For Medicare plans, the Plan notifies affected members at least 45 days in advance, whenever possible, of a primary care physician (PCP) termination or a behavioral health provider termination. For PCP terminations, PPGs must provide the Plan with the name of the new PCP as well as two alternative PCPs.

The written notification is sent by U.S. mail, and includes instructions on selecting a new PCP, the newly assigned PCP and two alternative PCPs. For PCPs and behavioral health providers, the Plan must make at least one attempt at telephonic notice to the identified members (unless the member has opted out of calls regarding Plan business). Telephonic provider termination notices must relay the same information as the written provider termination notice.

The Plan must provide written notice to members at least 30 days prior to the termination date for all other contracted providers and facilities.

For Medicare HMO plans, capitated and shared-risk PPGs must notify members in writing at least 30 days in advance of a specialist, behavioral health specialist or ancillary provider termination effective date, and the template sent to members must be approved by the Centers for Medicare & Medicaid Services (CMS).¹ The Plan's CMS-approved Medicare termination notification template (PDF) must be completed by the PPG and mailed to the member.

The Plan may allow a member to continue using a terminated provider when:

The terminated provider is subject to the same contractual terms and conditions imposed prior to termination until medical care to the member is completed. These terms and conditions include, but are not limited to:

Refer to the Transition of Care topic for more information.

Refer to definition of Opt Out Provider for more information.

¹Title 42 of the Code of Federal Regulations (CFR) section 422.111(e))