Market exits in Medicare Advantage are creating two distinct problems, but most plans are only focused on one of them.
A recent Johns Hopkins study found that nearly 2.9 million MA members are being displaced in 2026 as insurers exit markets, roughly 10% of MA enrollees and nearly a tenfold increase from the historical 1% forced disenrollment rate. Plans are reading that number and thinking about member acquisition. That’s the right instinct, but what those exits leave behind in unreconciled payments and lingering CMS liabilities is where the real financial damage accumulates. Plans without proactive CMS validation don’t find out about the exposure until CMS comes to collect, and by then, the bill comes due.
The Overpayment Problem No One Talks About
When a plan exits a market, CMS doesn’t stop paying immediately. Capitated payments can continue flowing for members who are no longer on your roster, creating a significant financial liability when the reconciliation process finally catches up. According to West Monroe, CMS is now actively pursuing overpayment recovery after years of delay.
The plans that exit markets cleanly are the ones that know exactly which members have left, when they left, and what CMS has paid. That requires a continuous reconciliation process, not one that catches up quarterly.
SNPs Are the Repositioning Play That Comes With a Catch.
As plans trim their PPO and HMO footprints, they’re repositioning around Special Needs Plans (SNPs), and the math makes sense.
D-SNP margins were more than double the average for all MA plans in 2022, and SNPs accounted for half of all MA enrollment growth from 2024 to 2025 according to a KFF article . Higher per-capita payments and more predictable revenue make these members incredibly valuable.
The catch is that SNP members are also more complex to manage. Higher acuity means more care coordination, more billing nuance, and less room for error. An operational platform built for standard commercial enrollment doesn’t hold up under that pressure. The plans winning in the SNP market have infrastructure designed for it, not adapted to it.
What Your Operations Need to Handle Right Now
The operational demands are the same for both absorbing displaced members and managing your own market contraction: accurate data, fast processing, and a reconciliation process that keeps pace with CMS.
| If You’re… | The Challenge Is… | The Solution Is… |
| Receiving New Members | A clunky, manual onboarding process that creates data gaps, frustrates new members, and leads to churn. | A seamless, automated onboarding experience with a unified member view that ensures a positive first impression and continuity of care. |
| Exiting a Market | A messy disenrollment process that leads to CMS overpayments and costly financial clawbacks months later. | An automated disenrollment and live eligibility matching process that prevents overpayments and ensures a clean financial exit. |
| Competing for SNP Members | Trying to manage high-acuity members on a platform not designed for their complex needs, leading to poor outcomes and lost revenue. | A purpose-built platform designed to manage the complexity of SNP members, with integrated care management and billing that captures the full value of these plans. |
What Plans Should Do Right Now
The market is shifting faster than most operational teams are prepared for. Whether you’re absorbing displaced members, managing a market exit, or competing for SNP enrollment, the path forward requires deliberate action on several fronts.
Conduct a gap analysis. Review your current member enrollment, disenrollment, and payment reconciliation workflows against the demands of today’s market. Identify where manual processes, batch runs, or data silos are creating exposure.
Develop a proactive reconciliation strategy. Rather than waiting for CMS to surface discrepancies, implement a process that validates enrollment and payment data against CMS records continuously. Tools like Miramar:Reveal are built specifically to catch retroactive adjustments before they compound into a six-month overpayment exposure.
Invest in modern, purpose-built technology. Evaluate whether your current systems can handle the full member lifecycle enrollment, billing, disenrollment, and reconciliation in an integrated way. Miramar:Member automates downstream updates when a member’s status changes, eliminating the manual handoffs that create enrollment gaps and reconciliation exposure.
Prepare for the growth of SNPs. If SNPs are not already part of your strategy, now is the time to assess your readiness. That means evaluating your care coordination capabilities, billing infrastructure, and whether your operational platform is designed for high-acuity populations not just adapted to them.
The market is shifting quickly. The plans that manage these transitions with precision are the ones that come out with stronger books of business and cleaner financials. The question is whether your operations are built for it.
Contact Us
Convey Health Solutions helps Medicare Advantage plans navigate member transitions, reconciliation, and SNP complexity with purpose-built technology designed for the demands of today’s market. To learn how we can support your operations, contact us at businesssolutions@conveyhs.com.
