42 U.S.C. § 1395w–21 — Eligibility, election, and enrollment

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

(1) In general. Subject to this section, each “Medicare+Choice eligible individual” may choose to receive benefits, other than qualified prescription drug^* benefits, under this subchapter in either of two ways: (A) through the original Medicare fee-for-service program under parts A and B; or (B) by enrolling in a Medicare+Choice plan^* under this part. The individual may also choose qualified prescription drug coverage under section 1395w–101 of this title. This section does not define the quoted terms “qualified prescription drug benefits” or “qualified prescription drug coverage.”

(2) Types of plans that may be available. A Medicare+Choice plan may be any of these health-insurance plan types:

(A) Coordinated care plans, including regional plans.

(i) In general. These are plans that provide health care services. They include, but are 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 regional or local preferred-provider-organization plans, including MA regional plans.

(ii) Specialized MA plans for people with special needs. A specialized MA plan for a special-needs individual, as defined in section 1395w–28(b)(6) of this title, may be any type of coordinated care plan.

(B) An MSA plan^* combined with contributions to a Medicare+Choice MSA. This means an MSA plan, as defined in section 1395w–28(b)(3) of this title, and a contribution to a Medicare+Choice medical savings account (MSA).

(C) Private fee-for-service plans. This means a Medicare+Choice private fee-for-service plan^*, as defined in section 1395w–28(b)(2) of this title.

(3) Medicare+Choice eligible individual. In this subchapter, “Medicare+Choice eligible individual” means a person^* entitled to benefits under part A and enrolled under part B. This section does not otherwise define the quoted term.

(b) Special rules

(1) Residence requirement.

(A) In general. Unless the Secretary^* provides otherwise, and except as provided in (C), a person may choose a Medicare+Choice plan offered by a Medicare+Choice organization^* only if the plan serves the geographic area where the person lives.

(B) Continued enrollment permitted. Under rules set by the Secretary, an MA local plan^* may offer every person living in a geographic area the option to stay enrolled even after the person moves outside the plan’s service area. To do so, the plan must provide that the person has reasonable access in that geographic area to the full range of basic benefits available under the original Medicare fee-for-service option. The person may be required to pay reasonable cost sharing for those benefits.

(C) Continued enrollment when the service area changes. In addition to (B), if a Medicare+Choice organization removes from its service area a Medicare+Choice payment area that used to be included, it may offer people living in all or part of the affected area the option to stay enrolled in an MA local plan, even though they otherwise could not stay enrolled, only if both conditions apply:

(i) The enrollee agrees to receive the full range of basic benefits, except emergency and urgently needed care, only at facilities the organization designates inside the plan’s service area; and

(ii) when the organization makes this choice, no other Medicare+Choice plan is offered in the area where the enrollee lives.

(2) Certain people covered by FEHBP or eligible for veterans’ or military health benefits.

(A) FEHBP. A person enrolled in a health-benefit plan under chapter 89 of title 5 may not enroll in an MSA plan until the Director^* of the Office of Management and Budget certifies to the Secretary that the Office of Personnel Management has adopted policies ensuring that enrollment of these people will not increase Federal Government spending for health-benefit plans under that chapter.

(B) VA and DOD. The Secretary may apply similar rules to people eligible for health-care benefits under chapter 55 of title 10 or chapter 17 of title 38.

(3) Limits on MSA enrollment for certain Medicare and Medicaid beneficiaries. A person may not enroll in an MSA plan if the person 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; a person described in section 1396a(a)(10)(E)(iii) of this title; or a person otherwise entitled to Medicare cost sharing under a State^* plan under subchapter XIX. This section does not define the quoted terms.

(4) Coverage under MSA plans.

(A) In general. Under the Secretary’s rules, a person may not enroll in, or remain enrolled in, an MSA plan for a year unless the person gives the Secretary satisfactory assurance that the person will live in the United States^* for at least 183 days during that year.

(B) Evaluation. The Secretary must regularly evaluate how allowing MSA enrollment under this part affects selection, including adverse selection; use of preventive care; access to care; and the financial condition of the Trust Funds under this subchapter.

