Insights and Strategies for Success for 2025 Medicare Advantage Open Enrollment
Featuring Jordan Armstrong, Chief Revenue Officer, North America, ResultsCX
Learn about key factors influencing the 2025 Medicare Advantage open enrollment period including payment rate adjustments, compliance regulations, behavioral health benefits, and the importance of hyper-personalization for enhancing customer experience.
Jordan Armstrong: My name is Jordan Armstrong, I have recently moved over to ResultsCX in the role of the chief revenue officer for North America. I work specifically with all our existing clients and the programs that we deliver today. I also support our sales and our larger go-to-market function by partnering closely with our marketing team to ensure we’re putting the right message out there to support our brand.
What major factors do you see influencing this year's 2025 Medicare Advantage open enrollment period?
Armstrong: There is a lot of hype surrounding the upcoming enrollment season for many reasons. A caveat I would add is that many of these I foresee as being more of a distraction than fundamental changes. The election year always has the potential to cause a distraction more so early in the enrollment period. It does have the potential for condensing enrollments into the back half of the season. The potential uncertainty with the election even further increases the likelihood of an intense enrollment season.
Additionally, all over the news, several of the major players are either ending Medicare Advantage coverage in markets due to profitability concerns or they're reducing their benefits in their plans. From a larger perspective, they’re looking to control their overall cost as we all are recognizing the double-digit increase year over year in health care spend.
Moving to more the provider perspective, what should providers specifically prepare for what consumer experience approaches could they possibly take to set themselves up for success in connecting with enrollees and then also targeting these members at risk of switching?
Armstrong: Just in our interactions with our clients on a day-to-day basis, let me maybe break that down into two different questions. Specifically, how are they preparing. From both the payer lens and also the provider lens we focus in discussions on the importance of being compliant. It’s a hyper competitive market today in that regard. And they need post-enrollment. They need effective operations and service delivery measures put in place to ensure that they remain compliant and provide that best experience for beneficiaries and patients.
If I were to break this down into 4-5 key themes around the changes that are anticipated this year, payers and providers are going to have to adapt to increase payment rates and adjustments. CMS had already announced a 3.7% increase in payments to Medicare Advantage plans. Where it is left up to the payers is how are they going to strategize and allocate those funds effectively. How will they balance that as an enhancement in the benefits that they offer to their beneficiaries while still controlling premiums and managing the overall administrative cost.
Second, there is continued updates around risk adjustment and further refining how models are calculated and subsequently reimbursed for care based on the risk stratification of the beneficiary population. The second theme mentioned earlier is that from a compliance standpoint, there's new regulatory requirements. If we start all the way upstream of the process from a broker marketing regulatory standpoint CMS has now mandated that there's a standardized broker compensation that limits third-party marketing organizations and their ability to share personal data without explicit consent. They want to make sure that the license agents are presenting the best plan for the member, not based on how they'll be compensated. Secondarily as it relates to the new regulations is utilization management, prior authorization is always a key theme throughout. And payers need to make sure that they're conducting health equity analysis regularly as it relates to their UM policies in the areas of prior authorization. They want to make sure that there's not disproportionate impacts on potential underserved areas.
Third is there is a requirement in CMS that has placed a large focus on enhancing plan offerings and supplemental benefits. Focus is specifically placed on behavioral health, that’s where a lot of the spend is focused today. Also, focus is on mid-year notifications that are requiring payers for those supplemental benefits that they have is that payers are now required at the mid-year mark to make sure that their beneficiaries and their enrollees understand that they've got X, Y, and Z supplemental benefits. Oftentimes one of the largest barriers to utilization and proactive care from a member is they simply don't understand the benefits that they have within the plan that they're participating in.
Fourth is streamlining the up-front enrollment and appeals processes, introducing new policies and around integrated care for dual eligibles and those enrollees, as it relates to the overall appeal process. It is important to make that more straightforward especially for enrollees that are subject to potentially facing termination for certain services. The payers must ensure that their appeals processes are upfront, proactive, transparent, accessible, and most importantly that they align with the CMS regulations.
