SubB

Medicare Plus Choice (M+C): Interim Final Rule

Subpart B–Eligibility, Election, and Enrollment

Sec. 422.50 Eligibility to elect an M+C plan.

(a) an individual is eligible to elect an M+C plan if he or she–
(1) Is entitled to Medicare under Part A and enrolled in Part B
(except that an individual entitled only to Part B and who is (or
was) enrolled in an HMO or CMP with a risk contract under part 417 of
this chapter on December 31, 1998 may continue to be enrolled in the
M+C organization may continue to be enrolled in the M+C organization
as an M+C plan enrollee); (2) Has not been medically determined to
have end-stage renal disease, except that an individual who develops
end-stage renal disease while enrolled in an M+C plan or in a health
plan offered by the M+C organization offering an M+C plan in the
service area or continuation area in which the individual resides may
continue to be enrolled in the M+C organization as an M+C plan
enrollee; (3) Resides in the service area of the plan, except that an
individual who resides in a continuation area of an M+C plan while
enrolled in a health plan offered by the M+C organization may
continue to be enrolled in the M+C organization as an M+C plan
enrollee; (4) Completes and signs an election form and gives
information required for enrollment; and (5) Agrees to abide by the
rules of the M+C organization after they are disclosed to him or her
in connection with the election process.

(b) An M+C eligible individual may not be enrolled in more than
one M+C plan at any given time.

Sec. 422.54 Continuation of enrollment.

(a) Definition. Continuation area
means an additional area (outside the service area) within which the
M+C organization furnishes or arranges for furnishing services to its
continuation-of-enrollment enrollees. Enrollees must reside in a
continuation area on a permanent basis. A continuation area does not
expand the service area of any plan.

(b) Basis rule. An M+C organization
may offer a continuation of enrollment option to enrollees when they
no longer reside in the service area of a plan and permanently move
into the geographic area designated by the M+C organization as a
continuation of enrollment area. The intent to no longer reside in an
area and permanently live in another area is verified through
documentation that establishes residency, such as, driver’s license,
voter registration.

(c) General requirements. (1) An M+C
organization that wishes to offer a continuation of enrollment option
must meet the following requirements: (i) Obtain HCFA’s approval of
the continuation area, the marketing materials that describe the
option, and the M+C organization’s assurances of access to services.
(ii) Describe the option(s) in the member materials it offers and
make the option available to all enrollees residing in the
continuation area. (2) An enrollee who moves out of the service area
and into the geographic area designated as the continuation area has
the choice of continuing enrollment or disenrolling from the plan.

(d) Specific requirements–(1) Basic
benefits. The M+C organization must, at a minimum, provide or arrange
for the Medicare-covered benefits described in Sec. 422.101(a). (2)
Reasonable access. The M+C organization must ensure reasonable access
in the continuation area– (i) Through contracts with providers, or
through direct payment of claims that satisfy the requirements in
Sec. 422.100(b)(2), to other providers who meet requirements in
subpart E of this part; and (ii) By ensuring that the access
requirements of Sec. 422.112 are met. (3) Reasonable cost-sharing.
For services furnished in the continuation area, an enrollee’s
cost-sharing liability is limited to– (i) The cost-sharing amounts
required in the M+C plan’s service area (in which the enrollee no
longer resides) if provided by contract providers; (ii) The
cost-sharing amounts required by the continuation area plan if
provided through agreements with another M+C plan; or (iii) The
amount for which a beneficiary would be liable under original
Medicare if noncontracting providers furnish the services. (4)
Protection of enrollee rights. An M+C organization that offers a
continuation of enrollment option must convey all enrollee rights
conferred under this rule, with the understanding that– (i) The
ultimate responsibility for all appeals and grievance requirements
remain with the organization that is receiving payment from HCFA; and
(ii) Organizations that require enrollees to give advance notice of
intent to use the continuation of enrollment option, must stipulate
the notification process in the marketing materials.

(e) Capitation payments. HCFA’s
capitation payments to all M+C organizations, for all Medicare
enrollees, are based on rates established on the basis of the
enrollee’s permanent residence, regardless of where he or she
receives services.

Sec. 422.56 Limitations on enrollment in an M+C MSA plan.

(a) General. An individual is not
eligible to elect an M+C MSA plan– (1) If the number of individuals
enrolled in M+C MSA plans has reached 390,000; (2) Unless the
individual provides assurances that are satisfactory to HCFA that he
or she will reside in the United States for at least 183 days during
the year for which the election is effective; or (3) On or after
January 1, 2003, unless the enrollment is the continuation of an
enrollment in effect as of that date.

