H. Rept. 115-935 - EMPOWERING SENIORS' ENROLLMENT DECISION ACT OF 2018115th Congress (2017-2018)
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115th Congress } { Rept. 115-935
HOUSE OF REPRESENTATIVES
2d Session } { Part 1
======================================================================
EMPOWERING SENIORS' ENROLLMENT DECISION ACT OF 2018
_______
September 10, 2018.--Committed to the Committee of the Whole House on
the State of the Union and ordered to be printed
_______
Mr. Brady of Texas, from the Committee on Ways and Means, submitted the
following
R E P O R T
[To accompany H.R. 6662]
[Including cost estimate of the Congressional Budget Office]
The Committee on Ways and Means, to whom was referred the
bill (H.R. 6662) to amend title XVIII of the Social Security
Act to extend the special election period under part C of the
Medicare program for certain deemed individuals enrolled in a
reasonable cost reimbursement contract to certain nondeemed
individuals enrolled in such contract, having considered the
same, report favorably thereon with an amendment and recommend
that the bill as amended do pass.
CONTENTS
Page
I. SUMMARY AND BACKGROUND...........................................2
A. Purpose and Summary................................. 2
B. Background and Need for Legislation................. 2
C. Legislative History................................. 4
II. EXPLANATION OF THE BILL..........................................4
A. Empowering Seniors' Enrollment Decision Act of 2018. 4
III. VOTES OF THE COMMITTEE...........................................5
IV. BUDGET EFFECTS OF THE BILL.......................................5
A. Committee Estimate of Budgetary Effects............. 5
B. Statement Regarding New Budget Authority and Tax
Expenditures Budget Authority...................... 5
C. Cost Estimate Prepared by the Congressional Budget
Office............................................. 5
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE.......6
A. Committee Oversight Findings and Recommendations.... 6
B. Statement of General Performance Goals and
Objectives......................................... 6
C. Information Relating to Unfunded Mandates........... 6
D. Congressional Earmarks, Limited Tax Benefits, and
Limited Tariff Benefits............................ 6
E. Duplication of Federal Programs..................... 6
F. Disclosure of Directed Rule Makings................. 7
VI. CORRESPONDENCE...................................................8
VII. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED...........11
A. Changes in Existing Law Proposed by the Bill, as
Reported........................................... 11
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Empowering Seniors' Enrollment
Decision Act of 2018''.
SEC. 2. EXTENDING THE SPECIAL ELECTION PERIOD UNDER PART C OF THE
MEDICARE PROGRAM FOR CERTAIN DEEMED INDIVIDUALS
ENROLLED IN A REASONABLE COST REIMBURSEMENT
CONTRACT TO CERTAIN NONDEEMED INDIVIDUALS ENROLLED
IN SUCH CONTRACT.
Section 1851(e)(2)(F) of the Social Security Act (42 U.S.C. 1395w-
21(e)(2)(F)) is amended--
(1) in the header, by striking ``deemed elections'' and
inserting ``individuals enrolled in a reasonable cost
reimbursement contract''; and
(2) by amending clause (i) to read as follows:
``(i) In general.--
``(I) Election period.--At any time
during the period beginning after the
last day of the annual, coordinated
election period under paragraph (3)
occurring during an applicable plan
year and ending on the last day of
February of the first plan year
following such applicable plan year, an
individual who is an eligible
individual (as defined in subclause
(II)) with respect to such applicable
plan year may change the election under
subsection (a)(1) (including changing
the MA plan or MA-PD plan in which the
individual is enrolled) for such first
plan year.
``(II) Eligible individual.--In this
clause, the term `eligible individual'
means, with respect to a plan year, an
individual enrolled in a reasonable
cost reimbursement contract under
section 1876(h) that was extended or
renewed for the last reasonable cost
reimbursement contract year of the
contract (as described in subclause (I)
of section 1876(h)(5)(C)(iv)) pursuant
to such section.''.
