[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR422.50]



[Page 976-977]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents

 

             Subpart B_Eligibility, Election, and Enrollment

 

Sec. 422.50  Eligibility to elect an MA plan.



    Source: 63 FR 35071, June 26, 1998, unless otherwise noted.





    For this subpart, all references to an MA plan include MA-PD and 

both MA local and MA regional plans, as defined in Sec. 422.2 unless 

specifically noted otherwise.

    (a) An individual is eligible to elect an MA plan if he or she--

    (1) Is entitled to Medicare under Part A and enrolled in Part B 

(except that an individual entitled only to Part B and who was enrolled 

in an HMO or CMP with a risk contract under part 417 of this chapter on 

December 31, 1998 may continue to be enrolled in the MA organization as 

an MA plan enrollee);

    (2) Has not been medically determined to have end-stage renal 

disease, except that--

    (i) An individual who develops end-stage renal disease while 

enrolled in an MA plan or in a health plan offered by the MA 

organization is eligible to elect an MA plan offered by that 

organization;

    (ii) An individual with end-stage renal disease whose enrollment in 

an MA plan was terminated or discontinued after December 31, 1998, 

because CMS or the MA organization terminated the MA organization's 

contract for the plan or discontinued the plan in the area in which the 

individual resides, is eligible to elect another MA plan. If the plan so 

elected is later terminated or discontinued in the area in which the 

individual resides, he or she may elect another MA plan; and

    (iii) An individual with end-stage renal disease may elect an MA 

special needs plan as defined in Sec. 422.2, as long as that plan has 

opted to enroll ESRD individuals.

    (3) Meets either of the following residency requirements:



[[Page 977]]



    (i) Resides in the service area of the MA plan.

    (ii) Resides outside of the service area of the MA plan and is 

enrolled in a health plan offered by the MA organization during the 

month immediately preceding the month in which the individual is 

entitled to both Medicare Part A and Part B, provided that an MA 

organization chooses to offer this option and that CMS determines that 

all applicable MA access requirements of Sec. 422.112 are met for that 

individual through the MA plan's established provider network. The MA 

organization must furnish the same benefits to these enrollees as to 

enrollees who reside in the service area;

    (4) Has been a member of an Employer Group Health Plan (EGHP) that 

includes the elected MA plan, even if the individual lives outside of 

the MA plan service area, provided that an MA organization chooses to 

offer this option and that CMS determines that all applicable MA access 

requirements at Sec. 422.112 are met for that individual through the MA 

plan's established provider network. The MA organization must furnish 

the same benefits to all enrollees, regardless of whether they reside in 

the service area;

    (5) Completes and signs an election form or completes another CMS-

approved election method offered by the MA organization and provides 

information required for enrollment; and

    (6) Agrees to abide by the rules of the MA organization after they 

are disclosed to him or her in connection with the election process.

    (b) An MA eligible individual may not be enrolled in more than one 

MA plan at any given time.



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

FR 40316, June 29, 2000; 68 FR 50855, Aug. 22, 2003; 70 FR 4715, Jan. 

28, 2005; 70 FR 52026, Sept. 1, 2005]