(b) Individuals eligible for or covered
under other health benefits program. An individual who is
enrolled in a Federal Employee Health Benefit plan under 5 U.S.C.
chapter 89, or is eligible for health care benefits through the
Veteran’s Administration under 10 U.S.C. chapter 55 or the Department
of Defense under 38 U.S.C. chapter 17, may not enroll in an M+C MSA
plan.

(c) Individuals eligible for Medicare
cost-sharing under Medicaid State plans. An individual who is
entitled to coverage of Medicare cost-sharing under a State plan
under title XIX of the Act is not eligible to enroll in an M+C MSA
plan.

(d) Other limitations. An individual
who receives health benefits that cover all or part of the annual
deductible under the M+C MSA plan may not enroll in an M+C MSA plan.
Examples of this type of coverage include, but are not limited to,
primary health care coverage other than Medicare, current coverage
under the Medicare hospice benefit, supplemental insurance policies
not specifically permitted under Sec. 422.103, and retirement health
benefits.

Sec. 422.57 Limited enrollment under M+C RFB plans.

An RFB society that offers an M+C RFB plan may offer that plan
only to members of the church, or convention or group of churches
with which the society is affiliated. [[Page 35072]]

Sec. 422.60 Election process.

(a) Acceptance of enrollees: General
rule. (1) Except for the limitations on enrollment in an M+C MSA plan
provided by Sec. 422.62(d)(1) and except as specified in paragraph
(a)(2) of this section, each M+C organization must accept without
restriction (except for an M+C RFB plan as provided by Sec. 422.57)
individuals who are eligible to elect an M+C plan that M+C
organization offers and who elect an M+C plan during initial coverage
election periods, annual election periods, and special election
periods specified in Sec. 422.62 (a)(1), (a)(2), and (b). (2) M+C
organizations must accept elections during the open enrollment
periods specified in Sec. 422.62(a)(3), (a)(4), and (a)(5) if their
M+C plans are open to new enrollees.

(b) Capacity to accept new enrollees.
(1) M+C organizations must submit information on enrollment
capacity of plans they offer by May 1 of each year as provided by
Sec. 422.306(a)(2). (2) If HCFA determines that an M+C plan offered
by an M+C organization has a capacity limit, and the number of M+C
eligible individuals who elect to enroll in that plan exceeds the
limit, the M+C organization offering the plan may limit enrollment in
the plan under this part, but only if it provides priority in
acceptance as follows: (i) First, for individuals who elected the
plan prior to the HCFA determination that capacity has been exceeded,
elections will be processed in chronological order by date of receipt
of their election forms. (ii) Then for other individuals in a manner
that does not discriminate on the basis of any factor related to
health as described in Sec. 422.110.

(c) Election forms. (1) The election
form must comply with HCFA instructions regarding content and format
and have been approved by HCFA as described in Sec. 422.80. The form
must be completed and signed by the M+C eligible individual
beneficiary (or the individual who will soon become entitled to
Medicare benefits) and include authorization for disclosure and
exchange of necessary information between the U.S. Department of
Health and Human Services and its designees and the M+C organization.
Persons who assist beneficiaries in completing forms must sign the
form and indicate their relationship to the beneficiary. (2) The M+C
organization must file and retain election forms for the period
specified in HCFA instructions.

(d) When an election is considered to have
been made. An election in an M+C plan is considered to have
been made on the date the election form is received by the M+C
organization.

(e) Handling of election forms. The
M+C organization must have an effective system for receiving,
controlling, and processing election forms. The system must meet the
following conditions and requirements: (1) Each election form is
dated as of the day it is received. (2) Election forms are processed
in chronological order, by date of receipt. (3) The M+C organization
gives the beneficiary prompt written notice of acceptance or denial
in a format specified by HCFA. (4) In a format specified by HCFA, a
notice of acceptance– (i) Promptly informs the beneficiary of the
date on which enrollment will be effective under Sec. 422.68; and
(ii) If the M+C plan is enrolled to capacity, explains the procedures
that will be followed when vacancies occur. (5) A notice of denial
explains the reasons for denial in a format specified by HCFA. (6)
Within 30 days from receipt of the election form (or from the date a
vacancy occurs for an individual who was accepted for future
enrollment), the M+C organization transmits the information necessary
for HCFA to add the beneficiary to its records as an enrollee of the
M+C organization.

Sec. 422.62 Election of coverage under an M+C plan.

