Medicare Program Administration and Outreach

Background

Medicare beneficiaries can be confused by the complexities of the program’s benefits and payment rules, as well as by the broad array of choices involving traditional Medicare, MA plans, and prescription drug plans. Beneficiaries need accurate, concise, and understandable information about the availability, quality, and cost of services. They also need efficient, responsive systems for obtaining information, including outreach and assistance programs.

The Centers for Medicare & Medicaid Services (CMS) distributes educational materials such as the annual Medicare & You handbook. CMS has also developed consumer-oriented information for its website, medicare.gov. But many beneficiaries, particularly the oldest ones, do not use the Internet.

Information that CMS provides about Medicare educates enrollees and the public about the program and complies with legal notice requirements. The CMS budget for administering Medicare—including education and outreach, program operations, and research—has not kept pace with increases in the program’s growth and complexity, or with the agency’s mandated activities. CMS’s operational requirements are currently met with a very large and complex set of hardware, software, and communications systems that vary in age and capability.

The 2010 Affordable Care Act (ACA) provided the Department of Health and Human Services (HHS) with $1 billion to implement various aspects of the law and improve Medicare’s administration. As a result, CMS now makes Medicare data available to support providers’ efforts to better manage and coordinate care. The data may also help CMS evaluate payment and delivery system reform efforts. The law also appropriated $10 billion over the period from fiscal year 2014 to fiscal year 2019, and $10 billion for each subsequent decade, for the Center for Medicare & Medicaid Innovation, which is developing and testing payment and delivery system arrangements to improve the quality of care and control program costs. In addition, HHS has developed a national strategy to improve health care service delivery, patient health outcomes, and population health. CMS also established an office to improve coordination of—and better integrate—Medicare and Medicaid benefits for people enrolled in both programs.

Medicare Program Administration and Outreach: Policy

Data systems

In this policy: Federal

CMS should continue modernizing its data systems. Congress should ensure adequate funding to support this work, especially in low-income and diverse communities.

Processes and services

In this policy: Federal

CMS should reinforce its methods for evaluating the performance of Medicare administrative contractors. The agency should ensure that Medicare beneficiaries are provided with:

  • clear, accurate, and easily accessible information;
  • prompt and accurate claims processing;
  • an explanation of the Medicare benefits form for all claims;
  • effective follow-through on beneficiary fraud and abuse complaints;
  • claim-by-claim enforcement of the law that limits charges (see this chapter’s section Health Care Coverage: Medicare—Traditional Fee-for-Service Medicare/Physician Balance Billing and Private Contracting); and
  • timely processing of appeals (see this chapter’s section Health Care Coverage: Medicare—Appeals in Medicare).

To further support beneficiaries’ information needs, CMS should:

  • maintain adequate access to the toll-free line for beneficiaries to get prompt, accurate, and easily understood information about existing benefits, benefits that do not require cost-sharing (e.g., certain immunizations), or claims;
  • encourage federal and state agencies with jurisdiction over programs for beneficiaries (e.g., Medicare, Medicaid, and State Health Insurance Assistance Programs [SHIPs]) to intensify their outreach and assistance programs;
  • simplify the billing process for beneficiaries and providers, including through coordination of Medicare and Medicare supplement insurance; and
  • implement a process that ensures quick remedies for Medicare denials that result from incorrect primary-payer information (see this chapter’s section Healthcare Coverage: Medicare—Appeals in Medicare).

Congress should increase program budgets for CMS administration, including beneficiary education and outreach, program operations, and research. Congress should also increase funding for SHIPs. SHIPs should assist beneficiaries with claims and appeals.

Consumer information

In this policy: Federal

Publicly reported information about consumers’ experiences with their care should be standardized and collected by an independent external entity with acceptable standardized cultural competency.

CMS should continue to expand the use of the suite of Consumer Assessment of Healthcare Providers and Systems instruments to measure hospital, medical group, physician, and other types of provider performance. Further research should be conducted to learn more about consumer preferences with respect to the types of information consumers want and how data are communicated to them. Literacy, health literacy, and numeracy levels should be taken into account when developing consumer information.

CMS should work with consumer organizations and experts in the field of consumer information and education to develop ways to present data on quality in formats useful to consumers. These should be tested to ensure their effectiveness.

To ensure that Medicare beneficiaries receive information to make informed health care choices, Congress must provide CMS with sufficient funds and personnel.

Medicare Advantage

In this policy: Federal

The federal government should establish and follow standards for reporting consumer information, including standards for the frequency and format of reports. Information must be collected in a manner that will ensure comparability across plans and providers, and should include data that is useful to beneficiaries, such as information on benefits, coverage restrictions, costs (including out-of-pocket liability), member and provider satisfaction, quality of care, credentialing, utilization management, grievances and appeals, and enrollment and disenrollment.

Data should be available to the public, unless disclosure is prohibited by federal law or regulation, based on the compelling needs of Medicare quality improvement and quality oversight efforts.

Prescription drugs

In this policy: Federal

CMS should ensure that the comparative plan information that CMS and the drug plans provide to beneficiaries is accurate and easy for beneficiaries to understand. CMS should regularly evaluate and improve the quality of this information.

Any major change in the Medicare program should be accompanied by extensive education and outreach to beneficiaries. For example, restrictions on when beneficiaries can enroll in a Medicare prescription drug benefit must be coupled with an aggressive education and marketing program to help beneficiaries understand their options and the limitations on their choices. Beneficiaries who involuntarily lose drug coverage provided by a non-Medicare source should have a period during which they could enroll in a Medicare drug benefit without penalty.