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entitled 'Medicare: Communications to Beneficiaries on the Prescription 
Drug Benefit Could Be Improved' which was released on May 3, 2006.

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United States Government Accountability Office:

GAO:

Report to Congressional Requesters:

May 2006:

Medicare:

Communications to Beneficiaries on the Prescription Drug Benefit Could 
Be Improved:

GAO-06-654:

GAO Highlights: 

Highlights of GAO-06-654, a report to congressional requesters.

Why GAO Did This Study: 

On January 1, 2006, Medicare began providing coverage for outpatient 
prescription drugs through its new Part D benefit. Beneficiaries who 
enroll in Part D may choose a drug plan from those offered by private 
plan sponsors under contract to the Centers for Medicare & Medicaid 
Services (CMS), which administers the Part D benefit. Beneficiaries 
have until May 15, 2006, to enroll in the Part D benefit and select a 
plan without the risk of penalties. 

GAO was asked to review the quality of CMS’s communications on the Part 
D benefit. GAO examined 70 CMS publications to select 6 documents for 
review and contracted with the American Institutes for Research to 
evaluate the clarity of these texts; made 500 calls to the 1-800-
MEDICARE help line; and contracted with the Nielsen Norman Group to 
evaluate the usability of the Medicare Web site.

What GAO Found: 

The information given in the six sample documents that GAO reviewed 
describing the Part D benefit was largely complete and accurate, 
although this information lacked clarity. The documents were unclear in 
two ways. First, although about 40 percent of seniors read at or below 
the fifth-grade level, the reading levels of these documents ranged 
from seventh grade to postcollege. Second, on average, the six 
documents did not comply with about half of 60 common guidelines for 
good communication. For example, the documents used too much technical 
jargon and often did not define difficult terms, such as formulary. 
Moreover, 16 beneficiaries and advisers that GAO tested reported 
frustration with the documents’ lack of clarity and had difficulty 
completing the tasks assigned to them. Although the documents lacked 
clarity, they informed readers of enrollment steps and factors 
affecting coverage decisions and were consistent with laws, 
regulations, and agency guidance.

Customer service representatives (CSR) responded to the 500 calls GAO 
placed to CMS’s 1-800-MEDICARE help line accurately and completely 
about two-thirds of the time. Of the remainder, 18 percent of the calls 
received inaccurate responses, 8 percent of the responses were 
inappropriate given the question asked, and about 3 percent received 
incomplete responses. In addition, about 5 percent of GAO’s calls were 
not answered, primarily because of disconnections. Accuracy and 
completeness rates of CSRs’ responses varied significantly across the 
five questions GAO asked. For example, while CSRs provided accurate and 
complete responses to calls about beneficiaries’ eligibility for extra 
help 90 percent of the time, the accuracy rate for calls concerning the 
drug plan that would cost the least for a specified beneficiary was 41 
percent. For this question, the CSRs responded inappropriately for 35 
percent of the calls by explaining that they could not identify the 
least costly plan without the beneficiary’s personal information—even 
though CSRs had the information needed to answer the question. The time 
GAO callers waited to speak with CSRs also varied, ranging from no wait 
time to over 55 minutes. For 75 percent of the calls—374 of the 500—the 
wait was less than 5 minutes.

The Part D benefit portion of the Medicare Web site can be difficult to 
use. GAO’s test of the site’s overall usability—the ease of finding 
needed information and performing various tasks—resulted in scores of 
47 percent for seniors and 53 percent for younger adults, out of a 
possible 100 percent. While there is no widely accepted benchmark for 
usability, these scores indicate that using the site can be difficult. 
For example, the prescription drug plan finder was complicated to use 
and some of its key functions, such as “continue” and “choose a drug 
plan,” were often not visible on the page without scrolling down.