I. SUMMARY AND BACKGROUND
A. Purpose and Summary
The bill, H.R. 6662, the ``Empowering Seniors' Enrollment
Decision Act of 2018,'' as ordered reported by the Committee on
Ways and Means on September 5, 2018, codifies existing
regulation which allows for non-deemed Medicare Cost Plan
enrollees to take advantage of the Special Enrollment Period
(SEP) offered in statute to the deemed Medicare Cost Plan
enrollees. This will ensure beneficiaries have adequate time to
make a decision about their Medicare coverage and know that the
plan they have chosen best fits their needs.
B. Background and Need for Legislation
A Medicare Cost Contract, also known as a Medicare Cost
Plan, provides the full Medicare benefit package. Payment,
however, is based on the reasonable cost of providing services
rather than a capitated payment established through a plan bid
and benchmark like Medicare Advantage (MA) Plans. Beneficiaries
enrolled in such plan have no network restrictions.
The Department of Health and Human Services Office of
Inspector General (HHS-OIG) has previously expressed concerns
over duplicative payments and higher costs that may result
under Medicare Cost Plan contracts. Individual physician
services are not identified by Medicare Cost Plans when they
submit cost reports. The cost report states only the aggregate
cost the plan has incurred for Medicare-covered physician
services. Medicare's fee-for-service (FFS) claims processing
contractors reimburse bills submitted by Cost Plans for any
service that a health plan has paid for and included in its
cost report. It is the responsibility of the Cost Plans to
detect duplicate payments and bring them to the attention of
FFS carriers and Medicare administrative contractors (MACs) for
recoupment of overpayments. The HHS-OIG has in the past found
that some cost plans lacked good systems for identifying
duplicate payments. The cost reimbursement rules applied to
Medicare Cost Plans allow the plans to pay their physicians
rates higher than Medicare FFS rates as long as the plan has
utilization control mechanisms in place; this has the potential
of increasing total Medicare expenditures for Medicare Cost
Plan enrollees above what the program would have otherwise
incurred if members were in traditional Medicare FFS (or, in
various geographic areas, enrolled in a MA Plan).
While the Balanced Budget Act of 1997 initiated the process
of phasing out Medicare Cost Plans, this transition has been
extended multiple times over the past 20 years. The Medicare
Access and CHIP Reauthorization Act (MACRA) of 2015 extended
the transition date and specified additional transition rules.
Under MACRA, a Medicare Cost Plan must transition to a MA Plan
by January 1, 2019. Under the current transition rules, as of
plan year 2019, Cost Plans may only operate if they: (1) have a
low monthly enrollment (i.e. 1,500 enrollees in rural areas or
5,000 enrollees in non-rural areas) and (2) if there are less
than two competing MA plans servicing the area.
There are approximately 628,989 Medicare beneficiaries
enrolled in a Cost Plan across the country. Medicare Cost Plans
are concentrated in certain states and territories such as
Minnesota, Maryland, Wisconsin, Texas, Virginia, South Dakota,
California, Colorado, Washington D.C., Iowa, Illinois, North
Dakota, and New York. Under the existing rules, only 191,296
beneficiaries, or 30 percent, will be able to remain in their
current Cost Plan.
Under existing regulations, certain Medicare beneficiaries
are entitled to a SEP outside of the two statutory open
enrollment periods for all Medicare beneficiaries. The first
statutory open enrollment period begins on October 15th and
ends on December 7th, and the second statutory open enrollment
period begins on January 1st and ends on March 31st.
In statute, Cost Plan enrollees impacted by the mandatory
transition that are deemed into another MA Plan are able to
participate in a SEP from December 8th to February 28th. This
statutory SEP, however, does not apply to non-deemed enrollees.
Non-deemed enrollees are beneficiaries that are enrolled in a
Medicare Cost Plan that has decided not to transition to a MA
Plan in the area in which the beneficiary lives. The non-deemed
enrollees are able to participate in the SEP due to existing
regulation.
C. Legislative History
Background
H.R. 6662 was introduced on August 10, 2018, and was
referred to the Committee on Ways and Means and additionally
the Committee on Energy and Commerce.
Committee hearings
On September 21, 2012, the Subcommittee on Health held a
hearing on Medicare Health Plans to examine the current status
of the Medicare Advantage program and other health plans,
including Medicare Cost Plans.
