791
‘‘(E) INFORMATION
ON
MEDIGAP
AND
MEDICARE SELECT.—A general description of
the benefits, enrollment rights, and other re-
quirements applicable to medicare supplemental
policies under section 1882 and provisions relat-
ing to medicare select policies described in sec-
tion 1882(t).
‘‘(F) POTENTIAL FOR CONTRACT TERMI-
NATION.—The fact that a MedicarePlus organi-
zation may terminate or refuse to renew its
contract under this part and the effect the ter-
mination or nonrenewal of its contract may
have 
on 
individuals 
enrolled 
with 
the
MedicarePlus plan under this part.
‘‘(4) INFORMATION
COMPARING
PLAN
OP-
TIONS.—Information under this paragraph, with re-
spect to a MedicarePlus plan for a year, shall in-
clude the following:
‘‘(A) BENEFITS.—The benefits covered
(and not covered) under the plan, including—
‘‘(i) covered items and services beyond
those provided under the medicare fee-for-
service program,
‘‘(ii) any beneficiary cost sharing,
792
‘‘(iii) any maximum limitations on
out-of-pocket expenses, and
‘‘(iv) in the case of an MSA plan, dif-
ferences in cost sharing and balance billing
under such a plan compared to under
other MedicarePlus plans.
‘‘(B) PREMIUMS.—The monthly premium
(and net monthly premium), if any, for the
plan.
‘‘(C) SERVICE AREA.—The service area of
the plan.
‘‘(D) QUALITY
AND
PERFORMANCE.—To
the extent available, plan quality and perform-
ance indicators for the benefits under the plan
(and how they compare to such indicators
under the medicare fee-for-service program
under parts A and B in the area involved), in-
cluding—
‘‘(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,
793
‘‘(iii) information on health outcomes,
and
‘‘(iv) the recent record regarding com-
pliance of the plan with requirements of
this part (as determined by the Secretary).
‘‘(E) 
SUPPLEMENTAL
BENEFITS
OP-
TIONS.—Whether the organization offering the
plan offers optional supplemental benefits and
the terms and conditions (including premiums)
for such coverage.
‘‘(5) MAINTAINING A TOLL-FREE NUMBER AND
INTERNET
SITE.—The Secretary shall maintain a
toll-free 
number 
for 
inquiries 
regarding
MedicarePlus options and the operation of this part
in all areas in which MedicarePlus plans are offered
and an Internet site through which individuals may
electronically obtain information on such options and
MedicarePlus plans.
‘‘(6) USE
OF
NONFEDERAL
ENTITIES.—The
Secretary may enter into contracts with non-Federal
entities to carry out activities under this subsection.
‘‘(7) 
PROVISION
OF
INFORMATION.—A
MedicarePlus organization shall provide the Sec-
retary with such information on the organization
and each MedicarePlus plan it offers as may be re-
794
quired for the preparation of the information re-
ferred to in paragraph (2)(A).
‘‘(e) COVERAGE ELECTION PERIODS.—
‘‘(1) INITIAL
CHOICE
UPON
ELIGIBILITY
TO
MAKE ELECTION IF MEDICAREPLUS PLANS AVAIL-
ABLE TO INDIVIDUAL.—If, at the time an individual
first becomes entitled to benefits under part A and
enrolled under part B, there is one or more
MedicarePlus plans offered in the area in which the
individual resides, the individual shall make the elec-
tion under this section during a period (of a dura-
tion and beginning at a time specified by the Sec-
retary) at such time. Such period shall be specified
in a manner so that, in the case of an individual who
elects a MedicarePlus plan during the period, cov-
erage under the plan becomes effective as of the first
date on which the individual may receive such cov-
erage.
‘‘(2) OPEN ENROLLMENT AND DISENROLLMENT
OPPORTUNITIES.—Subject to paragraph (5)—
‘‘(A) CONTINUOUS
OPEN
ENROLLMENT
AND DISENROLLMENT THROUGH 2000.—At any
time 
during 
1998, 
1999, 
and 
2000, 
a
MedicarePlus eligible individual may change the
election under subsection (a)(1).
