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United States Code (Last Updated: May 24, 2014) |
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Title 42. THE PUBLIC HEALTH AND WELFARE |
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Chapter 7. SOCIAL SECURITY |
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SubChapter XVIII. HEALTH INSURANCE FOR AGED AND DISABLED |
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Part C. Medicare+Choice Program |
§ 1395w–21. Eligibility, election, and enrollment
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(a) Choice of medicare benefits through Medicare+Choice plans (1) In general Subject to the provisions of this section, each Medicare+Choice eligible individual (as defined in paragraph (3)) is entitled to elect to receive benefits (other than qualified prescription drug benefits) under this subchapter— (A) through the original medicare fee-for-service program under parts A and B of this subchapter, or (B) through enrollment in a Medicare+Choice plan under this part, and may elect qualified prescription drug coverage in accordance with section 1395w–101 of this title. (2) Types of Medicare+Choice plans that may be available A Medicare+Choice plan may be any of the following types of plans of health insurance: (A) Coordinated care plans (including regional plans) (i) In general Coordinated care plans which provide health care services, including but not limited to health maintenance organization plans (with or without point of service options), plans offered by provider-sponsored organizations (as defined in section 1395w–25(d) of this title), and regional or local preferred provider organization plans (including MA regional plans).
(ii) Specialized MA plans for special needs individuals Specialized MA plans for special needs individuals (as defined in section 1395w–28(b)(6) of this title) may be any type of coordinated care plan.
(B) Combination of MSA plan and contributions to Medicare+Choice MSA An MSA plan, as defined in section 1395w–28(b)(3) of this title, and a contribution into a Medicare+Choice medical savings account (MSA).
(C) Private fee-for-service plans A Medicare+Choice private fee-for-service plan, as defined in section 1395w–28(b)(2) of this title.
(3) Medicare+Choice eligible individual (A) In general In this subchapter, subject to subparagraph (B), the term “Medicare+Choice eligible individual” means an individual who is entitled to benefits under part A of this subchapter and enrolled under part B of this subchapter.
(B) Special rule for end-stage renal disease Such term shall not include an individual medically determined to have end-stage renal disease, except that— (i) an individual who develops end-stage renal disease while enrolled in a Medicare+Choice plan may continue to be enrolled in that plan; and (ii) in the case of such an individual who is enrolled in a Medicare+Choice plan under clause (i) (or subsequently under this clause), if the enrollment is discontinued under circumstances described in subsection (e)(4)(A) of this section, then the individual will be treated as a “Medicare+Choice eligible individual” for purposes of electing to continue enrollment in another Medicare+Choice plan. (b) Special rules (1) Residence requirement (A) In general Except as the Secretary may otherwise provide and except as provided in subparagraph (C), an individual is eligible to elect a Medicare+Choice plan offered by a Medicare+Choice organization only if the plan serves the geographic area in which the individual resides.
(B) Continuation of enrollment permitted Pursuant to rules specified by the Secretary, the Secretary shall provide that an MA local plan may offer to all individuals residing in a geographic area the option to continue enrollment in the plan, notwithstanding that the individual no longer resides in the service area of the plan, so long as the plan provides that individuals exercising this option have, as part of the benefits under the original medicare fee-for-service program option, reasonable access within that geographic area to the full range of basic benefits, subject to reasonable cost sharing liability in obtaining such benefits.
(C) Continuation of enrollment permitted where service changed Notwithstanding subparagraph (A) and in addition to subparagraph (B), if a Medicare+Choice organization eliminates from its service area a Medicare+Choice payment area that was previously within its service area, the organization may elect to offer individuals residing in all or portions of the affected area who would otherwise be ineligible to continue enrollment the option to continue enrollment in an MA local plan it offers so long as— (i) the enrollee agrees to receive the full range of basic benefits (excluding emergency and urgently needed care) exclusively at facilities designated by the organization within the plan service area; and (ii) there is no other Medicare+Choice plan offered in the area in which the enrollee resides at the time of the organization’s election. (2) Special rule for certain individuals covered under FEHBP or eligible for veterans or military health benefits (A) FEHBP An individual who is enrolled in a health benefit plan under chapter 89 of title 5 is not eligible to enroll in an MSA plan until such time as the Director of the Office of Management and Budget certifies to the Secretary that the Office of Personnel Management has adopted policies which will ensure that the enrollment of such individuals in such plans will not result in increased expenditures for the Federal Government for health benefit plans under such chapter.
(B) VA and DOD The Secretary may apply rules similar to the rules described in subparagraph (A) in the case of individuals who are eligible for health care benefits under chapter 55 of title 10 or under chapter 17 of title 38.
(3) Limitation on eligibility of qualified medicare beneficiaries and other medicaid beneficiaries to enroll in an MSA plan An individual who is a qualified medicare beneficiary (as defined in section 1396d(p)(1) of this title), a qualified disabled and working individual (described in section 1396d(s) of this title), an individual described in section 1396a(a)(10)(E)(iii) of this title, or otherwise entitled to medicare cost-sharing under a State plan under subchapter XIX of this chapter is not eligible to enroll in an MSA plan.
(4) Coverage under MSA plans (A) In general Under rules established by the Secretary, an individual is not eligible to enroll (or continue enrollment) in an MSA plan for a year unless the individual provides assurances satisfactory to the Secretary that the individual will reside in the United States for at least 183 days during the year.
(B) Evaluation The Secretary shall regularly evaluate the impact of permitting enrollment in MSA plans under this part on selection (including adverse selection), use of preventive care, access to care, and the financial status of the Trust Funds under this subchapter.
(C) Reports The Secretary shall submit to Congress periodic reports on the numbers of individuals enrolled in such plans and on the evaluation being conducted under subparagraph (B).
