Without-Cause Network Terminations and Your Notice Rights

A termination letter that cites no reason, only a contract clause allowing either party to end the agreement "without cause," feels like the end of the discussion. It is the start of a short, important window. What you can do depends on the plan type, your state and your contract, and several rules apply even when the plan gives no reason at all.

What notice does a Medicare Advantage plan owe?

"An MA organization and a contracting provider must provide at least 60 days written notice to each other before terminating the contract without cause" (42 CFR 422.202(d)(4)).

For physicians, a coordinated care plan that suspends or terminates the agreement must also give written notice of "the reasons for the action, including, if relevant, the standards and profiling data used to evaluate the physician and the numbers and mix of physicians needed," and of "the affected physician's right to appeal the action and the process and timing for requesting a hearing," with a hearing panel the majority of whom are the physician's peers (422.202(d)(1) and (2)). CMS's manual says the preamble to the 1999 rule clarified that these notice and appeal requirements apply whether or not the termination is for quality, "unless the physician voluntarily agreed to leave the organization's network," and that they apply to nonrenewal too (Medicare Managed Care Manual, Chapter 6, section 60.4). See Medicare Advantage adverse participation decisions.

What do New York and Texas require?

New York managed care

An insurer "shall not terminate a contract" with a health care professional unless it provides "a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing" (N.Y. Ins. Law 4803(b)(1)). The notice must give at least 30 days to request the hearing or review, the panel must include a clinical peer, and "In no event shall termination be effective earlier than sixty days from the receipt of the notice of termination" (4803(b)(2) to (6)). Exceptions cover imminent harm to patient care, fraud and final disciplinary action.

Two further points matter. Non-renewal at the end of a contract term, on 60 days' notice, "shall not constitute a termination" under the section (4803(c)), so it does not carry the hearing right. And an insurer may not terminate or refuse to renew "solely because" a professional advocated on behalf of an insured, filed a complaint against the insurer, appealed one of its decisions or requested a hearing (4803(e)). Contract terms that impair the notice and hearing rights are void (4803(f) and (g)).

Texas PPOs

"Before terminating a contract with a preferred provider, an insurer shall" give written reasons and, for a practitioner, on request, a review mechanism with an advisory panel, completed within 60 days, except in cases of imminent harm, licensing board action or fraud (Tex. Ins. Code 1301.057(a) and (b)). On request, the insurer must provide "all information on which the insurer wholly or partly based the termination, including the economic profile of the preferred provider, the standards by which the provider is measured, and the statistics underlying the profile and standards," and an expedited review (1301.057(d)).

Other states have their own rules; many have none beyond the contract. Check yours on the network access laws index.

What do plans owe your patients?

• Medicare Advantage: for a primary care or behavioral health provider, written notice and one attempt at telephone notice at least 45 calendar days before the termination date, to enrollees assigned to that provider or seen by that provider within the past three years; for other specialties, written notice at least 30 calendar days before, to enrollees seen on a regular basis (42 CFR 422.111(e)).
• Medicaid managed care: a good faith effort to give written notice to each enrollee who received primary care from, or was seen regularly by, the terminated provider, by the later of 30 calendar days before the effective date or 15 calendar days after the termination notice (42 CFR 438.10(f)(1)).

Those notices tell you the plan's own timeline and remind you that your patients will hear about it, often before you have decided how to respond.

What should you do in the first week?

1. Calendar every date: effective date, any hearing request deadline, and the plan's patient notice dates.
2. Read the contract's termination clause and any amendment. Check whether the plan used the notice period the contract requires.
3. Ask in writing for the reasons and the information relied on, citing the rule that applies (for example, 422.202(d), N.Y. Ins. Law 4803(b) or Tex. Ins. Code 1301.057).
4. Request the hearing or review on time if one is available, even while you gather information.
5. Call a healthcare attorney if a hearing is involved, if the termination mentions quality of care, or if you believe it was retaliatory. See when a dispute needs a healthcare attorney.
6. Plan for patients: single-case agreements for those in active treatment may be possible if the network cannot replace you. See single-case agreements.

Is a recredentialing denial the same as a termination?

In effect, often yes. A Louisiana Medicaid plan's policy says that for practitioners "denied continued participation" at recredentialing, it "will send a termination notice effective fifteen (15) days from the date" of the notice (Louisiana Healthcare Connections, LA.CRED.01). See when recredentialing fails.

Where do we fit?

For a termination, we organize the record and prepare the written requests for reasons and information, and the hearing or review request, for you to sign and send on time, as part of a Payer Network Dispute ($799 per payer). We do not appear at hearings or represent anyone; when a hearing or a legal claim is involved, your healthcare attorney leads and we can support the paperwork. If you are out of network after the termination and want to rejoin, the same dispute tools apply as for any closed panel.