contributors
Zach Berger
Government Programs Practice Lead, RGP
Dr. Laura Reinhold
Senior Director, Revenue Cycle Management, RGP
October 14, 2025 • 7 Min Read
The Medicare Advantage (MA) landscape is shifting in ways that will define payer performance for years to come. CMS’s 2025 rules—like the $2,000 Part D out-of-pocket cap, stricter oversight of supplemental benefits, and new broker compensation limits—are already reshaping benefit design, member engagement, and payer economics.
Many organizations will treat these rules as a compliance tax: a cost to be absorbed, a checkbox to tick. That’s a mistake. Compliance, when treated strategically, can be a lever for growth, not just a shield against penalties.
Why This Matters Now
- Part D redesign shifts more financial liability to payers.
- Supplemental benefits oversight demands documented proof of eligibility and impact.
- Broker/agent compensation rules require real-time monitoring.
Over half of Medicare beneficiaries are in MA. Missteps aren’t just regulatory, they’re operational and financial, cascading to Stars ratings, member satisfaction, and provider networks. With the year closing, payers still have an opportunity to adjust systems, processes, and governance before 2026 begins.
A New Way to Think About Compliance
Treat compliance like a program, not a project. Borrowing from how tech companies manage products, payers can:
- Translate every CMS requirement into structured “user stories” tied to audit evidence.
- Redesign benefit governance to ensure accurate communications and Special Supplemental Benefits for the Chronically Ill (SSBC) eligibility
- Monitor agent and broker compensation in real time.
- Build dashboards that track key compliance metrics across the organization.
- Replace annual audit prep with sprint-based assurance cycles that continuously test and improve processes.
The difference is profound: when compliance is data-driven, continuously assured, and integrated into day-to-day operations, it protects margins, strengthens Stars performance, and builds member trust.
The Risks of Waiting
Failing to act now puts payers at risk of:
- CMS sanctions or fines
- Margin erosion
- Member churn and lower Stars scores
- Provider disruption
- Reputational damage
The real danger isn’t a single penalty, it’s getting stuck in a reactive cycle, where resources are drained, trust erodes, and financial stability suffers.
Where to Start
There’s still time before 2026 to move from reactive compliance to strategic advantage. Partnering with RGP can help you:
- Build audit-ready compliance frameworks and dashboards
- Modernize processes to meet Part D and SSBCI requirements
- Align compliance transformation with Stars and value-based care strategies
- Leverage flexible talent and audit support to stay ahead of enforcement
Done strategically, compliance can really strengthen Stars, protect members, and make your organization more resilient as Medicare Advantage continues to evolve. Contact our experts today to learn more or get started.