Medicare Advantage (“MA”) plans may want to think twice before modifying their provider networks. In an August 27, 2015 letter, CMS announced that MA plan enrollees may elect to change plans if their current plan makes a significant provider network change with substantial beneficiary impact.
The letter provides an overview of how CMS will implement the standards and guidelines intended to protect beneficiaries from significant provider network changes.
MA organizations (“MAOs”) are required to notify CMS of any significant no-cause mid-year network changes 90 days before they go into effect. CMS will then review the information provided to determine whether the change is sufficiently significant. CMS will also identify the group(s) of enrollees substantially impacted by the network change based on the enrollees’ current or recent uses of any services from a provider soon to be terminated from the network.
If CMS determines that a network change is significant, MAOs must notify enrollees substantially impacted by the change that they are eligible for a two month special election period, during which they can elect to choose a new plan. Enrollees can switch plans immediately after enrollees are notified of their eligibility to do so.