Committee action
The Committee on Ways and Means marked up H.R. 6662, the
``Empowering Seniors' Enrollment Decision Act of 2018,'' on
September 5, 2018, and ordered the bill, as amended, favorably
reported (with a quorum being present).
II. EXPLANATION OF THE BILL
A. Empowering Seniors' Enrollment Decision Act of 2018
PRESENT LAW
Cost Plan enrollees impacted by the mandatory transition
that are deemed into another Medicare Advantage (MA) plan are
able to participate in a special enrollment period (SEP) from
December 8 to February 28. This statutory SEP, however, does
not apply to non-deemed enrollees.
REASONS FOR CHANGE
The reason for this change is to align regulation with
statute and ensure that all impacted Cost Plan enrollees will
always have access to the SEP from December 8th to February
28th.
EXPLANATION OF PROVISIONS
Section 1: Short Title: ``Empowering Seniors' Enrollment
Decision Act of 2018''.
Section 2: Extending the Special Election Period Under Part
C of the Medicare Program for Certain Deemed Individuals
Enrolled in a Reasonable Cost Reimbursement Contract to Certain
Non-Deemed Individuals Enrolled in Such Contract.
This section changes the existing statute header to read
``INDIVIDUALS ENROLLED IN A REASONABLE COST REIMBURSEMENT
CONTRACT'' and changes the existing statute to include non-
deemed individuals as eligible individuals for the purpose of a
special enrollment period beginning after the last day of the
annual, coordinated election period (December 8th) until the
last day of February of the first plan year (February 28th).
EFFECTIVE DATE
Beginning after the last day of the annual, coordinated
election period (December 8th) until the last of February of
the first plan year (February 28th).
III. VOTES OF THE COMMITTEE
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, the following statement is made
concerning the vote of the Committee on Ways and Means in its
consideration of H.R. 6662, the ``Empowering Seniors'
Enrollment Decision Act of 2018,'' on September 5, 2018.
The Chairman's amendment in the nature of a substitute was
adopted by a voice vote (with a quorum being present).
The bill, H.R. 6662, was ordered favorably reported as
amended by voice vote (with a quorum being present).
IV. BUDGET EFFECTS OF THE BILL
A. Committee Estimate of Budgetary Effects
In compliance with clause 3(d) of rule XIII of the Rules of
the House of Representatives, the following statement is made
concerning the effects on the budget of the bill, H.R. 6662, as
reported. The Committee agrees with the estimate prepared by
the Congressional Budget Office (CBO), which is included below.
B. Statement Regarding New Budget Authority and Tax Expenditures Budget
Authority
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee states that the
bill involves no new or increased budget authority. The
Committee states further that the bill involves no new or
increased tax expenditures.
C. Cost Estimate Prepared by the Congressional Budget Office
In compliance with clause 3(c)(3) of rule XIII of the Rules
of the House of Representatives, requiring a cost estimate
prepared by the CBO, the following statement by CBO is
provided.
U.S. Congress,
Congressional Budget Office,
Washington, DC, September 10, 2018.
Hon. Kevin Brady,
Chairman, Committee on Ways and Means,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 6662, the
Empowering Seniors' Enrollment Decision Act of 2018.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Lori Housman.
Sincerely,
Keith Hall,
Director.
Enclosure.
H.R. 6662--Empowering Seniors' Enrollment Decision Act of 2018
H.R. 6662 would codify a current practice that allows
certain Medicare beneficiaries to use an existing election
period to change their enrollment in Medicare Advantage plans.
CBO estimates that enacting this bill would have no
significant effect on the federal budget. Enacting H.R. 6662
would not affect direct spending or revenues; therefore, pay-
as-you-go procedures do not apply. CBO estimates that enacting
H.R. 6662 would not increase net direct spending or on-budget
deficits in any of the four consecutive 10-year periods
beginning in 2029.
H.R. 6662 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act.
The CBO staff contact for this estimate is Lori Housman
(for federal costs) and Andrew Laughlin (for private-sector
mandates). The estimate was reviewed by Theresa Gullo,
Assistant Director for Budget Analysis.
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE
A. Committee Oversight Findings and Recommendations
With respect to clause 3(c)(1) of rule XIII of the Rules of
the House of Representatives, the Committee made findings and
recommendations that are reflected in this report.
