[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: 42CFR422.60]

[Page 837-838]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents
 
            Subpart B--Eligibility, Election, and Enrollment
 
Sec. 422.60  Election process.

    (a) Acceptance of enrollees: General rule. (1) Except for the 
limitations on enrollment in an M+C MSA plan provided by 
Sec. 422.62(d)(1) and except as specified in paragraph (a)(2) of this 
section, each M+C organization must accept without restriction (except 
for an M+C RFB plan as provided by Sec. 422.57) individuals who are 
eligible to elect an M+C plan that the M+C organization offers and who 
elect an M+C plan during initial coverage election periods under 
Sec. 422.62(a)(1), annual election periods under Sec. 422.62(a)(2), and 
under the circumstances described in Sec. 422.62(b)(1) through (b)(4).
    (2) M+C organizations must accept elections during the open 
enrollment periods specified in Sec. 422.62(a)(3), (a)(4), and (a)(5) if 
their M+C plans are open to new enrollees.
    (b) Capacity to accept new enrollees. (1) M+C organizations may 
submit information on enrollment capacity of plans they offer by July 1 
of each year as provided by Sec. 422.306(a)(1).
    (2) If CMS determines that an M+C plan offered by an M+C 
organization has a capacity limit, and the number of M+C eligible 
individuals who elect to enroll in that plan exceeds the limit, the M+C 
organization offering the plan may limit enrollment in the plan under 
this part, but only if it provides priority in acceptance as follows:
    (i) First, for individuals who elected the plan prior to the CMS 
determination that capacity has been exceeded, elections will be 
processed in chronological order by date of receipt of their election 
forms.
    (ii) Then for other individuals in a manner that does not 
discriminate on the basis of any factor related to health as described 
in Sec. 422.110.
    (3) CMS considers enrollment limit requests for an M+C plan service 
area, other than those submitted with the adjusted community rate 
proposal, or for a portion of the plan service area, only if the health 
and safety of beneficiaries is at risk, such as if the provider network 
is not available to serve the enrollees in all or a portion of the 
service area.
    (c) Election forms. (1) The election form must comply with CMS 
instructions regarding content and format and have been approved by CMS 
as described in Sec. 422.80. The form must be completed and signed by 
the M+C eligible individual (or the individual who will soon become 
entitled to Medicare benefits) and include authorization for disclosure 
and exchange of necessary information between the U.S. Department of 
Health and Human Services and its designees and the M+C organization. 
Persons who assist beneficiaries in completing forms must sign the form 
and indicate their relationship to the beneficiary.
    (2) The M+C organization must file and retain election forms for the 
period specified in CMS instructions.
    (d) When an election is considered to have been made. An election in 
an M+C plan is considered to have been made on the date the election 
form is received by the M+C organization.
    (e) Handling of election forms. The M+C organization must have an 
effective system for receiving, controlling,

[[Page 838]]

and processing election forms. The system must meet the following 
conditions and requirements:
    (1) Each election form is dated as of the day it is received.
    (2) Election forms are processed in chronological order, by date of 
receipt.
    (3) The M+C organization gives the beneficiary prompt written notice 
of acceptance or denial in a format specified by CMS.
    (4) In a format specified by CMS, a notice of acceptance--
    (i) Informs the beneficiary of the date on which enrollment will be 
effective under Sec. 422.68; and
    (ii) If the M+C plan is enrolled to capacity, explains the 
procedures that will be followed when vacancies occur.
    (5) A notice of denial explains the reasons for denial in a format 
specified by CMS.
    (6) Upon receipt of the election form or from the date a vacancy 
occurs for an individual who was accepted for future enrollment, the M+C 
organization transmits, within the timeframes specified by CMS, the 
information necessary for CMS to add the beneficiary to its records as 
an enrollee of the M+C organization.
    (f) Exception for employer group health plans.
    (1) In cases in which an M+C organization has both a Medicare 
contract and a contract with an employer group health plan, and in which 
the M+C organization arranges for the employer to process election forms 
for Medicare-entitled group members, who wish to enroll under the 
Medicare contract, the effective date of the election may be 
retroactive. Consistent with Sec. 422.250(b), payment adjustments based 
on a retroactive effective date may be made for up to a 90-day period.
    (2) In order to obtain the effective date described in paragraph 
(f)(1) of this section, the beneficiary must certify that, at the time 
of enrollment in the M+C organization, he or she received the disclosure 
statement specified in Sec. 422.111.
    (3) Upon receipt of the election form from the employer, the M+C 
organization must submit the enrollment within timeframes specified by 
CMS.

[63 FR 35071, June 26, 1998; 63 FR 52612, Oct. 1, 1998; 63 FR 54526, 
Oct. 9, 1998; 64 FR 7980, Feb. 17, 1999; 65 FR 40316, June 29, 2000]