(c) Process for exercising choice (1) In general The Secretary shall establish a process through which elections described in subsection (a) of this section are made and changed, including the form and manner in which such elections are made and changed. Such elections shall be made or changed only during coverage election periods specified under subsection (e) of this section and shall become effective as provided in subsection (f) of this section.
(2) Coordination through Medicare+Choice organizations (A) Enrollment Such process shall permit an individual who wishes to elect a Medicare+Choice plan offered by a Medicare+Choice organization to make such election through the filing of an appropriate election form with the organization.
(B) Disenrollment Such process shall permit an individual, who has elected a Medicare+Choice plan offered by a Medicare+Choice organization and who wishes to terminate such election, to terminate such election through the filing of an appropriate election form with the organization.
(3) Default (A) Initial election (i) In general Subject to clause (ii), an individual who fails to make an election during an initial election period under subsection (e)(1) of this section is deemed to have chosen the original medicare fee-for-service program option.
(ii) Seamless continuation of coverage The Secretary may establish procedures under which an individual who is enrolled in a health plan (other than Medicare+Choice plan) offered by a Medicare+Choice organization at the time of the initial election period and who fails to elect to receive coverage other than through the organization is deemed to have elected the Medicare+Choice plan offered by the organization (or, if the organization offers more than one such plan, such plan or plans as the Secretary identifies under such procedures).
(B) Continuing periods An individual who has made (or is deemed to have made) an election under this section is considered to have continued to make such election until such time as— (i) the individual changes the election under this section, or (ii) the Medicare+Choice plan with respect to which such election is in effect is discontinued or, subject to subsection (b)(1)(B) of this section, no longer serves the area in which the individual resides. (d) Providing information to promote informed choice (1) In general The Secretary shall provide for activities under this subsection to broadly disseminate information to medicare beneficiaries (and prospective medicare beneficiaries) on the coverage options provided under this section in order to promote an active, informed selection among such options.
(2) Provision of notice (A) Open season notification At least 15 days before the beginning of each annual, coordinated election period (as defined in subsection (e)(3)(B) of this section), the Secretary shall mail to each Medicare+Choice eligible individual residing in an area the following: (i) General information The general information described in paragraph (3).
(ii) List of plans and comparison of plan options A list identifying the Medicare+Choice plans that are (or will be) available to residents of the area and information described in paragraph (4) concerning such plans. Such information shall be presented in a comparative form.
(iii) Additional information Any other information that the Secretary determines will assist the individual in making the election under this section.
The mailing of such information shall be coordinated, to the extent practicable, with the mailing of any annual notice under section 1395b–2 of this title. (B) Notification to newly eligible Medicare+Choice eligible individuals To the extent practicable, the Secretary shall, not later than 30 days before the beginning of the initial Medicare+Choice enrollment period for an individual described in subsection (e)(1) of this section, mail to the individual the information described in subparagraph (A).
(C) Form The information disseminated under this paragraph shall be written and formatted using language that is easily understandable by medicare beneficiaries.
(D) Periodic updating The information described in subparagraph (A) shall be updated on at least an annual basis to reflect changes in the availability of Medicare+Choice plans and the benefits and Medicare+Choice monthly basic and supplemental beneficiary premiums for such plans.
(3) General information General information under this paragraph, with respect to coverage under this part during a year, shall include the following: (A) Benefits under original medicare fee-for-service program option A general description of the benefits covered under the original medicare fee-for-service program under parts A and B of this subchapter, including— (i) covered items and services, (ii) beneficiary cost sharing, such as deductibles, coinsurance, and copayment amounts, and (iii) any beneficiary liability for balance billing. (B) Election procedures Information and instructions on how to exercise election options under this section.
(C) Rights A general description of procedural rights (including grievance and appeals procedures) of beneficiaries under the original medicare fee-for-service program and the Medicare+Choice program and the right to be protected against discrimination based on health status-related factors under section 1395w–22(b) of this title.
(D) Information on medigap and medicare select A general description of the benefits, enrollment rights, and other requirements applicable to medicare supplemental policies under section 1395ss of this title and provisions relating to medicare select policies described in section 1395ss(t) of this title.
(E) Potential for contract termination The fact that a Medicare+Choice organization may terminate its contract, refuse to renew its contract, or reduce the service area included in its contract, under this part, and the effect of such a termination, nonrenewal, or service area reduction may have on individuals enrolled with the Medicare+Choice plan under this part.
(F) Catastrophic coverage and single deductible In the case of an MA regional plan, a description of the catastrophic coverage and single deductible applicable under the plan.
(4) Information comparing plan options Information under this paragraph, with respect to a Medicare+Choice plan for a year, shall include the following: (A) Benefits The benefits covered under the plan, including the following: (i) Covered items and services beyond those provided under the original medicare fee-for-service program. (ii) Any beneficiary cost sharing, including information on the single deductible (if applicable) under section 1395w–27a(b)(1) of this title. (iii) Any maximum limitations on out-of-pocket expenses. (iv) In the case of an MSA plan, differences in cost sharing, premiums, and balance billing under such a plan compared to under other Medicare+Choice plans. (v) In the case of a Medicare+Choice private fee-for-service plan, differences in cost sharing, premiums, and balance billing under such a plan compared to under other Medicare+Choice plans. (vi) The extent to which an enrollee may obtain benefits through out-of-network health care providers. (vii) The extent to which an enrollee may select among in-network providers and the types of providers participating in the plan’s network. (viii) The organization’s coverage of emergency and urgently needed care. (B) Premiums (i) In general The monthly amount of the premium charged to an individual.
(ii) Reductions The reduction in part B premiums, if any.
(C) Service area The service area of the plan.
