This particular Special Enrollment Period (SEP) is exceptional, and will only be granted if the changes to your provider network are considered as "significant". You also cannot just telephone Medicare and request this SEP. Instead, CMS will contact you if this particular SEP becomes available.
As you may know, your Medicare Advantage plan is allowed to change network providers (doctors and hospitals)
throughout the plan year - meaning that your plan can add or drop
doctors or other healthcare professionals at any time - and your
Medicare plan must provide you with a 30-day written notice of any plan
You may notice in the first part of your Medicare plan's Evidence of Coverage document the following
statement: “The [Medicare plan's formulary, pharmacy network, and/or provider network]
may change at any time. You will receive notice when necessary.”
And further in your Medicare Advantage plan's Evidence of Coverage document you can find a more-detailed statement similar to:
Network Changes and the Special Enrollment Period
"What if a specialist or another network provider leaves our plan?
We may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan but if your doctor or specialist does leave your plan you have certain rights and protections that are summarized below:
· Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists.
· We will make a good faith effort to provide you with at least 30 days’ notice that your provider is leaving our plan so that you have time to select a new provider.
· We will assist you in selecting a new qualified provider to continue managing your health care needs.
· If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.
If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed you have the right to file an appeal of our decision.
· If you find out your doctor or specialist is leaving your plan please contact us so we can assist you in finding a new provider and managing your care.
You may contact Customer Service at the number on the back cover of this Evidence of Coverage for assistance in selecting a new PCP or to identify other participating providers."
In 2014, the Centers for Medicare & Medicaid Services (CMS) announced a new 3-month Special Enrollment Period
allowing members of Medicare Advantage plans to switch to another
Medicare plan (or back to Original Medicare) if their Medicare Advantage
plan makes network changes (or provider terminations) that CMS
considers "significant based on the affect or potential to affect,
current [Medicare Advantage] plan enrollees”.
unlike other SEPs that are available automatically due to an event or
change (for example, moving out of your plans service area), this SEP for
mid-year network or provider changes is left to CMS discretion. In
general, CMS has noted that this Special Enrollment Period will be
decided on a case-by-case basis depending on:
- the number of Medicare plan members affected by the network change,
- the notice provided to the plan members (was the notice timely and adequate to prepare for the change),
- the size of the Medicare Advantage plan's service area, and
- when during the plan year the provider terminations occur.
If CMS decides that a Special Enrollment Period will be granted, the
Medicare Advantage plan will notify the plan members of their options to
change to another Medicare Advantage plan or return to Original
Again, unlike other automatic SEPs, Medicare Advantage plan
members affected by changes in a plan's network are not
request this Special Enrollment Period themselves so they can change to
Medicare Advantage plans that include their healthcare providers.
Rather, Medicare Advantage plan members must wait for CMS to determine
that the provider network reduction was "significant"
enough to justify
this Special Enrollment Period. Once CMS has determined that a SEP is
available, your Medicare plan will contact you and you will have a
3-month windows to change plans that includes the month of notification
plus an additional two months after the
notification. Your newly chosen Medicare plan option will become
effective the first day of the month after enrollment.
Also, remember that your Medicare plan can change your provider list
between plan years
and will provide you information about such changes
in your Annual Notice of Change (or ANOC) letter, along with an updated
provider list for the next year. In other words, the doctors that you
use this year may not be part of your Medicare Advantage plan's network next year - so please check the new provider list. Any such changes to your
Medicare Advantage plans provider list
that occur before the Annual Enrollment Period (AEP) and
implemented after January 1st of the next year are not considered
for this special enrollment period.
What are the chances that Medicare will grant you this SEP?
