Medicare Program Administration and Outreach

Background

MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). 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 MedicareTraditional Medicare, also known as Original or Fee-For-Service Medicare, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it… , Medicare AdvantageMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. , and prescription drug plans. Beneficiaries need timely, 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 MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services (CMS) distributes educational materials and has extensive information on its website medicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). .gov. But not all beneficiaries use the Internet. The CMS budget for administering MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). —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. Information that CMS provides about MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). educates enrollees and the public about the program and complies with legal notice requirements. The CMS budget for administering MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). —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 an extensive and complex set of hardware, software, and communications systems that vary in age and capability.

The 2010 Affordable Care Act provided the Department of Health and Human Services (HHS) with $1 billion to implement various aspects of the law and improve MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). ’s administration. As a result, CMS now makes MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). 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 between fiscal years 2014 and 2019, and $10 billion for each subsequent decade, for the Center for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. 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— MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. benefits for people enrolled in both programs.

MEDICARE PROGRAM ADMINISTRATION AND OUTREACH: Policy

MEDICARE PROGRAM ADMINISTRATION AND OUTREACH: Policy

Funding

Congress should increase the program budget for the Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services (CMS) administration, including beneficiary education and outreach, program operations, and research.

Congress should also increase funding for State Health Insurance Information Programs (SHIPs).

CMS should continue modernizing its data systems, and Congress should ensure adequate funding to support this work.

Strengthening processes

CMS should strengthen its methods for evaluating the performance of MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). administrative contractors. The agency should ensure that MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries are provided with:

  • clear, accurate, and easily accessible information;
  • prompt and accurate claims processing; and
  • timely processing of appeals (see also Appeals in Medicare for more information).

In addition, the agency should ensure that MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries are provided with:

  • an explanation of the MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). benefit forms for all claims,
  • effective follow-through on beneficiary fraud and abuse complaints, and
  • claim-by-claim enforcement of the law that limits charges (see also Physician Balance Billing and Private Contracting).

Information to beneficiaries

To meet 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 and programs providing financial assistance to people with lower incomes (such as the Medicare Savings ProgramsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. ), and about which benefits do not require cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. (e.g., certain immunizations), and claims;
  • encourage federal and state agencies with jurisdiction over programs (e.g., MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). , MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. , and SHIPs) to intensify their outreach and assistance programs;
  • simplify the billing process for beneficiaries and providers, including through coordination of MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). supplemental coverage;
  • implement a process that ensures quick remedies for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). denials that result from incorrect primary-payer information (see also Appeals in Medicare);
  • ensure that the comparative-plan information provided by MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and the drug plans is accurate, easy to understand, and regularly evaluated and improved; and
  • provide adequate information about programs that help beneficiaries with low incomes pay MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). premium and cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. expenses, including the Medicare Savings ProgramsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. and Part D Low-Income Subsidy program.

Any significant change in MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). should be accompanied by extensive education and outreach to beneficiaries. For example, restrictions on when beneficiaries can enroll in a MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). 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- MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). source should have a period during which they could enroll in a MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). drug benefit without penalty.

Information about consumer experiences

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 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 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 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 MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries receive information to make informed health care choices, Congress must provide CMS with sufficient funds and personnel.

Consumer information in Medicare AdvantageMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. : The federal government should establish and follow standards for reporting consumer information, including the frequency and format of reports. Information must be collected in a manner that will ensure comparability across plans and providers. It should include data that are 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 MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). quality improvement and quality oversight efforts.