Source: https://www.law.cornell.edu/uscode/text/42/1395w-21
Timestamp: 2018-11-16 06:17:13
Document Index: 19275168

Matched Legal Cases: ['§ 1395', '§ 1395', '§ 1851', '§ 4001', '§ 1000', '§ 321', '§ 501', '§ 1', '§ 606', '§ 532', '§ 102', '§ 221', '§ 206', '§ 2', '§ 103', '§ 4102', '§ 3201', '§ 1102', '§ 222', '§ 222', '§ 237', '§ 606', '§ 606', '§ 231']

U.S. Code › Title 42 › Chapter 7 › Subchapter XVIII › Part C › § 1395w–21
42 U.S. Code § 1395w–21 - Eligibility, election, and enrollment
(a) Choice of medicare benefits through Medicare Choice plans
Subject to the provisions of this section, each Medicare Choice eligible individual (as defined in paragraph (3)) is entitled to elect to receive benefits (other than qualified prescription drug benefits) under this subchapter—
(B) through enrollment in a Medicare Choice plan under this part,
(2) Types of Medicare Choice plans that may be available
A Medicare Choice plan may be any of the following types of plans of health insurance:
(i) In general Coordinated care plans which provide health care services, including but not limited to health maintenance organization plans (with or without point of service options), plans offered by provider-sponsored organizations (as defined in section 1395w–25 (d) of this title), and regional or local preferred provider organization plans (including MA regional plans).
(ii) Specialized MA plans for special needs individuals Specialized MA plans for special needs individuals (as defined in section 1395w–28 (b)(6) of this title) may be any type of coordinated care plan.
(B) Combination of MSA plan and contributions to Medicare Choice MSA
An MSA plan, as defined in section 1395w–28 (b)(3) of this title, and a contribution into a Medicare Choice medical savings account (MSA).
A Medicare Choice private fee-for-service plan, as defined in section 1395w–28 (b)(2) of this title.
(3) Medicare Choice eligible individual
In this subchapter, subject to subparagraph (B), the term “Medicare Choice eligible individual” means an individual who is entitled to benefits under part A of this subchapter and enrolled under part B of this subchapter.
(i) an individual who develops end-stage renal disease while enrolled in a Medicare Choice plan may continue to be enrolled in that plan; and
(ii) in the case of such an individual who is enrolled in a Medicare Choice plan under clause (i) (or subsequently under this clause), if the enrollment is discontinued under circumstances described in subsection (e)(4)(A) of this section, then the individual will be treated as a “Medicare Choice eligible individual” for purposes of electing to continue enrollment in another Medicare Choice plan.
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.
Notwithstanding subparagraph (A) and in addition to subparagraph (B), if a Medicare Choice organization eliminates from its service area a Medicare Choice payment area that was previously within its service area, the organization may elect to offer individuals residing in all or portions of the affected area who would otherwise be ineligible to continue enrollment the option to continue enrollment in an MA local plan it offers so long as—
(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.
An individual who is a qualified medicare beneficiary (as defined in section 1396d (p)(1) of this title), a qualified disabled and working individual (described in section 1396d (s) of this title), an individual described in section 1396a (a)(10)(E)(iii) of this title, or otherwise entitled to medicare cost-sharing under a State plan under subchapter XIX of this chapter is not eligible to enroll in an MSA plan.
(2) Coordination through Medicare Choice organizations
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.
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) of this section is deemed to have chosen the original medicare fee-for-service program option.
(ii) Seamless continuation of coverage The Secretary may establish procedures under which an individual who is enrolled in a health plan (other than Medicare Choice plan) offered by a Medicare Choice organization at the time of the initial election period and who fails to elect to receive coverage other than through the organization is deemed to have elected the Medicare Choice plan offered by the organization (or, if the organization offers more than one such plan, such plan or plans as the Secretary identifies under such procedures).
(ii) the Medicare Choice plan with respect to which such election is in effect is discontinued or, subject to subsection (b)(1)(B) of this section, no longer serves the area in which the individual resides.
At least 15 days before the beginning of each annual, coordinated election period (as defined in subsection (e)(3)(B) of this section), the Secretary shall mail to each Medicare Choice eligible individual residing in an area the following:
(i) General information The general information described in paragraph (3).