What GAO Recommends: 

GAO is recommending that the CMS Administrator enhance the quality of 
its communications by taking actions to improve written materials, its 
1-800-MEDICARE help line, and the Medicare Web site. CMS said that 
GAO’s findings did not present a complete and accurate picture of its 
activities. However, CMS said that it supports the goals of GAO’s 
recommendations and is already taking steps to implement them. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-654].

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Leslie G. Aronovitz at 
aronovitzl@gao.gov or (312) 220-7600. 

[End of section]

Contents:

Letter:

Results in Brief:

Conclusions:

Recommendations for Executive Action:

Agency Comments and Our Evaluation:

Appendix I: Briefing on Medicare Part D:

Appendix II: Objectives, Scope, and Methodology:

Appendix III: Comments from the Centers for Medicare & Medicaid 
Services:

Appendix IV: GAO Contact and Staff Acknowledgments:

Tables:

Table 1: Sample of Six Selected Documents:

Table 2: Questions and Criteria Used to Evaluate Accuracy:

Abbreviations:

AIR: American Institutes for Research: 
CMS: Centers for Medicare & Medicaid Services: 
CSR: customer service representative: 
MMA: Medicare Prescription Drug, Improvement, and Modernization Act of 
2003: 
NN/g: Nielsen Norman Group: 
SHIP: State Health Insurance Assistance Program:  
SMOG: Simplified Measure of Gobbledygook:

United States Government Accountability Office:
Washington, DC 20548:

May 3, 2006:

Congressional Requesters:

In the most significant change to the Medicare program since its 
inception, the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA)[Footnote 1] established an outpatient 
prescription drug benefit in Medicare, known as the Part D benefit. 
Coverage for this new benefit began on January 1, 2006. Until this 
time, Medicare, the federal program that finances health care benefits 
for about 42 million elderly and disabled beneficiaries, had not 
generally provided coverage for outpatient prescription drugs. 
Beneficiaries may choose a Part D plan[Footnote 2] from multiple plans 
offered by private sponsors[Footnote 3] under contract to the Centers 
for Medicare & Medicaid Services (CMS),[Footnote 4] the agency that is 
responsible for administering the Medicare program, including the Part 
D benefit. These plans differ in the drugs they cover and the 
pharmacies they use. In addition, the costs to the enrollee for the 
monthly premium, the annual deductible, and co-payments for covered 
drugs vary by plan. As of April 20, 2006, more than 30 million of 
Medicare's 42 million beneficiaries were enrolled in a Part D plan or 
had other outpatient prescription drug coverage. Beneficiaries have 
until May 15, 2006, to select a plan without the risk of penalties in 
the form of higher premiums.

Given the newness and complexity of the Part D benefit, it is critical 
that beneficiaries and their advisers, including members of their 
families, understand the available options so that beneficiaries can 
make informed decisions on whether to enroll in Part D, and if so, 
which drug plan to choose. Beneficiaries need to compare drug plans in 
light of their anticipated prescription drug needs and existing 
arrangements for paying for these drugs. In addition to comparing costs 
and drug coverage, beneficiaries need to consider whether the plans 
they are comparing have contracted with a local or mail-order pharmacy 
that will provide a convenient means of filling their prescriptions.

