June 12, 2024
Changes to requirements give members more time to find a new primary care or behavioral health provider
The Centers for Medicare & Medicaid Services (CMS) has updated requirements for Wellcare to notify members of provider contract terminations, effective for terminations on or after Jan. 1, 2024.
How this affects you
Be aware of these requirements so you can help members find a new physician or other provider if their current provider’s contract is terminated. Also:
- Independent practice associations (IPAs) must follow the requirements below pertaining to specialist terminations. For primary care physician (PCP) terminations, IPAs must provide the Plan with the name of the new PCP as well as two alternative PCPs.
- Ensure that you let the Plan know timely if you’re leaving the network.
- Help members proceed with their course of treatment to ensure continuity of care.
- Support their transition and communication with a new provider.
CMS requirements for notification to members
The Plan must provide members with notice of a termination of a contracted PCP or behavioral health provider, regardless of whether the termination is for cause or without cause. IPAs must provide members with notice of a termination of a contracted specialist provider, regardless of whether the termination is for cause or without cause. Also, the Plan and IPAs must meet the following timeframes for terminations without cause and must make a good faith effort to meet these timeframes for for-cause terminations.
Primary care physicians (PCPs)
The Plan must notify members at least 45 days prior to the termination date for contract terminations that involve a PCP. Also, the Plan must:
- Identify all members currently assigned to the PCP or who were a patient of that PCP within the past three years;
- Provide written notice to the identified members that includes the newly assigned PCP and two alternative PCPs; and
- Make at least one attempt at telephonic notice to the identified members unless the member has opted out of calls regarding plan business.
Behavioral health providers
The Plan must notify members at least 45 days prior to the termination date for contract terminations that involve a behavioral health provider. Also, the Plan must:
- Identify all members who are currently a patient of that behavioral health provider or who were a patient of that behavioral health provider within the past three years;
- Provide written notice to the identified members; and
- Make at least one attempt at telephonic notice to the identified members.
Behavior health specialists
For Medicare HMO plans, capitated and shared-risk IPAs must notify members in writing at least 30 days in advance of a specialist or ancillary provider termination effective date, and the template sent to members must be approved by CMS. The Plan's CMS-approved Medicare termination notification template (PDF) must be completed by the IPA and mailed to the member.
All other contracted providers and facilities
The Plan must notify members at least 30 days prior to the termination date for all other contracted providers and facilities:
- Identify all members who are patients seen on a regular basis by the provider whose contract is terminating;
- This includes members who are assigned to, currently receiving care from or have received care within the past three months from the provider or facility; and
- Provide written notice to the identified members.
Specialists
For Medicare HMO plans, capitated and shared-risk IPAs must notify members in writing at least 30 days in advance of a specialist or ancillary provider termination effective date, and the template sent to members must be approved by CMS. The Plan's CMS-approved Medicare termination notification template (PDF) must be completed by the IPA and mailed to the member.
Written and telephonic notice requirements
Written provider termination notice must:
- Be provided in hard copy via U.S. mail; and
- Include the following:
- The date the provider will leave the network;
- The name(s) and phone number(s) of in-network providers available to the member;
- This may be supplemented with information for accessing a current provider directory via online and direct mail options.
- An explanation regarding how to request continuation of ongoing medical treatment or therapies with their current provider;
- Information about the annual coordinated election period and the Medicare Advantage open enrollment period, as well as explain that an enrollee who is impacted by the provider termination may contact 800-MEDICARE to ask for help identifying and switching to other coverage, or to request consideration for a special election period (SEP) based on the individual's unique circumstances and consistent with existing parameters for this SEP; and
- The Plan’s call center phone number, TTY number, and hours and days of operation.
Telephonic provider termination notices must relay the same information as the written provider termination notice.
Additional information
Relevant sections of the Wellcare Provider Manual have been revised to reflect the information contained in this update as applicable. The manual is available online at www.wellcare.com/California/Providers/Medicare.
If you have questions regarding the information contained in this update, contact 866‑999‑3945.