(C) Reports. The Secretary must periodically report to Congress the number of people enrolled in these plans and the results of the evaluation under (B).

(c) Process for exercising choice

(1) In general. The Secretary must establish a process for making and changing the choices described in (a), including the required form and method. Subject to (4), a choice may be made or changed only during the coverage-election periods in (e), and it takes effect as provided in (f).

(2) Coordination through Medicare+Choice organizations.

(A) Enrollment. The process must allow a person who wants to choose a Medicare+Choice plan offered by a Medicare+Choice organization to make that choice by filing the proper election form with the organization.

(B) Disenrollment. The process must allow a person who chose such a plan and wants to end that choice to do so by filing the proper election form with the organization.

(3) Default choices.

(A) Initial choice.

(i) In general. Subject to (ii), a person who does not make a choice during the initial election period under (e)(1) is treated as having chosen the original Medicare fee-for-service option.

(ii) Seamless continuation of coverage. The Secretary may establish procedures treating a person as having chosen a Medicare+Choice plan offered by an organization if, during the initial election period, the person is enrolled in a different health plan^* offered by that organization and does not choose coverage outside the organization. If the organization offers more than one such plan, the procedures may identify which plan or plans the person is treated as choosing.

(B) Continuing periods. A person who has made, or is treated as having made, a choice under this section is treated as continuing that choice until either (i) the person changes it under this section, or (ii) the Medicare+Choice plan ends or, subject to (b)(1)(B), no longer serves the area where the person lives.

(4) Deemed enrollment after converted reasonable-cost reimbursement contracts.

(A) In general. On the first day of the annual coordinated election period under (e)(3), for plan years beginning on or after January 1, 2017, an MA-eligible person described in (B)(i) or (B)(ii) is treated as having chosen, and must be enrolled in, an applicable MA plan for that plan year unless the person chooses otherwise. This happens only if all of the following conditions are met:

(i) The person was enrolled in a reasonable-cost reimbursement contract under section 1395mm(h) of this title during the previous plan year.

(ii) That contract was extended or renewed for its last reasonable-cost-contract year under section 1395mm(h), as described in section 1395mm(h)(5)(C)(iv)(I).

(iii) The eligible organization offering the contract gave the notice described in section 1395mm(h)(5)(C)(iv)(III) stating that the contract would be converted.

(iv) The applicable MA plan (I) is the plan converted from that contract; (II) is offered by the same entity, or by an affiliated organization with common ownership or control, that entered into the contract; and (III) is offered in the service area where the person lives.

(v) For contracts covering parts A and B, and, when the Secretary finds it feasible, contracts covering only part B, the difference between the person’s estimated costs under the applicable MA plan and under the predecessor cost plan does not exceed a threshold set by the Secretary.

(vi) The applicable MA plan (I) lets people moving from the converted contract keep their current providers and suppliers and continue their course of treatment^* for at least 90 days after enrollment; and (II) during that period pays those providers and suppliers for items and services given to the enrollee at least the amount that would apply under the original Medicare fee-for-service program under parts A and B.

(B) MA-eligible people described.

(i) Without prescription drug coverage. For a plan year, this means an MA-eligible person who was enrolled in a reasonable-cost reimbursement contract under section 1395mm(h) during the previous plan year and was not enrolled during that previous year in a part D prescription drug plan, including coverage under section 1395w–132 of this title.

(ii) With prescription drug coverage. For a plan year, this means an MA-eligible person who was enrolled in such a contract during the previous plan year and was enrolled in a part D prescription drug plan either (I) through that contract, or (II) through a prescription drug plan whose sponsor is the same entity, or an affiliated organization, that entered into the contract.

(C) Definition of applicable MA plan. For a person described in (B)(i), “applicable MA plan” means an MA plan that is not an MA–PD plan. For a person described in (B)(ii), it means an MA–PD plan. This section does not otherwise define those quoted terms.