(D) Quality and performance To the extent available, plan quality and performance indicators for the benefits under the plan (and how they compare to such indicators under the original medicare fee-for-service program under parts A and B of this subchapter in the area involved), including— (i) disenrollment rates for medicare enrollees electing to receive benefits through the plan for the previous 2 years (excluding disenrollment due to death or moving outside the plan’s service area), (ii) information on medicare enrollee satisfaction, (iii) information on health outcomes, and (iv) the recent record regarding compliance of the plan with requirements of this part (as determined by the Secretary). (E) Supplemental benefits Supplemental health care benefits, including any reductions in cost-sharing under section 1395w–22(a)(3) of this title and the terms and conditions (including premiums) for such benefits.
(5) Maintaining a toll-free number and Internet site The Secretary shall maintain a toll-free number for inquiries regarding Medicare+Choice options and the operation of this part in all areas in which Medicare+Choice plans are offered and an Internet site through which individuals may electronically obtain information on such options and Medicare+Choice plans.
(6) Use of non-Federal entities The Secretary may enter into contracts with non-Federal entities to carry out activities under this subsection.
(7) Provision of information A Medicare+Choice organization shall provide the Secretary with such information on the organization and each Medicare+Choice plan it offers as may be required for the preparation of the information referred to in paragraph (2)(A).
(e) Coverage election periods (1) Initial choice upon eligibility to make election if Medicare+Choice plans available to individual If, at the time an individual first becomes entitled to benefits under part A of this subchapter and enrolled under part B of this subchapter, there is one or more Medicare+Choice plans offered in the area in which the individual resides, the individual shall make the election under this section during a period specified by the Secretary such that if the individual elects a Medicare+Choice plan during the period, coverage under the plan becomes effective as of the first date on which the individual may receive such coverage. If any portion of an individual’s initial enrollment period under part B of this subchapter occurs after the end of the annual, coordinated election period described in paragraph (3)(B)(iii), the initial enrollment period under this part shall further extend through the end of the individual’s initial enrollment period under part B of this subchapter.
(2) Open enrollment and disenrollment opportunities Subject to paragraph (5)— (A) Continuous open enrollment and disenrollment through 2005 At any time during the period beginning
January 1, 1998 , and ending onDecember 31, 2005 , a Medicare+Choice eligible individual may change the election under subsection (a)(1) of this section.(B) Continuous open enrollment and disenrollment for first 6 months during 2006 (i) In general Subject to clause (ii), subparagraph (C)(iii), and subparagraph (D), at any time during the first 6 months of 2006, or, if the individual first becomes a Medicare+Choice eligible individual during 2006, during the first 6 months during 2006 in which the individual is a Medicare+Choice eligible individual, a Medicare+Choice eligible individual may change the election under subsection (a)(1) of this section.
(ii) Limitation of one change An individual may exercise the right under clause (i) only once. The limitation under this clause shall not apply to changes in elections effected during an annual, coordinated election period under paragraph (3) or during a special enrollment period under the first sentence of paragraph (4).
(C) Annual 45-day period for disenrollment from MA plans to elect to receive benefits under the original Medicare fee-for-service program Subject to subparagraph (D), at any time during the first 45 days of a year (beginning with 2011), an individual who is enrolled in a Medicare Advantage plan may change the election under subsection (a)(1), but only with respect to coverage under the original medicare fee-for-service program under parts A and B, and may elect qualified prescription drug coverage in accordance with section 1395w–101 of this title.
(D) Continuous open enrollment for institutionalized individuals At any time after 2005 in the case of a Medicare+Choice eligible individual who is institutionalized (as defined by the Secretary), the individual may elect under subsection (a)(1) of this section— (i) to enroll in a Medicare+Choice plan; or (ii) to change the Medicare+Choice plan in which the individual is enrolled. (E) Limited continuous open enrollment of original fee-for-service enrollees in medicare advantage non-prescription drug plans (i) In general On any date during the period beginning on
January 1, 2007 , and ending onJuly 31, 2007 , on which a Medicare Advantage eligible individual is an unenrolled fee-for-service individual (as defined in clause (ii)), the individual may elect under subsection (a)(1) to enroll in a Medicare Advantage plan that is not an MA–PD plan.(ii) Unenrolled fee-for-service individual defined In this subparagraph, the term “unenrolled fee-for-service individual” means, with respect to a date, a Medicare Advantage eligible individual who— (I) is receiving benefits under this subchapter through enrollment in the original medicare fee-for-service program under parts A and B; (II) is not enrolled in an MA plan on such date; and (III) as of such date is not otherwise eligible to elect to enroll in an MA plan. (iii) Limitation of one change during the applicable period An individual may exercise the right under clause (i) only once during the period described in such clause.
(iv) No effect on coverage under a prescription drug plan Nothing in this subparagraph shall be construed as permitting an individual exercising the right under clause (i)— (I) who is enrolled in a prescription drug plan under part D, to disenroll from such plan or to enroll in a different prescription drug plan; or (II) who is not enrolled in a prescription drug plan, to enroll in such a plan. (3) Annual, coordinated election period (A) In general Subject to paragraph (5), each individual who is eligible to make an election under this section may change such election during an annual, coordinated election period.
(B) Annual, coordinated election period For purposes of this section, the term “annual, coordinated election period” means— (i) with respect to a year before 2002, the month of November before such year; (ii) with respect to 2002, 2003, 2004, and 2005, the period beginning on November 15 and ending on December 31 of the year before such year; (iii) with respect to 2006, the period beginning on November 15, 2005 , and ending onMay 15, 2006 ;(iv) with respect to 2007, 2008, 2009, and 2010, the period beginning on November 15 and ending on December 31 of the year before such year; and (v) with respect to 2012 and succeeding years, the period beginning on October 15 and ending on December 7 of the year before such year. (C) Medicare+Choice health information fairs During the fall season of each year (beginning with 1999) and during the period described in subparagraph (B)(iii), in conjunction with the annual coordinated election period defined in subparagraph (B), the Secretary shall provide for a nationally coordinated educational and publicity campaign to inform Medicare+Choice eligible individuals about Medicare+Choice plans and the election process provided under this section.
