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
(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.
(E)(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;
(E)(ii)#
the process and procedures of the plan for obtaining emergency services; and
(E)(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.
(F)(i)#
whether the supplemental benefits are optional,
(F)(ii)#
the supplemental benefits covered, and
(F)(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).