Source: https://www.ssa.gov/OP_Home/ssact/title18/1851.htm
Timestamp: 2019-04-19 13:10:55+00:00

Document:
and may elect qualified prescription drug coverage in accordance with section 1860D-1.
(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 1855(d)), 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 1859(b)(6)) 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 1859(b)(3), 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 1859(b)(2).
(3) Medicare+choice eligible individual.—In this title, the term Medicare+Choice eligible individual means an individual who is entitled to benefits under part A and enrolled under part B.
(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.
(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.
(A) FEHBP.—An individual who is enrolled in a health benefit plan under chapter 89 of title 5, United States Code, 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, United States Code, or under chapter 17 of title 38 of such Code.
(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 1905(p)(1)), a qualified disabled and working individual (described in section 1905(s)), an individual described in section 1902(a)(10)(E)(iii), or otherwise entitled to medicare cost–sharing under a State plan under title XIX is not eligible to enroll in an MSA plan.
(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 title.
(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).
(1) In general.—The Secretary shall establish a process through which elections described in subsection (a) are made and changed, including the form and manner in which Subject to paragraph (4), such elections are made and changed. Such elections shall be made or changed only during coverage election periods specified under subsection (e) and shall become effective as provided in subsection (f).
(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.
(i) In general.—Subject to clause (ii), an individual who fails to make an election during an initial election period under subsection (e)(1) 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).
(ii) the Medicare+Choice plan with respect to which such election is in effect is discontinued or, subject to subsection (b)(1)(B), no longer serves the area in which the individual resides.
(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.
(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 1804.
(i) Notification to newly eligible medicare advantage 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), mail to the individual the information described in subparagraph (A).
(V) other information theSecretary may specify.
(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.
(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 1852(b).
(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 1882 and provisions relating to medicare select policies described in section 1882(t).
(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.
(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 1858(b)(1).
(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.
(i) In general.—The monthly amount of the premium charged to an individual.
(ii) Reductions.—The reduction in part B premiums, if any.
The monthly amount of the premium charged to an individual.
(C) Service area.—The service area of the plan.
(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 1852(a)(3) 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).
(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 and enrolled under part B, 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.
(A) Continuous open enrollment and disenrollment through 2005.—At any time during the period beginning January 1, 1998, and ending on December 31, 2005, a Medicare+Choice eligible individual may change the election under subsection (a)(1).
(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 from 2011 through 2018 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 and ending with 2018), 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 1860D–1.
(ii) to change the Medicare+Choice plan in which the individual is enrolled.
(i) In general.—On any date during the period beginning on January 1, 2007, and ending on July 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.
(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.
(II) who is not enrolled in a prescription drug plan, to enroll in such a plan.
(i) In general.— At any time during theperiod beginning after the last day of the annual, coordinated election period under paragraph (3) in which an individual is deemed to have elected to enroll in an MA plan or MA-PD plan under subsection (c)(4) and ending on the last day of February of the first plan year for which the individual is enrolled in such plan, such individual may change the election under subsection (a)(1) (including changing the MA plan or MA-PD plan in which the individual is enrolled).
(ii) Limitation of one change.— An individual may exercise the right under clause (i) only once during the applicable period described in such clause. 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 paragraph (4).
(II) in the case of an individual who first becomes an MA eligible individual during a year (beginning with 2019) and enrolls in an MA plan, during the first 3 months during such year in which the individual is an MA eligible individual; such MA eligible individual may change the election under subsection (a)(1).
(ii) Limitation of one change during open enrollment period each yearAn individual may change the election pursuant to clause (i) only once during the applicable 3- month period described in such clause in each year. 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 paragraph (4).
(iii) Limited application to part dClauses (i) and (ii) of this subparagraph shall only apply with respect to changes in enrollment in a prescription drug plan under part D in the case of an individual who, previous to such change in enrollment, is enrolled in a Medicare Advantage plan.
