[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: 42CFR422.60]



[Page 979-980]

 

                         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. 422.60  Election process.



    (a) Acceptance of enrollees: General rule. (1) Except for the 

limitations on enrollment in an MA MSA plan provided by Sec. 

422.62(d)(1) and except as specified in paragraph (a)(2) of this 

section, each MA organization must accept without restriction (except 

for an MA RFB plan as provided by Sec. 422.57) individuals who are 

eligible to elect an MA plan that the MA organization offers and who 

elect an MA 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) MA organizations must accept elections during the open 

enrollment periods specified in Sec. 422.62(a)(3), (a)(4), and (a)(5) 

if their MA plans are open to new enrollees.

    (b) Capacity to accept new enrollees. (1) MA organizations may 

submit information on enrollment capacity of plans.

    (2) If CMS determines that an MA plan offered by an MA organization 

has a capacity limit, and the number of MA eligible individuals who 

elect to enroll in that plan exceeds the limit, the MA 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 MA plan service 

area, or 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 and other election mechanisms. (1) The election 

must comply with CMS instructions regarding content and format and be 

approved by CMS as described in Sec. 422.80. The election must be 

completed by the MA eligible individual (or the individual who will soon 

become eligible to elect an MA plan) 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 MA 

organization. Persons who assist beneficiaries in completing forms must 

sign the form, or through other approved mechanisms, indicate their 

relationship to the beneficiary.

    (2) The MA 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 MA plan is considered to have been made on the date the completed 

election is received by the MA organization.

    (e) Handling of elections. The MA organization must have an 

effective system for receiving, controlling, and processing elections. 

The system must meet the following conditions and requirements:

    (1) Each election is dated as of the day it is received in a manner 

acceptable to CMS.

    (2) Elections are processed in chronological order, by date of 

receipt.

    (3) The MA organization gives the beneficiary prompt notice of 

acceptance or denial in a format specified by CMS.

    (4) If the MA plan is enrolled to capacity, it explains the 

procedures that will be followed when vacancies occur.

    (5) Upon receipt of the election, or for an individual who was 

accepted for future enrollment from the date a vacancy occurs, the MA 

organization transmits, within the timeframes specified by CMS, the 

information necessary for CMS to add the beneficiary



[[Page 980]]



to its records as an enrollee of the MA organization.

    (f) Exception for employer group health plans. (1) In cases in which 

an MA organization has both a Medicare contract and a contract with an 

employer group health plan, and in which the MA organization arranges 

for the employer to process elections 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. 

422.308(f)(2), 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 MA organization, he or she received the disclosure 

statement specified in Sec. 422.111.

    (3) Upon receipt of the election from the employer, the MA 

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; 70 

FR 4716, Jan. 28, 2005; 70 FR 52026, Sept. 1, 2005]