(D) Identifying and notifying people subject to deemed elections. No later than 45 days before the first day of the annual coordinated election period under (e)(3) for plan years beginning on or after January 1, 2017, the Secretary must identify and notify the people who will be subject to deemed elections under (A) on the first day of that period.

(d) Providing information to promote informed choice

(1) In general. The Secretary must arrange activities that broadly provide Medicare beneficiaries and prospective beneficiaries with information about the coverage choices under this section, so they can make an active and informed choice.

(2) Notices.

(A) Open-season notice. At least 15 days before each annual coordinated election period defined in (e)(3)(B), the Secretary must mail each Medicare+Choice eligible individual living in an area:

(i) the general information described in (3);

(ii) a list of the Medicare+Choice plans that are, or will be, available to area residents, together with the information about those plans described in (4), presented in a comparison; and

(iii) any other information the Secretary decides will help the person make the choice under this section. To the extent practicable, this mailing must be coordinated with any annual notice mailed under section 1395b–2 of this title.

(B) Required notices.

(i) Newly eligible people. To the extent practicable, no later than 30 days before the initial Medicare+Choice enrollment period for a person described in (e)(1), the Secretary must mail that person the information described in (A).

(ii) Certain deemed elections. The Secretary must require a Medicare Advantage organization offering a plan converted from a reasonable-cost reimbursement contract under section 1395mm(h)(5)(C)(iv) to mail, no later than 30 days before the first day of that year’s annual coordinated election period, each person enrolled under the contract whom the Secretary identified under (c)(4)(D): (I) notice that on that day the person will be treated as having chosen and will be enrolled in the MA plan or MA–PD plan for the next plan year under (c)(4)(A), but may choose differently during that year’s annual period; (II) the information described in (A); (III) a description of differences between the MA plan or MA–PD plan and the person’s most recent reasonable-cost reimbursement contract, including cost sharing, premiums, drug coverage, and provider networks; (IV) information about the special election period under (e)(2)(F); and (V) any other information the Secretary specifies.

(C) Form. The information under this paragraph must be written and formatted in language Medicare beneficiaries can easily understand.

(D) Updating. The information in (A) must be updated at least once a year to show changes in available plans and in the benefits and Medicare+Choice monthly basic and supplemental beneficiary premiums for those plans.

(3) General information. For coverage under this part during a year, the general information must include:

(A) a general description of benefits under the original Medicare fee-for-service option under parts A and B, including (i) covered items and services, (ii) beneficiary cost sharing such as deductibles, coinsurance, and copayments, and (iii) any beneficiary responsibility for balance billing;

(B) information and instructions on how to make a choice under this section;

(C) a general description of beneficiaries’ procedural rights, including grievance and appeal procedures, under the original Medicare fee-for-service and Medicare+Choice programs, and the right to protection against discrimination based on health-status-related factors under section 1395w–22(b) of this title;

(D) a general description of the benefits, enrollment rights, and other requirements for Medicare supplemental policies under section 1395ss of this title and of the provisions for Medicare Select policies described in section 1395ss(t) of this title;

(E) the fact that a Medicare+Choice organization may terminate or refuse to renew its contract, or reduce the contract’s service area, under this part, and the possible effect on people enrolled in its plan; and

(F) for an MA regional plan^*, a description of the plan’s catastrophic coverage and single deductible.

(4) Information comparing plan choices. For a Medicare+Choice plan for a year, the information must include:

(A) benefits, including (i) covered items and services beyond those in the original fee-for-service program; (ii) beneficiary cost sharing, including the single deductible if applicable under section 1395w–27a(b)(1); (iii) any maximum on out-of-pocket expenses; (iv) for an MSA plan, how cost sharing, premiums, and balance billing differ from other Medicare+Choice plans; (v) for a private fee-for-service plan, those same differences compared with other plans; (vi) how far an enrollee may obtain benefits from out-of-network providers; (vii) how far an enrollee may choose among in-network providers and what kinds of providers are in the network; and (viii) the organization’s coverage of emergency and urgently needed care;

