For years, Fred Neary had relied on the Baylor Scott & White Health system, a network of 52 hospitals in North and Central Texas, where he saw five doctors, including those close to his home in Dallas. However, in October, his Humana Medicare Advantage plan—a private alternative to traditional government-run Medicare—alerted him that Baylor and Humana were in a contract dispute. If they couldn’t reach an agreement, Neary would be forced to choose between finding new doctors or switching insurance providers altogether.
“All my medical records are with Baylor Scott & White,” explained Neary, 87, a retired financial services professional. “My doctors are just a five-minute drive away. After so many years, starting over with new doctors didn’t feel like an option.”
After weeks of uncertainty, Neary discovered that Humana and Baylor were indeed parting ways, leaving him with a difficult decision. Thankfully, since this breakup occurred during the fall enrollment period for Medicare Advantage, Neary had the opportunity to switch plans, securing coverage that would begin January 1—just a day after his current coverage ended.
But not all Medicare Advantage members are so fortunate. While disputes between healthcare providers and insurance companies are fairly common, most members are stuck with their plans for the year, even when key providers exit the network. Unless members qualify for a special enrollment period, switching plans or reverting to traditional Medicare is generally only allowed at the end of the year, with coverage starting in January.
In the past 15 months, the Centers for Medicare & Medicaid Services (CMS), which oversees Medicare Advantage, has quietly granted special enrollment periods to thousands of members in at least 13 states, enabling them to switch plans or leave Advantage altogether without penalty. However, even when CMS allows members to leave a plan after losing a crucial provider, insurance companies can still sign up new members without informing them that their networks have shrunk.
According to Becker’s Hospital Review, 41 hospital systems have dropped out of 62 Advantage plans across 25 states since July. Over the last two years, such departures have tripled, according to FTI Consulting, a firm that tracks insurance disputes.
CMS spokesperson Catherine Howden stated that network changes are “a routine occurrence” and that the agency has seen an uptick in cases where changes trigger special enrollment periods. However, CMS has refused to disclose which plans allowed their members to disenroll after losing a major provider. The agency also didn’t clarify whether these plans were in violation of federal rules requiring Medicare Advantage networks to provide enough providers within specific geographic areas.
Senator Ron Wyden of Oregon, a senior Democrat on the Senate Finance Committee, has expressed concern about this lack of transparency. “Seniors enrolled in Medicare Advantage plans deserve to know they can change their plans when their local doctor or hospital drops out due to profit-driven business practices,” Wyden said.
The growing number of insurance-provider breakups is a direct result of Medicare Advantage’s increasing popularity. According to KFF Health News, nearly 54% of the 61.2 million people eligible for Medicare enrolled in Medicare Advantage plans for 2024. These plans offer extra benefits that traditional Medicare does not, thanks to additional payments from the federal government, which reimburse insurers about 20% more per member than the traditional Medicare per-member rates.
While traditional Medicare provides access to almost any doctor or hospital that accepts Medicare, Medicare Advantage often limits members to a more specific network of providers, which can change throughout the year. Sanford Health, the largest nonprofit healthcare system in the U.S., withdrew from a Humana Medicare Advantage plan last year, affecting 15,000 patients. “It’s not just about finances or management issues, though those are real concerns,” explained Sanford Health CFO Nick Olson. “The biggest issue is that delays and denials of coverage impact the care a patient receives, and that’s unacceptable.”
The National Association of Insurance Commissioners (NAIC), which represents state insurance regulators, has urged CMS to better assist Medicare Advantage members. “State regulators are seeing a rise in healthcare providers and systems dropping out of Medicare Advantage plans, leaving enrollees without sufficient access to care,” the NAIC wrote in a September letter. “CMS’s lack of action could lead to unnecessary financial and medical harm to seniors.”
State regulators have also lobbied for a nationwide special enrollment period for all Medicare Advantage members who lose access to a major provider, arguing that it should be easier for seniors to change plans without having to navigate complicated rules on their own. This would include guaranteed access to Medigap insurance, which helps cover out-of-pocket costs for those who switch to traditional Medicare.
Currently, only four states—Connecticut, Massachusetts, Maine, and New York—guarantee access to Medigap policies for people who wish to switch to traditional Medicare. However, as more hospital systems like Great Plains Health in Nebraska pull out of all Medicare Advantage plans, insurance commissioners are pushing for more flexibility. Great Plains Health had experienced delays and denials that led to subpar care for its patients, prompting Nebraska’s insurance commissioner to request a special enrollment period for 1,200 affected individuals.
In Delaware, when the Bayhealth system left a Cigna Advantage plan, CMS granted a special enrollment period for affected members starting in January. Similarly, when Northern Light Health in Maine dropped out of a Humana Advantage plan, CMS responded positively, ensuring that members had the opportunity to switch plans.
In Minnesota, after several health systems announced they would leave Advantage plans in 2025, state officials asked CMS for help. Although some members were granted a special enrollment period, others who lost access to providers were not, as CMS deemed that they still had sufficient options within their plan’s network.
The growing number of provider withdrawals and the complications they create for Medicare Advantage members highlight the importance of ensuring that seniors can easily access the care they need—without being trapped in insurance plans that no longer serve them well.