As part of its responsibilities, CMS has undertaken outreach and 
education efforts to provide beneficiaries and their advisers with the 
information they need about Part D through various media, including 
written documents, the 1-800-MEDICARE help line,[Footnote 5] and the 
Medicare Web site.[Footnote 6] As of December 2005, CMS has produced 
more than 70 written documents to explain Part D to beneficiaries. 
Medicare & You--the beneficiary handbook--is the most widely available 
of these documents and was sent directly to beneficiaries in October 
2005. Other CMS documents are targeted to specific groups of 
beneficiaries, such as dual-eligible beneficiaries[Footnote 7] and 
beneficiaries with Medicare Advantage or Medigap policies.[Footnote 8] 
Since March 1999, CMS has administered its nationwide 1-800-MEDICARE 
help line to answer beneficiaries' questions about the Medicare 
program. As of December 2005, about 7,500 customer service 
representatives (CSR) were handling calls on the help line, which 
operates 24 hours a day, 7 days a week, and is run by two CMS 
contractors. Calls are answered by an automated system and are routed 
to a CSR for specific questions, including those about Part D. CMS 
provides CSRs with detailed scripts to use in answering the questions. 
CSRs type in related keywords to generate a list of suggested scripts 
for a given question, select the script they consider best suited to 
the question, and read excerpts or the entire script. Call center 
contractors write the scripts, and CMS checks them for accuracy and 
completeness. CSRs can also consult other information sources, such as 
the Medicare Web site. CMS does not allow CSRs to offer individualized 
guidance to callers, including advice in choosing a drug plan. CMS's 
Medicare Web site provides information about all aspects of the 
Medicare program. The Web site contains basic information about the 
Part D benefit; suggests factors for beneficiaries to consider when 
choosing a plan; describes situations common to beneficiaries with 
guidance on next steps to take in deciding whether to enroll and what 
plan to choose; lists frequently asked questions; and allows users to 
view, print, or order publications. In addition, the site contains 
information on cost, coverage, and convenience of individual plans. 
There is also a tool that allows beneficiaries to enroll directly in 
the plan they have chosen.

CMS has also arranged for State Health Insurance Assistance Programs 
(SHIP) to provide Part D information on request to Medicare 
beneficiaries and their advisers. Currently, CMS provides grants to the 
54 SHIPs--one in each state, the District of Columbia, the Virgin 
Islands, Puerto Rico, and Guam. State SHIPs provide subgrants to over 
1,300 local organizations to assist SHIPs in their efforts. In total, 
SHIPs rely on over 12,000 trained counselors, most of whom are 
volunteers, to provide free counseling and assistance via telephone and 
face-to-face sessions, public education presentations and programs, and 
media activities.

Widespread confusion among beneficiaries about the costs and coverage 
under the new benefit has been reported by the media and others. For 
example, according to an October 2005 survey by a research 
organization, some beneficiaries are unaware of the penalties for late 
enrollment and others did not realize that beneficiaries had to sign up 
for the benefit.[Footnote 9] In light of your interest in ensuring that 
Medicare beneficiaries receive the information they need to make 
informed decisions, you asked us to examine the quality of the 
information being provided on the Part D benefit. In this report, we 
examined:

* the extent to which CMS's written documents describe the Part D 
benefit in a clear, complete, and accurate manner;

* the effectiveness of CMS's 1-800-MEDICARE help line in providing 
accurate, complete, and prompt responses to callers inquiring about the 
Part D benefit;

* whether CMS's Medicare Web site presents information on the Part D 
benefit in a usable manner; and:

* how CMS has used SHIPs to respond to the needs of Medicare 
beneficiaries for information on the Part D benefit.

We briefed your staff regarding the results of our review on April 19, 
2006. Appendix I contains information we provided during our briefing 
to your staff.

To evaluate CMS's written documents describing the Part D benefit, we 
examined 70 relevant CMS publications and selected a sample of six 
documents for in-depth review. These documents represent a variety of 
document types, content, and target audiences and include Section 6 of 
the Medicare & You beneficiary handbook, which discusses Part D. To 
assess the clarity of the sample documents, we contracted with the 
American Institutes for Research (AIR), a firm with experience in 
evaluating written documents. AIR evaluated the texts by using three 
standard readability tests;[Footnote 10] 60 commonly recognized good 
communications practices; and user testing with 11 Medicare 
beneficiaries and 5 advisers to beneficiaries, all of whom were asked 
to perform 18 specified tasks related to enrollment, coverage, costs, 
penalty, and informational resources and provide feedback about their 
experiences. To evaluate completeness, we reviewed the sample documents 
to determine if they included sufficient information for the 
beneficiaries to identify (1) their next steps in deciding whether to 
enroll and what plan to choose and (2) important factors, such as 
penalty provisions, that could affect their coverage decisions. To 
evaluate accuracy, we reviewed the sample documents for consistency 
with MMA, regulations, and CMS guidance.

