CMS Pub. 100-16, ch. mc86c17f, § 100

(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)

(42 CFR 417.436) A Medicare cost plan must offer its plan to Medicare beneficiaries

and provide to those interested in enrolling, adequate written descriptions of the Medicare

cost plan’s rules, procedures, benefits, fees and other charges, services, and other

information necessary for beneficiaries to make an informed decision about enrollment.

The Medicare cost plan must furnish a copy of the rules to each Medicare enrollee at the

time of enrollment and at least annually thereafter. If a Medicare cost plan changes its

rules, it must submit the changes to CMS in accordance with proper procedure and notify

its Medicare enrollees of the changes at least 30 days before the effective date of the

changes.

A Medicare cost plan must maintain written rules that deal with, but need not be limited

to the following:

• All benefits provided under the contract;

• To the extent the plan offers Part D as an MA-PD plan, the information at 42

CFR 423.128;

• How and where to obtain services from or through the Medicare cost plan;

• The restrictions on coverage for services furnished from sources outside the

Medicare cost plan, other than emergency services and urgently needed services;

• The obligation of the Medicare cost plan to assume financial responsibility and

provide reasonable reimbursement for emergency services and urgently needed

services;

• Any services other than the emergency or urgently needed services that the

Medicare cost plan chooses to provide from sources outside the Medicare cost

plan;

• The fact that the enrollee may receive services through any Medicare provider and

supplier at Medicare cost-sharing levels;

• Premium information, including the amount (or if the amount cannot be included,

the telephone number of the source from which this information may be obtained)

and the procedures for paying premiums and other charges for which enrollees

may be liable;

• Grievance and appeal procedures;

• Disenrollment rights;

• The obligation of an enrollee who is leaving the Medicare cost plan’s geographic

area for more than 90 days to notify the Medicare cost plan of the move or

extended absence and the Medicare cost plan’s policies concerning retention of

enrollees who leave the geographic area for more than 90 days;

• The expiration date of the Medicare contract with CMS and notice that both CMS

and the Medicare cost plan are authorized by law to terminate or refuse to renew

the contract, and that termination or nonrenewal of the contract may result in

termination of the individual’s enrollment in the Medicare cost plan;

• Advance directives (see §130 below); and

• Any other matters that CMS may prescribe.

For further information on disclosure see the subpart of this chapter that deals with

Marketing materials.