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[Laws in effect as of January 23, 2000]
[Document affected by Public Law 106-554 Section 1(a)(6)]
[Document affected by Public Law 106-554 Section 1(a)(6)[613(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[619(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[620(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[124]]
[Document affected by Public Law 106-554 Section 1(a)(6)[613(b)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[619(b)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[620(b)]]
[CITE: 42USC1395w-21]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                     Part C--Medicare+Choice Program
 
Sec. 1395w-21. Eligibility, election, and enrollment


(a) Choice of medicare benefits through Medicare+Choice plans

                           (1) In general

        Subject to the provisions of this section, each Medicare+Choice 
    eligible individual (as defined in paragraph (3)) is entitled to 
    elect to receive benefits under this subchapter--
            (A) through the original medicare fee-for-service program 
        under parts A and B of this subchapter, or
            (B) through enrollment in a Medicare+
        Choice plan under this part.

      (2) Types of Medicare+Choice plans that may be available

        A Medicare+Choice plan may be any of the following types of 
    plans of health insurance:

        (A) Coordinated care plans

            Coordinated care plans which provide health care services, 
        including but not limited to health maintenance organization 
        plans (with or without point of service options), plans offered 
        by provider-sponsored organizations (as defined in section 
        1395w-25(d) of this title), and preferred provider organization 
        plans.

        (B) Combination of MSA plan and contributions to Medicare+Choice 
                MSA

            An MSA plan, as defined in section 1395w-28(b)(3) of this 
        title, and a contribution into a Medicare+Choice medical savings 
        account (MSA).

        (C) Private fee-for-service plans

            A Medicare+Choice private fee-for-service plan, as defined 
        in section 1395w-28(b)(2) of this title.

               (3) Medicare+Choice eligible individual

        (A) In general

            In this subchapter, subject to subparagraph (B), the term 
        ``Medicare+Choice eligible individual'' means an individual who 
        is entitled to benefits under part A of this subchapter and 
        enrolled under part B of this subchapter.

        (B) Special rule for end-stage renal disease

            Such term shall not include an individual medically 
        determined to have end-stage renal disease, except that an 
        individual who develops end-stage renal disease while enrolled 
        in a Medicare+Choice plan may continue to be enrolled in that 
        plan.

(b) Special rules

                      (1) Residence requirement

        (A) In general

            Except as the Secretary may otherwise provide and except as 
        provided in subparagraph (C), an individual is eligible to elect 
        a Medicare+Choice plan offered by a Medicare+Choice organization 
        only if the plan serves the geographic area in which the 
        individual resides.

        (B) Continuation of enrollment permitted

            Pursuant to rules specified by the Secretary, the Secretary 
        shall provide that a plan may offer to all individuals residing 
        in a geographic area the option to continue enrollment in the 
        plan, notwithstanding that the individual no longer resides in 
        the service area of the plan, so long as the plan provides that 
        individuals exercising this option have, as part of the basic 
        benefits described in section 1395w-22(a)(1)(A) of this title, 
        reasonable access within that geographic area to the full range 
        of basic benefits, subject to reasonable cost sharing liability 
        in obtaining such benefits.

        (C) Continuation of enrollment permitted where service changed

            Notwithstanding subparagraph (A) and in addition to 
        subparagraph (B), if a Medicare+Choice organization eliminates 
        from its service area a Medicare+Choice payment area that was 
        previously within its service area, the organization may elect 
        to offer individuals residing in all or portions of the affected 
        area who would otherwise be ineligible to continue enrollment 
        the option to continue enrollment in a Medicare+Choice plan it 
        offers so long as--
                (i) the enrollee agrees to receive the full range of 
            basic benefits (excluding emergency and urgently needed 
            care) exclusively at facilities designated by the 
            organization within the plan service area; and
                (ii) there is no other Medicare+Choice plan offered in 
            the area in which the enrollee resides at the time of the 
            organization's election.

    (2) Special rule for certain individuals covered under FEHBP 
            or eligible for veterans or military health benefits

        (A) FEHBP

            An individual who is enrolled in a health benefit plan under 
        chapter 89 of title 5 is not eligible to enroll in an MSA plan 
        until such time as the Director of the Office of Management and 
        Budget certifies to the Secretary that the Office of Personnel 
        Management has adopted policies which will ensure that the 
        enrollment of such individuals in such plans will not result in 
        increased expenditures for the Federal Government for health 
        benefit plans under such chapter.

        (B) VA and DOD

            The Secretary may apply rules similar to the rules described 
        in subparagraph (A) in the case of individuals who are eligible 
        for health care benefits under chapter 55 of title 10 or under 
        chapter 17 of title 38.