And last but definitely not the least, data will continue to remain king. And the better that plans understand their enrollees and beneficiaries, the better they can service them. A heightened focus on overall data collection and analysis are important. What are the key insights? How can they focus in, where do they have opportunities, what about health equity. What are ongoing refinements from a payment standpoint and risk adjustment models so that they can best service their beneficiaries in a cost-efficient manner? I would sum it up into those five key themes around where the payers will need to make sure that they're prepared. And those are the discussions that happen day in and day out with our clients.
If I pivot to the second part of the question and address themes around customer experience, that's where we play. How are they thinking about bringing in these new regulations, the hyper-competitive market. The theme that I ended on is a theme from a CX standpoint. Plans, to be competitive and to create memorable experiences need to have hyper-personalization. How can they best utilize data to best service that that specific beneficiary, that member, based on what their specific needs are. Leveraging different AI driven insights that are now available within the market. And also behavioral segmentation of their of their populations. How do you fully understand what the health needs, behaviors, and preferences are of each member so that when that call comes in or when that inquiry comes in via the portal you can best service their unique needs? I would even say in the Medicare Advantage population that there is a need for enhanced omnichannel communications. Let them interact with the plan with which they want to interact.
It comes down to integrated digital and human touch points. There is a lot of hype in the market right now around Gen AI and the tools available out there. I would always stress on that it has to be an “and” versus an “or”. How can they interact in a digitally enabled way, but still have the human touch point at the appropriate part of that member's journey? This goes back to the core and essential priority of leveraging data and that real-time feedback loop. It's not only important to aggregate and understand that 360-degree profile of the member, but how can they install into their larger workflows that instant feedback mechanism? That way whether it's a week since an interactions with that member or that member is calling every day based on an urgent priority, how can they make sure that those real time feedback loops are being integrated into the intelligence that they can best service their member population?
I would also double down against the hyper focus on the net promoter scores. They need to make sure that they're regularly measuring overall member satisfaction and other consumer customer satisfaction metrics. Use these insights to proactively identify at-risk members and make sure that they're designing interventions to improve that experience. How can they improve the personalized outbound research and leverage that to enhance from a service standpoint. There are a lot of other areas but that would be the top 3 areas where our discussions are focused.
What changes should patients anticipate during this enrollment period and any feedback for them?
Given all of the factors we've talked about in terms of change, new entrants coming in every year to the markets, new plan designs, from a payer perspective this year is about retaining members is going to be king. But that said, for members the plan that they've had for the last couple years is going to look and feel different. There are critical plan design changes that need to happen just from a regulatory standpoint. But also payers have to ensure that they can control the overall costs. We need to make sure that we are articulating the specific details of the plan in a way that can be understood. And that's where a lot of the payers have historically been challenged.
There is also going to be new plan benefits. There's going to be retired plan benefits. There's going to be adjustments. Patients need to pay attention, what are their core needs? How are they utilizing their benefits today and mapping their current vs future needs to the best plan for them? We talked about the new plan benefits around the enhanced behavioral health service, the mid-year notification of those unused benefits. There will be better tools like this out there to support them.
From a secondary factor there are going to be changes in costs and premiums. And there could be potential premium increases and in markets. And segments of those increases could be the sole driver of enrollment and plan decisions for that member. Time will tell how payers are going to incorporate that 3.7 % increase that we talked about at the start of our discussion. How much of that is going to get passed on to the beneficiaries versus absorbed into their larger strategy? It's going to be important around the stability and the enhanced benefits. If we put costs solely aside, many plans may offer enhanced benefits. And many will have benefits that roll off. An area of key focus this year, and this is no hidden secret, is going to be around the prescription drug coverage and also the support for chronic condition management. Just given the regulatory changes there will be more focus on health equity. How can they make sure there is improved access from a market standpoint for those underserved populations? CMS has put regulations in place to help support that. From a patient view, I think that will be a key decision driver. And then making sure that we're doing what's best to inform the member about the plans such as stricter guidelines around marketing and privacy protections to make sure that we are supporting an informed decision based on the best plan for the member versus the commission payout. That simplified appeal process will make it easier for patients and beneficiaries to interact with their plan. It will also create an opportunity. As we talked, retention is going to be king and the name of the game is what I protect. Opportunity is created in the market with new entrants and exits for plan comparison and potential switching. We’re creating a lot of confusion combined with it being an election year. From that standpoint, you've got two very different schools of thought around how to consume health care. This is definitely a very chaotic and dynamic year for enrollment.
