[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: 42CFR422.54]



[Page 977-978]

 

                         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. 422.54  Continuation of enrollment for MA local plans.



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

the service area) within which the MA organization offering a local plan 

furnishes or arranges to furnish 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 MA local plan.

    (b) Basic rule. An MA organization may offer a continuation of 

enrollment option to MA local plan enrollees when they no longer reside 

in the service area of a plan and permanently move into the geographic 

area designated by the MA organization as a continuation area. The 

intent to no longer reside in



[[Page 978]]



an area and permanently live in another area is verified through 

documentation that establishes residency, such as a driver's license or 

voter registration card.

    (c) General requirements. (1) An MA 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 MA 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 MA local plan enrollees residing in the 

continuation area.

    (2) An enrollee who moves out of the service area and into the 

geographic area designated as the continuation area has the choice of 

continuing enrollment or disenrolling from the MA local 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 MA organization must, 

at a minimum, provide or arrange for the Medicare-covered benefits as 

described in Sec. 422.101(a).

    (2) Reasonable access. The MA 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 MA local plan's service area 

(in which the enrollee no longer resides).

    (4) Protection of enrollee rights. An MA 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 MA 

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; 70 FR 4716, Jan. 28, 2005]