(ii) List of plans and comparison of plan options A list identifying the Medicare Choice plans that are (or will be) available to residents of the area and information described in paragraph (4) concerning such plans. Such information shall be presented in a comparative form.
(iii) Additional information Any other information that the Secretary determines will assist the individual in making the election under this section.
(B) Notification to newly eligible Medicare Choice eligible individuals
To the extent practicable, the Secretary shall, not later than 30 days before the beginning of the initial Medicare Choice enrollment period for an individual described in subsection (e)(1) of this section, mail to the individual the information described in subparagraph (A).
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.
A general description of procedural rights (including grievance and appeals procedures) of beneficiaries under the original medicare fee-for-service program and the Medicare Choice program and the right to be protected against discrimination based on health status-related factors under section 1395w–22 (b) of this title.
A general description of the benefits, enrollment rights, and other requirements applicable to medicare supplemental policies under section 1395ss of this title and provisions relating to medicare select policies described in section 1395ss (t) of this title.
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.
Information under this paragraph, with respect to a Medicare Choice plan for a year, shall include the following:
(ii) Any beneficiary cost sharing, including information on the single deductible (if applicable) under section 1395w–27a (b)(1) of this title.
(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.
(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.
(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),
Supplemental health care benefits, including any reductions in cost-sharing under section 1395w–22 (a)(3) of this title and the terms and conditions (including premiums) for such benefits.
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.
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 of this subchapter and enrolled under part B of this subchapter, there is one or more Medicare Choice plans offered in the area in which the individual resides, the individual shall make the election under this section during a period specified by the Secretary such that if the individual elects a Medicare Choice plan during the period, coverage under the plan becomes effective as of the first date on which the individual may receive such coverage. If any portion of an individual’s initial enrollment period under part B of this subchapter occurs after the end of the annual, coordinated election period described in paragraph (3)(B)(iii), the initial enrollment period under this part shall further extend through the end of the individual’s initial enrollment period under part B of this subchapter.
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) of this section.
(i) In general Subject to clause (ii), subparagraph (C)(iii), [1] and subparagraph (D), at any time during the first 6 months of 2006, or, if the individual first becomes a Medicare Choice eligible individual during 2006, during the first 6 months during 2006 in which the individual is a Medicare Choice eligible individual, a Medicare Choice eligible individual may change the election under subsection (a)(1) of this section.
(ii) Limitation of one change An individual may exercise the right under clause (i) only once. The limitation under this clause shall not apply to changes in elections effected during an annual, coordinated election period under paragraph (3) or during a special enrollment period under the first sentence of paragraph (4).
(C) Annual 45-day period for disenrollment from MA plans to elect to receive benefits under the original Medicare fee-for-service program
Subject to subparagraph (D), at any time during the first 45 days of a year (beginning with 2011), an individual who is enrolled in a Medicare Advantage plan may change the election under subsection (a)(1), but only with respect to coverage under the original medicare fee-for-service program under parts A and B, and may elect qualified prescription drug coverage in accordance with section 1395w–101 of this title.
At any time after 2005 in the case of a Medicare Choice eligible individual who is institutionalized (as defined by the Secretary), the individual may elect under subsection (a)(1) of this section—
(i) to enroll in a Medicare Choice plan; or
(ii) to change the Medicare Choice plan in which the individual is enrolled.
(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.
(ii) Unenrolled fee-for-service individual defined In this subparagraph, the term “unenrolled fee-for-service individual” means, with respect to a date, a Medicare Advantage eligible individual who—
(iii) Limitation of one change during the applicable period An individual may exercise the right under clause (i) only once during the period described in such clause.
(iv) No effect on coverage under a prescription drug plan Nothing in this subparagraph shall be construed as permitting an individual exercising the right under clause (i)—
(iii) with respect to 2006, the period beginning on November 15, 2005, and ending on May 15, 2006;
(iv) with respect to 2007, 2008, 2009, and 2010, the period beginning on November 15 and ending on December 31 of the year before such year; and
(v) with respect to 2012 and succeeding years, the period beginning on October 15 and ending on December 7 of the year before such year.
(C) Medicare Choice health information fairs
During the fall season of each year (beginning with 1999) and during the period described in subparagraph (B)(iii), in conjunction with the annual coordinated election period defined in subparagraph (B), the Secretary shall provide for a nationally coordinated educational and publicity campaign to inform Medicare Choice eligible individuals about Medicare Choice plans and the election process provided under this section.