(D) Special information campaigns During November 1998 the Secretary shall provide for an educational and publicity campaign to inform Medicare+Choice eligible individuals about the availability of Medicare+Choice plans, and eligible organizations with risk-sharing contracts under section 1395mm of this title, offered in different areas and the election process provided under this section. During the period described in subparagraph (B)(iii), the Secretary shall provide for an educational and publicity campaign to inform MA eligible individuals about the availability of MA plans (including MA–PD plans) offered in different areas and the election process provided under this section.
(4) Special election periods Effective as of January 1, 2006 , an individual may discontinue an election of a Medicare+ÐChoice plan offered by a Medicare+Choice organization other than during an annual, coordinated election period and make a new election under this section if—(A) (i) the certification of the organization or plan under this part has been terminated, or the organization or plan has notified the individual of an impending termination of such certification; or (ii) the organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides, or has notified the individual of an impending termination or discontinuation of such plan; (B) the individual is no longer eligible to elect the plan because of a change in the individual’s place of residence or other change in circumstances (specified by the Secretary, but not including termination of the individual’s enrollment on the basis described in clause (i) or (ii) of subsection (g)(3)(B) of this section); (C) the individual demonstrates (in accordance with guidelines established by the Secretary) that— (i) the organization offering the plan substantially violated a material provision of the organization’s contract under this part in relation to the individual (including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide such covered care in accordance with applicable quality standards); or (ii) the organization (or an agent or other entity acting on the organization’s behalf) materially misrepresented the plan’s provisions in marketing the plan to the individual; or (D) the individual meets such other exceptional conditions as the Secretary may provide. Effective as of January 1, 2006 , an individual who, upon first becoming eligible for benefits under part A of this subchapter at age 65, enrolls in a Medicare+Choice plan under this part, the individual may discontinue the election of such plan, and elect coverage under the original fee-for-service plan, at any time during the 12-month period beginning on the effective date of such enrollment.(5) Special rules for MSA plans Notwithstanding the preceding provisions of this subsection, an individual— (A) may elect an MSA plan only during— (i) an initial open enrollment period described in paragraph (1), or (ii) an annual, coordinated election period described in paragraph (3)(B); (B) subject to subparagraph (C), may not discontinue an election of an MSA plan except during the periods described in clause (ii) or (iii) of subparagraph (A) and under the first sentence of paragraph (4); and (C) who elects an MSA plan during an annual, coordinated election period, and who never previously had elected such a plan, may revoke such election, in a manner determined by the Secretary, by not later than December 15 following the date of the election. (6) Open enrollment periods Subject to paragraph (5), a Medicare+Choice organization— (A) shall accept elections or changes to elections during the initial enrollment periods described in paragraph (1), during the month of November 1998 and during the annual, coordinated election period under paragraph (3) for each subsequent year, and during special election periods described in the first sentence of paragraph (4); and (B) may accept other changes to elections at such other times as the organization provides. (f) Effectiveness of elections and changes of elections (1) During initial coverage election period An election of coverage made during the initial coverage election period under subsection (e)(1) of this section shall take effect upon the date the individual becomes entitled to benefits under part A of this subchapter and enrolled under part B of this subchapter, except as the Secretary may provide (consistent with section 1395q of this title) in order to prevent retroactive coverage.
(2) During continuous open enrollment periods An election or change of coverage made under subsection (e)(2) of this section shall take effect with the first day of the first calendar month following the date on which the election or change is made.
(3) Annual, coordinated election period An election or change of coverage made during an annual, coordinated election period (as defined in subsection (e)(3)(B) of this section, other than the period described in clause (iii) of such subsection) in a year shall take effect as of the first day of the following year.
(4) Other periods An election or change of coverage made during any other period under subsection (e)(4) of this section shall take effect in such manner as the Secretary provides in a manner consistent (to the extent practicable) with protecting continuity of health benefit coverage.
(g) Guaranteed issue and renewal (1) In general Except as provided in this subsection, a Medicare+Choice organization shall provide that at any time during which elections are accepted under this section with respect to a Medicare+Choice plan offered by the organization, the organization will accept without restrictions individuals who are eligible to make such election.
(2) Priority If the Secretary determines that a Medicare+Choice organization, in relation to a Medicare+Choice plan it offers, has a capacity limit and the number of Medicare+Choice eligible individuals who elect the plan under this section exceeds the capacity limit, the organization may limit the election of individuals of the plan under this section but only if priority in election is provided— (A) first to such individuals as have elected the plan at the time of the determination, and (B) then to other such individuals in such a manner that does not discriminate, on a basis described in section 1395w–22(b) of this title, among the individuals (who seek to elect the plan). The preceding sentence shall not apply if it would result in the enrollment of enrollees substantially nonrepresentative, as determined in accordance with regulations of the Secretary, of the medicare population in the service area of the plan. (3) Limitation on termination of election (A) In general Subject to subparagraph (B), a Medicare+ÐChoice organization may not for any reason terminate the election of any individual under this section for a Medicare+Choice plan it offers.
(B) Basis for termination of election A Medicare+Choice organization may terminate an individual’s election under this section with respect to a Medicare+Choice plan it offers if— (i) any Medicare+Choice monthly basic and supplemental beneficiary premiums required with respect to such plan are not paid on a timely basis (consistent with standards under section 1395w–26 of this title that provide for a grace period for late payment of such premiums), (ii) the individual has engaged in disruptive behavior (as specified in such standards), or (iii) the plan is terminated with respect to all individuals under this part in the area in which the individual resides. (C) Consequence of termination (i) Terminations for cause Any individual whose election is terminated under clause (i) or (ii) of subparagraph (B) is deemed to have elected the original medicare fee-for-service program option described in subsection (a)(1)(A) of this section.
