[Code of Federal Regulations]
[Title 42, Volume 3]
[Revised as of October 1, 2006]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR422.60]

[Page 238-239]
 
                         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.

[[Page 239]]

    (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 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]