(a) General: Coverage election
periods–(1) Initial coverage election period. The initial coverage
election period is the period during which a new M+C eligible
individual may make an initial election. This period begins 3 months
prior to the month the individual is first entitled to both Part A
and Part B and ends the last day of the month preceding the month of
entitlement. (2) Annual election period. (i) Beginning in 1999, the
month of November is the annual election period for the following
calendar year. Organizations offering M+C plans in January 1999 must
open enrollment to Medicare beneficiaries in November 1998. (ii)
During the annual election period, an individual eligible to enroll
in an M+C plan may change his or her election from an M+C plan to
original Medicare or to a different M+C plan, or from original
Medicare to an M+C plan. (3) Open enrollment and disenrollment
opportunities through 2001. From 1998 through 2001, the number of
elections or changes that an M+C eligible individual may make is not
limited (except as provided for in paragraph (d) of this section for
M+C MSA plans). Subject to the M+C plan being open to enrollees as
provide under Sec. 422.60(a)(2), an individual eligible to elect an
M+C plan may change his or her election from an M+C plan to original
Medicare or to a different M+C plan, or from original Medicare to an
M+C plan. (4) Open enrollment and disenrollment during 2002. (i)
Except as provided in paragraphs (a)(4)(ii) and (a)(4)(iii) of this
section, an individual who is eligible to elect an M+C plan in 2002
may elect an M+C plan or change his or her election from an M+C plan
to original Medicare or to a different M+C plan, or from original
Medicare to an M+C plan, but only once during the first 6 months of
the year. (ii) Newly eligible M+C individual. An individual who
becomes an M+C eligible individual during 2002 may elect an M+C plan
or original Medicare and then change his or her election once during
the period that begins the month the individual is entitled to both
Part A and Part B and ends on the last day of the 6th month of such
entitlement, or on December 31, whichever is earlier. The individual
can change the election from an M+C plan to original Medicare or to a
different M+C plan, or from original Medicare to an M+C plan during
this period. (iii) The limitation to one election or change in
paragraphs (a)(4)(i) and (a)(4)(ii) of this section does not apply to
elections or changes made during the annual election period specified
in (a)(2) of this section or during a special enrollment period
specified in paragraph (b) of this section. (5) Open enrollment and
disenrollment beginning in 2003. (i) For 2003 and subsequent years,
except as provided in paragraphs (a)(5)(ii) and (a)(5)(iii) of this
section, an individual who is eligible to elect an M+C plan may elect
an M+C plan or change his or her election from an M+C plan to
original Medicare or to a different M+C plan, or from original
Medicare to an M+C plan, but only once during the first 3 months of
the year. (ii) Newly eligible M+C individual. An individual who
becomes an M+C eligible individual during 2003 or later may elect an
M+C plan or original Medicare and then change his or her election
once during the period that begins the month the individual is
entitled to both Part A and Part B and ends on the last day of the
3rd month of such entitlement, or on December 31, whichever is
earlier. The individual can change the election from an M+C plan to
original Medicare or to a different [[Page 35073]] M+C plan, or from
original Medicare to an M+C plan during this period. (iii) The
limitation to one election or change in paragraphs (a)(5)(i) and
(a)(5)(ii) of this section does not apply to elections or changes
made during the annual election period specified in paragraph (a)(2)
of this section or during a special election period specified in
paragraph (b) of this section.

(b) Special election periods.
Effective as of January 1, 1999 for M+C plans, and as of
January 1, 2002, for all MSA other types of M+C MSA plans, an
individual may at any time (that is, not limited to the annual
election period) discontinue the election of an M+C plan offered by
an M+C organization and change his or her election, in the form and
manner specified by HCFA, from an M+C plan to original Medicare or to
a different M+C plan under any of the following circumstances: (1)
HCFA has terminated the organization’s contract for that plan or the
organization has terminated or discontinued offering the plan in the
service area or continuation area in which the individual resides.
(2) The individual is not eligible to remain enrolled in the plan
because of a change in his or her place of residence to a location
out of the service area or continuation area or other change in
circumstances as determined by HCFA but not including terminations
resulting from a failure to make timely payment of an M+C monthly or
supplemental beneficiary premium, or from disruptive behavior. (3)
The individual demonstrates to HCFA, in accordance with guidelines
issued by HCFA, that– (i) The organization offering the plan
substantially violated a material provision of its contract under
this part in relation to the individual, including, but not limited
to the following: (A) Failure to provide the beneficiary on a timely
basis medically necessary services for which benefits are available
under the plan. (B) Failure to provide medical services in accordance
with applicable quality standards; or (ii) The organization (or its
agent, representative, or plan provider) materially misrepresented
the plan’s provisions in marketing the plan to the individual. (4)
The individual meets such other exceptional conditions as HCFA may
provide.

