Medicare Advantage Network Participation: What the Rules Require

Medicare Advantage plans are private plans paid by Medicare, and the coordinated care versions (HMOs and PPOs) build their own provider networks. A provider who wants to see those members at in-network rates needs a contract with each plan. The federal rules in 42 CFR Part 422, Subpart E, decide how much say a provider has in that decision. The short version: a plan may choose its network and may refuse providers it does not need, but it must explain a refusal in writing, publish its participation rules, credential through a documented process, and keep a network that meets county standards set by CMS.

Knowing which of those duties applies to your situation is the first step in any network dispute. It tells you what to ask for, what evidence matters, and when a refusal is simply a lawful business decision.

Can a Medicare Advantage plan refuse to contract with you?

Yes, within limits. The antidiscrimination rule says an MA organization "may select the practitioners that participate in its plan provider networks" but may not discriminate in participation, reimbursement or indemnification against a health care professional acting within the scope of a license "solely on the basis of the license or certification" (42 CFR 422.205(a)). That protects a license type, such as clinical social workers or nurse practitioners as a class. It does not give any individual a right to a contract.

The same section spells out what plans may still do. A plan may refuse "to grant participation to health care professionals in excess of the number necessary to meet the needs of the plan's enrollees," may pay different amounts to different specialties or practitioners, and may use measures "designed to maintain quality and control costs" (42 CFR 422.205(b)). The one exception to the network-size refusal is the private fee-for-service plan, which "may not refuse to contract on this basis." Our post on private fee-for-service plans and the network-size exception explains why that exception rarely helps in practice.

What must the plan tell you when it says no?

Two federal duties apply. First, "If an MA organization declines to include a given provider or group of providers in its network, it must furnish written notice to the effected provider(s) of the reason for the decision" (42 CFR 422.205(a)). CMS repeats this in Section 60.1 of Chapter 6 of the Medicare Managed Care Manual, titled "Notice of Reason for Not Granting Participation."

Second, a plan that operates a coordinated care plan or network MSA plan must provide physicians with "Written notice of participation decisions that are adverse to physicians" and "A process for appealing adverse participation procedures, including the right of physicians to present information and their views on the decision" (42 CFR 422.202(a)(3) and (4)). The same paragraph requires written notice of the rules of participation, "including terms of payment, credentialing, and other rules directly related to participation decisions," and notice of material changes before they take effect (422.202(a)(1) and (2)).

If you were turned down by phone, by portal message or by silence, the first useful move is a short written request for the reason and for the plan's participation rules. A one-line "network is closed" reply is a reason, but it opens questions the plan has to answer with numbers, which the network adequacy rules below make concrete. See your right to a written reason for how to frame that request.

Does every rejected applicant get a hearing?

No. The hearing rights in 422.202(d) apply when a plan "suspends or terminates an agreement" with a physician. In that case the plan must give written reasons, "including, if relevant, the standards and profiling data used to evaluate the physician and the numbers and mix of physicians needed," explain the right to appeal and how to request a hearing, and make sure "the majority of the hearing panel members are peers of the affected physician." CMS's manual (Section 60.4) adds that, per the preamble to the February 17, 1999 final rule, these notice and appeal requirements also apply to nonrenewal.

A provider applying for the first time is in a different position. The guaranteed federal right is the written reason. The appeal process in 422.202(a)(4) speaks of "adverse participation procedures," and plans read it in different ways; some offer a reconsideration to applicants, others reserve it for credentialing denials. Ask for the plan's written procedure rather than assuming either way. Our post on adverse participation decisions and appeals works through the difference.

How does credentialing work in an MA plan?

Every MA organization must have "written policies and procedures for the selection and evaluation of providers" (42 CFR 422.204(a)). For physicians and other health care professionals, the process must cover initial credentialing with a written application, verification of licensure from primary sources, disciplinary status, eligibility for Medicare payment and site visits as appropriate, plus recredentialing "at least every 3 years" (422.204(b)(2)).