        (3) Limitation on eligibility of qualified medicare 
             beneficiaries and other medicaid beneficiaries to 
                            enroll in an MSA plan

        An individual who is a qualified medicare beneficiary (as 
    defined in section 1396d(p)(1) of this title), a qualified disabled 
    and working individual (described in section 1396d(s) of this 
    title), an individual described in section 1396a(a)(10)(E)(iii) of 
    this title, or otherwise entitled to medicare cost-sharing under a 
    State plan under subchapter XIX of this chapter is not eligible to 
    enroll in an MSA plan.

        (4) Coverage under MSA plans on a demonstration basis

        (A) In general

            An individual is not eligible to enroll in an MSA plan under 
        this part--
                (i) on or after January 1, 2003, unless the enrollment 
            is the continuation of such an enrollment in effect as of 
            such date; or
                (ii) as of any date if the number of such individuals so 
            enrolled as of such date has reached 390,000.

        Under rules established by the Secretary, an individual is not 
        eligible to enroll (or continue enrollment) in an MSA plan for a 
        year unless the individual provides assurances satisfactory to 
        the Secretary that the individual will reside in the United 
        States for at least 183 days during the year.

        (B) Evaluation

            The Secretary shall regularly evaluate the impact of 
        permitting enrollment in MSA plans under this part on selection 
        (including adverse selection), use of preventive care, access to 
        care, and the financial status of the Trust Funds under this 
        subchapter.

        (C) Reports

            The Secretary shall submit to Congress periodic reports on 
        the numbers of individuals enrolled in such plans and on the 
        evaluation being conducted under subparagraph (B). The Secretary 
        shall submit such a report, by not later than March 1, 2002, on 
        whether the time limitation under subparagraph (A)(i) should be 
        extended or removed and whether to change the numerical 
        limitation under subparagraph (A)(ii).

(c) Process for exercising choice

                           (1) In general

        The Secretary shall establish a process through which elections 
    described in subsection (a) of this section are made and changed, 
    including the form and manner in which such elections are made and 
    changed. Such elections shall be made or changed only during 
    coverage election periods specified under subsection (e) of this 
    section and shall become effective as provided in subsection (f) of 
    this section.

       (2) Coordination through Medicare+Choice organizations

        (A) Enrollment

            Such process shall permit an individual who wishes to elect 
        a Medicare+Choice plan offered by a Medicare+Choice organization 
        to make such election through the filing of an appropriate 
        election form with the organization.

        (B) Disenrollment

            Such process shall permit an individual, who has elected a 
        Medicare+Choice plan offered by a Medicare+Choice organization 
        and who wishes to terminate such election, to terminate such 
        election through the filing of an appropriate election form with 
        the organization.

                             (3) Default

        (A) Initial election

            (i) In general

                Subject to clause (ii), an individual who fails to make 
            an election during an initial election period under 
            subsection (e)(1) of this section is deemed to have chosen 
            the original medicare fee-for-service program option.
            (ii) Seamless continuation of coverage

                The Secretary may establish procedures under which an 
            individual who is enrolled in a health plan (other than 
            Medicare+
            Choice plan) offered by a Medicare+Choice organization at 
            the time of the initial election period and who fails to 
            elect to receive coverage other than through the 
            organization is deemed to have elected the Medicare+Choice 
            plan offered by the organization (or, if the organization 
            offers more than one such plan, such plan or plans as the 
            Secretary identifies under such procedures).

        (B) Continuing periods

            An individual who has made (or is deemed to have made) an 
        election under this section is considered to have continued to 
        make such election until such time as--
                (i) the individual changes the election under this 
            section, or
                (ii) the Medicare+Choice plan with respect to which such 
            election is in effect is discontinued or, subject to 
            subsection (b)(1)(B) of this section, no longer serves the 
            area in which the individual resides.

(d) Providing information to promote informed choice

                           (1) In general

        The Secretary shall provide for activities under this subsection 
    to broadly disseminate information to medicare beneficiaries (and 
    prospective medicare beneficiaries) on the coverage options provided 
    under this section in order to promote an active, informed selection 
    among such options.

                       (2) Provision of notice

        (A) Open season notification

            At least 15 days before the beginning of each annual, 
        coordinated election period (as defined in subsection (e)(3)(B) 
        of this section), the Secretary shall mail to each 
        Medicare+Choice eligible individual residing in an area the 
        following:
            (i) General information

                The general information described in paragraph (3).
            (ii) List of plans and comparison of plan options

                A list identifying the Medicare+Choice plans that are 
            (or will be) available to residents of the area and 
            information described in paragraph (4) concerning such 
            plans. Such information shall be presented in a comparative 
            form.
            (iii) Additional information

                Any other information that the Secretary determines will 
            assist the individual in making the election under this 
            section.

        The mailing of such information shall be coordinated, to the 
        extent practicable, with the mailing of any annual notice under 
        section 1395b-2 of this title.