(B) premiums, including (i) the monthly premium charged to the person and (ii) any reduction in part B premiums;

(C) the plan’s service area;

(D) available quality and performance measures for the plan’s benefits, including how they compare with measures for the original fee-for-service program under parts A and B in the area. These measures include (i) Medicare enrollee disenrollment rates for the previous two years, excluding disenrollment because of death or moving outside the service area; (ii) enrollee satisfaction; (iii) health outcomes; and (iv) the plan’s recent record of complying with this part, as determined by the Secretary;

(E) supplemental health-care benefits, including any cost-sharing^* reductions under section 1395w–22(a)(3) of this title and the terms and conditions, including premiums, for those benefits; and

(F) beginning with plan years on or after January 1, 2029, for a specified MA plan as defined in section 1395w–22(c)(3)(C) of this title, the plan’s provider-directory accuracy score, as reported under section 1395w–27(e)(6)(A)(ii), displayed prominently on the provider directory.

(5) Toll-free number and Internet site. The Secretary must maintain a toll-free number for questions about Medicare+Choice options and how this part operates in every area where Medicare+Choice plans are offered. The Secretary must also maintain an Internet site where people can electronically obtain information about those options and plans.

(6) Non-Federal entities. The Secretary may contract with non-Federal entities to carry out this subsection.

(7) Information from organizations. A Medicare+Choice organization must give the Secretary the information about the organization and each plan it offers that the Secretary requires to prepare the information described in (2)(A).

(e) Coverage-election periods

(1) Initial choice when a person becomes eligible and plans are available. If, when a person first becomes entitled to part A and enrolled in part B, one or more Medicare+Choice plans are offered in the area where the person lives, the person must make the choice during a period set by the Secretary. If the person chooses a plan during that period, coverage begins on the first date the person may receive that coverage. If any part of the person’s initial part B enrollment period occurs after the end of the annual coordinated election period described in (3)(B)(iii), this part’s initial election period extends through the end of the person’s initial part B enrollment period.

(2) Open enrollment and disenrollment opportunities. Subject to (5):

(A) From January 1, 1998, through December 31, 2005, a Medicare+Choice eligible individual could change the choice under (a)(1) at any time.

(B) During the first six months of 2006, or, for a person who first became eligible during 2006, during that person’s first six eligible months, the person could change the choice under (a)(1), subject to (C)(iii), (D), and the following limit. The person could use this right only once. The one-change limit did not apply to a change made during an annual coordinated election period under (3) or the special enrollment period in the first sentence of (4).

(C) During the first 45 days of each year from 2011 through 2018, an individual enrolled in a Medicare Advantage plan could change the choice under (a)(1), but only to switch to coverage under the original Medicare fee-for-service program under parts A and B. The individual could choose qualified prescription drug coverage under section 1395w–101 of this title.

(D) At any time after 2005, an institutionalized Medicare+Choice eligible individual, as defined by the Secretary, could choose under (a)(1) to enroll in a Medicare+Choice plan or change the Medicare+Choice plan in which the individual was enrolled.

(E) Limited continuous enrollment for original fee-for-service enrollees in non-prescription-drug Medicare Advantage plans.

(i) In general. On any date from January 1, 2007, through July 31, 2007, a Medicare Advantage eligible individual who was an unenrolled fee-for-service individual, as defined in (ii), could choose under (a)(1) to enroll in a Medicare Advantage plan that was not an MA–PD plan.

(ii) Meaning of unenrolled fee-for-service individual. For a date, this means a Medicare Advantage eligible individual who (I) received benefits under this subchapter through the original fee-for-service program under parts A and B; (II) was not enrolled in an MA plan on that date; and (III) was not otherwise eligible on that date to choose enrollment in an MA plan.

(iii) One change. The individual could use the right in (i) only once during the period in (i).

(iv) No effect on part D coverage. This subparagraph did not allow a person using the right in (i) (I) who was enrolled in a part D prescription drug plan to leave that plan or enroll in another part D plan, or (II) who was not enrolled in a part D plan to enroll in one.

