[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR422.54]

[Page 835-836]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents
 
            Subpart B--Eligibility, Election, and Enrollment
 
Sec. 422.54  Continuation of enrollment.

    (a) Definition. Continuation area means an additional area (outside 
the

[[Page 836]]

service area) within which the M+C organization furnishes or arranges 
for furnishing services to its continuation-of-enrollment enrollees. 
Enrollees must reside in a continuation area on a permanent basis. A 
continuation area does not expand the service area of any plan.
    (b) Basic rule. An M+C organization may offer a continuation of 
enrollment option to enrollees when they no longer reside in the service 
area of a plan and permanently move into the geographic area designated 
by the M+C organization as a continuation of enrollment area. The intent 
to no longer reside in an area and permanently live in another area is 
verified through documentation that establishes residency, such as, 
driver's license, voter registration.
    (c) General requirements. (1) An M+C organization that wishes to 
offer a continuation of enrollment option must meet the following 
requirements:
    (i) Obtain CMS's approval of the continuation area, the marketing 
materials that describe the option, and the M+C organization's 
assurances of access to services.
    (ii) Describe the option(s) in the member materials it offers and 
make the option available to all enrollees residing in the continuation 
area.
    (2) An enrollee who moves out of the service area into the 
geographic area designated as the continuation area has the choice of 
continuing enrollment or disenrolling from the plan. The enrollee must 
make the choice of continuing enrollment in a manner specified by CMS. 
If no choice is made, the enrollee must be disenrolled from the plan.
    (d) Specific requirements--
    (1) Continuation of enrollment benefits. The M+C organization must, 
at a minimum, provide or arrange for the Medicare-covered benefits as 
described in Sec. 422.101(a).
    (2) Reasonable access. The M+C organization must ensure reasonable 
access in the continuation area--
    (i) Through contracts with providers, or through direct payment of 
claims that satisfy the requirements in Sec. 422.100(b)(2), to other 
providers who meet the requirement in subpart E of this part; and
    (ii) By ensuring that the access requirements of Sec. 422.112 are 
met.
    (3) Reasonable cost-sharing. For services furnished in the 
continuation area, an enrollee's cost-sharing liability is limited to 
the cost-sharing amounts required in the M+C plan's service area (in 
which the enrollee no longer resides).
    (4) Protection of enrollee rights. An M+C organization that offers a 
continuation of enrollment option must convey all enrollee rights 
conferred under this rule, with the understanding that--
    (i) The ultimate responsibility for all appeals and grievance 
requirements remain with the organization that is receiving payment from 
CMS; and
    (ii) Organizations that require enrollees to give advance notice of 
intent to use the continuation of enrollment option, must stipulate the 
notification process in the marketing materials.
    (e) Capitation payments. CMS's capitation payments to all M+C 
organizations, for all Medicare enrollees, are based on rates 
established on the basis of the enrollee's permanent residence, 
regardless of where he or she receives services.

[63 FR 35071, June 26, 1998; 63 FR 52611, Oct. 1, 1998, as amended at 65 
FR 40316, June 29, 2000]