        (B) Notification to newly eligible Medicare+
                Choice eligible individuals

            To the extent practicable, the Secretary shall, not later 
        than 30 days before the beginning of the initial Medicare+Choice 
        enrollment period for an individual described in subsection 
        (e)(1) of this section, mail to the individual the information 
        described in subparagraph (A).

        (C) Form

            The information disseminated under this paragraph shall be 
        written and formatted using language that is easily 
        understandable by medicare beneficiaries.

        (D) Periodic updating

            The information described in subparagraph (A) shall be 
        updated on at least an annual basis to reflect changes in the 
        availability of Medicare+Choice plans and the benefits and 
        Medicare+Choice monthly basic and supplemental beneficiary 
        premiums for such plans.

                       (3) General information

        General information under this paragraph, with respect to 
    coverage under this part during a year, shall include the following:

        (A) Benefits under original medicare fee-for-service program 
                option

            A general description of the benefits covered under the 
        original medicare fee-for-service program under parts A and B of 
        this subchapter, including--
                (i) covered items and services,
                (ii) beneficiary cost sharing, such as deductibles, 
            coinsurance, and copayment amounts, and
                (iii) any beneficiary liability for balance billing.

        (B) Election procedures

            Information and instructions on how to exercise election 
        options under this section.

        (C) Rights

            A general description of procedural rights (including 
        grievance and appeals procedures) of beneficiaries under the 
        original medicare fee-for-service program and the Medicare+
        Choice program and the right to be protected against 
        discrimination based on health status-related factors under 
        section 1395w-22(b) of this title.

        (D) Information on medigap and medicare select

            A general description of the benefits, enrollment rights, 
        and other requirements applicable to medicare supplemental 
        policies under section 1395ss of this title and provisions 
        relating to medicare select policies described in section 
        1395ss(t) of this title.

        (E) Potential for contract termination

            The fact that a Medicare+Choice organization may terminate 
        its contract, refuse to renew its contract, or reduce the 
        service area included in its contract, under this part, and the 
        effect of such a termination, nonrenewal, or service area 
        reduction may have on individuals enrolled with the 
        Medicare+Choice plan under this part.

               (4) Information comparing plan options

        Information under this paragraph, with respect to a 
    Medicare+Choice plan for a year, shall include the following:

        (A) Benefits

            The benefits covered under the plan, including the 
        following:
                (i) Covered items and services beyond those provided 
            under the original medicare fee-for-service program.
                (ii) Any beneficiary cost sharing.
                (iii) Any maximum limitations on out-of-pocket expenses.
                (iv) In the case of an MSA plan, differences in cost 
            sharing, premiums, and balance billing under such a plan 
            compared to under other Medicare+Choice plans.
                (v) In the case of a Medicare+Choice private fee-for-
            service plan, differences in cost sharing, premiums, and 
            balance billing under such a plan compared to under other 
            Medicare+Choice plans.
                (vi) The extent to which an enrollee may obtain benefits 
            through out-of-network health care providers.
                (vii) The extent to which an enrollee may select among 
            in-network providers and the types of providers 
            participating in the plan's network.
                (viii) The organization's coverage of emergency and 
            urgently needed care.

        (B) Premiums

            The Medicare+Choice monthly basic beneficiary premium and 
        Medicare+Choice monthly supplemental beneficiary premium, if 
        any, for the plan or, in the case of an MSA plan, the 
        Medicare+Choice monthly MSA premium.

        (C) Service area

            The service area of the plan.

        (D) Quality and performance

            To the extent available, plan quality and performance 
        indicators for the benefits under the plan (and how they compare 
        to such indicators under the original medicare fee-for-service 
        program under parts A and B of this subchapter in the area 
        involved), including--
                (i) disenrollment rates for medicare enrollees electing 
            to receive benefits through the plan for the previous 2 
            years (excluding disenrollment due to death or moving 
            outside the plan's service area),
                (ii) information on medicare enrollee satisfaction,
                (iii) information on health outcomes, and
                (iv) the recent record regarding compliance of the plan 
            with requirements of this part (as determined by the 
            Secretary).

        (E) Supplemental benefits

            Whether the organization offering the plan includes 
        mandatory supplemental benefits in its base benefit package or 
        offers optional supplemental benefits and the terms and 
        conditions (including premiums) for such coverage.

        (5) Maintaining a toll-free number and Internet site

        The Secretary shall maintain a toll-free number for inquiries 
    regarding Medicare+
    Choice options and the operation of this part in all areas in which 
    Medicare+Choice plans are offered and an Internet site through which 
    individuals may electronically obtain information on such options 
    and Medicare+Choice plans.

                   (6) Use of non-Federal entities

        The Secretary may enter into contracts with non-Federal entities 
    to carry out activities under this subsection.