(ii) Termination based on plan termination or service area reduction Any individual whose election is terminated under subparagraph (B)(iii) shall have a special election period under subsection (e)(4)(A) of this section in which to change coverage to coverage under another Medicare+Choice plan. Such an individual who fails to make an election during such period is deemed to have chosen to change coverage to the original medicare fee-for-service program option described in subsection (a)(1)(A) of this section.
(D) Organization obligation with respect to election forms Pursuant to a contract under section 1395w–27 of this title, each Medicare+Choice organization receiving an election form under subsection (c)(2) of this section shall transmit to the Secretary (at such time and in such manner as the Secretary may specify) a copy of such form or such other information respecting the election as the Secretary may specify.
(h) Approval of marketing material and application forms (1) Submission No marketing material or application form may be distributed by a Medicare+Choice organization to (or for the use of) Medicare+ÐChoice eligible individuals unless— (A) at least 45 days (or 10 days in the case described in paragraph (5)) before the date of distribution the organization has submitted the material or form to the Secretary for review, and (B) the Secretary has not disapproved the distribution of such material or form. (2) Review The standards established under section 1395w–26 of this title shall include guidelines for the review of any material or form submitted and under such guidelines the Secretary shall disapprove (or later require the correction of) such material or form if the material or form is materially inaccurate or misleading or otherwise makes a material misrepresentation.
(3) Deemed approval (1-stop shopping) In the case of material or form that is submitted under paragraph (1)(A) to the Secretary or a regional office of the Department of Health and Human Services and the Secretary or the office has not disapproved the distribution of marketing material or form under paragraph (1)(B) with respect to a Medicare+Choice plan in an area, the Secretary is deemed not to have disapproved such distribution in all other areas covered by the plan and organization except with regard to that portion of such material or form that is specific only to an area involved.
(4) Prohibition of certain marketing practices Each Medicare+Choice organization shall conform to fair marketing standards, in relation to Medicare+Choice plans offered under this part, included in the standards established under section 1395w–26 of this title. Such standards— (A) shall not permit a Medicare+Choice organization to provide for, subject to subsection (j)(2)(C), cash, gifts, prizes, or other monetary rebates as an inducement for enrollment or otherwise; (B) may include a prohibition against a Medicare+Choice organization (or agent of such an organization) completing any portion of any election form used to carry out elections under this section on behalf of any individual; (C) shall not permit a Medicare Advantage organization (or the agents, brokers, and other third parties representing such organization) to conduct the prohibited activities described in subsection (j)(1); and (D) shall only permit a Medicare Advantage organization (and the agents, brokers, and other third parties representing such organization) to conduct the activities described in subsection (j)(2) in accordance with the limitations established under such subsection. (5) Special treatment of marketing material following model marketing language In the case of marketing material of an organization that uses, without modification, proposed model language specified by the Secretary, the period specified in paragraph (1)(A) shall be reduced from 45 days to 10 days.
(6) Required inclusion of plan type in plan name For plan years beginning on or after
January 1, 2010 , a Medicare Advantage organization must ensure that the name of each Medicare Advantage plan offered by the Medicare Advantage organization includes the plan type of the plan (using standard terminology developed by the Secretary).(7) Strengthening the ability of States to act in collaboration with the Secretary to address fraudulent or inappropriate marketing practices (A) Appointment of agents and brokers Each Medicare Advantage organization shall— (i) only use agents and brokers who have been licensed under State law to sell Medicare Advantage plans offered by the Medicare Advantage organization; (ii) in the case where a State has a State appointment law, abide by such law; and (iii) report to the applicable State the termination of any such agent or broker, including the reasons for such termination (as required under applicable State law). (B) Compliance with State information requests Each Medicare Advantage organization shall comply in a timely manner with any request by a State for information regarding the performance of a licensed agent, broker, or other third party representing the Medicare Advantage organization as part of an investigation by the State into the conduct of the agent, broker, or other third party.
(i) Effect of election of Medicare+Choice plan option (1) Payments to organizations Subject to sections 1395w–22(a)(5), 1395w–23(a)(4), 1395w–23(g), 1395w–23(h), 1395ww(d)(11), 1395ww(h)(3)(D), and 1395w–23(m) of this title, payments under a contract with a Medicare+Choice organization under section 1395w–23(a) of this title with respect to an individual electing a Medicare+Choice plan offered by the organization shall be instead of the amounts which (in the absence of the contract) would otherwise be payable under parts A and B of this subchapter for items and services furnished to the individual.
(2) Only organization entitled to payment Subject to sections 1395w–23(a)(4), 1395w–23(e), 1395w–23(g), 1395w–23(h), 1395w–27(f)(2), 1395w–27a(h), 1395ww(d)(11), and 1395ww(h)(3)(D) of this title, only the Medicare+Choice organization shall be entitled to receive payments from the Secretary under this subchapter for services furnished to the individual.
(j) Prohibited activities described and limitations on the conduct of certain other activities (1) Prohibited activities described The following prohibited activities are described in this paragraph: (A) Unsolicited means of direct contact Any unsolicited means of direct contact of prospective enrollees, including soliciting door-to-door or any outbound telemarketing without the prospective enrollee initiating contact.
(B) Cross-selling The sale of other non-health related products (such as annuities and life insurance) during any sales or marketing activity or presentation conducted with respect to a Medicare Advantage plan.
(C) Meals The provision of meals of any sort, regardless of value, to prospective enrollees at promotional and sales activities.
