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(1) IN GENERAL.—Section 1857(d) of the So-
cial Security Act (42 U.S.C. 1395w–27(d)), as 
amended by subsection (b)(1), is further amended by 
adding at the end the following new paragraph: 
‘‘(7) MARKETING
AND
ADVERTISING
STAND-
ARDS.—The contract shall require the organization 
to meet all standards adopted under section 
1852(m) (including those enforced by the State in-
volved pursuant to section 1856(b)(3)) relating to 
marketing and advertising conduct.’’. 
(2) EFFECTIVE DATE.—The amendment made 
by paragraph (1) shall apply to contracts for plan 
years beginning on or after January 1, 2011. 
(e) APPLICATION OF SANCTIONS.— 
(1) APPLICATION TO VIOLATION OF MARKETING 
AND
ENROLLMENT
STANDARDS.—Section 
1857(g)(1) of such Act (42 U.S.C. 1395w–27(g)(1)), 
as amended by the preceding provisions of this Act, 
is further amended— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (G); 
(B) by adding ‘‘and’’ at the end of sub-
paragraph (H); and 
(C) by inserting after subparagraph (H) 
the following new subparagraph: 
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‘‘(I) violates marketing and enrollment 
standards adopted under section 1852(m);’’. 
(2) ENHANCED
CIVIL
MONEY
SANCTIONS.— 
Such section is further amended— 
(A) in paragraph (2)(A), by striking 
‘‘$25,000’’, ‘‘$100,000’’, and ‘‘$15,000’’ and 
inserting 
‘‘$50,000’’, 
‘‘$200,000’’, 
and 
‘‘$30,000’’, respectively; and 
(B) in subparagraphs (A), (B), and (D) of 
paragraph 
(3), 
by 
striking 
‘‘$25,000’’, 
‘‘$10,000’’, and ‘‘$100,000’’, respectively, and 
inserting 
‘‘$50,000’’, 
‘‘$20,000’’, 
and 
‘‘$200,000’’, respectively. 
(3) EFFECTIVE DATE.—The amendments made 
by paragraph (2) shall apply to violations occurring 
on or after the date of the enactment of this Act. 
(f) DISCLOSURE
OF MARKET
AND ADVERTISING 
CONTRACT VIOLATIONS AND IMPOSED SANCTIONS.—Sec-
tion 1857 of such Act is amended by adding at the end 
the following new subsection: 
‘‘(j) DISCLOSURE
OF MARKET
AND ADVERTISING 
CONTRACT VIOLATIONS AND IMPOSED SANCTIONS.—For 
years beginning with 2009, the Secretary shall post on its 
public website for the Medicare program an annual report 
that— 
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‘‘(1) lists each MA organization for which the 
Secretary made during the year a determination 
under subsection (c)(2) the basis of which is de-
scribed in paragraph (1)(E); and 
‘‘(2) that describes any applicable sanctions 
under subsection (g) applied to such organization 
pursuant to such determination.’’. 
(g) STANDARD DEFINITIONS
OF BENEFITS
AND 
FORMATS FOR USE IN MARKETING MATERIALS.—Section 
1851(h) of such Act (42 U.S.C. 1395w–21(h)) is amended 
by adding at the end the following new paragraph: 
‘‘(6) STANDARD
DEFINITIONS
OF
BENEFITS 
AND
FORMATS
FOR
USE
IN
MARKETING
MATE-
RIALS.— 
‘‘(A) IN GENERAL.—Not later than Janu-
ary 1, 2010, the Secretary, in consultation with 
the National Association of Insurance Commis-
sioners and a working group of the type de-
scribed in section 1852(m)(7)(E), shall develop 
standard descriptions and definitions for bene-
fits under this title for use in marketing mate-
rial distributed by Medicare Part C organiza-
tions and formats for including such descrip-
tions in such marketing material. 
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‘‘(B) REQUIRED USE OF STANDARD DEFI-
NITIONS.—For plan years beginning on or after 
January 1, 2011, the Secretary shall disapprove 
the distribution of marketing material under 
paragraph (1)(B) if such marketing material 
does not use, without modification, the applica-
ble descriptions and formats specified under 
subparagraph (A).’’. 
