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(1) Detailed description of plan provisions
A Medicare+Choice organization shall disclose, in clear, accurate, and standardized form to each enrollee with a Medicare+Choice plan offered by the organization under this part at the time of enrollment and at least annually thereafter, the following information regarding such plan:
(A) Service area The plan’s service area.
(B) Benefits Benefits offered under the plan, including information described in section 1395w–21(d)(3)(A) of this title and exclusions from coverage and, if it is an MSA plan, a comparison of benefits under such a plan with benefits under other Medicare+Choice plans.
(C) Access The number, mix, and distribution of plan providers, out-of-network coverage (if any) provided by the plan, any point-of-service option (including the supplemental premium for such option), and, in the case of a specified MA plan (as defined in paragraph (3)(C)), for plan year 2028 and subsequent plan years, the information described in paragraph (3)(B).
(D) Out-of-area coverage Out-of-area coverage provided by the plan.
(E) Emergency coverage Coverage of emergency services, including— (i) the appropriate use of emergency services, including use of the 911 telephone system or its local equivalent in emergency situations and an explanation of what constitutes an emergency situation; (ii) the process and procedures of the plan for obtaining emergency services; and (iii) the locations of (I) emergency departments, and (II) other settings, in which plan physicians and hospitals provide emergency services and post-stabilization care.
(F) Supplemental benefits Supplemental benefits available from the organization offering the plan, including— (i) whether the supplemental benefits are optional, (ii) the supplemental benefits covered, and (iii) the Medicare+Choice monthly supplemental beneficiary premium for the supplemental benefits.
(G) Prior authorization rules Rules regarding prior authorization or other review requirements that could result in nonpayment.
(H) Plan grievance and appeals procedures All plan appeal or grievance rights and procedures.
(I) Quality improvement program A description of the organization’s quality improvement program under subsection (e).
The plan’s service area.
Benefits offered under the plan, including information described in section 1395w–21(d)(3)(A) of this title and exclusions from coverage and, if it is an MSA plan, a comparison of benefits under such a plan with benefits under other Medicare+Choice plans.
The number, mix, and distribution of plan providers, out-of-network coverage (if any) provided by the plan, any point-of-service option (including the supplemental premium for such option), and, in the case of a specified MA plan (as defined in paragraph (3)(C)), for plan year 2028 and subsequent plan years, the information described in paragraph (3)(B).
Out-of-area coverage provided by the plan.
Coverage of emergency services, including—
(i) the appropriate use of emergency services, including use of the 911 telephone system or its local equivalent in emergency situations and an explanation of what constitutes an emergency situation;
(ii) the process and procedures of the plan for obtaining emergency services; and
(iii) the locations of (I) emergency departments, and (II) other settings, in which plan physicians and hospitals provide emergency services and post-stabilization care.
the appropriate use of emergency services, including use of the 911 telephone system or its local equivalent in emergency situations and an explanation of what constitutes an emergency situation;
the process and procedures of the plan for obtaining emergency services; and
the locations of (I) emergency departments, and (II) other settings, in which plan physicians and hospitals provide emergency services and post-stabilization care.
Supplemental benefits available from the organization offering the plan, including—
(i) whether the supplemental benefits are optional,
(ii) the supplemental benefits covered, and
(iii) the Medicare+Choice monthly supplemental beneficiary premium for the supplemental benefits.
whether the supplemental benefits are optional,
the supplemental benefits covered, and
the Medicare+Choice monthly supplemental beneficiary premium for the supplemental benefits.
Rules regarding prior authorization or other review requirements that could result in nonpayment.
All plan appeal or grievance rights and procedures.
A description of the organization’s quality improvement program under subsection (e).
Upon request of a Medicare+Choice eligible individual, a Medicare+Choice organization must provide the following information to such individual:
(A) The general coverage information and general comparative plan information made available under clauses (i) and (ii) of section 1395w–21(d)(2)(A) of this title .
(B) Information on procedures used by the organization to control utilization of services and expenditures.
(C) Information on the number of grievances, redeterminations, and appeals and on the disposition in the aggregate of such matters.
(D) An overall summary description as to the method of compensation of participating physicians.