To assess the accuracy, completeness, and promptness of the help line 
responses, we made 500 calls to 1-800-MEDICARE, posing one of five 
questions about Part D in each call so that each question was asked 100 
times. To develop the questions, we considered topics listed on the 
Medicare Web site and topics addressed in scripts frequently accessed 
by CSRs. To develop our criteria for evaluating the accuracy and 
completeness of CSRs' responses, we used three resources: (1) the 
prescription drug finder tool on the Medicare Web site, (2) the 1-800- 
MEDICARE scripts, and (3) input from CMS officials. We also recorded 
the length of each call, including wait times, and the time it took to 
be connected to a CSR.

To assess whether the Medicare Web site presents information on the 
Part D benefit in a usable manner, we contracted with the Nielsen 
Norman Group (NN/g), a firm with expertise in Web design. NN/g 
conducted three evaluations: (1) it calculated an overall usability 
score for the site--considering factors such as site navigation, 
customer support, and presentation of online forms--to reflect the ease 
of finding necessary information and performing various tasks; (2) it 
determined the usability of 137 detailed aspects of the Web site, 
including aspects of Web design, online tools, and writing style; and 
(3) it tested the ability of seven participants (five beneficiaries and 
two advisers to beneficiaries) to complete a total of 34 user tests to 
determine the ease of performing a variety of Web-related tasks, such 
as browsing the site and determining how to join a plan. We also 
reviewed the results of CMS's analysis of its Web site's compliance 
with requirements that federal government Web sites be accessible to 
people with disabilities.

Finally, to examine how CMS has used SHIPs to meet the information 
needs of beneficiaries regarding Part D, we obtained information about 
SHIPs, their funding, changes made in response to the new benefit, and 
the impact of Part D on the demand for SHIP services. In addition, we 
interviewed CMS officials who monitor SHIP activities as well as SHIP 
coordinators in the five states with the largest populations of 
Medicare beneficiaries--California, Florida, New York, Pennsylvania, 
and Texas.

We performed our work from November 2005 through May 2006 in accordance 
with generally accepted government auditing standards. For more 
information on our methodology, see appendix II.

Results in Brief:

The sample of CMS's written documents we reviewed describing the Part D 
benefit to Medicare beneficiaries and their advisers were largely 
complete and accurate, but the information these documents presented 
lacked clarity. The documents were unclear in two ways. First, about 40 
percent of seniors read at or below the fifth-grade level, but the 
reading levels of the documents ranged from seventh grade to 
postcollege. As a result, documents at these levels are not completely 
clear and understandable for many seniors. Second, on average, the six 
documents did not comply with about half of the 60 commonly recognized 
guidelines for good communications. For example, although the documents 
included concise and descriptive headings, they used too much technical 
jargon and often did not define difficult terms, such as 
formulary.[Footnote 11] The 11 beneficiaries and 5 advisers we tested 
reported frustration with the documents' lack of clarity as they 
encountered difficulties in understanding and attempting to complete 18 
specified tasks. For example, none of these beneficiaries and only 2 of 
the advisers were able to complete the task of computing their 
projected total out-of-pocket costs for a plan that provided Part D's 
standard coverage. Only 1 of the 18 tasks was completed by all 
beneficiaries and advisers. Even those who were able to complete a 
given task expressed confusion and frustration as they worked to 
comprehend the relevant text. Although the sample documents lacked 
clarity, the information presented in them was generally complete. The 
documents informed readers of next steps in determining whether to 
enroll and what plan to choose, and of important factors that could 
affect their coverage decisions. The information in the sample 
documents was also generally accurate when evaluated for consistency 
with MMA, implementing regulations, and agency guidance.