(iv) Limitations on marketingPursuant to subsection (j), no unsolicited marketing or marketing materials may be sent to an individual described in clause (i) during the continuous open enrollment and disenrollment period established for the individual under such clause, notwithstanding marketing guidelines established by the Centers for Medicare & Medicaid Services.
(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.
(iv) with respect to 2007 and , 2008, 2009, and 2010, the period beginning on November 15 and ending on December 31 of the year before such year.
(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), 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 campaign in 1998.—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 1876, offered in different areas and the election process provided under this section.
(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 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.
(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.
(B) may accept other changes to elections at such other times as the organization provides.
(1) During initial coverage election period.—An election of coverage made during the initial coverage election period under subsection (e)(1) shall take effect upon the date the individual becomes entitled to benefits under part A and enrolled under part B, except as the Secretary may provide (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 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)) 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) 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.
(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.
(B) then to other such individuals in such a manner that does not discriminate, on a basis described in section 1852(b), 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.
(A) In general.—Subject to subparagraph (B), a Medicare+Choice organization may not for any reason terminate the election of any individual under this section for a Medicare+Choice plan it offers.
(iii) the plan is terminated with respect to all individuals under this part in the area in which the individual resides.
(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).
(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) 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).
(D) Organization obligation with respect to election forms.—Pursuant to a contract under section 1857, each Medicare+Choice organization receiving an election form under subsection (c)(2) 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.
(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 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.
(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).
(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.
(1) Payments to organizations.—Subject to sections 1852(a)(5), 1853(a)(4), 1853(g), 1853(h), 1886(d)(11), and 1886(h)(3)(D), payments under a contract with a Medicare+Choice organization under section 1853(a) 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 for items and services furnished to the individual.
(2) Only organization entitled to payment.—Subject to sections 1853(a)(4), 1853(e), 1853(g), 1853(h), 1857(f)(2), 1858(h), 1886(d)(11), and 1886(h)(3)(D), only the Medicare+Choice organization shall be entitled to receive payments from the Secretary under this title for services furnished to the individual.
(3) FFS payment for expenses for kidney acquisitionsParagraphs (1) and (2) shall not apply with respect to expenses for organ acquisitions for kidney transplants described in section 1852(a)(1)(B)(i).
(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.
(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.
(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.
 See Vol. II, P.L. 108-173, §231(e), with respect to a study on the impact of specialized MA plans for special needs individuals.
See Vol. II, P.L. 110-173, §108(b), with respect to a moratorium on the designation of plans and the enrollment in new plans.
See Vol. II, P.L. 110-275, §168, with respect to a MEDPAC study and report on quality measures.
 P.L.114-255, §17006(a)(1)(A-B); struck subparagraph (B); restructured to remove subparagraph (A); struck “subject to subparagraph (B),” after “In this title”. Effective December 10, 2016.
 P.L. 114-10, §209(b)(1)(A), struck “Such elections'', inserted “Subject to paragraph (4), such elections”. Effective April 16, 2015.
 P.L. 114-10, §209(c) subparagraph retitled, restructured, and clause (ii) added. Effective April 16, 2015.
 P.L.114-255, §17005(1)(A-B); A) In heading, inserted “from 2011 through 2018” after “45-day period”; B) inserted “and ending with 2018” after “beginning with 2011. Effective December 10, 2016.
 P.L. 114-10, §209(b)(2)(B), inserted subparagraph (F). Effective April 16, 2015.
 P.L.114-255, §17005(2); inserted subparagraph (G). Effective December 10, 2016.
 P.L. 114-10, §209(b)(2)(B)(i), struck “paragraph (1),” and inserted “paragraph (1), during the period described in paragraph (2)(F),”. Effective April 16, 2015.
 P.L.114-255, §17006(c)(2); inserted paragraph 1851(i)(3). Effective December 10, 2016.

References: §231
 §108
 §168
 §17006
 §209
 §209
 §17005
 §209
 §17005
 §209
 §17006