Some bars are absolute. A plan must comply with the rules against contracting with individuals excluded from Medicare and with the rules on physicians who opt out of Medicare (422.204(b)(4)), and it must follow the CMS preclusion list (422.204(c)). A denial on one of those grounds is not a network dispute. It has to be fixed at the source, with the OIG, with CMS, or by ending an opt-out, and a plan cannot waive it.

CMS's manual also describes a streamlined option for newly trained clinicians: an MA organization may adopt a policy that permits initial credentialing "for a period of up to 60 days" for someone who completed training within the last 12 months, if it verifies the license and malpractice settlements and its credentialing committee approves (Chapter 6, Section 60.3). It is a permission, not a requirement, so ask whether the plan uses it.

Which network standards does CMS hold plans to?

Coordinated care plans must keep a network "sufficient to provide adequate access to covered services to meet the needs of the population served," and the network "must include providers that specialize in behavioral health services" (42 CFR 422.112(a)(1)(i)). When an in-network provider "is unavailable or inadequate to meet an enrollee's medical needs," the plan must cover the service out of network "at in-network cost sharing" (422.112(a)(1)(iii)).

The measurable part is 42 CFR 422.116. CMS sets maximum time and distance standards and minimum provider counts for each county type (large metro, metro, micro, rural and counties with extreme access considerations). The list of provider specialty types runs from primary care and cardiology through chiropractor, podiatry, psychiatry, clinical psychology and clinical social work, and the facility list includes physical therapy, occupational therapy, speech therapy and outpatient behavioral health (422.116(b)). At least 90 percent of beneficiaries in large metro and metro counties, and 85 percent in micro, rural and extreme-access counties, must have access to at least one provider of each type within the published limits (422.116(d)(4)).

Two details matter for a provider who has been told the network is full. Telehealth-only providers do not count toward the minimum number standard (422.116(e)(1)(ii)), and providers contracted only for a plan's commercial or Medicaid products do not count toward MA adequacy (422.116(a)(4)(i)(C)). A network that looks crowded in one product can be thin in another.

Why don't state insurance laws help with MA plans?

Medicare Advantage is federal. CMS's manual notes that under Section 1856(b)(3) of the Social Security Act, "state laws or regulations relating to inclusion or treatment of providers are specifically superseded by Federal law" (Chapter 6, Section 10). Virginia's statute on paying new provider applicants during credentialing even says so directly: it "shall not apply to coverages issued by a Medicare Advantage plan" (Va. Code 38.2-3407.10:1(H)). State any willing provider laws, credentialing deadline laws and state insurance department complaints are therefore the wrong tools for an MA network denial, even when the same carrier's commercial products in that state are covered by them.

Where does a provider actually have leverage?

• The written reason. It fixes what the plan said, which you can then test against its own rules and its network data.
• The participation rules. Under 422.202(a)(1) they must be in writing. Check whether the plan applied them as written.
• The county standards. If your specialty is a 422.116 type and the plan relies on an exception in your county, that is a concrete point to raise. See MA network adequacy exceptions.
• Member access. When no in-network provider can meet a member's needs, 422.112(a)(1)(iii) points toward out-of-network coverage at in-network cost sharing, which can support a single-case agreement while the larger question is open.
• Credentialing defects. Incomplete files, stale attestations and mismatched data are fixable, and they are the most common reasons we see a file stall.

How can White Glove Network Access help?

We research, prepare and organize; we are not a law firm and do not represent providers. A Network Rejection Review ($249, credited toward a dispute) reads the plan's letter, checks for exclusion or preclusion issues, maps which of the rules above apply and gives you a written plan. A Payer Network Dispute ($799 per payer) includes the reason request, the reconsideration or exception letter and the access evidence. You sign and send every letter yourself, and we track the deadlines and replies. If the plan offers a contract or approves credentialing, the Contract or Credentialing Win Fee is a flat $1,500 per win. Questions about your legal rights, a termination hearing or contract terms as counsel belong with a healthcare attorney you hire directly. For first-time enrollment rather than a dispute, White Glove Credentialing's guide to Medicare Advantage versus traditional Medicare is the better starting point, and our closed panels hub lays out the levers by plan type.