(c) Special election period for individual
age 65. Effective January 1, 2002, an M+C eligible individual
who elects an M+C plan during the initial coverage election period,
as defined under section 1837(d) of the Act, that surrounds his or
her 65th birthday (this period begins 3 months before and ends 3
months after the month of the individual’s 65th birthday) may
discontinue the election of that plan and elect coverage under
original Medicare at any time during the 12- month period that begins
on the effective date of enrollment in the M+C plan.

(d) Special rules for M+C plans–(1)
Enrollment. An individual may enroll in an M+C plan only during an
initial or annual election period described in paragraphs (a)(1) and
(a)(2) of this section or during November 1998. (2) Disenrollment.
(i) Except as provided in paragraph (d)(2)(ii) of this section, an
individual may disenroll from an M+C plan only during– (A) November
1998; (B) An annual election period; or (C) The special election
period described in paragraph (b) of this section. (ii) Exception. An
individual who elects an M+C MSA plan during an annual election
period and has never before elected an M+C MSA plan may revoke that
election, no later than December 15 of that same year, by submitting
to the organization that offers the M+C MSA plan a signed and dated
request in the form and manner prescribed by HCFA or by filing the
appropriate disenrollment form through other mechanisms as determined
by HCFA.

Sec. 422.64 Information about the M+C program.

(a) Source of information. Each M+C
organization must provide, on an annual basis and in a format and
using standard terminology that may be specified by HCFA, the
information necessary to enable HCFA to provide to current and
potential beneficiaries the information they need to make informed
decisions with respect to the available choices for Medicare
coverage.

(b) Timing and recipients of the
information. HCFA mails a notice containing the information
described in paragraph (c) of this section– (1) At least 15 days
before each annual election period, to each individual eligible to
elect an M+C plan; and (2) To the extent practicable, not later than
30 days before his or her initial coverage election period to each
individual who will become eligible to elect an M+C plan.

(c) Content of notice–(1) Benefits
under original Medicare. (i) Covered services. (ii) Beneficiary cost
sharing, such as deductibles, coinsurance, and copayment amounts.
(iii) Any beneficiary liability for balance billing. (2) Enrollment
procedures. Information and instructions on how to exercise election
options under this subpart. (3) Rights. A general description of
procedural rights (including grievance and appeals procedures) under
original Medicare and the M+C program and the right to be protected
against discrimination based on factors related to health status in
accordance with Sec. 422.110. (4) Medigap and Medicare Select. A
general description of the benefits, enrollment rights, and
requirements applicable to Medicare supplemental policies under
section 1882 of the Act, and provisions relating to Medicare Select
policies under section 1882(t) of the Act. (5) Potential for contract
termination. The fact that an M+C organization may terminate or
refuse to renew its contract, or reduce the service area included in
its contract, and the effect that any of those actions may have on
individuals enrolled in that organization’s M+C plan. (6) Comparative
information. A list of M+C plans that are or will be available to
residents of the service area in the following calendar year, and,
for each available plan, information on the aspects described in
paragraphs (c)(7) through (c)(11) of this section, presented in a
manner that facilitates comparison among the plans. (7) Benefits. (i)
Covered services beyond those provided under original Medicare. (ii)
Any beneficiary cost sharing. (iii) Any maximum limitations on
out-of-pocket expenses. (iv) In the case of an M+C MSA plan, the
amount of the annual MSA deposit and the differences in cost-sharing,
enrollee premiums, and balance billing, as compared to M+C plans. (v)
In the case of a M+C private fee-for-service plan, differences in
cost-sharing, enrollee premiums, and balance billing, as compared to
M+C plans. (vi) The extent to which an enrollee may obtain benefits
through out-of-network health care providers. (vii) The types of
providers that participate in the plan’s network and the extent to
which an enrollee may select among those providers. (viii) The
coverage of emergency and urgently needed services. (8) Premiums. (i)
The M+C monthly basic beneficiary premiums. (ii) The M+C monthly
supplemental beneficiary premium. (9) The plan’s service area. (10)
Quality and performance indicators for benefits under a plan to
[[Page 35074]] the extent they are available as follows (and how they
compare with indicators under original Medicare): (i) Disenrollment
rates for Medicare enrollees for the 2 previous years, excluding
disenrollment due to death or moving outside the plan’s service area,
calculated according to HCFA guidelines. (ii) Medicare enrollee
satisfaction. (iii) Health outcomes. (iv) Plan-level appeal data. (v)
The recent record of plan compliance with the requirements of this
part, as determined by the Secretary. (vi) Other performance
indicators. (11) Supplemental benefits. Whether the plan offers
mandatory supplemental benefits or offers optional supplemental
benefits and the premiums and other terms and conditions for those
benefits.

