Medicare Program Administration

Congress should increase the program budget for the Centers for Medicare & Medicaid Services (CMS) administration, including beneficiary education and outreach, program operations, and research.

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

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

CMS should strengthen its methods for evaluating and overseeing the performance of Medicare Administrative Contractors (MACs). In addition to ensuring that MACs impart accurate information to providers on Medicare coverage, the agency should ensure that Medicare beneficiaries are provided with:

• clear, accurate, and easily accessible information;
• prompt and accurate claims processing in compliance with Medicare laws and regulations; and
• timely processing of appeals (see also Medicare Beneficiary Rights).

In addition, the agency should ensure that Medicare beneficiaries receive:

• an explanation of the Medicare 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 Medicare—Physician Balance Billing and Private Contracting). 

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 Programs) and about which benefits do not require cost-sharing (e.g., certain immunizations), and claims;
• encourage federal and state agencies with jurisdiction over programs (e.g., Medicare, Medicaid, and SHIPs) to intensify their outreach and assistance programs;
• simplify the billing process for beneficiaries and providers, including through coordination of Medicare and Medicare supplemental coverage;
• implement a process that ensures quick remedies for Medicare denials that result from incorrect primary-payer information (see also Appeals in Medicare Parts A & B);
• ensure that the comparative-plan information provided by Medicare 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 Medicare premiums and cost-sharing expenses, including the Medicare Savings Programs and Part D Low-Income Subsidy program.

Any significant change in Medicare should be accompanied by extensive education and outreach to beneficiaries. For example, restrictions on when beneficiaries can enroll in a Medicare prescription drug plan must be coupled with an aggressive education and marketing program to help beneficiaries understand their options and the limitations on their choices. 

Publicly reported information about consumers’ experiences with their care should be standardized and collected by an independent external entity with acceptable standards for 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 considered 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 Medicare beneficiaries receive information to make informed health care choices, Congress must provide CMS with sufficient funds and personnel.

Consumer information in Medicare Advantage: 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 Medicare quality improvement and quality oversight efforts.