Notification to Enrollees

110.1.2.3 – Notification to Enrollees (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) Pursuant to 42 CFR §422.111(e), when an MAO makes changes to its provider network, the MAO must make a good faith effort to provide written notice of a termination of a contracted provider at least 30 calendar days before the termination effective date to all enrollees who are patients seen on a regular basis by the provider whose contract is terminating, irrespective of whether the termination was for cause or without cause. When a contract termination involves a primary care professional, all enrollees who are patients of that primary care professional must be notified. Please note that CMS considers “enrollees who are patients seen on a regular basis by the provider whose contract is terminating” to be “affected enrollees.” An “affected enrollee” as an enrollee who is assigned to, currently receiving care from, or has received care within the past three months from a provider or facility being terminated. When an MAO makes significant network changes, at any point during the contract year, the MAO must also follow the requirements at 42 CFR §422.111(e). CMS recommends that as a best practice, MAOs making significant no-cause network changes should provide affected enrollees more than the required 30 days advance notice. A longer notification period is important, not only to address enrollee concerns, furnish enrollees with needed assistance in selecting new providers, and manage the continuity of care for those undergoing medical treatment, but also for maintaining enrollee satisfaction. If enrollees are notified sooner than 30 days prior to a significant provider termination, then they will be afforded additional time to transition to a new provider. CMS expects that when an MAO has 60 days advance notice that a contract with a provider will be terminated (as discussed in section 110.1.2.4 below), the MAO should notify affected enrollees at least 30 days in advance of the contract termination but preferably more than 30 days in advance. For those MAOs that do not have the 60 days advance notice of a contract termination, they must make a good faith effort to notify affected enrollees as soon as possible and at least 30 days before termination. As a best practice, MAOs should include the following information in notices to enrollees in addition to the mandatory identification of the provider(s) being terminated from the network: • Names and phone numbers of in-network providers that enrollees may access for continued care (Note: This information may be supplemented with information for accessing a current provider directory, including both online and direct mail options); • Information regarding how enrollees can request continuation of ongoing medical treatment or therapies with their current providers; and • Customer service number(s) where answers to questions about the network changes will be available. MAOs should also develop detailed scripts, call center talking points and frequently asked questions so it can effectively respond to phone inquiries from enrollees and other stakeholders.