On (03.29.2016) Kaiser Health News noted
: "In the past eight months, Medicare officials have quietly granted special enrollment periods to more than 15,000 Medicare Advantage members in seven states
the District of Columbia and Puerto Rico based on provider cuts. These
decisions offer important details about how members can get permission
to follow their doctors who leave their plans. The number of
beneficiaries affected has ranged from 344 members who lost access to 125
and hospitals (3 percent of the network) in a New West Health Services
plan in southwestern Montana to 7,830 members of MMM Healthcare and PMC
Medicare Choice, which dropped 268
providers (about 5 percent)
in Puerto Rico. Richard Shinto, president and CEO of InnovaCare, which
runs both Puerto Rican plans, said poorly performing doctors were dropped so that the plans could improve their star ratings from CMS
." [emphasis added]
When can you expect to hear from your Medicare plan about provider or network changes?
The 2016 Medicare Marketing Guidelines state:
Advantage] Plans must, and Part D Sponsors are expected to, make a good
to provide the enrollee with written notice of
termination of a contracted provider/pharmacy at least thirty (30)
calendar days before the termination effective date, whether the
termination was for or without cause. When a contract termination
involves a primary care provider, all enrollees who are patients of that
primary care provider must be notified. For other provider types, all
enrollees who regularly use the provider/pharmacy’s services must be
notified." [emphasis added]
(Source: Medicare Marketing Guidelines For Medicare Advantage
Plans, Medicare Advantage Prescription Drug Plans, Prescription Drug
Plans, Employer/Union-Sponsored Group Health Plans, Medicare-Medicaid
Plans, and Section 1876 Cost Plans (Issued: 07/02/2015) p.33)
And the Medicare Marketing Guidelines continue further:
Advantage] Plans/Part D Sponsors should include the following
additional information in the written notice of termination of a
- Names and phone numbers of in-network providers that enrollees may access for continued care;
regarding how enrollees can request continuation of ongoing medical
treatment or therapies with their current providers;
- Customer service number(s) where answers to questions about the network changes will be available; and
on notices to enrollees who will be affected by a provider termination:
“If you want a Provider/Pharmacy Directory mailed to you or if you need
help finding a network provider/pharmacy, please call [phone #]. You
may also email your request for the directory at [email address]. You
can always access our online [searchable, if applicable] directory at
Plans/Part D Sponsors should develop detailed
scripts, call center talking points, and frequently asked questions so
they can effectively respond to phone inquiries from enrollees and other
In instances where there will be significant
changes to the provider/pharmacy and/or facility network, the
organization should work with CMS through their Account Manager to
create a special mailing to be sent to enrollees."
Medicare Marketing Guidelines For Medicare Advantage Plans1, Medicare
Advantage Prescription Drug Plans, Prescription Drug Plans,
Employer/Union-Sponsored Group Health Plans, Medicare-Medicaid Plans,
and Section 1876 Cost Plans (Issued: 07/02/2015) p.34)
Background and Reference Material
, here is the actual Special Enrollment Period text from the "The Medicare
Managed Care Manual", Chapter 2 - Medicare Advantage Enrollment and
Disenrollment, Updated: August 19, 2011 (Revised: November 16, 2011, August 7, 2012, August 30, 2013, August 14, 2014, July 6, 2015,
September 1, 2015, September 14, 2015, December 30, 2015, May 27, 2016, August 25, 2016, June 15,
2017 & July 31, 2018)
30.4.6 – SEP for Significant Change in Provider Network
An SEP exists for situations in which CMS determines that changes to an MA plan’s provider network
that occur outside the course of routine contract initiation and renewal cycles are considered
based on the affect or potential to affect, current plan enrollees.
CMS will establish an SEP, on a case-by-case basis, if it determines a network change to be
The SEP will be in effect once CMS makes its determination and enrollees have been
notified. The SEP begins the month the individual is notified of the network change and continues for
an additional two months. Enrollment in the new plan is effective the first day of the month after the
plan receives the enrollment request.
