2026 Changes to Medicare Advantage Affecting Member Care

In 2026, at least 25 health systems across the U.S. plan to terminate their contracts with Medicare Advantage plans, leaving affected members needing to find new healthcare providers with minimal notice. When a hospital exits a Medicare Advantage network, the cost implications for policyholders can be substantial. For instance, out-of-pocket expenses for Preferred Provider Organization (PPO) members may nearly double, increasing from an in-network limit of $5,421 to a combined maximum of $9,825.

The exit of a provider from an individual's Medicare Advantage plan doesn't automatically initiate a continuity of care period or grant a Special Enrollment Period (SEP). Members must actively seek any available protections or enrollment options. Regulations state that a hospital's contract termination does not ensure automatic protections for ongoing treatment, though plan members can request a transition of care.

Current rules stipulate that Medicare Advantage plans must notify members at least 45 days in advance for primary and behavioral health providers and 30 days for other specialists. This notice should include information on requesting continued treatment. However, protections such as those under the No Surprises Act do not apply to Medicare Advantage due to its specific regulatory compliance requirements.

Medicare Advantage plans must ensure necessary medical care is arranged outside the network while maintaining in-network cost-sharing, only if the network cannot provide adequate in-network care. This is relevant in cases such as specialized treatments not available within the network.

A change within a Medicare Advantage network does not automatically allow a member the right to an SEP. The Centers for Medicare & Medicaid Services (CMS) may grant an SEP when a network shift significantly affects coverage, but beneficiaries should not expect automatic eligibility. They are advised to seek guidance on eligibility through resources like 1-800-MEDICARE.

Individuals wishing to switch plans typically have to wait for the Annual Enrollment Period from October 15 to December 7, with changes taking effect on January 1. Returning to Original Medicare is possible during designated periods, but securing a Medigap policy post-enrollment window often requires medical underwriting unless specific conditions for a guaranteed issue are met.

When a hospital exits a Medicare Advantage plan, patients face the challenge of rebuilding their doctor networks, sometimes necessitating multiple procedures to ensure continued care. This shift underscores the ongoing complexities in managing healthcare coverage within dynamic insurance frameworks.