(d) Format and updating. The
information is written and formatted using language that is easily
understandable, and is updated at least annually.

(e) Mailing. The mailing is
coordinated, to the extent practicable, with the mailing of the
annual notice of Medicare benefits under section 1804 of the
Act.

Sec. 422.66 Coordination of enrollment and disenrollment
through M+C organizations.

(a) Enrollment. An individual who
wishes to elect an M+C plan offered by an M+C organization may make
or change his or her election during the election periods specified
in Sec. 422.62 by filing the appropriate election form with the
organization or through other mechanisms as determined by HCFA.

(b) Disenrollment–(1) Basic rule. An
individual who wishes to disenroll from an M+C plan may change his or
her election during the election periods specified in Sec. 422.62 in
either of the following manners: (i) Elect a different M+C plan by
filing the appropriate election form with the M+C organization or
through other mechanisms as determined by HCFA. (ii) Submit a signed
and dated request for disenrollment to the M+C organization in the
form and manner prescribed by HCFA or file the appropriate
disenrollment form through other mechanisms as determined by HCFA.
(2) When a disenrollment request is considered to have been made. A
disenrollment request is considered to have been made on the date the
disenrollment request is received by the M+C organization. (3)
Responsibilities of the M+C organization. The M+C organization must–
(i) Submit a disenrollment notice to HCFA within 15 days of receipt;
(ii) Provide the enrollee with a copy of the request for
disenrollment; and (iii) In the case of a plan where lock-in applies,
also provide the enrollee with a statement explaining that he or
she– (A) Remains enrolled until the effective date of disenrollment;
and (B) Until that date, neither the M+C organization nor HCFA pays
for services not provided or arranged for by the M+C plan in which
the enrollee is enrolled; and (iv) File and retain disenrollment
requests for the period specified in HCFA instructions. (4) Effect of
failure to submit disenrollment notice to HCFA promptly. If the M+C
organization fails to submit the correct and complete notice required
in paragraph (b)(3)(i) of this section, the M+C organization must
reimburse HCFA for any capitation payments received after the month
in which payment would have ceased if the requirement had been met
timely. (5) Retroactive disenrollment. HCFA may grant retroactive
disenrollment in the following cases: (i) There never was a legally
valid enrollment. (ii) A valid request for disenrollment was properly
made but not processed or acted upon.

(c) Election by default: Initial
coverage election period. An individual who fails to make an election
during the initial coverage election period is deemed to have elected
original Medicare.

(d) Conversion of enrollment (seamless
continuation of coverage)— (1) Basic rule. An M+C plan
offered by an M+C organization must accept any individual (residing
in the service area or continuation area of the M+C plan) who is
enrolled in a health plan offered by an M+C organization (regardless
of whether the individual has end-stage renal disease) during the
month immediately preceding the month in which he or she is entitled
to both Part A and Part B as provided by Sec. 422.50(a)(2) and
(a)(3). (2) Reserved vacancies. Subject to HCFA’s approval, an M+C
organization may set aside a reasonable number of vacancies in order
to accommodate enrollment of conversions. Any set aside vacancies
that are not filled within a reasonable time must be made available
to other M+C eligible individuals. (3) Effective date of conversion.
Unless the individual chooses to disenroll from the health plan
offered by the M+C organization, the individual’s conversion to an
M+C enrollee is effective the month in which he or she is entitled to
both Part A and Part B. (4) Prohibition against disenrollment. The
M+C organization may disenroll an individual who is converting under
the provisions of paragraph (a) of this section only under the
conditions specified in Sec. 422.74. (5) Election form. The
individual who is converting must complete and sign an election form
as described in Sec. 422.60(c)(1). (6) Submittal of information to
HCFA. The M+C organization must transmit the information necessary
for HCFA to add the individual to its records as specified in Sec.
422.60(e)(6).

(e) Maintenance of enrollment. An
individual who has made or is deemed to have made an election under
this section is considered to have continued to have made that
election until either of the following, whichever occurs first: (1)
The individual changes the election under this section. (2) The
elected M+C plan is discontinued or no longer serves the service area
in which the individual resides, and the organization does not offer
or the individual does not elect the option of continuing enrollment,
as provided in Sec. 422.54.

422.68 Effective dates of coverage and change of coverage.

(a) Initial coverage election period.
An election made during an initial coverage election period as
described in Sec. 422.62(a)(1) is effective as of the first day of
the month of entitlement to both Part A and Part B.