                    (7) Provision of information

        A Medicare+Choice organization shall provide the Secretary with 
    such information on the organization and each Medicare+Choice plan 
    it offers as may be required for the preparation of the information 
    referred to in paragraph (2)(A).

(e) Coverage election periods

      (1) Initial choice upon eligibility to make election if 
                Medicare+Choice plans available to individual

        If, at the time an individual first becomes entitled to benefits 
    under part A of this subchapter and enrolled under part B of this 
    subchapter, there is one or more Medicare+Choice plans offered in 
    the area in which the individual resides, the individual shall make 
    the election under this section during a period specified by the 
    Secretary such that if the individual elects a Medicare+Choice plan 
    during the period, coverage under the plan becomes effective as of 
    the first date on which the individual may receive such coverage.

         (2) Open enrollment and disenrollment opportunities

        Subject to paragraph (5)--

        (A) Continuous open enrollment and disenrollment through 2001

            At any time during 1998, 1999, 2000, and 2001, a 
        Medicare+Choice eligible individual may change the election 
        under subsection (a)(1) of this section.

        (B) Continuous open enrollment and disenrollment for first 6 
                months during 2002

            (i) In general

                Subject to clause (ii) and subparagraph (D), at any time 
            during the first 6 months of 2002, or, if the individual 
            first becomes a Medicare+Choice eligible individual during 
            2002, during the first 6 months during 2002 in which the 
            individual is a Medicare+Choice eligible individual, a 
            Medicare+Choice eligible individual may change the election 
            under subsection (a)(1) of this section.
            (ii) Limitation of one change

                An individual may exercise the right under clause (i) 
            only once. The limitation under this clause shall not apply 
            to changes in elections effected during an annual, 
            coordinated election period under paragraph (3) or during a 
            special enrollment period under the first sentence of 
            paragraph (4).

        (C) Continuous open enrollment and disenrollment for first 3 
                months in subsequent years

            (i) In general

                Subject to clause (ii) and subparagraph (D), at any time 
            during the first 3 months of a year after 2002, or, if the 
            individual first becomes a Medicare+Choice eligible 
            individual during a year after 2002, during the first 3 
            months of such year in which the individual is a 
            Medicare+Choice eligible individual, a Medicare+Choice 
            eligible individual may change the election under subsection 
            (a)(1) of this section.
            (ii) Limitation of one change during open enrollment 
                    period each year

                An individual may exercise the right under clause (i) 
            only once during the applicable 3-month period described in 
            such clause in each year. The limitation under this clause 
            shall not apply to changes in elections effected during an 
            annual, coordinated election period under paragraph (3) or 
            during a special enrollment period under paragraph (4).

        (D) Continuous open enrollment for institutionalized individuals

            At any time after 2001 in the case of a Medicare+Choice 
        eligible individual who is institutionalized (as defined by the 
        Secretary), the individual may elect under subsection (a)(1) of 
        this section--
                (i) to enroll in a Medicare+Choice plan; or
                (ii) to change the Medicare+Choice plan in which the 
            individual is enrolled.

               (3) Annual, coordinated election period

        (A) In general

            Subject to paragraph (5), each individual who is eligible to 
        make an election under this section may change such election 
        during an annual, coordinated election period.

        (B) Annual, coordinated election period

            For purposes of this section, the term ``annual, coordinated 
        election period'' means, with respect to a calendar year 
        (beginning with 2000), the month of November before such year.

        (C) Medicare+Choice health information fairs

            During the fall season of each year (beginning with 1999), 
        in conjunction with the annual coordinated election period 
        defined in subparagraph (B), the Secretary shall provide for a 
        nationally coordinated educational and publicity campaign to 
        inform Medicare+Choice eligible individuals about 
        Medicare+Choice plans and the election process provided under 
        this section.

        (D) Special information campaign in 1998

            During November 1998 the Secretary shall provide for an 
        educational and publicity campaign to inform Medicare+Choice 
        eligible individuals about the availability of Medicare+Choice 
        plans, and eligible organizations with risk-sharing contracts 
        under section 1395mm of this title, offered in different areas 
        and the election process provided under this section.

                    (4) Special election periods

        Effective as of January 1, 2002, an individual may discontinue 
    an election of a Medicare+
    Choice plan offered by a Medicare+Choice organization other than 
    during an annual, coordinated election period and make a new 
    election under this section if--
            (A)(i) the certification of the organization or plan under 
        this part has been terminated, or the organization or plan has 
        notified the individual of an impending termination of such 
        certification; or
            (ii) the organization has terminated or otherwise 
        discontinued providing the plan in the area in which the 
        individual resides, or has notified the individual of an 
        impending termination or discontinuation of such plan;
            (B) the individual is no longer eligible to elect the plan 
        because of a change in the individual's place of residence or 
        other change in circumstances (specified by the Secretary, but 
        not including termination of the individual's enrollment on the 
        basis described in clause (i) or (ii) of subsection (g)(3)(B) of 
        this section);
            (C) the individual demonstrates (in accordance with 
        guidelines established by the Secretary) that--
                (i) the organization offering the plan substantially 
            violated a material provision of the organization's contract 
            under this part in relation to the individual (including the 
            failure to provide an enrollee on a timely basis medically 
            necessary care for which benefits are available under the 
            plan or the failure to provide such covered care in 
            accordance with applicable quality standards); or
                (ii) the organization (or an agent or other entity 
            acting on the organization's behalf) materially 
            misrepresented the plan's provisions in marketing the plan 
            to the individual; or