During November 1998 the Secretary shall provide for an educational and publicity campaign to inform Medicare Choice eligible individuals about the availability of Medicare Choice plans, and eligible organizations with risk-sharing contracts under section 1395mm of this title, offered in different areas and the election process provided under this section. During the period described in subparagraph (B)(iii), the Secretary shall provide for an educational and publicity campaign to inform MA eligible individuals about the availability of MA plans (including MA–PD plans) offered in different areas and the election process provided under this section.
Effective as of January 1, 2006, an individual may discontinue an election of a Medicare Choice plan offered by a Medicare Choice organization other than during an annual, coordinated election period and make a new election under this section if—
(i) the certification of the organization or plan under this part has been terminated, or the organization or plan has notified the individual of an impending termination of such certification; or
(B) the individual is no longer eligible to elect the plan because of a change in the individual’s place of residence or other change in circumstances (specified by the Secretary, but not including termination of the individual’s enrollment on the basis described in clause (i) or (ii) of subsection (g)(3)(B) of this section);
(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
Subject to paragraph (5), a Medicare Choice organization—
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.
If the Secretary determines that a Medicare Choice organization, in relation to a Medicare Choice plan it offers, has a capacity limit and the number of Medicare Choice eligible individuals who elect the plan under this section exceeds the capacity limit, the organization may limit the election of individuals of the plan under this section but only if priority in election is provided—
(B) then to other such individuals in such a manner that does not discriminate, on a basis described in section 1395w–22 (b) of this title, among the individuals (who seek to elect the plan).
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.
A Medicare Choice organization may terminate an individual’s election under this section with respect to a Medicare Choice plan it offers if—
(i) any Medicare Choice monthly basic and supplemental beneficiary premiums required with respect to such plan are not paid on a timely basis (consistent with standards under section 1395w–26 of this title that provide for a grace period for late payment of such premiums),
(i) Terminations for cause Any individual whose election is terminated under clause (i) or (ii) of subparagraph (B) is deemed to have elected the original medicare fee-for-service program option described in subsection (a)(1)(A) of this section.
(ii) Termination based on plan termination or service area reduction Any individual whose election is terminated under subparagraph (B)(iii) shall have a special election period under subsection (e)(4)(A) of this section in which to change coverage to coverage under another Medicare Choice plan. Such an individual who fails to make an election during such period is deemed to have chosen to change coverage to the original medicare fee-for-service program option described in subsection (a)(1)(A) of this section.
Pursuant to a contract under section 1395w–27 of this title, each Medicare Choice organization receiving an election form under subsection (c)(2) of this section shall transmit to the Secretary (at such time and in such manner as the Secretary may specify) a copy of such form or such other information respecting the election as the Secretary may specify.
No marketing material or application form may be distributed by a Medicare Choice organization to (or for the use of) Medicare Choice eligible individuals unless—
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.
Each Medicare Choice organization shall conform to fair marketing standards, in relation to Medicare Choice plans offered under this part, included in the standards established under section 1395w–26 of this title. Such standards—
(A) shall not permit a Medicare Choice organization to provide for, subject to subsection (j)(2)(C), cash, gifts, prizes, or other monetary rebates as an inducement for enrollment or otherwise;
(B) may include a prohibition against a Medicare Choice organization (or agent of such an organization) completing any portion of any election form used to carry out elections under this section on behalf of any individual;
(i) Effect of election of Medicare Choice plan option
Subject to sections 1395w–22 (a)(5), 1395w–23 (a)(4), 1395w–23 (g), 1395w–23 (h), 1395ww (d)(11), 1395ww (h)(3)(D), and 1395w–23 (m) of this title, payments under a contract with a Medicare Choice organization under section 1395w–23 (a) of this title with respect to an individual electing a Medicare Choice plan offered by the organization shall be instead of the amounts which (in the absence of the contract) would otherwise be payable under parts A and B of this subchapter for items and services furnished to the individual.
Subject to sections 1395w–23 (a)(4), 1395w–23 (e), 1395w–23 (g), 1395w–23 (h), 1395w–27 (f)(2), 1395w–27a (h), 1395ww (d)(11), and 1395ww (h)(3)(D) of this title, only the Medicare Choice organization shall be entitled to receive payments from the Secretary under this subchapter for services furnished to the individual.
