Your Hospital May Leave Your Medicaid Plan Soon - Here's What You Need to Know

If you get Medicaid and go to certain hospitals, your coverage might change soon. You should get a letter in the mail 45 days before any changes happen.

 

State Medicaid officials recently reported that several contracts between Medicaid managed care organizations (MCOs) and hospital systems are set to expire in late 2025.  Even if negotiations are continuing, the Medicaid managed care plans are required to mail letters to impacted members 45 days in advance of any potential end to a contract.  New contract agreements or contract extensions can still be reached after notices have been mailed. 

 

Which Hospitals Are Affected?

Several hospitals are having contract disputes with Medicaid insurance plans. The table below describes what might happen:

 

What Should You Do?

Individuals who receive notice that their doctor(s) or hospital will no longer be in network with their Medicaid plan have the following two main choices:

OPTION 1:  Keep Your Doctors & Hospital -- Switch Insurance Plans

This is a good option for people who really want to stay with their current doctors and hospital.

How to do it:

• Choose a new Medicaid plan that covers your hospital
• All the hospitals listed in the table above work with other Medicaid plans in PA
• Important timing: You need to switch by the second Thursday of the month for it to start the next month
   

Before switching plans, think about:

• Do you see specialists? Make sure they take the new plan too
• Do you use home health services or medical equipment? Check if those are covered
• Compare what each plan offers (do this by visiting www.enrollnow.net or call PA Enrollment Services at 1-800-440-3989/TTY: 1-800-618-4225)
   

OPTION 2:  Keep Your Current Insurance Plan – Find New Doctors/Hospital

This option is good for people who are happy with their current Medicaid plan and don’t mind finding new doctors and other providers.

To find other doctors, hospitals, specialists and other providers in your plan’s network, call your MCO’s member services number (listed on the back of your insurance card) and ask for a list of in-network doctors and other providers, or visit the Find a Provider section of EnrollNow.net to find a list of doctors, hospitals, specialists and other providers that accept your plan.

 

How to Make Changes

To switch insurance plans:

• Go to www.EnrollNow.net
• Or call 1-800-440-3989 (TTY: 1-800-618-4225)

To find new doctors/hospitals:

• Visit EnrollNow.net's Provider Search
• Call your insurance plan directly and ask for help

 

 

If You Are in the Middle of Treatment

Those individuals in an ongoing course of treatment with a certain doctor or hospital can keep seeing their hospital doctors for up to 60 days after the contract ends by asking their Medicaid plan for “continuity of care”. This allows for time to make a smooth transition to a new doctor or other provider now that your current provider(s) are no longer in a contract (in network) with your Medicaid plan.

How to request continuity of care:

• Call your Medicaid insurance plan (MCO) at the number on the back of your insurance card and ask for continuity of care
• This works for ongoing treatments as well as services that need prior approval (prior authorization)
• If they say no, you can appeal their decision

If you need help planning or coordinating your care transition, contact your insurance plan’s Enhanced Member Services Unit (EMSU, formerly known as the Special Needs Unit). They can help figure out next steps. Click here for a directory of each plan’s EMSU phone number.

 

Key Takeaways

✅ You'll get 45 days notice before any changes
✅ You have options - you're not stuck
✅ The hospitals and insurance companies might still work things out
✅ If you're getting treatment, you have 60 days to transition
✅ Help is available if you need it

 

Questions?  

Call PA Enrollment Services at 1-800-440-3989 - they can walk you through your options.