795
‘‘(B) CONTINUOUS
OPEN
ENROLLMENT
AND
DISENROLLMENT
FOR
FIRST
MONTHS
DURING 2001.—
‘‘(i) IN GENERAL.—Subject to clause
(ii), at any time during the first 6 months
of 2001, or, if the individual first becomes
a MedicarePlus eligible individual during
2001, during the first 6 months during
2001 
in 
which 
the 
individual 
is 
a
MedicarePlus 
eligible 
individual, 
a
MedicarePlus 
eligible 
individual 
may
change the election under subsection
(a)(1).
‘‘(ii) LIMITATION
OF
ONE
CHANGE
PER
YEAR.—An individual may exercise
the right under clause (i) only once during
2001. The limitation under this clause
shall not apply to changes in elections ef-
fected during an annual, coordinated elec-
tion period under paragraph (3) or during
a special enrollment period under para-
graph (4).
‘‘(C) CONTINUOUS
OPEN
ENROLLMENT
AND DISENROLLMENT FOR FIRST 3 MONTHS IN
SUBSEQUENT YEARS.—
796
‘‘(i) IN GENERAL.—Subject to clause
(ii), at any time during the first 3 months
of a year after 2001, or, if the individual
first becomes a MedicarePlus eligible indi-
vidual during a year after 2001, during the
first 3 months of such year in which the
individual is a MedicarePlus eligible indi-
vidual, a MedicarePlus eligible individual
may change the election under subsection
(a)(1).
‘‘(ii) LIMITATION
OF
ONE
CHANGE
PER
YEAR.—An individual may exercise
the right under clause (i) only once a year.
The limitation under this clause shall not
apply to changes in elections effected dur-
ing an annual, coordinated election period
under paragraph (3) or during a special
enrollment period under paragraph (4).
‘‘(3) ANNUAL, COORDINATED
ELECTION
PE-
RIOD.—
‘‘(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.
797
‘‘(B) ANNUAL, COORDINATED
ELECTION
PERIOD.—For purposes of this section, the
term ‘annual, coordinated election period’
means, with respect to a calendar year (begin-
ning with 2001), the month of October before
such year.
‘‘(C) MEDICAREPLUS HEALTH FAIRS.—In
the month of October of each year (beginning
with 1998), the Secretary shall provide for a
nationally coordinated educational and publicity
campaign to inform MedicarePlus eligible indi-
viduals about MedicarePlus plans and the elec-
tion process provided under this section.
‘‘(4) SPECIAL
ELECTION
PERIODS.—Effective
as of January 1, 2001, an individual may dis-
continue an election of a MedicarePlus plan offered
by a MedicarePlus organization other than during
an annual, coordinated election period and make a
new election under this section if—
‘‘(A) the organization’s or plan’s certifi-
cation under this part has been terminated or
the organization has terminated or otherwise
discontinued providing the plan;
‘‘(B) the individual is no longer eligible to
elect the plan because of a change in the indi-
798
vidual’s place of residence or other change in
circumstances (specified by the Secretary, but
not including termination of the individual’s en-
rollment on the basis described in clause (i) or
(ii) of subsection (g)(3)(B));
‘‘(C) the individual demonstrates (in ac-
cordance with guidelines established by the Sec-
retary) 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
799
‘‘(D) the individual meets such other ex-
ceptional conditions as the Secretary may pro-
vide.
‘‘(5) SPECIAL RULES FOR MSA PLANS.—Not-
withstanding the preceding provisions of this sub-
section, an individual—
‘‘(A) may elect an MSA plan only during—
‘‘(i) an initial open enrollment period
described in paragraph (1),
‘‘(ii) an annual, coordinated election
period described in paragraph (3)(B), or
‘‘(iii) the months of October 1998 and
October 1999; and
‘‘(B) may not discontinue an election of an
MSA plan except during the periods described
in clause (ii) or (iii) of subparagraph (A) and
under paragraph (4).
‘‘(f) EFFECTIVENESS OF ELECTIONS AND CHANGES
OF ELECTIONS.—
‘‘(1) DURING INITIAL COVERAGE ELECTION PE-
RIOD.—An election of coverage made during the ini-
tial coverage election period under subsection (e)(1)
shall take effect upon the date the individual be-
comes entitled to benefits under part A and enrolled
under part B, except as the Secretary may provide
800
(consistent with section 1838) in order to prevent
retroactive coverage.