(b) Annual election periods. For an
election or change of election made during an annual election period
as described in Sec. 422.62(a)(2), coverage is effective as of the
first day of the following calendar year.

(c) Open enrollment periods. For an
election or change of election made during an open enrollment period
as described in Sec. 422.62(a)(3) through (a)(5), coverage is
effective as of the first day of the first calendar month following
the month in which the election is made.

(d) Special election periods. For an
election or change of election made during a special election period
as described in Sec. 422.62(b), the effective date of coverage shall
be determined by HCFA, to the extent practicable, in a manner
consistent with protecting the continuity of health benefits
coverage.

(e) Special election period for individual
age 65. For an election of coverage under original Medicare
made during a special election period for an individual age 65 as
described in [[Page 35075]] Sec. 422.62(c), coverage is effective as
of the first day of the first calendar month following the month in
which the election is made.

Sec. 422.74 Disenrollment by the M+C organization.

(a) General rule. Except as provided
in paragraphs (b) through (d) of this section, an M+C organization
may not– (1) Disenroll an individual from any M+C plan it offers; or
(2) Orally or in writing, or by any action or inaction, request or
encourage an individual to disenroll.

(b) Basis for disenrollment--(1)
Optional disenrollment. An M+C organization may disenroll an
individual from an M+C plan it offers in any of the following
circumstances: (i) Any monthly basic and supplementary beneficiary
premiums are not paid on a timely basis, subject to the grace period
for late payment established under paragraph (d)(1) of this section.
(ii) The individual has engaged in disruptive behaviors specified at
paragraph (d)(2) of this section. (iii) The individual provides
fraudulent information on his or her election form or permits abuse
of his or her enrollment card as specified in paragraph (d)(3) of
this section. (2) Required disenrollment. An M+C organization must
disenroll an individual from an M+C plan it offers in any of the
following circumstances: (i) The individual no longer resides in the
M+C plan’s service area as specified in paragraph (d)(4) of this
section, and optional continued enrollment has not been offered or
elected pursuant to Sec. 422.54. (ii) The individual loses
entitlement to Part A or Part B benefits as described in paragraph
(d)(5) of this section. (iii) Death of the individual as described in
paragraph (d)(6) of this section. (3) Plan termination or reduction
of service area or continuation area. An M+C plan offered by an M+C
organization that terminates with respect to all M+C individuals in
the area where the individual resides or is terminated or reduces
service area or continuation area must comply with the process for
disenrollment set forth at paragraph (d)(7) of this section.

(c) Notice requirement. If the
disenrollment is for any of the reasons specified in paragraphs
(b)(1) through (b)(2)(i) and (b)(3) of this section, that is, other
than death or loss of entitlement to Part A or Part B, the M+C
organization must give the individual a written notice of the
disenrollment with an explanation of why the M+C organization is
planning to disenroll the individual. (1) The notice must be mailed
to the individual before submission of the disenrollment notice to
HCFA. (2) The notice must include an explanation of the individual’s
right to a hearing under the M+C organization’s grievance procedures.