B. Statement of General Performance Goals and Objectives
With respect to clause 3(c)(4) of rule XIII of the Rules of
the House of Representatives, the Committee advises that the
bill contains no measure that authorizes funding, so no
statement of general performance goals and objectives for which
any measure authorizes funding is required.
C. Information Relating to Unfunded Mandates
This information is provided in accordance with section 423
of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104-
4).
The Committee has determined that the bill does not contain
Federal mandates on the private sector. The Committee has
determined that the bill does not impose a Federal
intergovernmental mandate on State, local, or tribal
governments.
D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff
Benefits
With respect to clause 9 of rule XXI of the Rules of the
House of Representatives, the Committee has carefully reviewed
the provisions of the bill, and states that the provisions of
the bill do not contain any congressional earmarks, limited tax
benefits, or limited tariff benefits within the meaning of the
rule.
E. Duplication of Federal Programs
In compliance with Sec. 3(g)(2) of H. Res. 5 (114th
Congress), the Committee states that no provision of the bill
establishes or reauthorizes: (1) a program of the Federal
Government known to be duplicative of another Federal program;
(2) a program included in any report from the Government
Accountability Office to Congress pursuant to section 21 of
Public Law 111-139; or (3) a program related to a program
identified in the most recent Catalog of Federal Domestic
Assistance, published pursuant to the Federal Program
Information Act (Pub. L. No. 95-220, as amended by Pub. L. No.
98-169).
F. Disclosure of Directed Rule Makings
In compliance with Sec. 3(i) of H. Res. 5 (114th Congress),
the following statement is made concerning directed rule
makings: The Committee estimates that the bill requires no
directed rule makings within the meaning of such section.
VII. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED
A. Changes in Existing Law Proposed by the Bill, as Reported
In compliance with clause 3(e)(1)(B) of rule XIII of the
Rules of the House of Representatives, changes in existing law
proposed by the bill, as reported, are shown as follows
(existing law proposed to be omitted is enclosed in black
brackets, new matter is printed in italic, existing law in
which no change is proposed is shown in roman):
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, and existing law in which no
change is proposed is shown in roman):
SOCIAL SECURITY ACT
* * * * * * *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED
* * * * * * *
Part C--Medicare+Choice Program
eligibility, election, and enrollment
Sec. 1851. (a) Choice of Medicare Benefits Through
Medicare+Choice Plans.--
(1) In general.--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 title--
(A) through the original medicare fee-for-
service program under parts A and B, or
(B) through enrollment in a Medicare+Choice
plan under this part,
and may elect qualified prescription drug coverage in
accordance with section 1860D-1.
(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:
(A) Coordinated care plans (including
regional plans).--
(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.
(b) Special Rules.--
(1) Residence requirement.--
(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 thatan 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.
(C) Continuation of enrollment permitted
where service changed.--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--
(i) the enrollee agrees to receive
the full range of basic benefits
(excluding emergency and urgently
needed care) exclusively at facilities
designated by the organization within
the plan service area; and
(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.
(2) Special rule for certain individuals covered
under fehbp or eligible for veterans or military health
benefits, veterans.--
(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.
(4) Coverage under msa plans.--
(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).
(c) Process for Exercising Choice.--
(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 such elections are made and changed. Subject
to paragraph (4), 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).
(2) Coordination through medicare+choice
organizations.--
(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.
(3) Default.--
(A) Initial election.--
(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).
(B) Continuing periods.--An individual who
has made (or is deemed to have made) an
election under this section is considered to
have continued to make such election until such
time as--
(i) the individual changes the
election under this section, or
(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.