‘‘(2) DURING CONTINUOUS OPEN ENROLLMENT
PERIODS.—An election or change of coverage made
under subsection (e)(2) shall take effect with the
first day of the first calendar month following the
date on which the election is made.
‘‘(3) ANNUAL, COORDINATED
ELECTION
PE-
RIOD.—An election or change of coverage made dur-
ing an annual, coordinated election period (as de-
fined in subsection (e)(3)(B)) in a year shall take ef-
fect 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) 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 MedicarePlus organization shall pro-
vide that at any time during which elections are ac-
cepted under this section with respect to a
MedicarePlus plan offered by the organization, the
801
organization will accept without restrictions individ-
uals who are eligible to make such election.
‘‘(2) PRIORITY.—If the Secretary determines
that a MedicarePlus organization, in relation to a
MedicarePlus plan it offers, has a capacity limit and
the number of MedicarePlus eligible individuals who
elect the plan under this section exceeds the capacity
limit, the organization may limit the election of indi-
viduals of the plan under this section but only if pri-
ority in election is provided—
‘‘(A) first to such individuals as have elect-
ed 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 1852(b), among the individ-
uals (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 popu-
lation in the service area of the plan.
‘‘(3) LIMITATION ON TERMINATION OF ELEC-
TION.—
802
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), a MedicarePlus organization may
not for any reason terminate the election of any
individual under this section for a MedicarePlus
plan it offers.
‘‘(B) BASIS FOR TERMINATION OF ELEC-
TION.—A MedicarePlus organization may ter-
minate an individual’s election under this sec-
tion with respect to a MedicarePlus plan it of-
fers if—
‘‘(i) any net monthly premiums re-
quired with respect to such plan are not
paid on a timely basis (consistent with
standards under section 1856 that provide
for a grace period for late payment of net
monthly premiums),
‘‘(ii) the individual has engaged in
disruptive behavior (as specified in such
standards), or
‘‘(iii) the plan is terminated with re-
spect 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
803
under clause (i) or (ii) of subparagraph
(B) is deemed to have elected the medicare
fee-for-service program option described in
subsection (a)(1)(A).
‘‘(ii) TERMINATION BASED ON PLAN
TERMINATION OR SERVICE AREA REDUC-
TION.—Any individual whose election is
terminated under subparagraph (B)(iii)
shall have a special election period under
subsection (e)(4)(A) in which to change
coverage 
to 
coverage 
under 
another
MedicarePlus plan. Such an individual who
fails to make an election during such pe-
riod is deemed to have chosen to change
coverage to the medicare fee-for-service
program option described in subsection
(a)(1)(A).
‘‘(D) ORGANIZATION
OBLIGATION
WITH
RESPECT TO ELECTION FORMS.—Pursuant to a
contract under section 1857, each MedicarePlus
organization receiving an election form under
subsection (c)(2) shall transmit to the Secretary
(at such time and in such manner as the Sec-
retary may specify) a copy of such form or such
804
other information respecting the election as the
Secretary may specify.
‘‘(h) APPROVAL OF MARKETING MATERIAL AND AP-
PLICATION FORMS.—
‘‘(1) SUBMISSION.—No marketing material or
application 
form 
may 
be 
distributed 
by 
a
MedicarePlus organization to (or for the use of)
MedicarePlus eligible individuals unless—
‘‘(A) at least 45 days 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 1856 shall include guidelines for the
review of all such 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 mis-
representation.
‘‘(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 re-
805
gional office of the Department of Health and
Human Services and the Secretary or the office has
not disapproved the distribution of marketing mate-
rial or form under paragraph (1)(B) with respect to
a MedicarePlus 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 to the extent that such material or form is
specific only to an area involved.
‘‘(4) PROHIBITION
OF
CERTAIN
MARKETING
PRACTICES.—Each MedicarePlus organization shall
conform to fair marketing standards, in relation to
MedicarePlus plans offered under this part, included
in the standards established under section 1856.
Such standards shall include a prohibition against a
MedicarePlus organization (or agent of such an or-
ganization) completing any portion of any election
form used to carry out elections under this section
on behalf of any individual.