(d) Process for disenrollment–(1)
Monthly basic and supplementary premiums are not paid timely. An M+C
organization may disenroll an individual from the M+C plan for
failure to pay any basic or supplementary premiums if the M+C
organization– (i) Makes a reasonable effort to collect unpaid
premium amounts by sending a written notice of nonpayment to the
enrollee within 20 days after the date that the delinquent charges
were due– (A) Alerting the individual that the premiums are
delinquent; (B) Providing the individual with an explanation of the
disenrollment procedures and any lock-in requirements of the M+C
plan; and (C) Advising that failure to pay the premiums within the
90-day grace period will result in termination of M+C coverage; (ii)
Only disenrolls a Medicare enrollee when the organization has not
received payment within 90 days after the date it has sent the notice
of nonpayment to the enrollee; and (iii) Gives the individual a
written notice of disenrollment that meets the requirements set forth
in paragraph (c) of this section. (2) Disenrollment for disruptive
behavior–(i) Basis for disenrollment. An M+C organization may
disenroll an individual from the M+C plan if the individual’s
behavior is disruptive, unruly, abusive, or uncooperative to the
extent that his or her continued enrollment in the plan seriously
impairs the M+C plan’s ability to furnish services to either the
particular individual or other individuals enrolled in the plan. (ii)
Effort to resolve the problem. The M+C organization must make a
serious effort to resolve the problems presented by the individual,
including the use (or attempted use) of the M+C organization’s
grievance procedures. The beneficiary has a right to submit any
information or explanation that he or she may wish to submit to the
M+C organization. (iii) Consideration of extenuating circumstances.
The M+C organization must establish that the individual’s behavior is
not related to the use of medical services or to diminished mental
capacity. (iv) Documentation. The M+C organization must document the
enrollee’s behavior, its own efforts to resolve any problems, and any
extenuating circumstances, as described in paragraphs (d)(2)(i)
through (d)(2)(iii) of this section. (v) HCFA review of the M+C
organization’s proposed disenrollment. (A) HCFA decides after
reviewing the documentation submitted by the M+C organization and any
information submitted by the beneficiary (which the M+C organization
must forward to HCFA) whether the M+C organization has met the
disenrollment requirements. (B) HCFA makes the decision within 20
working days after receipt of the documentation and notifies the M+C
organization within 5 working days after making its decision. (vi)
Effective date of disenrollment. If HCFA permits an M+C organization
to disenroll an individual for disruptive behavior, the termination
is effective the first day of the calendar month after the month in
which the M+C organization gives the individual written notice of the
disenrollment that meets the requirements set forth in paragraph (c)
of this section. (3) Individual commits fraud or permits abuse of
enrollment care. (i) Basis for disenrollment. An M+C organization may
disenroll the individual from an M+C plan if the individual– (A)
Knowingly provides, on the election form, fraudulent information that
materially affects the individual’s eligibility to enroll in the M+C
plan; or (B) Intentionally permits others to use his or her
enrollment card to obtain services under the M+C plan. (ii) Notice of
disenrollment. The M+C organization must give the individual a
written notice of the disenrollment that meets the requirements set
forth in paragraph (c) of this section. (iii) Report to HCFA. The M+C
organization must report to HCFA any disenrollment based on fraud or
abuse by the individual. (4) Individual no longer resides in the M+C
plan’s service area– (i) Basis for disenrollment. Unless
continuation of enrollment is elected under Sec. 422.54, the M+C
organization must disenroll an individual who moves out of a plan’s
service area if the M+C organization establishes, on the basis of a
written statement from the individual, or other evidence acceptable
to HCFA, that the individual has moved out of a plan’s service area
for over 12 months. (ii) Notice of disenrollment. The M+C
organization must give the individual a written notice of the
disenrollment that [[Page 35076]] meets the requirements set forth in
paragraph (c) of this section. (5) Loss of entitlement to Part A or
Part B benefits. If an individual is no longer entitled to Part A or
Part B benefits, HCFA notifies the M+C organization that the
disenrollment is effective the first day of the calendar month
following the last month of entitlement to Part A or Part B benefits.
(6) Death of the individual. If the individual dies, disenrollment is
effective the first day of the calendar month following the month of
death. (7) Plan termination or area reduction. (i) If the plan
terminates or is terminated or the service area or continuation area
are reduced with respect to all M+C enrollees in the area in which
they reside, the M+C organization must give each Medicare enrollee a
written notice of the effective date of the plan termination or area
reduction and a description of alternatives for obtaining benefits
under the M+C program. (ii) The notice must be sent before the
effective date of the plan termination or area reduction.

(e) Consequences of
disenrollment–(1) Disenrollment for non- payment of premiums,
disruptive behavior, fraud or abuse, loss of Part A or Part B. An
individual who is disenrolled under paragraph (b)(1)(i), (b)(1)(ii),
(b)(1)(iii), or paragraph (b)(2)(ii) of this section is deemed to
have elected original Medicare. (2) Disenrollment based on plan
termination, area reduction, or individual moves out of area. (i) An
individual who is disenrolled under paragraph (b)(2)(i) or (b)(3) of
this section has a special election period in which to make a new
election as provided in Sec. 422.62(b)(1) and (b)(2). (ii) An
individual who fails to make an election during the special election
period is deemed to have elected original Medicare.

Sec. 422.80 Approval of marketing materials and election
forms.

(a) HCFA review of marketing materials.
An M+C organization may not distribute any marketing materials
(as defined in paragraph (b)), or election forms, or make such
materials or forms available to individuals eligible to elect an M+C
plan, unless– (1) At least 45 days before the date of distribution
the M+C organization has submitted the material or form to HCFA for
review under the guidelines in paragraph (c); and (2) HCFA has not
disapproved the distribution of the material or form.