            (D) the individual meets such other exceptional conditions 
        as the Secretary may provide.

    Effective as of January 1, 2002, an individual who, upon first 
    becoming eligible for benefits under part A of this subchapter at 
    age 65, enrolls in a Medicare+Choice plan under this part, the 
    individual may discontinue the election of such plan, and elect 
    coverage under the original fee-for-service plan, at any time during 
    the 12-month period beginning on the effective date of such 
    enrollment.

                   (5) Special rules for MSA plans

        Notwithstanding the preceding provisions of this subsection, an 
    individual--
            (A) may elect an MSA plan only during--
                (i) an initial open enrollment period described in 
            paragraph (1),
                (ii) an annual, coordinated election period described in 
            paragraph (3)(B), or
                (iii) the month of November 1998;

            (B) subject to subparagraph (C), may not discontinue an 
        election of an MSA plan except during the periods described in 
        clause (ii) or (iii) of subparagraph (A) and under the first 
        sentence of paragraph (4); and
            (C) who elects an MSA plan during an annual, coordinated 
        election period, and who never previously had elected such a 
        plan, may revoke such election, in a manner determined by the 
        Secretary, by not later than December 15 following the date of 
        the election.

                     (6) Open enrollment periods

        Subject to paragraph (5), a Medicare+Choice organization--
            (A) shall accept elections or changes to elections during 
        the initial enrollment periods described in paragraph (1), 
        during the month of November 1998 and each subsequent year (as 
        provided in paragraph (3)), and during special election periods 
        described in the first sentence of paragraph (4); and
            (B) may accept other changes to elections at such other 
        times as the organization provides.

(f) Effectiveness of elections and changes of elections

             (1) During initial coverage election period

        An election of coverage made during the initial coverage 
    election period under subsection (e)(1)(A) of this section shall 
    take effect upon the date the individual becomes entitled to 
    benefits under part A of this subchapter and enrolled under part B 
    of this subchapter, except as the Secretary may provide (consistent 
    with section 1395q of this title) in order to prevent retroactive 
    coverage.

            (2) During continuous open enrollment periods

        An election or change of coverage made under subsection (e)(2) 
    of this section shall take effect with the first day of the first 
    calendar month following the date on which the election or change is 
    made, except that if such election or change is made after the 10th 
    day of any calendar month, then the election or change shall not 
    take effect until the first day of the second calendar month 
    following the date on which the election or change is made.

               (3) Annual, coordinated election period

        An election or change of coverage made during an annual, 
    coordinated election period (as defined in subsection (e)(3)(B) of 
    this section) in a year shall take effect as of the first day of the 
    following year.

                          (4) Other periods

        An election or change of coverage made during any other period 
    under subsection (e)(4) of this section shall take effect in such 
    manner as the Secretary provides in a manner consistent (to the 
    extent practicable) with protecting continuity of health benefit 
    coverage.

(g) Guaranteed issue and renewal

                           (1) In general

        Except as provided in this subsection, a Medicare+Choice 
    organization shall provide that at any time during which elections 
    are accepted under this section with respect to a Medicare+Choice 
    plan offered by the organization, the organization will accept 
    without restrictions individuals who are eligible to make such 
    election.

                            (2) Priority

        If the Secretary determines that a Medicare+Choice organization, 
    in relation to a Medicare+Choice plan it offers, has a capacity 
    limit and the number of Medicare+Choice eligible individuals who 
    elect the plan under this section exceeds the capacity limit, the 
    organization may limit the election of individuals of the plan under 
    this section but only if priority in election is provided--
            (A) first to such individuals as have elected the plan at 
        the time of the determination, and
            (B) then to other such individuals in such a manner that 
        does not discriminate, on a basis described in section 1395w-
        22(b) of this title, among the individuals (who seek to elect 
        the plan).

    The preceding sentence shall not apply if it would result in the 
    enrollment of enrollees substantially nonrepresentative, as 
    determined in accordance with regulations of the Secretary, of the 
    medicare population in the service area of the plan.

              (3) Limitation on termination of election

        (A) In general

            Subject to subparagraph (B), a Medicare+
        Choice organization may not for any reason terminate the 
        election of any individual under this section for a 
        Medicare+Choice plan it offers.