(F) Special period for certain deemed elections.

(i) In general. During the period starting after the last day of the annual coordinated election period under (3) in which a person was treated under (c)(4) as choosing an MA plan or MA–PD plan, and ending on the last day of February of the first plan year in which the person was enrolled in that plan, the person could change the choice under (a)(1), including changing the MA plan or MA–PD plan.

(ii) One change. The person could use this right only once during that period. The limit did not apply to changes made during an annual coordinated election period under (3) or a special enrollment period under the first sentence of (4).

(G) Continuous enrollment and disenrollment during the first three months of later years.

(i) In general. Subject to (ii) and (D), for years beginning with 2019, an MA-eligible person enrolled in an MA plan could change the choice at any time during the year’s first three months. A person who first became MA-eligible during such a year and enrolled in an MA plan could do so during the first three months of that year in which the person was MA-eligible.

(ii) One change each year. The person could use this right only once during the applicable three-month period. This limit did not apply to changes made during an annual coordinated election period under (3) or a special enrollment period under (4).

(iii) Limited part D application. Clauses (i) and (ii) applied to changes in part D prescription-drug-plan enrollment only when the person had been enrolled in a Medicare Advantage plan before the change.

(iv) Marketing limit. Under (j), no unsolicited marketing or marketing materials could be sent to a person described in (i) during that person’s three-month period, despite marketing guidelines established by the Centers for Medicare & Medicaid Services.

(3) Annual coordinated election period.

(A) In general. Subject to (5), each person eligible to make a choice under this section could change it during an annual coordinated election period.

(B) Meaning of annual coordinated election period. For this section, the period meant:

(i) for a year before 2002, the November before that year;

(ii) for 2002 through 2005, November 15 through December 31 of the preceding year;

(iii) for 2006, November 15, 2005, through May 15, 2006;

(iv) for 2007 through 2010, November 15 through December 31 of the preceding year; and

(v) for 2012 and later years, October 15 through December 7 of the preceding year.

(C) Medicare+Choice health-information fairs. During the fall of each year beginning in 1999, and during the period in (B)(iii), in connection with the annual coordinated election period, the Secretary must arrange a nationally coordinated education and publicity campaign to tell Medicare+Choice eligible individuals about Medicare+Choice plans and the election process under this section.

(D) Special information campaigns. During November 1998, the Secretary had to arrange an education and publicity campaign about Medicare+Choice plans available in different areas, eligible organizations with risk-sharing contracts under section 1395mm of this title, and the election process. During the period in (B)(iii), the Secretary had to arrange an education and publicity campaign about MA plans, including MA–PD plans, available in different areas and the election process.

(4) Special election periods. Effective January 1, 2006, a person could end an election of a Medicare+Choice plan outside an annual coordinated election period and make a new choice under this section if:

(A) (i) the organization’s or plan’s certification under this part ended, or the organization or plan notified the person that certification was about to end; or (ii) the organization stopped, or notified the person that it was about to stop, providing the plan in the area where the person lived;

(B) the person was no longer eligible to choose the plan because of a move or another change in circumstances specified by the Secretary, except termination of enrollment for the reasons in (g)(3)(B)(i) or (ii);

(C) the person showed, under the Secretary’s guidelines, that (i) the organization substantially violated an important provision of its contract in relation to the person, including failing to provide timely medically necessary covered care or failing to provide covered care according to applicable quality standards; or (ii) the organization, its agent, or another person acting for it materially misrepresented the plan’s provisions when marketing the plan; or

(D) the person met other exceptional conditions provided by the Secretary.

Also effective January 1, 2006, a person who enrolled in a Medicare+Choice plan upon first becoming eligible for part A at age 65 could end that election and choose the original fee-for-service plan at any time during the 12 months beginning on the plan’s effective enrollment date.