Responses to the 500 calls we placed to CMS's 1-800-MEDICARE help line 
regarding the Part D benefit were frequently accurate and complete. 
However, we nonetheless received a substantial number of responses that 
were inaccurate, incomplete, or inappropriate and that sometimes 
involved an extensive wait before we could speak to a CSR. CSRs 
answered 67 percent of the calls accurately and completely. Of the 
remainder, 18 percent of the calls received inaccurate responses, 8 
percent of the responses were inappropriate given the question asked, 
and about 3 percent received incomplete responses. In addition, about 5 
percent of our calls were not answered, primarily because of 
disconnections.[Footnote 12] Accuracy and completeness rates of CSRs' 
responses varied significantly for the five questions we asked. For 
example, for the question on whether a beneficiary qualifies for extra 
help, CSRs provided an accurate and complete response 90 percent of the 
time. However, for a question concerning which drug plan would cost the 
least for a beneficiary with certain specified prescription drug needs, 
the accuracy rate was 41 percent. CSRs inappropriately responded 35 
percent of the time that this question could not be answered without 
personal identifying information--such as the beneficiary's Medicare 
number or date of birth--even though the CSRs could have answered our 
question using CMS's Web-based prescription drug plan finder tool. The 
amount of time we waited to speak with a CSR also varied, ranging from 
no wait time to over 55 minutes. For 75 percent of the calls--374 of 
the 500--we waited less than 5 minutes. For the remainder of the calls, 
62 were answered in less than 15 minutes, 39 calls were answered in 
from 15 minutes to less than 25 minutes, and 25 led to a wait of 25 
minutes or more.

We found that the Part D benefit portion of the Medicare Web site can 
be difficult to use. In our evaluation of overall usability--the ease 
of finding needed information and performing various tasks--we found 
usability scores of 47 percent for seniors and 53 percent for younger 
adults, out of a possible 100 percent. While there is no widely 
accepted benchmark for usability, these scores indicate that using the 
site can be difficult. For example, tools such as the drug plan finder 
were complicated to use, and forms that collect information online from 
users were difficult to correct if the user made an error. In our 
evaluation of the usability of 137 detailed aspects of the Part D 
portion of the site, including features of Web design and online tools, 
we found that 70 percent of these aspects could be expected to cause 
users confusion. For example, key functions of the prescription drug 
plan finder tool, such as the "continue" and "choose a drug plan" 
buttons, were often not visible on the page without scrolling down. In 
our evaluation of the ability of seven participants to collectively 
complete 34 user tests, we found that on average, participants were 
able to proceed slightly more than halfway through each test. In 
addition, CMS evaluated whether its Web site complied with pertinent 
federal requirements regarding accessibility for people with 
disabilities in March 2006. Although CMS has established features to 
make information on its Web site accessible to disabled users, it found 
that two requirements were not met, making it difficult for the 
visually impaired to use. A CMS official told us that the agency made 
the appropriate corrections on April 20, 2006. Because of time 
constraints, we did not verify that these corrections were made.

CMS relies on SHIPs to play a significant role in providing counseling 
and education on the Part D benefit to Medicare beneficiaries. CMS 
increased SHIP funding from $12 million for the 2003 SHIP grant 
year[Footnote 13] to $31.7 million for the 2005 grant year. CMS kept 
funding relatively high for the 2006 grant year--$30 million--to ensure 
that SHIPs continued to play an important role in educating 
beneficiaries about Part D. The number of beneficiaries served by SHIPs 
has also increased. During the 2004 SHIP grant year, SHIPs served 
approximately 2.52 million people. During the first 9 months of the 
2005 SHIP grant year--when CMS was gearing up its outreach and 
education on Part D--SHIPs served approximately 3.3 million 
individuals, an increase of nearly 770,000 from the prior full grant 
year. CMS attributes the increase in demand for SHIP services--as 
reflected in increases in the number of calls, face-to-face assistance, 
and referrals from the 1-800-MEDICARE help line--to beneficiaries' need 
for assistance on Part D. The average number of calls per month 
referred from the help line to SHIPs, for example, increased from about 
16,000 referrals for May through September 2005 to an average of about 
43,000 for October and November 2005, about the time Part D enrollment 
began. According to CMS officials, this increased demand can be 
attributed to callers seeking advice on choosing a drug plan. Unlike 
CSRs on the help line, SHIP counselors can offer individualized 
guidance to callers on enrollment and plan selection. SHIP coordinators 
in the five states we contacted confirmed that there was a substantial 
increase in the demand for their services because of the new Part D 
benefit. For example, the California SHIP served over 120,000 people in 
January 2006, compared to about 35,000 served in all of 2005.

