[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: 42CFR422.62] [Page 838-840] TITLE 42--PUBLIC HEALTH HUMAN SERVICES PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents Subpart B--Eligibility, Election, and Enrollment Sec. 422.62 Election of coverage under an M+C plan. (a) General: Coverage election periods--(1) Initial coverage election period. The initial coverage election period is the period during which a new M+C eligible individual may make an initial election. This period begins 3 months prior to the month the individual is first entitled to both Part A and Part B and ends the last day of the month preceding the month of entitlement. (2) Annual election period. (i) Beginning in 1999, the month of November is the annual election period for the following calendar year. Organizations offering M+C plans in January 1999 must open enrollment to Medicare beneficiaries in November 1998. (ii) During the annual election period, an individual eligible to enroll in an M+C plan may change his or her election from an M+C plan to original Medicare or to a different M+C plan, or from original Medicare to an M+C plan. (3) Open enrollment and disenrollment opportunities through 2001. From 1998 through 2001, the number of elections or changes that an M+C eligible individual may make is not limited (except as provided for in paragraph (d) of this section for M+C MSA plans). Subject to the M+C plan being open to enrollees as provided under Sec. 422.60(a)(2), an individual eligible to elect an M+C plan may change his or her election from an M+C plan to original Medicare or to a different M+C plan, or from original Medicare to an M+C plan. (4) Open enrollment and disenrollment during 2002. (i) Except as provided in paragraphs (a)(4)(ii), (a)(4)(iii), and (a)(6) of this section, an individual who is eligible to elect an M+C plan in 2002 may elect an M+C plan or change his or her election from an M+C plan to original Medicare or to a different M+C plan, or from original Medicare to an M+C plan, but only once during the first 6 months of the year. (ii) Newly eligible M+C individual. An individual who becomes an M+C eligible individual during 2002 may elect an [[Page 839]] M+C plan or original Medicare and then change his or her election once during the period that begins the month the individual is entitled to both Part A and Part B and ends on the last day of the 6th month of such entitlement, or on December 31, whichever is earlier. The individual can change the election from an M+C plan to original Medicare or to a different M+C plan, or from original Medicare to an M+C plan during this period. (iii) The limitation to one election or change in paragraphs (a)(4)(i) and (a)(4)(ii) of this section does not apply to elections or changes made during the annual election period specified in (a)(2) of this section or during a special enrollment period specified in paragraph (b) of this section. (5) Open enrollment and disenrollment beginning in 2003. (i) For 2003 and subsequent years, except as provided in paragraphs (a)(5)(ii), (a)(5)(iii), and (a)(6) of this section, an individual who is eligible to elect an M+C plan may elect an M+C plan, change his or her election from an M+C plan to original Medicare or to a different M+C plan, or from original Medicare to an M+C plan, but only once during the first 3 months of the year. (ii) Newly eligible M+C individual. An individual who becomes an M+C eligible individual during 2003 or later may elect an M+C plan or original Medicare and then change his or her election once during the period that begins the month the individual is entitled to both Part A and Part B and ends on the last day of the 3rd month of such entitlement, or on December 31, whichever is earlier. The individual can change the election from an M+C plan to original Medicare or to a different M+C plan, or from original Medicare to an M+C plan during this period. (iii) The limitation to one election or change in paragraphs (a)(5)(i) and (a)(5)(ii) of this section does not apply to elections or changes made during the annual election period specified in paragraph (a)(2) of this section or during a special election period specified in paragraph (b) of this section. (6) Open enrollment period for institutionalized individuals. After 2001, an individual who is eligible to elect an M+C plan and who is institutionalized, as defined by CMS, is not limited (except as provided for in paragraph (d) of this section for M+C MSA plans) in the number of elections or changes he or she may make. Subject to the M+C plan being open to enrollees as provided under Sec. 422.60(a)(2), an M+C eligible institutionalized individual may at any time elect an M+C plan or change his or her election from an M+C plan to original Medicare, to a different M+C plan, or from iginal Medicare to an M+C plan. (b) Special election periods. Effective as of January 1, 1999 for M+C MSA plans, and as of January 1, 2002, for all other types of M+C plans, an individual may at any time (that is, not limited to the annual election period) discontinue the election of an M+C plan offered by an M+C organization and change his or her election, in the form and manner specified by CMS, from an M+C plan to original Medicare or to a different M+C plan under any of the following circumstances: (1) CMS or the organization has terminated the organization's contract for the plan, discontinued the plan in the area in which the individual resides, or the organization has notified the individual of the impending termination of the plan, or the impending discontinuation of the plan in the area in which the individual resides. (2) The individual is not eligible to remain enrolled in the plan because of a change in his or her place of residence to a location out of the service area or continuation area or other change in circumstances as determined by CMS but not including terminations resulting from a failure to make timely payment of an M+C monthly or supplemental beneficiary premium, or from disruptive behavior. (3) The individual demonstrates to CMS, in accordance with guidelines issued by CMS, that-- (i) The organization offering the plan substantially violated a material provision of its contract under this part in relation to the individual, including, but not limited to the following: (A) Failure to provide the beneficiary on a timely basis medically necessary services for which benefits are available under the plan. [[Page 840]] (B) Failure to provide medical services in accordance with applicable quality standards; or (ii) The organization (or its agent, representative, or plan provider) materially misrepresented the plan's provisions in marketing the plan to the individual. (4) The individual meets such other exceptional conditions as CMS may provide. (c) Special election period for individual age 65. Effective January 1, 2002, an M+C eligible individual who elects an M+C plan during the initial enrollment period, as defined under section 1837(d) of the Act, that surrounds his or her 65th birthday (this period begins 3 months before and ends 3 months after the month of the individual's 65th birthday) may discontinue the election of that plan and elect coverage under original Medicare at any time during the 12-month period that begins on the effective date of enrollment in the M+C plan. (d) Special rules for M+C MSA plans--(1) Enrollment. An individual may enroll in an M+C MSA plan only during an initial or annual election period described in paragraphs (a)(1) and (a)(2) of this section or during November 1998. (2) Disenrollment. (i) Except as provided in paragraph (d)(2)(ii) of this section, an individual may disenroll from an M+C MSA plan only during-- (A) November 1998; (B) An annual election period; or (C) The special election period described in paragraph (b) of this section. (ii) Exception. An individual who elects an M+C MSA plan during an annual election period and has never before elected an M+C MSA plan may revoke that election, no later than December 15 of that same year, by submitting to the organization that offers the M+C MSA plan a signed and dated request in the form and manner prescribed by CMS or by filing the appropriate disenrollment form through other mechanisms as determined by CMS. [63 FR 35071, June 26, 1998; 63 FR 52612, Oct. 1, 1998, as amended at 65 FR 40317, June 29, 2000]