In the Contract Year 2027 Proposed Rule (CMS-4212-P), CMS introduced significant changes to how provider network changes are handled, which will directly impact health plan operations and enrollment stability.
For health plan leaders, the headline is clear: the proposed changes remove historical guardrails around network stability, potentially reshaping how plans approach provider contracting, retention, and member communication.
The Core Change: Expanded Special Enrollment Period (SEP)
The most impactful proposal regarding provider network operations is the creation of a new “SEP for Provider Terminations.”
Under current regulations, a network change must be deemed “significant” by the plan or CMS before it triggers a Special Enrollment Period (SEP) for an enrollee to switch plans. The new proposal fundamentally shifts this dynamic by removing the “significance” requirement.
The proposal would allow beneficiaries to change plans whenever any of their providers leave a network, regardless of whether the change is considered significant. CMS’s stated goal is to prioritize continuity of care, ensuring enrollees can follow their preferred doctors to a new plan if a contract ends mid-year.
Strategic Impacts on Health Plan Operations
These changes will likely require health plans to adjust their member and provider operational and retention strategies. Below are key impact areas your team should be considering:
- Enrollment Volatility: Plans may face higher year-round disenrollment as it becomes easier for members to leave due to a single provider contract ending.
- Provider Negotiations: The increased risk of losing members mid-year may give providers more leverage during contract negotiations, as a termination has a more direct and immediate impact on a plan’s membership.
- Retention Marketing: Agents and health plans will need to focus more on proactive retention for affected individuals throughout the year, rather than just during the Annual Enrollment Period (AEP).
- Provider Agreement Clauses: Health plans should carefully review provider agreement termination clauses to ensure adequate notice periods. This allows time to renegotiate terms, resolve issues, and meet CMS Provider Termination and Enrollee notification requirements.
Operational Compliance: Notification Requirements
While managing the strategic fallout, plans must also maintain strict operational compliance. Under the proposal, plans would still need to provide notice of provider terminations, but they may also be required to include information about the start of the SEP in those notices.
As a refresher, here are the notification requirements scenarios that plans must navigate:
| Scenario | Notification To | Requirement |
|---|---|---|
| Directory Change | CMS | Within 30 days of awareness |
| Plan-Level Termination | Enrollees | 90 days (if effective Dec 31) |
| PCP / Behavioral Health | Enrollees | At least 45 days prior |
| Specialist / Facility | Enrollees | At least 30 days prior |
Additional Proposals: Network Reporting & SNPs
Beyond the SEP changes, the proposed rule includes other network-related adjustments:
- Reporting and Data Simplification: CMS is exploring ways to streamline reporting obligations related to provider networks through automated data sharing and new technology solutions to reduce administrative burden.
- Special Needs Plans (SNPs): For incoming enrollees whose networks may not perfectly align, CMS proposes that SNPs offer a 120-day continuation of care to ensure specialized services are not interrupted.
Is Your Plan Prepared? Process Alignment & Compliance
With these changes on the horizon, health plans must ask: Are your end-to-end processes aligned to sufficiently support these changes? Do you have a solid provider termination and member notification process in place today?
ATTAC Consulting can review your operational policies and workflows to help ensure your health plan has the best opportunity to succeed with member and provider retention while supporting compliance. We have supported client partners with provider network operations workflows and member enrollment processes to ensure that they are both efficient and enhance accuracy.
Article by Tina Gallagher
Tina is a provider network contracting leader with 25+ years’ experience building Medicare, Medicaid and Marketplace networks and applying value-based payment models. She has C-Suite expertise in managing all aspects of health plan operations, including P&L, policy, strategy, plan management, network development, regulatory and compliance.
