Another Hospital System Just Went Out-of-Network Mid-Year. Medicare Advantage Members Have Fewer Protections Than They May Assume.

A letter lands in late July. A regional health system where a Medicare Advantage member sees her cardiologist, oncologist, and primary care doctor will terminate its contract with her insurer on September 30. Her plan card remains valid. Her doctors do not. She has about two months to determine what happens next, caught in a wave that is not slowing.

Becker’s Hospital Review counted 25 U.S. health systems dropping at least some Medicare Advantage contracts in 2026. Mayo Clinic went out of network with most UnitedHealthcare and Humana Advantage plans on January 1, and regional systems have followed on their own timelines. This exposure belongs to Medicare Advantage. Original Medicare does not use a private plan’s provider network, and Medigap follows services Original Medicare covers.

Why the Advertised Out-of-Pocket Cap Changes

A Medicare Advantage plan’s in-network maximum limits spending only on covered care received under the plan’s network rules. Once a hospital exits, treatment there moves into a different cost bucket. On an HMO, routine out-of-network care is generally not covered, although emergency and urgent care remain protected. On a PPO, the plan usually covers out-of-network treatment at higher cost sharing under a larger combined ceiling.

According to KFF, the average 2026 out-of-pocket limit is $5,421 for in-network care. Among PPOs, the average combined limit for in- and out-of-network care is $9,825. The cap does not disappear, but the sick-year ceiling can nearly double. An HMO member receiving uncovered routine care outside the network may owe the full amount.

Hospitals and insurers usually describe these splits as failed contract negotiations. Behind that phrase sit items like payment rates, prior authorization, claim denials, and the rising cost of treating older patients. When the hospital and insurer walk away from the negotiating table, the enrollee is the one locked out of the exam room.

The 90-Day Rule Is Narrower Than It Sounds

Medicare Advantage plans must notify affected members when contracted providers leave. Current federal rules generally require at least 45 days’ notice for a primary care or behavioral health provider and 30 days for other specialists and facilities. The notice must explain how to request continuation of ongoing treatment. That does not create an automatic 90-day extension with every departing doctor.

The federal 90-day protection in 42 CFR 422.112 applies when someone enrolls in a new Medicare Advantage plan after beginning an active course of treatment. It prevents the new plan from immediately disrupting or reauthorizing that care, even when the provider is outside its network. A provider leaving someone’s current plan is different. The No Surprises Act’s continuing-care protections do not apply to Medicare Advantage because Medicare programs follow their own rules. A plan may still approve transitional care under its policies, and state protections can sometimes help. The termination notice should explain how to ask.

Another federal rule matters if the remaining network cannot meet the patient’s medical needs. The Advantage plan must arrange medically necessary care outside its network at in-network cost sharing when an appropriate in-network provider is unavailable or inadequate. That argument is stronger for a specialized oncology treatment than for keeping a familiar primary care doctor.

The Trap on the Way Out

A provider departure does not automatically create a Special Enrollment Period. CMS may authorize one when it determines that a network change is significant, but the member should not assume the letter itself opens the door. The notice must provide information about requesting help from 1-800-MEDICARE, including consideration for an SEP based on the individual circumstances.

Otherwise, the next dependable switching opportunity is the Annual Enrollment Period from October 15 through December 7, with new coverage beginning January 1. Returning to Original Medicare is allowed during an applicable enrollment period. Buying Medigap afterward is the uncertain part. Once the federal six-month Medigap enrollment window has closed, insurers in most states may medically underwrite an application unless another guaranteed-issue right applies. A hospital leaving an Advantage network does not, by itself, create a federal Medigap guarantee.

What to Do Before September 30

The letter starts three separate conversations, and each requires a written response:

1. Request continued care from the current plan. Identify every active treatment, prior authorization, scheduled procedure, and specialist involved. Ask the plan to issue a written decision stating what it will cover, at what cost sharing, and through what date.
2. Call 1-800-MEDICARE about switching rights. Ask whether CMS has approved a significant-network-change SEP for the termination. If not, use the fall enrollment period to find another Advantage plan that contracts with the hospital, then confirm every physician individually.
3. Secure Medigap approval before leaving Advantage. Price Plan G, Plan N, and high-deductible Plan G, but do not drop the current plan based on an estimate. Obtain written underwriting approval and coordinate Original Medicare, Medigap, and Part D effective dates first.

The hospital and insurer can end their relationship with a contract notice. The patient still has to rebuild hers one doctor at a time.

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