The general coverage information and general comparative plan information made available under clauses (i) and (ii) of section 1395w–21(d)(2)(A) of this title .
Information on procedures used by the organization to control utilization of services and expenditures.
Information on the number of grievances, redeterminations, and appeals and on the disposition in the aggregate of such matters.
An overall summary description as to the method of compensation of participating physicians.
(A) In general For plan year 2028 and subsequent plan years, each MA organization offering a specified MA plan (as defined in subparagraph (C)) shall, for each such plan offered by the organization— (i) maintain, on a publicly available internet website, an accurate provider directory that includes the information described in subparagraph (B); (ii) not less frequently than once every 90 days (or, in the case of a hospital or any other facility determined appropriate by the Secretary, at a lesser frequency specified by the Secretary but in no case less frequently than once every 12 months), verify the provider directory information of each provider listed in such directory and, if applicable, update such information; (iii) if the organization is unable to verify such information with respect to a provider, include in such directory an indication that the information of such provider may not be up to date; and (iv) remove a provider from such directory within 5 business days if the organization determines that the provider is no longer a provider participating in the network of such plan.
(B) Provider directory information The information described in this subparagraph is information enrollees may need to access covered benefits from a provider with which such organization offering such plan has an agreement for furnishing items and services covered under such plan, such as name, specialty, contact information, primary office or facility addresses where items or services are furnished, whether the provider is accepting new patients, accommodations for people with disabilities, cultural and linguistic capabilities, and telehealth capabilities.
(C) Specified MA plan In this paragraph, the term “specified MA plan” means— (i) a network-based plan (as defined in subsection (d)(5)(C)); or (ii) a Medicare Advantage private fee-for-service plan (as defined in section 1395w–28(b)(2) of this title ) that meets the access standards under subsection (d)(4), in whole or in part, through entering into contracts or agreements as provided for under subparagraph (B) of such subsection.
For plan year 2028 and subsequent plan years, each MA organization offering a specified MA plan (as defined in subparagraph (C)) shall, for each such plan offered by the organization—
(i) maintain, on a publicly available internet website, an accurate provider directory that includes the information described in subparagraph (B);
(ii) not less frequently than once every 90 days (or, in the case of a hospital or any other facility determined appropriate by the Secretary, at a lesser frequency specified by the Secretary but in no case less frequently than once every 12 months), verify the provider directory information of each provider listed in such directory and, if applicable, update such information;
(iii) if the organization is unable to verify such information with respect to a provider, include in such directory an indication that the information of such provider may not be up to date; and
(iv) remove a provider from such directory within 5 business days if the organization determines that the provider is no longer a provider participating in the network of such plan.
maintain, on a publicly available internet website, an accurate provider directory that includes the information described in subparagraph (B);
not less frequently than once every 90 days (or, in the case of a hospital or any other facility determined appropriate by the Secretary, at a lesser frequency specified by the Secretary but in no case less frequently than once every 12 months), verify the provider directory information of each provider listed in such directory and, if applicable, update such information;
if the organization is unable to verify such information with respect to a provider, include in such directory an indication that the information of such provider may not be up to date; and
remove a provider from such directory within 5 business days if the organization determines that the provider is no longer a provider participating in the network of such plan.
The information described in this subparagraph is information enrollees may need to access covered benefits from a provider with which such organization offering such plan has an agreement for furnishing items and services covered under such plan, such as name, specialty, contact information, primary office or facility addresses where items or services are furnished, whether the provider is accepting new patients, accommodations for people with disabilities, cultural and linguistic capabilities, and telehealth capabilities.
In this paragraph, the term “specified MA plan” means—
(i) a network-based plan (as defined in subsection (d)(5)(C)); or
(ii) a Medicare Advantage private fee-for-service plan (as defined in section 1395w–28(b)(2) of this title ) that meets the access standards under subsection (d)(4), in whole or in part, through entering into contracts or agreements as provided for under subparagraph (B) of such subsection.
a network-based plan (as defined in subsection (d)(5)(C)); or
a Medicare Advantage private fee-for-service plan (as defined in section 1395w–28(b)(2) of this title ) that meets the access standards under subsection (d)(4), in whole or in part, through entering into contracts or agreements as provided for under subparagraph (B) of such subsection.