MA Provider Termination Notice model document_12-14-22

Medicare Advantage Provider Termination Notice - CMS Model Document
IMPORTANT NOTICE:
Your health care [provider/facility] is leaving your plan’s network.

Dear ,
will no longer be
in the network as of .

How to continue getting your care
Contact one of these different in-network [providers/facilities] to continue your care:

You can also call to speak with someone who can help you find another [provider/facility] in our
network.
Visit to review ’s current online provider directory. Or,
if you want a paper copy of our provider directory, call .
If you want to continue ongoing medical treatment or therapies with your current
[provider/facility], .

How to change plans
You can change health plans only at certain times during the year. From October 15 – December
7, you can join, switch, or drop a Medicare health or drug plan for the following year. In
addition, from January 1 – March 31, anyone enrolled in a Medicare Advantage Plan (except an
MSA plan) can switch plans or return to Original Medicare (and join a stand-alone Medicare
drug plan). Generally, you can’t make changes at other times except in certain situations, like if
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Medicare Advantage Provider Termination Notice - CMS Model Document
you move out of your plan’s service area, want to join a plan in your area with a 5-star quality
rating, or qualify for (or lose) Extra Help paying for prescription drug coverage.
If this change in our network impacts you, you can call 1-800-MEDICARE (1-800-633-4227) to
ask for a special enrollment period to change plans and for help finding other coverage. Tell
them you got this notice saying your [provider/facility] is leaving our network. This toll-free help
line is available 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
If you need more information, call us at . Tell the customer service representative you got this notice.

Sincerely,

You can get this information for free in other formats, such as large print, braille, or audio. Call
our toll-free number at .
ATTENTION: If you speak [insert language], we can offer you language assistance services,
free of charge. Call 1-XXX-XXX-XXXX (TTY: 1-XXX-XXX-XXXX) for assistance.
[Material ID]
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