(D) Sales and marketing in health care settings and at educational events Sales and marketing activities for the enrollment of individuals in Medicare Advantage plans that are conducted— (i) in health care settings in areas where health care is delivered to individuals (such as physician offices and pharmacies), except in the case where such activities are conducted in common areas in health care settings; and (ii) at educational events. (2) Limitations The Secretary shall establish limitations with respect to at least the following: (A) Scope of marketing appointments The scope of any appointment with respect to the marketing of a Medicare Advantage plan. Such limitation shall require advance agreement with a prospective enrollee on the scope of the marketing appointment and documentation of such agreement by the Medicare Advantage organization. In the case where the marketing appointment is in person, such documentation shall be in writing.
(B) Co-branding The use of the name or logo of a co-branded network provider on Medicare Advantage plan membership and marketing materials.
(C) Limitation of gifts to nominal dollar value The offering of gifts and other promotional items other than those that are of nominal value (as determined by the Secretary) to prospective enrollees at promotional activities.
(D) Compensation The use of compensation other than as provided under guidelines established by the Secretary. Such guidelines shall ensure that the use of compensation creates incentives for agents and brokers to enroll individuals in the Medicare Advantage plan that is intended to best meet their health care needs.
(E) Required training, annual retraining, and testing of agents, brokers, and other third parties The use by a Medicare Advantage organization of any individual as an agent, broker, or other third party representing the organization that has not completed an initial training and testing program and does not complete an annual retraining and testing program.
References In Text
Subsec. (e)(2)(C) of this section, referred to in subsec. (e)(2)(B)(i), was amended generally by section 3204(a)(1) of Pub. L. 111–148 and, as so amended, no longer contains a cl. (iii).
Amendments
2010—Subsec. (b)(1)(C). Pub. L. 111–148, § 3201(e)(2)(A)(i), which directed that subpar. (C) be struck out, was repealed by Pub. L. 111–152, § 1102(a). See Effective Date of 2010 Amendment note below.
Subsec. (e)(2)(C). Pub. L. 111–148, § 3204(a)(1), amended subpar. (C) generally. Prior to amendment, subpar. (C) related to continuous open enrollment and disenrollment for first 3 months of a year after 2006.
Subsec. (e)(3)(B)(iv). Pub. L. 111–148, § 3204(b)(2)(A), substituted “, 2008, 2009, and 2010” for “and succeeding years”.
Subsec. (e)(3)(B)(v). Pub. L. 111–148, § 3204(b)(1), (2)(B), (3), added cl. (v).
2009—Subsec. (i)(1). Pub. L. 111–5 substituted “1395ww(h)(3)(D), and 1395w–23(m)” for “and 1395ww(h)(3)(D)”.
2008—Subsec. (h)(4)(A). Pub. L. 110–275, § 103(a)(1)(A)(i)(I)(aa), substituted “, subject to subsection (j)(2)(C), cash, gifts, prizes, or other monetary rebates” for “cash or other monetary rebates”.
Subsec. (h)(4)(C). Pub. L. 110–275, § 103(a)(1)(A)(i)(I)(bb)–(III), added subpar. (C).
Subsec. (h)(4)(D). Pub. L. 110–275, § 103(b)(1)(A), added subpar. (D).
Subsec. (h)(6). Pub. L. 110–275, § 103(c)(1), added par. (6).
Subsec. (h)(7). Pub. L. 110–275, § 103(d)(1), added par. (7).
Subsec. (j). Pub. L. 110–275, § 103(a)(1)(A)(ii), added subsec. (j).
Subsec. (j)(2). Pub. L. 110–275, § 103(b)(1)(B), added par. (2).
2007—Subsec. (e)(2)(E)(i). Pub. L. 110–48, § 2(1), substituted “the period beginning on
Subsec. (e)(2)(E)(iii). Pub. L. 110–48, § 2(2), substituted “the applicable period” for “year” in heading and “the period described in such clause” for “the year” in text.
2006—Subsec. (e)(2)(E). Pub. L. 109–432 added subpar. (E).
2003—Subsec. (a)(1). Pub. L. 108–173, § 102(c)(1)(A), (C), inserted “(other than qualified prescription drug benefits)” after “benefits” in introductory provisions and inserted concluding provisions.
Subsec. (a)(1)(B). Pub. L. 108–173, § 102(c)(1)(B), substituted comma for period at end.
Subsec. (a)(2)(A). Pub. L. 108–173, § 221(a)(1), substituted “Coordinated care plans (including regional plans)” for “Coordinated care plans” in heading, inserted cl. (i) designation and heading before “Coordinated”, and inserted “regional or local” before “preferred provider organization plans” and “(including MA regional plans)” before period at end.
Subsec. (a)(2)(A)(ii). Pub. L. 108–173, § 231(a), added cl. (ii).
Subsec. (a)(3)(B)(ii). Pub. L. 108–173, § 222(l)(3)(D), made technical amendment to reference in original act which appears in text as reference to subsection (e)(4)(A) of this section.
Subsec. (b)(1)(B). Pub. L. 108–173, § 222(l)(3)(A)(i), (ii), substituted “an MA local plan” for “a plan” and “benefits under the original medicare fee-for-service program option” for “basic benefits described in section 1395w–22(a)(1)(A) of this title”.
Subsec. (b)(1)(C). Pub. L. 108–173, § 222(l)(3)(A)(iii), substituted “in an MA local plan” for “in a Medicare+Choice plan” in introductory provisions.
Subsec. (b)(4). Pub. L. 108–173, § 233(b)(1), struck out “on a demonstration basis” after “plans” in heading.
Subsec. (b)(4)(A). Pub. L. 108–173, § 233(b)(2), struck out first sentence which read as follows: “An individual is not eligible to enroll in an MSA plan under this part—
“(i) on or after
“(ii) as of any date if the number of such individuals so enrolled as of such date has reached 390,000.”
