Rising Provider Disputes in Medicare Advantage Prompt Special Enrollment Periods
Medicare Advantage (MA) plans, which provide an alternative to traditional government-run Medicare, are experiencing a rising number of contract disputes with hospital systems across the United States.
These disputes often lead to major providers leaving MA plan networks, forcing affected beneficiaries to either find new doctors or switch plans. Since July, about 41 hospital systems have exited 62 MA plans in 25 states, with such breakups tripling over the past two years according to FTI Consulting. This puts beneficiaries in a difficult position as they typically can only change Medicare plans during the annual enrollment period, limiting their options if a key provider leaves mid-year. \n\nIn response, the Centers for Medicare & Medicaid Services (CMS) has quietly offered special three-month enrollment periods in the last 15 months for thousands of members in at least 13 states.
These special enrollment windows allow affected MA members to change plans or return to traditional Medicare without penalty, regardless of when the provider loss occurred. However, CMS does not publicly disclose which plans are affected or if federal network adequacy standards have been violated. \n\nThe increased provider turnover in MA plans is linked to the growing enrollment, with 54% of Medicare beneficiaries choosing Advantage plans in 2024.
While these plans receive roughly 20% higher federal payments per enrollee than traditional Medicare, they often restrict provider choice to manage costs. \n\nProvider dissatisfaction centers on administrative burdens, coverage denials, and prior authorization delays, which they argue can negatively impact patient care. Sanford Health, the largest rural health system in the U.S., left a Humana MA plan last year citing these issues.
Some hospital systems, such as Great Plains Health in Nebraska, have withdrawn from all MA plans citing similar challenges. \n\nState insurance regulators including the National Association of Insurance Commissioners (NAIC) have urged CMS to provide clearer guidance and protections to MA members when providers leave. They advocate for standardized special enrollment periods allowing members affected by network reductions to switch plans or enroll in traditional Medicare anytime during the year, along with guaranteed access to Medigap supplemental insurance without preexisting condition restrictions. \n\nThis issue is significant as traditional Medicare does not limit provider choice, but transitioning from MA to traditional Medicare can be complicated due to potential Medigap underwriting barriers in states without guaranteed issue laws.
Only four states offer guaranteed Medigap access to all patients switching from MA to traditional Medicare. CMS has granted special enrollment periods in response to state appeals, including for some 75,000 Minnesota members affected by multiple provider exits in 2025. However, not all affected members qualify if CMS determines other providers are accessible, leaving some beneficiaries without enrollment relief.
Regulatory transparency on when special enrollment rights apply and consistent network adequacy enforcement remain concerns for policymakers and advocates. The ongoing provider-insurer conflicts and resulting network changes highlight the dynamic and complex nature of the Medicare Advantage market and its implications for beneficiary access and plan regulation.