(4) Deemed enrollment relating to converted
reasonable cost reimbursement contracts.--
(A) In general.--On the first day of the
annual, coordinated election period under
subsection (e)(3) for plan years beginning on
or after January 1, 2017, an MA eligible
individual described in clause (i) or (ii) of
subparagraph (B) is deemed, unless the
individual elects otherwise, to have elected to
receive benefits under this title through an
applicable MA plan (and shall be enrolled in
such plan) beginning with such plan year, if--
(i) the individual is enrolled in a
reasonable cost reimbursement contract
under section 1876(h) in the previous
plan year;
(ii) such reasonable cost
reimbursement contract was extended or
renewed for the last reasonable cost
reimbursement contract year of the
contract (as described in subclause (I)
of section 1876(h)(5)(C)(iv)) pursuant
to such section;
(iii) the eligible organization that
is offering such reasonable cost
reimbursement contract provided the
notice described in subclause (III) of
such section that the contract was to
be converted;
(iv) the applicable MA plan--
(I) is the plan that was
converted from the reasonable
cost reimbursement contract
described in clause (iii);
(II) is offered by the same
entity (or an organization
affiliated with such entity
that has a common ownership
interest of control) that
entered into such contract; and
(III) is offered in the
service area where the
individual resides;
(v) in the case of reasonable cost
reimbursement contracts that provide
coverage under parts A and B (and, to
the extent the Secretary determines it
to be feasible, contracts that provide
only part B coverage), the difference
between the estimated individual costs
(as determined applicable by the
Secretary) for the applicable MA plan
and such costs for the predecessor cost
plan does not exceed a threshold
established by the Secretary; and
(vi) the applicable MA plan--
(I) provides coverage for
enrollees transitioning from
the converted reasonable cost
reimbursement contract to such
plan to maintain current
providers of services and
suppliers and course of
treatment at the time of
enrollment for a period of at
least 90 days after enrollment;
and
(II) during such period, pays
such providers of services and
suppliers for items and
services furnished to the
enrollee an amount that is not
less than the amount of payment
applicable for such items and
services under the original
Medicare fee-for-service
program under parts A and B.
(B) MA eligible individuals described.--
(i) Without prescription drug
coverage.--An MA eligible individual
described in this clause, with respect
to a plan year, is an MA eligible
individual who is enrolled in a
reasonable cost reimbursement contract
under section 1876(h) in the previous
plan year and who is not, for such
previous plan year, enrolled in a
prescription drug plan under part D,
including coverage under section 1860D-
22.
(ii) With prescription drug
coverage.--An MA eligible individual
described in this clause, with respect
to a plan year, is an MA eligible
individual who is enrolled in a
reasonable cost reimbursement contract
under section 1876(h) in the previous
plan year and who, for such previous
plan year, is enrolled in a
prescription drug plan under part D--
(I) through such contract; or
(II) through a prescription
drug plan, if the sponsor of
such plan is the same entity
(or an organization affiliated
with such entity) that entered
into such contract.
(C) Applicable ma plan defined.--In this
paragraph, the term ``applicable MA plan''
means, in the case of an individual described
in--
(i) subparagraph (B)(i), an MA plan
that is not an MA-PD plan; and
(ii) subparagraph (B)(ii), an MA-PD
plan.
(D) Identification and notification of deemed
individuals.--Not later than 45 days before the
first day of the annual, coordinated election
period under subsection (e)(3) for plan years
beginning on or after January 1, 2017, the
Secretary shall identify and notify the
individuals who will be subject to deemed
elections under subparagraph (A) on the first
day of such period.
(d) Providing Information To Promote Informed Choice.--
(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.
(2) Provision of notice.--
(A) Open season notification.--At least 15
days before the beginning of each annual,
coordinated election period (as defined in
subsection (e)(3)(B)), 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.
The mailing of such information shall be
coordinated, to the extent practicable, with
the mailing of any annual notice under section
1804.
(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),
mail to the individual the information
described in subparagraph (A).
(ii) Notification related to certain
deemed elections.--The Secretary shall
require a Medicare Advantage
organization that is offering a
Medicare Advantage plan that has been
converted from a reasonable cost
reimbursement contract pursuant to
section 1876(h)(5)(C)(iv) to mail, not
later than 30 days prior to the first
day of the annual, coordinated election
period under subsection (e)(3) of a
year, to any individual enrolled under
such contract and identified by the
Secretary under subsection (c)(4)(D)
for such year--
(I) a notification that such
individual will, on such day,
be deemed to have made an
election with respect to such
plan to receive benefits under
this title through an MA plan
or MA-PD plan (and shall be
enrolled in such plan) for the
next plan year under subsection
(c)(4)(A), but that the
individual may make a different
election during the annual,
coordinated election period for
such year;
(II) the information
described in subparagraph (A);
(III) a description of the
differences between such MA
plan or MA-PD plan and the
reasonable cost reimbursement
contract in which the
individual was most recently
enrolled with respect to
benefits covered under such
plans, including cost-sharing,
premiums, drug coverage, and
provider networks;
(IV) information about the
special period for elections
under subsection (e)(2)(F); and
(V) other information the
Secretary 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.
