When Hospital Systems Leave Medicare Advantage Plans, Members Can Apply for a Special Enrollment Period, Though the Path Is Quiet and Uneven

As dozens of hospital systems have dropped out of Medicare Advantage plan networks, federal regulators have quietly granted special enrollment periods to more than 15,000 affected members in seven states, the District of Columbia, and Puerto Rico, according to a KFF Health News report. The grants allow those members to switch Medicare plans outside the usual enrollment calendar when their hospital or provider network changes significantly.

At least 41 hospital systems have withdrawn from contracts with 62 Medicare Advantage plans across 25 states in recent months, continuing a trend driven by disputes over payment rates, prior authorization requirements, and claim denials. The wave of departures has forced many enrollees to decide between keeping their doctors or keeping their plans.

CMS officials declined to explain publicly what level of network change qualifies a member for a special enrollment period, and the agency has not published a written standard. The result is a process that varies case by case, with affected members often learning about their options through media coverage rather than from their insurer or the government.

Members who believe a significant provider loss in their Medicare Advantage plan qualifies them for a special enrollment period can contact Medicare directly at 1-800-MEDICARE or call a local State Health Insurance Assistance Program counselor. The approaching annual enrollment period, which runs October 15 through December 7, also gives all Medicare beneficiaries a chance to switch plans without demonstrating a qualifying life event.