        (B) Basis for termination of election

            A Medicare+Choice organization may terminate an individual's 
        election under this section with respect to a Medicare+Choice 
        plan it offers if--
                (i) any Medicare+Choice monthly basic and supplemental 
            beneficiary premiums required with respect to such plan are 
            not paid on a timely basis (consistent with standards under 
            section 1395w-26 of this title that provide for a grace 
            period for late payment of such premiums),
                (ii) the individual has engaged in disruptive behavior 
            (as specified in such standards), or
                (iii) the plan is terminated with respect to all 
            individuals under this part in the area in which the 
            individual resides.

        (C) Consequence of termination

            (i) Terminations for cause

                Any individual whose election is terminated under clause 
            (i) or (ii) of subparagraph (B) is deemed to have elected 
            the original medicare fee-for-service program option 
            described in subsection (a)(1)(A) of this section.
            (ii) Termination based on plan termination or 
                    service area reduction

                Any individual whose election is terminated under 
            subparagraph (B)(iii) shall have a special election period 
            under subsection (e)(4)(A) of this section in which to 
            change coverage to coverage under another Medicare+Choice 
            plan. Such an individual who fails to make an election 
            during such period is deemed to have chosen to change 
            coverage to the original medicare fee-for-service program 
            option described in subsection (a)(1)(A) of this section.

        (D) Organization obligation with respect to election forms

            Pursuant to a contract under section 1395w-27 of this title, 
        each Medicare+Choice organization receiving an election form 
        under subsection (c)(2) of this section shall transmit to the 
        Secretary (at such time and in such manner as the Secretary may 
        specify) a copy of such form or such other information 
        respecting the election as the Secretary may specify.

(h) Approval of marketing material and application forms

                           (1) Submission

        No marketing material or application form may be distributed by 
    a Medicare+Choice organization to (or for the use of) Medicare+
    Choice eligible individuals unless--
            (A) at least 45 days before the date of distribution the 
        organization has submitted the material or form to the Secretary 
        for review, and
            (B) the Secretary has not disapproved the distribution of 
        such material or form.

                             (2) Review

        The standards established under section 1395w-26 of this title 
    shall include guidelines for the review of any material or form 
    submitted and under such guidelines the Secretary shall disapprove 
    (or later require the correction of) such material or form if the 
    material or form is materially inaccurate or misleading or otherwise 
    makes a material misrepresentation.

                (3) Deemed approval (1-stop shopping)

        In the case of material or form that is submitted under 
    paragraph (1)(A) to the Secretary or a regional office of the 
    Department of Health and Human Services and the Secretary or the 
    office has not disapproved the distribution of marketing material or 
    form under paragraph (1)(B) with respect to a Medicare+Choice plan 
    in an area, the Secretary is deemed not to have disapproved such 
    distribution in all other areas covered by the plan and organization 
    except with regard to that portion of such material or form that is 
    specific only to an area involved.

           (4) Prohibition of certain marketing practices

        Each Medicare+Choice organization shall conform to fair 
    marketing standards, in relation to Medicare+Choice plans offered 
    under this part, included in the standards established under section 
    1395w-26 of this title. Such standards--
            (A) shall not permit a Medicare+Choice organization to 
        provide for cash or other monetary rebates as an inducement for 
        enrollment or otherwise, and
            (B) may include a prohibition against a Medicare+Choice 
        organization (or agent of such an organization) completing any 
        portion of any election form used to carry out elections under 
        this section on behalf of any individual.

(i) Effect of election of Medicare+Choice plan option

                    (1) Payments to organizations

        Subject to sections 1395w-22(a)(5), 1395w-23(g), 1395w-23(h), 
    1395ww(d)(11), and 1395ww(h)(3)(D) of this title, payments under a 
    contract with a Medicare+Choice organization under section 1395w-
    23(a) of this title with respect to an individual electing a 
    Medicare+
    Choice plan offered by the organization shall be instead of the 
    amounts which (in the absence of the contract) would otherwise be 
    payable under parts A and B of this subchapter for items and 
    services furnished to the individual.

              (2) Only organization entitled to payment

        Subject to sections 1395w-23(e), 1395w-23(g), 1395w-23(h), 
    1395w-27(f)(2), 1395ww(d)(11), and 1395ww(h)(3)(D) of this title, 
    only the Medicare+Choice organization shall be entitled to receive 
    payments from the Secretary under this subchapter for services 
    furnished to the individual.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1851, as added Pub. L. 105-
33, title IV, Sec. 4001, Aug. 5, 1997, 111 Stat. 275; amended Pub. L. 
106-113, div. B, Sec. 1000(a)(6) [title III, Sec. 321(k)(6)(A), title V, 
Secs. 501(a)(1), (b), (c), 502(a), 519(a)], Nov. 29, 1999, 113 Stat. 
1536, 1501A-367, 1501A-378 to 1501A-380, 1501A-385.)