(3) General information.--General information under
this paragraph, with respect to coverage under this
part during a year, shall include the following:
(A) Benefits under original medicare fee-for-
service program option.--A general description
of the benefits covered under the original
medicare fee-for-service program under parts A
and B, including--
(i) covered items and services,
(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.
(4) Information comparing plan options.--Information
under this paragraph, with respect to a Medicare+Choice
plan for a year, shall include the following:
(A) Benefits.--The benefits covered under the
plan, including the following:
(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.
(B) Premiums.--
(i) In general.--The monthly amount
of the premium charged to an
individual.
(ii) Reductions.--The reduction in
part B premiums, if any.
(C) Service area.--The service area of the
plan.
(D) Quality and performance.--To the extent
available, plan quality and performance
indicators for the benefits under the plan (and
how they compare to such indicators under the
original medicare fee-for-service program under
parts A and B in the area involved),
including--
(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,
(iii) information on health outcomes,
and
(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).
(e) Coverage Election Periods.--
(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. If any portion of an individual's initial
enrollment period under part B 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.
(2) Open enrollment and disenrollment
opportunities.--Subject to paragraph (5)--
(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).
(B) Continuous open enrollment and
disenrollment for first 6 months during 2006.--
(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).
(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.
(D) Continuous open enrollment for
institutionalized individuals.--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)--
(i) to enroll in a Medicare+Choice
plan; or
(ii) to change the Medicare+Choice
plan in which the individual is
enrolled.
(E) Limited continuous open enrollment of
original fee-for-service enrollees in medicare
advantage non-prescription drug plans.--
(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--
(I) is receiving benefits
under this title through
enrollment in the original
medicare fee-for-service
program under parts A and B;
(II) is not enrolled in an MA
plan on such date; and
(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.
(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)--
(I) who is enrolled in a
prescription drug plan under
part D, to disenroll from such
plan or to enroll in a
different prescription drug
plan; or
(II) who is not enrolled in a
prescription drug plan, to
enroll in such a plan.
(F) Special period for certain [deemed
elections] individuals enrolled in a reasonable
cost reimbursement contract.--
[(i) In general.--At any time during
the period 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).]
(i) In general.--
(I) Election period.--At any
time during the period
beginning after the last day of
the annual, coordinated
election period under paragraph
(3) occurring during an
applicable plan year and ending
on the last day of February of
the first plan year following
such applicable plan year, an
individual who is an eligible
individual (as defined in
subclause (II)) with respect to
such applicable plan year may
change the election under
subsection (a)(1) (including
changing the MA plan or MA-PD
plan in which the individual is
enrolled) for such first plan
year.
(II) Eligible individual.--In
this clause, the term
``eligible individual'' means,
with respect to a plan year, an
individual enrolled in a
reasonable cost reimbursement
contract under section 1876(h)
that was extended or renewed
for the last reasonable cost
reimbursement contract year of
the contract (as described in
subclause (I) of section
1876(h)(5)(C)(iv)) pursuant to
such section.
(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).
(G) Continuous open enrollment and
disenrollment for first 3 months in 2016 and
subsequent years.--
(i) In general.--Subject to clause
(ii) and subparagraph (D)--
(I) in the case of an MA
eligible individual who is
enrolled in an MA plan, at any
time during the first 3 months
of a year (beginning with
2019); or
(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 year.--An
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
d.--Clauses (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 marketing.--
Pursuant 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.
(3) Annual, coordinated election period.--
(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.
(B) Annual, coordinated election period.--For
purposes of this section, the term ``annual,
coordinated election period'' means--
(i) with respect to a year before
2002, the month of November before such
year;
(ii) with respect to 2002, 2003,
2004, and 2005, the period beginning on
November 15 and ending on December 31
of the year before such year;
(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.
