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Can I get a Special Enrollment Period if my Medicare Advantage plan drops my doctor from the plan's network?

Category: Your Healthcare Network
Updated: Jul, 13 2023

Maybe. This particular Special Enrollment Period (SEP) is exceptional, and will only be granted if the changes to your provider network are considered as "significant".

In addition, you cannot simply telephone Medicare and request this SEP.  Instead, CMS will contact you if this particular SEP becomes available.

Changes to your healthcare network

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 changes.

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:
"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."

Healthcare Network Changes and the Special Enrollment Period

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”.

Unfortunately, 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 Medicare.

Please note:  Again, unlike other automatic SEPs, Medicare Advantage plan members affected by changes in a plan's network are not permitted to 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?

Kaiser Health News noted (on 03.29.2016):
"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 physicians 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:

"[Medicare Advantage] Plans must, and Part D Sponsors are expected to, make a good faith effort 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:

"[Medicare Advantage] Plans/Part D Sponsors should include the following additional information in the written notice of termination of a contracted provider:
  • Names and phone numbers of in-network providers that enrollees may access for continued care;
  • Information 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
  • Language 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 [URL].”
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 stakeholders.

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."

(Source: 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

As reference, 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 & August 12, 2021)

30.4.6 – SEP for Significant Change in Provider Network
42 CFR 422.62(b)(23) (Rev. 1, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)
CMS will establish a SEP, on a case by case basis, for situations in which CMS determines that changes to an MA plan’s provider network are significant based on the affect, or potential to affect, current plan enrollees who are assigned to, are currently receiving care from, or who have received care within the past 3 months from a provider or facility being terminated from the provider network.

The SEP can be used only once per significant change in provider network. It begins the month enrollees are notified of eligibility for the SEP and continues for an additional two calendar months thereafter. [emphasis added]

Historical note:  Previous Section 30.4.6 text from 2019 Medicare Manual
(Source: see p.51,https://www.cms.gov/ Medicare/Eligibility-and-Enrollment/ MedicareMangCareEligEnrol/ Downloads/ CY_2019_MA_Enrollment_and_Disenrollment_Guidance.pdf)
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 significant 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 significant. 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]

Additional Special Enrollment Periods may be applicable

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 request.
(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))

See 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):
"UnitedHealthcare Dropping Hundreds Of Doctors From Medicare Advantage Plans" (https://khn.org/news/ medicare-advantage-unitedhealthcare -narrow-networks-doctors/)

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