Conclusions:

Within the past 6 months, millions of Medicare beneficiaries have been 
making important decisions about their prescription drug coverage and 
have needed access to information about the new Part D benefit to make 
appropriate choices. CMS faced a tremendous challenge in responding to 
this need and, within short time frames, developed a range of outreach 
and educational materials to inform beneficiaries and their advisers 
about Part D. To disseminate these materials, CMS largely added 
information to existing resources, including written documents, such as 
Medicare & You; the 1-800-MEDICARE help line; the Medicare Web site; 
and support for SHIPs. However, CMS has not ensured that its 
communications to beneficiaries and their advisers are provided in a 
manner that is consistently clear, complete, accurate, and usable. Six 
months have passed since these materials were first made available to 
beneficiaries, and their limitations could result in confusion among 
those seeking to make coverage decisions. Although the initial 
enrollment period for Part D will end on May 15, 2006, CMS will 
continue to play a pivotal role in providing beneficiaries with 
information about the drug benefit during the year and in subsequent 
enrollment periods. CMS has an opportunity to enhance its 
communications on the Part D benefit. This would allow beneficiaries 
and their advisers to be better prepared when deciding whether to 
enroll in the benefit, and if enrolling, which drug plan to choose.

Recommendations for Executive Action:

In order to improve the Part D benefit education and outreach materials 
that CMS provides to Medicare beneficiaries, we are recommending that 
the CMS Administrator take the following four actions:

* Ensure that CMS's written documents describe the Part D benefit in a 
manner that is consistent with commonly recognized communications 
guidelines and that is responsive to the intended audience's needs.

* Determine why CSRs frequently do not search for available drug plans 
if the caller does not provide personal identifying information.

* Monitor the accuracy and completeness of CSRs' responses to callers' 
inquiries and identify tools targeted to improve their performance in 
responding to questions concerning the Part D benefit, such as 
additional scripts and training.

* Improve the usability of the Part D portion of the Medicare Web site 
by refining Web-based tools, providing workable site navigation 
features and links, and making Web-based forms easier to use and 
correct.

Agency Comments and Our Evaluation:

We received written comments on a draft of this report from CMS (see 
app. III). CMS said that it did not believe our findings presented a 
complete and accurate picture of its Part D communications activities. 
CMS discussed several concerns regarding our findings on its written 
documents and the 1-800-MEDICARE help line. However, CMS did not 
disagree with our findings regarding the Medicare Web site or the role 
of SHIPs. CMS also said that it supports the goals of our 
recommendations and is already taking steps to implement them, such as 
continually enhancing and refining its Web-based tools.

CMS discussed concerns regarding the completeness and accuracy of our 
findings in terms of activities we did not examine, as well as those we 
did. CMS stated that our findings were not complete because our report 
did not examine all of the agency's efforts to educate Medicare 
beneficiaries and specifically mentioned that we did not examine the 
broad array of communication tools it has made available, including the 
development of its network of grassroots partners throughout the 
country. We recognize that CMS has taken advantage of many vehicles to 
communicate with beneficiaries and their advisers. However, we focused 
our work on the four specific mechanisms that we believed would have 
the greatest impact on beneficiaries--written materials, the 1-800- 
MEDICARE help line, the Medicare Web site, and the SHIPs. In addition, 
CMS stated that our report is based on information from January and 
February 2006, and that it has undertaken a number of activities since 
then to address the problems we identified. Although we appreciate 
CMS's efforts to improve its Part D communications to beneficiaries on 
an ongoing basis, we believe it is unlikely that the problems we 
identified in this report could have been corrected yet given their 
nature and scope.

