Doctors Can Exit Your Medicare Advantage Network Anytime - You're Locked In Until January

Imagine that you are a retiree who receives a letter in early April from your primary care doctor.

In the note, the physician who has managed your care for nine years announces they are leaving your Medicare Advantage network by the end of the month.

Such unwelcome news was not in your retirement plan. What should you do now to protect both your health and wallet?

How you become trapped when a doctor exits

Perhaps you start by reaching out to your plan to ask what your options are. However, the answer might be more complicated and less favorable than you expect. Providers have the right to exit a Medicare Advantage network in the middle of the year, but you are likely stuck with your plan because the ability to switch coverage is tightly restricted.

Once the annual Medicare Advantage Open Enrollment Period closes on March 31, you are probably locked into your plan until the Annual Enrollment Period opens the following Oct. 15. And even if you wait things out and make the switch in October, the new plan won't go into effect until the following January.

The bottom line is that a doctor who leaves the network after March 31 puts their patients in a position where the patients have no routine switching rights for many months.

3 possible 'escape hatches'

If you are in this position, you don't necessarily have to simply accept your fate. Three "escape hatches," a term coined by Wall Street 24/7, are available that might allow you to escape your unfortunate situation.

However, all three of these options also come with limitations. The following are the escape hatches to try.

File an appeal

When a provider you regularly see disappears from your plan, the plan must give you at least 30 days' advance written notice of the change. This rule is in effect to give you enough time to find a new provider.

If that notice arrived late or you did not get it at all, document the situation and file an appeal.

Request transitional care from your plan

CMS requires Medicare Advantage plans to provide continuity of care protections when a provider leaves the network. If you're in the middle of active treatment, such as chemotherapy, post-surgical recovery, or management of a serious chronic condition, you may be able to continue seeing your existing provider at in-network cost-sharing for a transition period, typically up to 90 days. Contact your plan directly to request this transitional care.

Unfortunately, routine visits and medication management for stable conditions don't qualify for this exception.

Try to qualify for a Special Enrollment Period

The Centers for Medicare & Medicaid Services (CMS) may offer you a Special Enrollment Period if the network change is deemed to be "significant." This allows you to either change to another Medicare Advantage plan or to switch to Original Medicare coverage.

For example, CMS has allowed such Special Enrollment Periods in at least 13 states in recent years following major insurer-hospital system breakups.

However, CMS does not define "significant," and the process is not automatic. Instead, it typically requires advocacy from state insurance commissioners or congressional delegations.

What to do when the 'escape hatches' fail

It is possible that despite your best efforts, you won't be able to use any of the three "escape hatches" to remain with your doctor. Even if you get a brief reprieve through something like the No Surprises Act, you probably need to find a new physician eventually.

Remember that during the next Medicare open enrollment cycle, you should have the option to shop for a new Medicare Advantage plan that includes your favored physician. Until then, you might have to exercise a little patience.

A word of warning

One additional thing to keep in mind: Leaving Medicare Advantage is easy, but rebuilding Original Medicare with a Medigap supplement afterward carries its own trap.

The guaranteed-issue window for Medigap opens only once, at initial Part B enrollment. That means beneficiaries who want to switch to Original Medicare and add a supplement outside that window typically face medical underwriting. During this underwriting process, insurers have the right to deny coverage or charge more based on your health history.

A few states may offer broader Medigap rights. They include New York, Connecticut, Massachusetts and Maine. But whether you live in one of these states or another, make sure to verify your state's rules before exiting Medicare Advantage.

Bottom line

The practical takeaway from all of this is that you should not treat your plan's current provider directory as a guarantee that your favorite doctor is going to remain in the plan throughout the year.

Before choosing or renewing a Medicare Advantage plan, call your doctor's billing office directly each fall to confirm that their contract with the plan is up for renewal.

Knowing that your doctor is likely to remain in your plan for the full year is likely to eliminate some money stress and also remove some emotional worry from your life.

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