Subsec. (b)(4)(C). Pub. L. 108–173, § 233(b)(3), struck out at end “The Secretary shall submit such a report, by not later than
Subsec. (d)(3)(F). Pub. L. 108–173, § 222(l)(3)(B)(i), added subpar. (F).
Subsec. (d)(4)(A)(ii). Pub. L. 108–173, § 222(l)(3)(B)(ii), inserted “, including information on the single deductible (if applicable) under section 1395w–27a(b)(1) of this title” after “cost sharing”.
Subsec. (d)(4)(B)(i). Pub. L. 108–173, § 222(l)(3)(B)(iii), substituted “monthly amount of the premium charged to an individual” for “Medicare+Choice monthly basic beneficiary premium and Medicare+Choice monthly supplemental beneficiary premium, if any, for the plan or, in the case of an MSA plan, the Medicare+Choice monthly MSA premium”.
Subsec. (d)(4)(E). Pub. L. 108–173, § 222(l)(3)(B)(iv), reenacted heading without change and amended text generally. Prior to amendment, text read as follows: “Whether the organization offering the plan includes mandatory supplemental benefits in its base benefit package or offers optional supplemental benefits and the terms and conditions (including premiums) for such coverage.”
Subsec. (e)(1). Pub. L. 108–173, § 102(a)(4), inserted at end “If any portion of an individual’s initial enrollment period under part B of this subchapter occurs after the end of the annual, coordinated election period described in paragraph (3)(B)(iii), the initial enrollment period under this part shall further extend through the end of the individual’s initial enrollment period under part B of this subchapter.”
Subsec. (e)(2). Pub. L. 108–173, § 102(a)(1)(A), substituted “2005” and “2006” for “2004” and “2005”, respectively, wherever appearing.
Subsec. (e)(2)(B)(i). Pub. L. 108–173, § 102(a)(6)(A), inserted “, subparagraph (C)(iii),” after “clause (ii)”.
Subsec. (e)(2)(C)(i). Pub. L. 108–173, § 102(a)(6)(B), substituted “clauses (ii) and (iii)” for “clause (ii)”.
Subsec. (e)(2)(C)(iii). Pub. L. 108–173, § 102(a)(6)(C), added cl. (iii).
Subsec. (e)(3)(B). Pub. L. 108–173, § 102(a)(2), reenacted heading without change and amended text generally. Prior to amendment, text read as follows: “For purposes of this section, the term ‘annual, coordinated election period’ means, with respect to a year before 2003 and after 2005, the month of November before such year and with respect to 2003, 2004, and 2005, the period beginning on November 15 and ending on December 31 of the year before such year.”
Subsec. (e)(3)(C). Pub. L. 108–173, § 102(a)(3)(A), inserted “and during the period described in subparagraph (B)(iii)” after “(beginning with 1999)”.
Subsec. (e)(3)(D). Pub. L. 108–173, § 102(a)(3)(B), in heading, substituted “campaigns” for “campaign in 1998” and, in text, inserted at end “During the period described in subparagraph (B)(iii), the Secretary shall provide for an educational and publicity campaign to inform MA eligible individuals about the availability of MA plans (including MA–PD plans) offered in different areas and the election process provided under this section.”
Subsec. (e)(4). Pub. L. 108–173, § 102(a)(1)(B), substituted “2006” for “2005” in two places.
Subsec. (e)(5)(A)(i). Pub. L. 108–173, § 233(d)(1), inserted “or” at end.
Subsec. (e)(5)(A)(ii). Pub. L. 108–173, § 233(d)(2), substituted semicolon for “, or”.
Subsec. (e)(5)(A)(iii). Pub. L. 108–173, § 233(d)(3), struck out cl. (iii) which read as follows: “the month of November 1998;”.
Subsec. (f)(1). Pub. L. 108–173, § 222(l)(3)(E), substituted “subsection (e)(1)” for “subsection (e)(1)(A)”.
Subsec. (f)(3). Pub. L. 108–173, § 102(a)(5), inserted “, other than the period described in clause (iii) of such subsection” after “subsection (e)(3)(B) of this section”.
Subsec. (i)(1). Pub. L. 108–173, § 237(b)(2)(A)(i), inserted “1395w–23(a)(4),” after “Subject to sections 1395w–22(a)(5),”.
Subsec. (i)(2). Pub. L. 108–173, § 237(b)(2)(A)(ii), inserted “1395w–23(a)(4),” after “Subject to sections”.
Pub. L. 108–173, § 221(d)(5), inserted “1395w–27a(h),” after “1395w–27(f)(2),”.
2002—Subsec. (e)(2)(A). Pub. L. 107–188, § 532(a)(1), substituted “through 2004” for “through 2001” in heading and “during the period beginning
Subsec. (e)(2)(B). Pub. L. 107–188, § 532(a)(2), substituted “during 2005” for “during 2002” in heading.
Subsec. (e)(2)(B)(i), (C)(i). Pub. L. 107–188, § 532(a)(3), substituted “2005” for “2002” wherever appearing.
Subsec. (e)(2)(D). Pub. L. 107–188, § 532(a)(4), substituted “2004” for “2001”.
Subsec. (e)(3)(B). Pub. L. 107–188, § 532(c)(1)(A), substituted “means, with respect to a year before 2003 and after 2005, the month of November before such year and with respect to 2003, 2004, and 2005, the period beginning on November 15 and ending on December 31 of the year before such year” for “means, with respect to a calendar year (beginning with 2000), the month of November before such year”.
Subsec. (e)(4). Pub. L. 107–188, § 532(a)(5), substituted “2005” for “2002” in introductory and concluding provisions.
Subsec. (e)(6)(A). Pub. L. 107–188, § 532(c)(1)(B), substituted “during the annual, coordinated election period under paragraph (3) for each subsequent year” for “each subsequent year (as provided in paragraph (3))”.
