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 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 Advantage (MA), 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 Medicare & Medicaid Services (CMS) distributes educational materials and has extensive information on its website: medicare.gov. But not all beneficiaries use the Internet. 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. 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 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 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

Funding

In this policy: Federal

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 Information Programs (SHIPs).

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

Strengthening processes

In this policy: Federal

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

In addition, the agency should ensure that Medicare beneficiaries are provided with:

  • 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 Health Care Coverage: Medicare—Traditional Fee-for-Service Medicare/Physician Balance Billing and Private Contracting).

Providing information to beneficiaries

In this policy: FederalStateLocal

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), benefits that 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 insurance;
  • implement a process that ensures quick remedies for Medicare denials that result from incorrect primary-payer information (see also this chapter’s section on Healthcare Coverage: Medicare—Appeals in Medicare);
  • 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 premium 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 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.

Information about consumer experiences

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 Consumer Assessment of Healthcare Providers and Systems(CAHPS) 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 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.

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, and 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.