(Aug. 14, 1935, ch. 531, title XVIII, § 1851, as added Pub. L. 105–33, title IV, § 4001,Aug. 5, 1997, 111 Stat. 275; amended Pub. L. 106–113, div. B, § 1000(a)(6) [title III, § 321(k)(6)(A), title V, §§ 501(a)(1), (b), (c), 502 (a), 519(a)], Nov. 29, 1999, 113 Stat. 1536, 1501A–367, 1501A–378 to 1501A–380, 1501A–385; Pub. L. 106–554, § 1(a)(6) [title VI, §§ 606(a)(2)(C), 613 (a), 619 (a), 620 (a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–558, 2763A–560, 2763A–563; Pub. L. 107–188, title V, § 532(a), (c)(1),June 12, 2002, 116 Stat. 696; Pub. L. 108–173, title I, § 102(a), (c)(1), title II, §§ 221(a)(1), (d)(5), 222 (l)(3)(A), (B), (D), (E), 231 (a), 233 (b), (d), 237 (b)(2)(A),Dec. 8, 2003, 117 Stat. 2152, 2154, 2180, 2193, 2206, 2207, 2209, 2212; Pub. L. 109–432, div. B, title II, § 206(a),Dec. 20, 2006, 120 Stat. 2990; Pub. L. 110–48, § 2,July 18, 2007, 121 Stat. 244; Pub. L. 110–275, title I, § 103(a)(1), (b)(1), (c)(1), (d)(1),July 15, 2008, 122 Stat. 2498–2501; Pub. L. 111–5, div. B, title IV, § 4102(d)(2),Feb. 17, 2009, 123 Stat. 486; Pub. L. 111–148, title III, §§ 3201(e)(2)(A)(i), 3204(a)(1), (b),Mar. 23, 2010, 124 Stat. 446, 456; Pub. L. 111–152, title I, § 1102(a),Mar. 30, 2010, 124 Stat. 1040.)
Subsec. (b)(1)(B). Pub. L. 108–173, § 222(l)(3)(A)(i), (ii), substituted “an MA local plan” for “a plan” and “benefits under the original medicare fee-for-service program option” for “basic benefits described in section 1395w–22 (a)(1)(A) of this title”.
Subsec. (d)(4)(A)(ii). Pub. L. 108–173, § 222(l)(3)(B)(ii), inserted “, including information on the single deductible (if applicable) under section 1395w–27a (b)(1) of this title” after “cost sharing”.
Subsec. (i)(1). Pub. L. 108–173, § 237(b)(2)(A)(i), inserted “1395w–23(a)(4),” after “Subject to sections 1395w–22 (a)(5),”.
Amendment by section 1 (a)(6) [title VI, § 606(a)(2)(C)] of Pub. L. 106–554applicable to years beginning with 2003, see section 1 (a)(6) [title VI, § 606(b)] of Pub. L. 106–554, set out as a note under section 1395r of this title.
“(2) Application to prior plan terminations.—Clause (ii) of section 1851(a)(3)(B) of the Social Security Act [42 U.S.C. 1395w–21 (a)(3)(B)(ii)] (as inserted by subsection (a)) shall also apply to individuals whose enrollment in a Medicare Choice plan was terminated or discontinued after December 31, 1998, and before the date of the enactment of this Act. In applying this paragraph, such an individual shall be treated, for purposes of part C of title XVIII of the Social Security Act [42 U.S.C. 1395w–21 et seq.], as having discontinued enrollment in such a plan as of the date of the enactment of this Act.”
Pub. L. 108–173, title II, § 231(d),Dec. 8, 2003, 117 Stat. 2208, provided that: “In promulgating regulations to carry out section 1851(a)(2)(A)(ii) of the Social Security Act [42 U.S.C. 1395w–21 (a)(2)(A)(ii)] (as added by subsection (a)) andsection 1859(b)(6) of such Act [42 U.S.C. 1395w–28 (b)(6)] (as added by subsection (b)), the Secretary [of Health and Human Services] may provide (notwithstanding section 1859(b)(6)(A) of such Act) for the offering of specialized MA plans for special needs individuals by MA plans that disproportionately serve special needs individuals.”