(b) Definition of marketing materials.
Marketing materials include any informational materials
targeted to Medicare beneficiaries which: (1) Promote the M+C
organization, or any M+C plan offered by the M+C organization; (2)
Inform Medicare beneficiaries that they may enroll, or remain
enrolled in, an M+C plan offered by the M+C organization; (3) Explain
the benefits of enrollment in an M+C plan, or rules that apply to
enrollees; (4) Explain how Medicare services are covered under an M+C
plan, including conditions that apply to such coverage; (5) Examples
of marketing materials include, but are not limited to: (i) General
audience materials such as general circulation brochures, newspapers,
magazines, television, radio, billboards, yellow pages, or the
internet. (ii) Marketing representative materials such as scripts or
outlines for telemarketing or other presentations. (iii) Presentation
materials such as slides and charts. (iv) Promotional materials such
as brochures or leaflets, including materials for circulation by
third parties (e.g., physicians or other providers). (v) Membership
communication materials such as membership rules, subscriber
agreements (evidence of coverage), member handbooks, and newsletters.
(vi) Letters to members about contractual changes; changes in
providers, premiums, benefits, plan procedures etc. (vii) Membership
or claims processing activities (e.g., materials on rules involving
non-payment of premiums, confirmation of enrollment or disenrollment,
or annual notification information).

(c) Guidelines for HCFA Review. In
reviewing marketing material or election forms under paragraph (a) of
this section, HCFA determines that the marketing materials: (1)
Provide, in a format (and, where appropriate, print size), and using
standard terminology that may be specified by HCFA, the following
information to Medicare beneficiaries interested in enrolling: (i)
Adequate written description of rules (including any limitations on
the providers from whom services can be obtained), procedures, basic
benefits and services, and fees and other charges. (ii) Adequate
written description of any supplemental benefits and services. (iii)
Adequate written explanation of the grievance and appeals process,
including differences between the two, and when it is appropriate to
use each. (iv) Any other information necessary to enable
beneficiaries to make an informed decision about enrollment. (2)
Notify the general public of its enrollment period (whether
time-limited or continuous) in an appropriate manner, through
appropriate media, throughout its service and continuation area. (3)
Include in the written materials notice that the organization is
authorized by law to refuse to renew its contract with HCFA, that
HCFA also may refuse to renew the contract, and that termination or
non-renewal may result in termination of the beneficiary’s enrollment
in the plan. (4) Contain no statements that are inaccurate or
misleading or otherwise make misrepresentations. (5) For markets with
a significant non-English speaking population, provide materials in
the language of these individuals.

(d) Deemed approval (one-stop shopping).
If HCFA has not disapproved the distribution of marketing
material or forms submitted by an M+C organization with respect to an
M+C plan in an area, HCFA is deemed not to have disapproved the
distribution in all other areas covered by the M+C plan and
organization except with regard to any portion of the material or
form that is specific to the particular area.

(e) Standards for M+C organization
marketing. (1) In conducting marketing activities, M+C
organizations may not: (i) Provide for cash or other monetary rebates
as an inducement for enrollment or otherwise. This does not prohibit
explanation of any legitimate benefits the beneficiary might obtain
as an enrollee of the M+C plan, such as eligibility to enroll in a
supplemental benefit plan that covers deductibles and coinsurance, or
preventive services. (ii) Engage in any discriminatory activity such
as, for example, attempts to recruit Medicare beneficiaries from
higher income areas without making comparable efforts to enroll
Medicare beneficiaries from lower income areas. (iii) Solicit
door-to-door for Medicare beneficiaries. (iv) Engage in activities
that could mislead or confuse Medicare beneficiaries, or misrepresent
the M+C organization, the M+C organization may not claim that it is
recommended or endorsed by HCFA or Medicare or that HCFA or Medicare
recommends that the beneficiary enroll in the M+C plan. It may,
however, explain that the organization is approved for participation
in Medicare. (v) Distribute marketing materials for which, before
expiration of the 45-day [[Page 35077]] period, the M+C organization
receives from HCFA written notice of disapproval because it is
inaccurate or misleading, or misrepresents the M+C organization, its
marketing representatives, or HCFA. (2) In its marketing, the M+C
organization must: (i) Demonstrate the HCFA’s satisfaction that
marketing resources are allocated to marketing to the disabled
Medicare population as well as beneficiaries age 65 and over. (ii)
Establish and maintain a system for confirming that enrolled
beneficiaries have in fact, enrolled in the M+C plan, and understand
the rules applicable under the plan.

(f) Employer group retiree Marketing.
HCFA may permit M+C organizations to develop marketing materials
designed for members of an employer group who are eligible for
employer-sponsored benefits through the M+C organization, and to
furnish these materials only to such group members. While such
materials must be submitted for approval under paragraph (a) of this
section, HCFA will only review potions of these materials that
related to M+C plan benefits.

---

Health Hippo ©1996-2015