‘‘(i) EFFECT OF ELECTION OF MEDICAREPLUS PLAN
OPTION.—Subject to sections 1852(a)(5), 1857(f)(2), and
1857(g)—
‘‘(1) payments under a contract with a
MedicarePlus organization under section 1853(a)
with respect to an individual electing a MedicarePlus
806
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 for
items and services furnished to the individual, and
‘‘(2) subject to subsections (e) and (f) of section
1853, only the MedicarePlus organization shall be
entitled to receive payments from the Secretary
under this title for services furnished to the individ-
ual.
‘‘BENEFITS AND BENEFICIARY PROTECTIONS
‘‘SEC. 1852. (a) BASIC BENEFITS.—
‘‘(1) IN GENERAL.—Except as provided in sec-
tion 1859(b)(2) for MSA plans, each MedicarePlus
plan shall provide to members enrolled under this
part, through providers and other persons that meet
the applicable requirements of this title and part A
of title XI—
‘‘(A) those items and services for which
benefits are available under parts A and B to
individuals residing in the area served by the
plan, and
‘‘(B) additional benefits required under
section 1854(f)(1)(A).
‘‘(2) 
SATISFACTION
OF
REQUIREMENT.—A
MedicarePlus plan (other than an MSA plan) offered
by a MedicarePlus organization satisfies paragraph
807
(1)(A), with respect to benefits for items and serv-
ices furnished other than through a provider that
has a contract with the organization offering the
plan, if the plan provides (in addition to any cost
sharing provided for under the plan) for at least the
total dollar amount of payment for such items and
services as would otherwise be authorized under
parts A and B (including any balance billing per-
mitted under such parts).
‘‘(3) SUPPLEMENTAL BENEFITS.—
‘‘(A) BENEFITS
INCLUDED
SUBJECT
TO
SECRETARY’S
APPROVAL.—Each MedicarePlus
organization may provide to individuals enrolled
under this part, other than under an MSA plan,
(without affording those individuals an option
to decline the coverage) supplemental health
care benefits that the Secretary may approve.
The Secretary shall approve any such supple-
mental benefits unless the Secretary determines
that including such supplemental benefits would
substantially 
discourage 
enrollment 
by
MedicarePlus eligible individuals with the orga-
nization.
‘‘(B) 
AT
ENROLLEES’ 
OPTION.—A
MedicarePlus organization may provide to indi-
809
of the next announcement under such section and
the Secretary projects that the determination will re-
sult in a significant change in the costs to a
MedicarePlus organization of providing the benefits
that are the subject of such national coverage deter-
mination and that such change in costs was not in-
corporated in the determination of the annual
MedicarePlus capitation rate under section 1853 in-
cluded in the announcement made at the beginning
of such period—
‘‘(A) such determination shall not apply to
contracts under this part until the first contract
year that begins after the end of such period,
and
‘‘(B) if such coverage determination pro-
vides for coverage of additional benefits or cov-
erage under additional circumstances, section
1851(i) shall not apply to payment for such ad-
ditional benefits or benefits provided under such
additional circumstances until the first contract
year that begins after the end of such period,
unless otherwise required by law.
‘‘(b) ANTIDISCRIMINATION.—
‘‘(1) IN GENERAL.—A MedicarePlus organiza-
tion may not deny, limit, or condition the coverage
810
or provision of benefits under this part, for individ-
uals permitted to be enrolled with the organization
under this part, based on any health status-related
factor described in section 2702(a)(1) of the Public
Health Service Act.
‘‘(2) CONSTRUCTION.—Paragraph (1) shall not
be construed as requiring a MedicarePlus organiza-
tion to enroll individuals who are determined to have
end-stage renal disease, except as provided under
section 1851(a)(3)(B).
‘‘(c) DETAILED
DESCRIPTION
OF
PLAN
PROVI-
SIONS.—A MedicarePlus organization shall disclose, in
clear, accurate, and standardized form to each enrollee
with a MedicarePlus plan offered by the organization
under this part at the time of enrollment and at least an-
nually thereafter, the following information regarding such
plan:
‘‘(1) SERVICE AREA.—The plan’s service area.
‘‘(2) BENEFITS.—Benefits offered (and not of-
fered) under the plan offered, including information
described in section 1851(d)(3)(A) and exclusions
from coverage and, if it is an MSA plan, a compari-
son of benefits under such a plan with benefits
under other MedicarePlus plans.