(h) SUPPORT FOR STATE HEALTH INSURANCE AS-
SISTANCE PROGRAMS (SHIPS).—Section 1857(e)(2) of 
the Social Security Act (42 U.S.C. 1395w–27(e)(2)) is 
amended— 
(1) in subparagraph (B), by adding at the end 
the following: ‘‘Of the amounts so collected, no less 
than $55,000,000 for fiscal year 2009, $65,000,000 
for fiscal year 2010, $75,000,000 for fiscal year 
2011, and $85,000,000 for fiscal year 2012 and 
each succeeding fiscal year shall be used to support 
Medicare Part C and Part D counseling and assist-
ance provided by State Health Insurance Assistance 
Programs.’’; 
(2) in subparagraph (C)— 
(A) 
by 
striking 
‘‘and’’ 
after 
‘‘$100,000,000,’’; and 
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(B) by striking ‘‘an amount equal to 
$200,000,000’’ and inserting ‘‘and ending with 
fiscal 
year 
2008 
an 
amount 
equal 
to 
$200,000,000, for fiscal year 2009 an amount 
equal to $255,000,000, for fiscal year 2010 an 
amount equal to $265,000,000, for fiscal year 
2011 an amount equal to $275,000,000, and 
for fiscal year 2012 and each succeeding fiscal 
year an amount equal to $285,000,000’’; and 
(3) in subparagraph (D)(ii)— 
(A) by striking ‘‘and’’ at the end of sub-
clause (IV); 
(B) in subclause (V), by striking the period 
at the end and inserting ‘‘before fiscal year 
2009; and’’; and 
(C) by adding at the end the following new 
subclause: 
‘‘(VI) for fiscal year 2009 and each 
succeeding fiscal year the applicable por-
tion (as so defined) of the amount specified 
in subparagraph (C) for that fiscal year.’’. 
SEC. 412. LIMITATION ON OUT-OF-POCKET COSTS FOR INDI-
VIDUAL HEALTH SERVICES. 
(a) IN GENERAL.—Section 1852(a)(1) of the Social 
Security Act (42 U.S.C. 1395w–22(a)(1)) is amended— 
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(1) in subparagraph (A), by inserting before the 
period at the end the following: ‘‘with cost-sharing 
that is no greater (and may be less) than the cost- 
sharing that would otherwise be imposed under such 
program option’’; 
(2) in subparagraph (B)(i), by striking ‘‘or an 
actuarially equivalent level of cost-sharing as deter-
mined in this part’’; and 
(3) by amending clause (ii) of subparagraph 
(B) to read as follows: 
‘‘(ii) PERMITTING USE OF FLAT CO-
PAYMENT OR PER DIEM RATE.—Nothing in 
clause (i) shall be construed as prohibiting 
a Medicare part C plan from using a flat 
copayment or per diem rate, in lieu of the 
cost-sharing that would be imposed under 
part A or B, so long as the amount of the 
cost-sharing imposed does not exceed the 
amount of the cost-sharing that would be 
imposed under the respective part if the in-
dividual were not enrolled in a plan under 
this part.’’. 
(b) LIMITATION FOR DUAL ELIGIBLES AND QUALI-
FIED MEDICARE BENEFICIARIES.—Section 1852(a) of 
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such Act is amended by adding at the end the following 
new paragraph: 
‘‘(7) LIMITATION ON COST-SHARING FOR DUAL 
ELIGIBLES
AND
QUALIFIED
MEDICARE
BENE-
FICIARIES.—In the case of a individual who is a full- 
benefit dual eligible individual (as defined in section 
1935(c)(6)) or a qualified medicare beneficiary (as 
defined in section 1905(p)(1)) who is enrolled in a 
Medicare Part C plan, the plan may not impose 
cost-sharing that exceeds the amount of cost-sharing 
that would be permitted with respect to the indi-
vidual under this title and title XIX if the individual 
were not enrolled with such plan.’’. 
(c) EFFECTIVE DATES.— 
(1) The amendments made by subsection (a) 
shall apply to plan years beginning on or after Janu-
ary 1, 2009. 
(2) The amendments made by subsection (b) 
shall apply to plan years beginning on or after Janu-
ary 1, 2008. 
SEC. 413. MA PLAN ENROLLMENT MODIFICATIONS. 
(a) 
IMPROVED
PLAN
ENROLLMENT, 
DISENROLLMENT, AND CHANGE OF ENROLLMENT.— 
(1) CONTINUOUS
OPEN
ENROLLMENT
FOR 
FULL-BENEFIT
DUAL
ELIGIBLE
INDIVIDUALS
AND 
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QUALIFIED MEDICARE BENEFICIARIES (QMB).—Sec-
tion 1851(e)(2)(D) of the Social Security Act (42 
U.S.C. 1395w–21(e)(2)(D)) is amended— 
(A) in the heading, by inserting ‘‘, FULL- 
BENEFIT
DUAL
ELIGIBLE
INDIVIDUALS, AND 
QUALIFIED
MEDICARE
BENEFICIARIES’’ after 
‘‘INSTITUTIONALIZED INDIVIDUALS’’; 
(B) in the matter before clause (i), by in-
serting ‘‘, a full-benefit dual eligible individual 
(as defined in section 1935(c)(6)), or a quali-
fied medicare beneficiary (as defined in section 
1905(p)(1))’’ after ‘‘institutionalized (as defined 
by the Secretary)’’; and 
(C) in clause (i), by inserting ‘‘or 
disenroll’’ after ‘‘enroll’’. 
