As the year comes to a close, healthcare payers face a landscape marked by significant regulatory shifts and evolving compliance demands. New mandates from CMS, adjustments to Medicare Part D, enhanced HIPAA compliance standards, and a push toward value-based care models will all impact how payers operate, interact with providers, and serve members. Staying ahead of these changes is crucial—not only to ensure compliance but also to strengthen operations, improve member experience, and achieve strategic objectives in a rapidly evolving landscape.
In this blog, I’ll summarize the key regulatory shifts from 2024 and what they mean for healthcare payers moving forward.
1. CMS Updates and Interoperability Requirements
The Centers for Medicare & Medicaid Services (CMS) has made significant strides this year, with updates to its interoperability mandates. Notably, the CMS Interoperability & Prior Authorization Final Rule sets new expectations for streamlining data exchange and improving the prior authorization process. Healthcare payers will need to enhance their technology infrastructure to comply with requirements that promote seamless sharing of patient data with in-network providers by January 2027, with several milestones taking effect sooner.1
For payers, this means investing in advanced systems capable of supporting real-time data sharing. Compliance with these updates will not only minimize administrative burdens but also help facilitate improved care coordination for beneficiaries.
2. Medicare Part D and Prescription Payment Plan Adjustments
Changes to the Medicare Prescription Payment Plan have also been finalized, impacting how prescription drug costs are handled. For those managing Medicare Part D plans, adjustments to out-of-pocket caps and cost-sharing structures will require attention. The goal of these changes is to provide beneficiaries with greater transparency and affordability when managing their prescription needs.
Stakeholders should be prepared to revise benefit designs and communicate these changes effectively to members to ensure a seamless implementation. Proactive communication and robust training programs for healthcare providers and pharmacies will also help maintain alignment and clarity.
3. HIPAA Compliance Enhancements
This year has seen heightened emphasis on strengthening data privacy and security practices under Health Insurance Portability and Accountability Act (HIPAA).2 New guidelines have clarified expectations around the secure exchange of electronic health information (EHI). Compliance officers and consultants will need to focus on ensuring their data-sharing practices align with the updated standards to avoid penalties.
Particularly, payers working within Medicare Advantage or Medicaid need to revisit their privacy policies and conduct internal audits to ensure all departments are fully compliant. With the increasing push towards digital healthcare, staying vigilant about cybersecurity remains a top priority.
4. Changes to Value-Based Payment Models
CMS continues to advance value-based payment models, shifting the focus from volume to value by prioritizing health outcomes and patient experience. These models reward healthcare payers and providers that implement effective care coordination and population health strategies. For example, the Hospital Value-Based Purchasing Program incentivizes hospitals to improve the quality and efficiency of care.3 Additionally, the Medicare Advantage Value-Based Insurance Design Model emphasizes person-centered innovations, such as offering targeted benefits for chronic disease management.4 The Expanded Home Health Value-Based Purchasing Model further supports providers in delivering high-quality care while controlling costs.5
Healthcare payers should continue aligning their operations with value-based care principles by investing in advanced analytics, fostering provider partnerships, and driving initiatives to enhance member outcomes.
Looking Ahead to 2025
The changes from 2024 set the stage for a transformative 2025 in healthcare. Healthcare payers should focus on strengthening partnerships with providers, enhancing compliance and data privacy practices, and preparing their organizations for a continued shift toward value-driven care.
Proactive preparation is key—from enhancing IT systems to conducting training for staff and partners. By anticipating and adapting to these changes, healthcare payers can position themselves to navigate the evolving regulatory environment effectively while continuing to serve their members with quality and care.
The year-end regulatory updates are a reminder of the rapid evolution of the healthcare industry. As healthcare payers, the best approach is to stay informed, stay adaptable, and commit to continuous improvement. By doing so, you can ensure compliance, support your beneficiaries, and thrive in the year ahead.
At HealthAxis, compliance is embedded into our technology and services, ensuring health plans can operate with confidence in a complex regulatory landscape. Schedule a call with our experts to learn how we can help fortify your organization against risks and ensure continuous alignment with healthcare regulations.
Author:
Kelly Thao
Sr. Compliance Analyst
HealthAxis
Sources:
1. Interoperability and Prior Authorization Final Rule (CMS-0057-F), CMS
2. Fact Sheet 42 CFR Part 2 Final Rule, U.S. Department of Health and Human Services
3. Hospital Value-Based Purchasing Program, CMS
4. Medicare Advantage Value-Based Insurance Design Model, CMS
5. Expanded Home Health Value-Based Purchasing Model, CMS