(5) Special rules for MSA plans. Despite the earlier rules in this subsection:

(A) a person could choose an MSA plan only during (i) an initial open enrollment period under (1), or (ii) an annual coordinated election period under (3)(B);

(B) subject to (C), a person could not end an MSA-plan election except during the periods in (A)(ii) or (A)(iii) and under the first sentence of (4); and

(C) a person who chose an MSA plan during an annual coordinated election period and had never chosen one before could cancel that choice, in the way the Secretary set, no later than December 15 after the choice date.

(6) Open enrollment periods. Subject to (5), a Medicare+Choice organization (A) had to accept choices and changes during the initial enrollment periods in (1), the period in (2)(F), November 1998, each later annual coordinated election period under (3), and the special election periods in the first sentence of (4); and (B) could accept other changes at other times the organization provided.

(f) When choices and changes take effect

(1) Initial coverage period. A coverage choice made during the initial period under (e)(1) took effect when the person became entitled to part A and enrolled in part B, except that the Secretary could provide, consistently with section 1395q of this title, to prevent retroactive coverage.

(2) Continuous open enrollment periods. A choice or coverage change under (e)(2) took effect on the first day of the first calendar month after the choice or change was made.

(3) Annual coordinated election period. A choice or coverage change made during an annual coordinated election period, other than the period in (e)(3)(B)(iii), took effect on the first day of the following year.

(4) Other periods. A choice or change made during another period under (e)(4) took effect in the way the Secretary provided, consistently as far as practicable with protecting continuous health-benefit coverage.

(g) Guaranteed issue and renewal

(1) In general. Except as this subsection provides, whenever choices are accepted under this section for a plan offered by a Medicare+Choice organization, the organization must accept, without restrictions, people eligible to make that choice.

(2) Priority when a plan has limited capacity. If the Secretary decides that an organization’s plan has a capacity limit and more eligible people choose it than the limit allows, the organization may limit enrollment only if it gives priority first to people who had already chosen the plan when the Secretary made the decision, and then to other people in a way that does not discriminate on a basis described in section 1395w–22(b) of this title. This priority rule does not apply if it would produce enrollment that, under the Secretary’s regulations^*, is substantially unrepresentative of the Medicare population in the plan’s service area.

(3) Limits on ending a choice.

(A) In general. Subject to (B), an organization may not end a person’s election of one of its Medicare+Choice plans for any reason.

(B) Reasons for ending an election. The organization may end the election if (i) required monthly basic or supplemental beneficiary premiums were not paid on time, consistently with standards under section 1395w–26 of this title that provide a late-payment grace period; (ii) the person engaged in disruptive behavior as specified in those standards; or (iii) the plan ended for everyone under this part in the area where the person lived.

(C) Result of ending an election.

(i) Ending for cause. A person whose election ends for either reason in (B)(i) or (B)(ii) is treated as having chosen the original Medicare fee-for-service option described in (a)(1)(A).

(ii) Plan termination or service-area reduction. A person whose election ends under (B)(iii) gets a special election period under (e)(4)(A) to change to another Medicare+Choice plan. If the person does not make a choice during that period, the person is treated as having chosen the original Medicare fee-for-service option described in (a)(1)(A).

(D) Organization’s duty regarding election forms. Under a contract under section 1395w–27 of this title, each organization that receives an election form under (c)(2) must send the Secretary a copy of the form, or other information about the election that the Secretary specifies, at the time and in the manner the Secretary specifies.

(h) Approval of marketing materials and application forms

(1) Submission. An organization may not distribute marketing material or an application form to, or for the use of, Medicare+Choice eligible people unless, at least 45 days before distribution (or 10 days in the case in (5)), it submitted the material or form to the Secretary for review and the Secretary has not disapproved distribution.

(2) Review. The standards under section 1395w–26 of this title must include review guidelines. Under those guidelines, the Secretary must disapprove, or later require correction of, material or a form that is materially inaccurate or misleading or otherwise makes a material misrepresentation.

(3) Deemed approval across areas. If material or a form is submitted to the Secretary or a regional Department of Health and Human Services office and neither the Secretary nor the office disapproves distribution for a Medicare+Choice plan in one area, the Secretary is treated as not having disapproved distribution in all other areas covered by the plan and organization. This does not apply to the part of the material or form that is specific only to the area involved.