(2) SPECIAL
ELECTION
PERIODS
FOR
ADDI-
TIONAL
CATEGORIES
OF
INDIVIDUALS.—Section 
1851(e)(4) of such Act (42 U.S.C. 1395w(e)(4)) is 
amended— 
(A) in subparagraph (C), by striking at the 
end ‘‘or’’; 
(B) in subparagraph (D), by inserting ‘‘, 
taking into account the health or well-being of 
the individual’’ before the period and redesig-
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nating such subparagraph as subparagraph (F); 
and 
(C) by inserting after subparagraph (C) 
the following new subparagraphs: 
‘‘(D) the individual is described in section 
1902(a)(10)(E)(iii) (relating to specified low-in-
come medicare beneficiaries); 
‘‘(E) the individual is enrolled in an MA 
plan and enrollment in the plan is suspended 
under paragraph (2)(B) or (3)(C) of section 
1857(g) because of a failure of the plan to meet 
applicable requirements; or’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall take effect on the date of the 
enactment of this Act. 
(b) ACCESS TO MEDIGAP COVERAGE FOR INDIVID-
UALS WHO LEAVE MA PLANS.— 
(1) IN
GENERAL.—Section 1882(s)(3) of the 
Social Security Act (42 U.S.C. 1395ss(s)(3)) is 
amended— 
(A) in each of clauses (v)(III) and (vi) of 
subparagraph (B), by striking ‘‘12 months’’ 
and inserting ‘‘24 months’’; and 
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(B) in each of subclauses (I) and (II) of 
subparagraph (F)(i), by striking ‘‘12 months’’ 
and inserting ‘‘24 months’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply to terminations of en-
rollments in MA plans occurring on or after the date 
of the enactment of this Act. 
(c) IMPROVED ENROLLMENT POLICIES.— 
(1) NO
AUTO-ENROLLMENT
OF
MEDICAID 
BENEFICIARIES.— 
(A) IN GENERAL.—Section 1851(e) of such 
Act (42 U.S.C. 1395w–21(e)) is amended by 
adding at the end the following new paragraph: 
‘‘(7) NO
AUTO-ENROLLMENT
OF
MEDICAID 
BENEFICIARIES.—In no case may the Secretary pro-
vide for the enrollment in a MA plan of a Medicare 
Advantage eligible individual who is eligible to re-
ceive medical assistance under title XIX as a full- 
benefit dual eligible individual or a qualified medi-
care beneficiary, without the affirmative application 
of such individual (or authorized representative of 
the individual) to be enrolled in such plan.’’. 
(B) NO
APPLICATION
TO
PRESCRIPTION 
DRUG
PLANS.—Section 1860D–1(b)(1)(B)(iii) 
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of 
such 
Act 
(42 
U.S.C. 
1395w– 
101(b)(1)(B)(iii)) is amended— 
(i) by striking ‘‘paragraph (2) and’’ 
and by inserting ‘‘paragraph (2),’’; and 
(ii) by inserting ‘‘, and paragraph 
(7),’’ after ‘‘paragraph (4)’’. 
(C) EFFECTIVE DATE.—The amendments 
made by this paragraph shall apply to enroll-
ments that are effective on or after the date of 
the enactment of this Act. 
SEC. 414. INFORMATION FOR BENEFICIARIES ON MA PLAN 
ADMINISTRATIVE COSTS. 
(a) DISCLOSURE OF MEDICAL LOSS RATIOS AND 
OTHER EXPENSE DATA.—Section 1851 of the Social Se-
curity Act (42 U.S.C. 1395w–21) is amended by adding 
at the end the following new subsection: 
‘‘(j) PUBLICATION OF MEDICAL LOSS RATIOS AND 
OTHER COST-RELATED INFORMATION.— 
‘‘(1) IN GENERAL.—The Secretary shall pub-
lish, not later than October 1 of each year (begin-
ning with 2009), for each Medicare Part C plan con-
tract, the following: 
‘‘(A) The medical loss ratio of the plan in 
the previous year. 
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