new LIS members fully understand and utilize their new benefits.
Want to learn more about addressing health inequities? Download the white paper »
4. Inflation Reduction Act – Part D Redesign
- Medicare Prescription Payment Plan (M3P)
- Elimination of Coverage Gap
- Part D annual out-of-pocket maximum reduced to $2000
mPulse’s Strategic Approach
CMS continues to strengthen protections for individuals who rely on Part D coverage. Between the 2022 IRA and 2025 Final Rate & Rules and beginning on January 1, 2025, beneficiaries will have a lower out-of-pocket maximum, no coverage gap phase, and the opportunity to spread the cost of their drugs out over the year with monthly average payments instead of all at once at the POS.
While all are favorable financially to beneficiaries, some of these changes are bound to cause confusion. Even when a 2025 copay or coinsurance is less than it was in 2024, beneficiaries will still call and ask why. The M3P is likely to confuse your members, call centers, and network pharmacies. Relying on traditional means of communication won’t be sufficient. Highly tailored and personalized communications to members who may need it the most (high spend and utilizers, early donut hole goers in 2024, etc.) will not only help them navigate this new Part D world, but it should also reduce the need for inbound calls and ideally yield favorable satisfaction and retention for CAHPS and OEP.
5. Member Experience and Access Measures, CAHPS & HOS
- Member Experience and Access Measure Weights Reducing from 4x to 2x for Stars Year 2026
- Improving or Maintaining Mental Health & Improving or Maintaining Physical Health Weight Increasing from 1x to 3x each for Measurement Year 2025
mPulse’s Strategic Approach
CMS is realigning the weight of experience and access (also known as administrative) measures while ensuring beneficiaries still have a significant ‘voice’ that holds plans accountable and impacts ratings. These measures will continue to account for nearly 20-30% of the overall Star Rating over the next few years, with a trend towards less emphasis moving forward.
The two longitudinal Healthcare Outcomes Survey (HOS) measures will return to their original weights after being moved to the display page due to data collection disruptions during the pandemic.
Health Plan Member Engagement Strategies: Weight shifts and the temporary retirement of measures on the display page should never be used as an excuse for neglecting improvements in any measure category. There is no one-size-fits-all approach to CAHPS and HOS; rather, it requires a data-driven and personalized strategy to understand what is working, what isn’t, and who needs more focused attention. Leverage data from regulatory and off-cycle surveys, along with health plan data, both clinical and non-clinical, to develop an informed strategy for outreach. Provide live agent calls to those most at risk, and deploy high-touch digital communications to other segments. This dual approach allows health plans to cover the largest volume of membership without sacrificing personalization and service recovery.
6. Colorectal Cancer & Breast Cancer Screening
- Expand Screening Age for Colorectal Cancer Screenings
- Gender-Neutral Terms for Breast Cancer Screening
mPulse’s Strategic Approach
In alignment with NCQA, CMS will also expand eligible member populations to include those aged 45-49 for colorectal cancer screening measure and begin using gender-neutral terminology for the breast cancer screening measure.
While changes to Stars often lag other measure stewards (NCQA, PQA, USPSTF), this shouldn’t necessarily stop plans from early adopting some changes. The two listed above are a prime example. New age bands should be included in educational outreach as soon as they are available and aligned with preventive coverage. And we don’t necessarily need a measure steward to tell us when to use gender-neutral terminology.
The best practice here is to incorporate these changes early on, educate your member-facing teams, and update your stock and custom printed materials, digital communications, and landing pages.
If you’d like to learn more about how we are applying DecisionPoint by mPulse predictive analytics and mPulse digital health engagement technology to these and other changes across all lines of business, reach out to me directly or visit our solutions page at www.mpulse.com.