                       References in Text

    Parts A and B of this subchapter, referred to in text, are 
classified to section 1395c et seq. and section 1395j et seq., 
respectively, of this title.


                               Amendments

    1999--Subsec. (b)(1)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 501(c)(1)], inserted ``and except as provided in subparagraph (C)'' 
after ``may otherwise provide''.
    Subsec. (b)(1)(C). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 501(c)(2)], added subpar. (C).
    Subsec. (e)(2)(B)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 501(b)(1)], inserted ``and subparagraph (D)'' after ``clause 
(ii)''.
    Subsec. (e)(2)(C)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 501(b)(2)], inserted ``and subparagraph (D)'' after ``clause 
(ii)''.
    Subsec. (e)(2)(D). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 501(b)(3)], added subpar. (D).
    Subsec. (e)(3)(C). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 519(a)], substituted ``During the fall season'' for ``In the month 
of November''.
    Subsec. (e)(4)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 501(a)(1)], added subpar. (A) and struck out former subpar. (A) 
which read as follows: ``the organization's or plan's certification 
under this part has been terminated or the organization has terminated 
or otherwise discontinued providing the plan in the area in which the 
individual resides;''.
    Subsec. (f)(2). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 502(a)], inserted ``or change'' before ``is made'' and ``, except 
that if such election or change is made after the 10th day of any 
calendar month, then the election or change shall not take effect until 
the first day of the second calendar month following the date on which 
the election or change is made'' before the period at end.
    Subsec. (i)(2). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(6)(A)], struck out ``and'' after ``1395w-27(f)(2),''.


                    Effective Date of 1999 Amendment

    Amendment by section 1000(a)(6) [title III, Sec. 321(k)(6)(A)] of 
Pub. L. 106-113 effective as if included in the enactment of the 
Balanced Budget Act of 1997, Pub. L. 105-33, except as otherwise 
provided, see section 1000(a)(6) [title III, Sec. 321(m)] of Pub. L. 
106-113, set out as a note under section 1395d of this title.
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 501(d)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-379, provided that:
    ``(1) The amendments made by subsection (a) [amending this section 
and section 1395ss of this title] apply to notices of impending 
terminations or discontinuances made on or after the date of the 
enactment of this Act [Nov. 29, 1999].
    ``(2) The amendments made by subsection (c) [amending this section] 
apply to elections made on or after the date of the enactment of this 
Act [Nov. 29, 1999] with respect to eliminations of Medicare+Choice 
payment areas from a service area that occur before, on, or after the 
date of the enactment of this Act.''
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 502(b)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-380, provided that: ``The 
amendments made by this section [amending this section] apply to 
elections and changes of coverage made on or after January 1, 2000.''
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 519(b)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-385, provided that: ``The amendment 
made by subsection (a) [amending this section] first applies to 
campaigns conducted beginning in 2000.''


      Report on Accounting for VA and DOD Expenditures for Medicare 
                              Beneficiaries

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 551], Nov. 
29, 1999, 113 Stat. 1536, 1501A-392, provided that: ``Not later [than] 
April 1, 2001, the Secretary of Health and Human Services, jointly with 
the Secretaries of Defense and of Veterans Affairs, shall submit to 
Congress a report on the estimated use of health care services furnished 
by the Departments of Defense and of Veterans Affairs to medicare 
beneficiaries, including both beneficiaries under the original medicare 
fee-for-service program and under the Medicare+Choice program. The 
report shall include an analysis of how best to properly account for 
expenditures for such services in the computation of Medicare+Choice 
capitation rates.''


         Report on Medicare MSA (Medical Savings Account) Plans

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 552(b)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-393, provided that: ``Not later 
than 1 year after the date of the enactment of this Act [Nov. 29, 1999], 
the Medicare Payment Assessment Commission shall submit to Congress a 
report on specific legislative changes that should be made to make MSA 
plans (as defined in section 1859(b)(3) of the Social Security Act, 42 
U.S.C. 1395w-29(b)(3) [1395w-28(b)(3)]) a viable option under the 
Medicare+Choice program.''


GAO Audit and Reports on Provision of Medicare+Choice Health Information 
                            to Beneficiaries

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 553(b)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-393, provided that:
    ``(1) In general.--Beginning in 2000, the Comptroller General shall 
conduct an annual audit of the expenditures by the Secretary of Health 
and Human Services during the preceding year in providing information 
regarding the Medicare+Choice program under part C of title XVIII of the 
Social Security Act (42 U.S.C. 1395w-21 et seq.) to eligible medicare 
beneficiaries.
    ``(3) [(2)] Reports.--Not later than March 31 of 2001, 2004, 2007, 
and 2010, the Comptroller General shall submit a report to Congress on 
the results of the audit of the expenditures of the preceding 3 years 
conducted pursuant to subsection (a) [enacting provisions set out as a 
note under section 1395ss of this title], together with an evaluation of 
the effectiveness of the means used by the Secretary of Health and Human 
Services in providing information regarding the Medicare+Choice program 
under part C of title XVIII of the Social Security Act (42 U.S.C. 1395w-
21 et seq.) to eligible medicare beneficiaries.''