The scope of the SEP will be determined by CMS, and it may include enrollees who have been
affected, or who may be affected, by the network change. Individuals eligible for the SEP may
disenroll from the MA plan and elect Original Medicare or another MA plan, including an MA-PD
even if they did not have prescription drug coverage previously. CMS will provide specific
instructions directly to the affected organization, including instructions on required beneficiary
notifications and information to be provided to affected beneficiaries regarding other enrollment
options, if applicable. [emphasis added]
see p.51,https://www.cms.gov/ Medicare/Eligibility-and-Enrollment/ MedicareMangCareEligEnrol/ Downloads/ CY_2019_MA_Enrollment_and_Disenrollment_Guidance.pdf)
There is also a similar Special Enrollment Period (SEP) for people
who are leaving their Medicare Advantage plans, returning to Original
Medicare, and joining a stand-alone Medicare Part D prescription drug
plan rather than joining another Medicare Advantage plan.
30.3.8 - SEPs for Exceptional Conditions
I. SEP to enroll in a PDP - MA enrollees using the “SEP for
Significant Change in Provider Network” to disenroll from an MA Plan
MA enrollees using the “SEP for Significant Change in Provider Network”
to disenroll from an MA plan may request enrollment in a PDP. This
coordinating SEP begins the month the individual is notified of the
network change and continues for an additional two months. This SEP
permits one enrollment and ends when the individual has enrolled in the
PDP. An individual may use this SEP to request enrollment in a PDP
subsequent to having submitted a disenrollment to the MA plan or may
simply request enrollment in the PDP, resulting in automatic
disenrollment from the MA plan. Enrollment in the PDP is effective the
first day of the month after the plan sponsor receives the enrollment
(Source: see p.33, "Medicare Prescription Drug Benefit Manual", Chapter 3
- Eligibility, Enrollment and Disenrollment, Updated: August 19, 2011
(Revised November 16, 2011, August 7, 2012, August 30, 2013 &
August 30, 2014)
(https://www.cms.gov/ Medicare/ Eligibility-and-Enrollment/ MedicarePresDrugEligEnrol/ Downloads/ CY-2015-PDP-Enrollment-and- Disenrollment-Guidance.pdf))
also: Medicare Managed Care Manual Chapter 4, “Benefits and Beneficiary
Protections”, p. 68, Section 110.1.2 – Significant Changes to Networks
(https://www.cms.gov/ Regulations-and-Guidance/ Guidance/ Manuals/ downloads/ mc86c04.pdf)
- "In addition, pursuant to 42 CFR § 422.62(b)(4), enrollees affected
by substantial mid-year provider network terminations initiated by an
MAO without cause may be afforded a special enrollment period (SEP). If
CMS determines that a SEP is warranted, the MAO may be required to
notify its members of the SEP as part of the 30-day notification about
the network change. For more information regarding a SEP due to
significant network changes, please see Chapter 2 of the Medicare
Managed Care Manual."
In 2014, members of Congress asked CMS for a clarification on this policy in a letter noting that:
"CMS should define the “significant” provider changes
that would make an enrollee eligible for a SEP in a way that reflects
the needs of individuals, allowing beneficiaries to change plans if
their providers who were a part of the network when they signed up for a
specific plan are no longer in-network. At the same time, we ask the
agency to carefully monitor the use of such SEPs and any related
marketing by health plans, to minimize gaming and other discriminatory
practices. These policy changes will preserve beneficiary choice and
minimize disruptions in care continuity."
(Source: the December 19, 2014 letter to Marilyn Tavenner, Administrator for the Centers for Medicare & Medicaid Services
The U.S. Department of Health and Human Services, from U.S. Senator Richard Blumenthal (D-Conn.) and U.S.
Representatives Rosa DeLauro (D-Conn.), Joe Courtney (D-Conn.), Jim
Himes (D-Conn.) and Elizabeth Esty (D-Conn.)
) (for full text see:
https://www.blumenthal.senate.gov/ newsroom/press/release/ blumenthal-delauro-courtney -himes-esty-15-senators-and- representatives-call-for- increased-consumer- protections-in-medicare -advantage-plans)
Additional reading from Kaiser Health News (12.01.2013):
Dropping Hundreds Of Doctors From Medicare Advantage Plans"
(https://khn.org/news/ medicare-advantage-unitedhealthcare -narrow-networks-doctors/)