(D) Special information campaigns.--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. 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.
(4) Special election periods.--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--
(A)(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
(ii) the organization has terminated or
otherwise discontinued providing the plan in
the area in which the individual resides, or
has notified the individual of an impending
termination or discontinuation of such plan;
(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));
(C) the individual demonstrates (in
accordance with guidelines established by the
Secretary) 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
(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.
(5) Special rules for msa plans.--Notwithstanding the
preceding provisions of this subsection, an
individual--
(A) may elect an MSA plan only during--
(i) an initial open enrollment period
described in paragraph (1), or
(ii) an annual, coordinated election
period described in paragraph (3)(B);
(B) subject to subparagraph (C), may not
discontinue an election of an MSA plan except
during the periods described in clause (ii) or
(iii) of subparagraph (A) and under the first
sentence of paragraph (4); and
(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.
(6) Open enrollment periods.--Subject to paragraph
(5), a Medicare+Choice organization--
(A) shall accept elections or changes to
elections during the initial enrollment periods
described in paragraph (1), during the period
described in paragraph (2)(F), during the month
of November 1998 and during the annual,
coordinated election period under paragraph (3)
for each subsequent year, and during special
election periods described in the first
sentence of paragraph (4); and
(B) may accept other changes to elections at
such other times as the organization provides.
(f) Effectiveness of Elections and Changes of Elections.--
(1) During initial coverage election period.--An
election of coverage made during the initial coverage
election period under subsection (e)(1) 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), other than the period described in clause
(iii) of such subsection) 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.
(g) Guaranteed Issue and Renewal.--
(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.
(2) Priority.--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--
(A) first to such individuals as have elected
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
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.
(3) Limitation on termination of election.--
(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.
(B) Basis for termination of election.--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 1856 that
provide for a grace period for late
payment of such premiums),
(ii) the individual has engaged in
disruptive behavior (as specified in
such standards), or
(iii) the plan is terminated with
respect 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
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.
(h) Approval of Marketing Material and Application Forms.--
(1) Submission.--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--
(A) at least 45 days (or 10 days in the case
described in paragraph (5)) 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 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.
(4) Prohibition of certain marketing practices.--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 1856. 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;
(C) shall not permit a Medicare Advantage
organization (or the agents, brokers, and other
third parties representing such organization)
to conduct the prohibited activities described
in subsection (j)(1); and
(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).
(7) Strengthening the ability of states to act in
collaboration with the secretary to address fraudulent
or inappropriate marketing practices.--
(A) Appointment of agents and brokers.--Each
Medicare Advantage organization shall--
(i) only use agents and brokers who
have been licensed under State law to
sell Medicare Advantage plans offered
by the Medicare Advantage organization;
(ii) in the case where a State has a
State appointment law, abide by such
law; and
(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.
(i) Effect of Election of Medicare+Choice Plan Option.--
(1) Payments to organizations.--Subject to sections
1852(a)(5), 1853(a)(4), 1853(g), 1853(h), 1886(d)(11),
1886(h)(3)(D), and 1853(m), 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
acquisitions.--Paragraphs (1) and (2) shall not apply
with respect to expenses for organ acquisitions for
kidney transplants described in section
1852(a)(1)(B)(i).
(j) Prohibited Activities Described and Limitations on the
Conduct of Certain Other Activities.--
(1) Prohibited activities described.--The following
prohibited activities are described in this paragraph:
(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.
(D) Sales and marketing in health care
settings and at educational events.--Sales and
marketing activities for the enrollment of
individuals in Medicare Advantage plans that
are conducted--
(i) in health care settings in areas
where health care is delivered to
individuals (such as physician offices
and pharmacies), except in the case
where such activities are conducted in
common areas in health care settings;
and
(ii) at educational events.
(2) Limitations.--The Secretary shall establish
limitations with respect to at least the following:
(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.
(C) Limitation of gifts to nominal dollar
value.--The offering of gifts and other
promotional items other than those that are of
nominal value (as determined by the Secretary)
to prospective enrollees at promotional
activities.
(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.
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