                       Enrollment Transition Rule

    Section 4002(c) of Pub. L. 105-33 provided that: ``An individual who 
is enrolled on December 31, 1998, with an eligible organization under 
section 1876 of the Social Security Act (42 U.S.C. 1395mm) shall be 
considered to be enrolled with that organization on January 1, 1999, 
under part C of title XVIII of such Act [this part] if that organization 
has a contract under that part for providing services on January 1, 1999 
(unless the individual has disenrolled effective on that date).''


             Secretarial Submission of Legislative Proposal

    Section 4002(f)(2) of title IV of Pub. L. 105-33 provided that: 
``Not later than 6 months after the date of the enactment of this Act 
[Aug. 5, 1997], the Secretary of Health and Human Services shall submit 
to the appropriate committees of Congress a legislative proposal 
providing for such technical and conforming amendments in the law as are 
required by the provisions of this chapter [chapter 1 (Secs. 4001-4006) 
of subtitle A of title IV of Pub. L. 105-33, see Tables for 
classification].''


                  Report on Integration and Transition

    Section 4014(c) of Pub. L. 105-33 provided that:
    ``(1) In general.--The Secretary of Health and Human Services shall 
submit to Congress, by not later than January 1, 1999, a plan for the 
integration of health plans offered by social health maintenance 
organizations (including SHMO I and SHMO II sites developed under 
section 2355 of the Deficit Reduction Act of 1984 [Pub. L. 98-369, 98 
Stat. 1103] and under the amendment made by section 4207(b)(3)(B)(i) of 
OBRA-1990 [Pub. L. 101-508, amending provisions set out as a note under 
section 1395pp of this title], respectively) and similar plans as an 
option under the Medicare+Choice program under part C of title XVIII of 
the Social Security Act [this part].
    ``(2) Provision for transition.--Such plan shall include a 
transition for social health maintenance organizations operating under 
demonstration project authority under such section.
    ``(3) Payment policy.--The report shall also include recommendations 
on appropriate payment levels for plans offered by such organizations, 
including an analysis of the application of risk adjustment factors 
appropriate to the population served by such organizations.''


                Medicare Enrollment Demonstration Project

    Section 4018 of Pub. L. 105-33 provided that:
    ``(a) Demonstration Project.--
        ``(1) Establishment.--The Secretary shall implement a 
    demonstration project (in this section referred to as the `project') 
    for the purpose of evaluating the use of a third-party contractor to 
    conduct the Medicare+Choice plan enrollment and disenrollment 
    functions, as described in part C of title XVIII of the Social 
    Security Act [this part] (as added by section 4001 of this Act), in 
    an area.
        ``(2) Consultation.--Before implementing the project under this 
    section, the Secretary shall consult with affected parties on--
            ``(A) the design of the project;
            ``(B) the selection criteria for the third-party contractor; 
        and
            ``(C) the establishment of performance standards, as 
        described in paragraph (3).
        ``(3) Performance standards.--
            ``(A) In general.--The Secretary shall establish performance 
        standards for the accuracy and timeliness of the Medicare+Choice 
        plan enrollment and disenrollment functions performed by the 
        third-party contractor.
            ``(B) Noncompliance.--In the event that the third-party 
        contractor is not in substantial compliance with the performance 
        standards established under subparagraph (A), such enrollment 
        and disenrollment functions shall be performed by the 
        Medicare+Choice plan until the Secretary appoints a new third-
        party contractor.
    ``(b) Report to Congress.--The Secretary shall periodically report 
to Congress on the progress of the project conducted pursuant to this 
section.
    ``(c) Waiver Authority.--The Secretary shall waive compliance with 
the requirements of part C of title XVIII of the Social Security Act 
[this part] (as amended by section 4001 of this Act) to such extent and 
for such period as the Secretary determines is necessary to conduct the 
project.
    ``(d) Duration.--A demonstration project under this section shall be 
conducted for a 3-year period.
    ``(e) Separate From Other Demonstration Projects.--A project 
implemented by the Secretary under this section shall not be conducted 
in conjunction with any other demonstration project.''

                  Section Referred to in Other Sections

    This section is referred to in sections 1395w-22, 1395w-23, 1395w-
24, 1395w-27, 1395w-28, 1395mm, 1395nn, 1395ss, 1395ggg of this title.