2000—Subsec. (a)(3)(B). Pub. L. 106–554, § 1(a)(6) [title VI, § 620(a)], substituted “except that—” and cls. (i) and (ii) for “except that an individual who develops end-stage renal disease while enrolled in a Medicare+Choice plan may continue to be enrolled in that plan.”
Subsec. (d)(4)(B). Pub. L. 106–554, § 1(a)(6) [title VI, § 606(a)(2)(C)], designated existing provisions as cl. (i), inserted heading, and added cl. (ii).
Subsec. (f)(2). Pub. L. 106–554, § 1(a)(6) [title VI, § 619(a)], struck out “, except that if such election or change is made after the 10th day of any calendar month, then the election or change shall not take effect until the first day of the second calendar month following the date on which the election or change is made” before period at end.
Subsec. (h)(1)(A). Pub. L. 106–554, § 1(a)(6) [title VI, § 613(a)(1)], inserted “(or 10 days in the case described in paragraph (5))” after “45 days”.
Subsec. (h)(5). Pub. L. 106–554, § 1(a)(6) [title VI, § 613(a)(2)], added par. (5).
1999—Subsec. (b)(1)(A). Pub. L. 106–113, § 1000(a)(6) [title V, § 501(c)(1)], inserted “and except as provided in subparagraph (C)” after “may otherwise provide”.
Subsec. (b)(1)(C). Pub. L. 106–113, § 1000(a)(6) [title V, § 501(c)(2)], added subpar. (C).
Subsec. (e)(2)(B)(i). Pub. L. 106–113, § 1000(a)(6) [title V, § 501(b)(1)], inserted “and subparagraph (D)” after “clause (ii)”.
Subsec. (e)(2)(C)(i). Pub. L. 106–113, § 1000(a)(6) [title V, § 501(b)(2)], inserted “and subparagraph (D)” after “clause (ii)”.
Subsec. (e)(2)(D). Pub. L. 106–113, § 1000(a)(6) [title V, § 501(b)(3)], added subpar. (D).
Subsec. (e)(3)(C). Pub. L. 106–113, § 1000(a)(6) [title V, § 519(a)], substituted “During the fall season” for “In the month of November”.
Subsec. (e)(4)(A). Pub. L. 106–113, § 1000(a)(6) [title V, § 501(a)(1)], added subpar. (A) and struck out former subpar. (A) which read as follows: “the organization’s or plan’s certification under this part has been terminated or the organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides;”.
Subsec. (f)(2). Pub. L. 106–113, § 1000(a)(6) [title V, § 502(a)], inserted “or change” before “is made” and “, except that if such election or change is made after the 10th day of any calendar month, then the election or change shall not take effect until the first day of the second calendar month following the date on which the election or change is made” before the period at end.
Subsec. (i)(2). Pub. L. 106–113, § 1000(a)(6) [title III, § 321(k)(6)(A)], struck out “and” after “1395w–27(f)(2),”.
Effective Date Of Amendment
Pub. L. 111–152, title I, § 1102(a),
Pub. L. 111–148, title III, § 3201(e)(2)(B),
Pub. L. 111–148, title III, § 3204(a)(2),
Pub. L. 110–275, title I, § 103(a)(3),
Pub. L. 110–275, title I, § 103(b)(3),
Pub. L. 110–275, title I, § 103(d)(3),
Pub. L. 108–173, title I, § 102(c)(2),
Pub. L. 108–173, title II, § 223(a),
Pub. L. 108–173, title II, § 231(f)(1),
Amendment by section 237(b)(2)(A) of Pub. L. 108–173 applicable to services provided on or after
Pub. L. 107–188, title V, § 532(c)(2),
Amendment by section 1(a)(6) [title VI, § 606(a)(2)(C)] of Pub. L. 106–554 applicable to years beginning with 2003, see section 1(a)(6) [title VI, § 606(b)] of Pub. L. 106–554, set out as a note under section 1395r of this title.
Pub. L. 106–554, § 1(a)(6) [title VI, § 613(b)],
Pub. L. 106–554, § 1(a)(6) [title VI, § 619(b)],
Pub. L. 106–554, § 1(a)(6) [title VI, § 620(b)],
Amendment by section 1000(a)(6) [title III, § 321(k)(6)(A)] of Pub. L. 106–113 effective as if included in the enactment of the Balanced Budget Act of 1997, Pub. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title III, § 321(m)] of Pub. L. 106–113, set out as a note under section 1395d of this title.
Pub. L. 106–113, div. B, § 1000(a)(6) [title V, § 501(d)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title V, § 502(b)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title V, § 519(b)],
Miscellaneous
Pub. L. 108–173, title II, § 223(b),
Pub. L. 108–173, title II, § 221(b)(2),
Pub. L. 111–148, title III, § 3602,
Pub. L. 108–173, title II, § 201,
Pub. L. 108–173, title II, § 211(g),
Pub. L. 108–173, title II, § 211(h),
Pub. L. 108–173, title II, § 221(a)(2),
Pub. L. 110–275, title I, § 164(b),
Pub. L. 110–173, title I, § 108(b),
Pub. L. 108–173, title II, § 231(d),
Pub. L. 108–173, title II, § 231(e),
Pub. L. 106–554, § 1(a)(6) [title I, § 124],
Pub. L. 106–113, div. B, § 1000(a)(6) [title V, § 551],
Pub. L. 106–113, div. B, § 1000(a)(6) [title V, § 552(b)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title V, § 553(b)],
Pub. L. 105–33, title IV, § 4002(c),
Pub. L. 105–33, title IV, § 4002(f)(2),
Pub. L. 105–33, title IV, § 4014(c),
Pub. L. 105–33, title IV, § 4018,