(4) Certain marketing practices^*. Each organization must follow the fair-marketing standards for plans under this part that are included in the standards under section 1395w–26. Those standards (A) may not allow an organization, subject to (j)(2)(C), to offer cash, gifts, prizes, or other monetary rebates as an enrollment inducement or otherwise; (B) may prohibit an organization or its agent from completing any part of an election form for a person; (C) may not allow a Medicare Advantage organization or its agents, brokers, or other representatives to engage in the prohibited activities in (j)(1); and (D) may allow a Medicare Advantage organization and its agents, brokers, and other representatives to engage in activities in (j)(2) only within the limits set under that paragraph.

(5) Materials using model language. If an organization uses, without changing it, model language proposed by the Secretary, the submission period in (1) is reduced from 45 days to 10 days.

(6) Plan type in plan name. For plan years beginning on or after January 1, 2010, a Medicare Advantage organization must ensure that each Medicare Advantage plan’s name includes the plan type, using standard terminology developed by the Secretary.

(7) State cooperation against improper marketing.

(A) Agents and brokers. Each Medicare Advantage organization must (i) use only agents and brokers licensed under State law to sell its Medicare Advantage plans; (ii) follow a State appointment law if the State has one; and (iii) report to the applicable State the termination of any such agent or broker, including the reasons, as required by State law.

(B) State information requests. Each organization must respond promptly to a State’s request for information about the performance of a licensed agent, broker, or other representative when the request is part of a State investigation into that person’s conduct.

(i) Effect of choosing a Medicare+Choice plan

(1) Payments to organizations. Subject to the sections listed in this paragraph, payments under a contract with a Medicare+Choice organization under section 1395w–23(a) for a person who chooses the organization’s plan replace the amounts that, without the contract, would otherwise be payable under parts A and B for items and services provided to that person.

(2) Only the organization receives payment. Subject to the sections listed in this paragraph, only the Medicare+Choice organization may receive payments from the Secretary under this subchapter for services provided to the person.

(3) Kidney-acquisition expenses paid under fee-for-service. Paragraphs (1) and (2) do not apply to organ-acquisition expenses for kidney transplants described in section 1395w–22(a)(1)(B)(i) of this title.

(j) Prohibited activities and limits on certain other activities

(1) Prohibited activities. The prohibited activities are:

(A) Unsolicited direct contact. Any unsolicited direct contact with prospective enrollees, including door-to-door solicitation or outbound telemarketing when the prospective enrollee did not initiate the contact.

(B) Cross-selling. Selling other products unrelated to health, such as annuities or life insurance, during a sales or marketing activity or presentation for a Medicare Advantage plan.

(C) Meals. Providing prospective enrollees with meals of any kind, regardless of value, at promotional or sales activities.

(D) Sales and marketing in health-care settings and at educational events. Conducting enrollment sales or marketing for Medicare Advantage plans (i) in areas of health-care settings where health care is delivered, such as physician^* offices and pharmacies, except in common areas of those settings; or (ii) at educational events.

(2) Limits. The Secretary must establish limits on at least the following:

(A) Scope of marketing appointments. The scope of an appointment about marketing a Medicare Advantage plan. The limit must require advance agreement with the prospective enrollee about the appointment’s scope and documentation of that agreement by the organization. If the appointment is in person, the documentation must be written.

(B) Co-branding. The use of the name or logo of a co-branded network provider on Medicare Advantage plan membership and marketing materials.

(C) Gifts. Offering prospective enrollees gifts or other promotional items at promotional activities, except items of nominal value as determined by the Secretary.

(D) Compensation. Using compensation except as allowed by the Secretary’s guidelines. The guidelines must ensure that compensation creates incentives for agents and brokers to enroll people in the Medicare Advantage plan intended to best meet their health-care needs.

(E) Training, retraining, and testing. A Medicare Advantage organization may not use a person as its agent, broker, or other representative unless that person has completed an initial training and testing program and completes an annual retraining and testing program.)