CMS raised two concerns with our examination of a sample of written 
materials. First, it criticized our use of readability tests to assess 
the clarity of the six sample documents we reviewed. For example, CMS 
said that common multisyllabic words would inappropriately inflate the 
reading level. However, we found that reading levels remained high 
after adjusting for 26 multisyllabic words a Medicare beneficiary would 
encounter, such as Social Security Administration. CMS also pointed out 
that some experts find such assessments to be misleading. Because we 
recognize that there is some controversy surrounding the use of reading 
levels, we included two additional assessments to supplement this 
readability analysis--the assessment of design and organization of the 
sample documents based on 60 commonly recognized communications 
guidelines and an examination of the usability of six sample documents, 
involving 11 beneficiaries and 5 advisers.

Second, CMS expressed concern about our examination of the usability of 
the six sample documents. The participating beneficiaries and advisers 
were called on to perform 18 specified tasks, after reading the 
selected materials, including a section of the Medicare & You handbook. 
CMS suggested that the task asking beneficiaries and advisers to 
calculate their out-of-pocket drug costs was inappropriate because 
there are many other tools that can be used to more effectively compare 
costs. We do not disagree with CMS that there are a number of ways 
beneficiaries may complete this calculation; however, we nonetheless 
believe that it is important that beneficiaries be able to complete 
this task on the basis of reading Medicare & You, which, as CMS points 
out, is widely disseminated to beneficiaries, reaching all beneficiary 
households each year. In addition, CMS noted that it was not able to 
examine our detailed methodology regarding the clarity of written 
materials--including assessments performed by one of our contractors 
concerning readability and document design and organization. We plan to 
share this information with CMS, once our report has become public.

Finally, CMS took issue with one aspect of our evaluation of the 1-800- 
MEDICARE help line. Specifically, CMS said the 41 percent accuracy rate 
associated with one of the five questions we asked was misleading, 
because, according to CMS, we failed to analyze 35 of the 100 
responses. However, we disagree. This question addressed which drug 
plan would cost the least for a beneficiary with certain specified 
prescription drug needs. We analyzed these 35 responses to this 
question and found the responses to be inappropriate. The CSRs would 
not provide us with the information we were seeking because we did not 
supply personal identifying information, such as the beneficiary's 
Medicare number or date of birth. We considered such responses 
inappropriate because the CSRs could have answered this question 
without personal identifying information by using CMS's Web-based 
prescription drug plan finder tool. Although CMS said that it has 
emphasized to CSRs, through training and broadcast messages, that it is 
permissible to provide the information we requested without requiring 
information that would personally identify a beneficiary, in these 35 
instances, the CSR simply told us that our question could not be 
answered. CMS also said that the bulk of these inappropriate responses 
were related to our request that the CSR use only brand-name drugs. 
This is incorrect--none of these 35 responses were considered incorrect 
or inappropriate because of a request that the CSR use only brand-name 
drugs--as that was not part of our question.

As arranged with your offices, unless you publicly announce the 
contents of this report earlier, we plan no further distribution of it 
until 30 days after its date. At that time, we will send copies of this 
report to the Secretary of Health and Human Services, the Administrator 
of the Centers for Medicare & Medicaid Services, and other interested 
parties. We will also make copies available to others on request. In 
addition, the report will be available at no charge on the GAO Web site 
at [Hyperlink, http://www.gao.gov].

If you or your staff have any questions about this report, please 
contact me at (312) 220-7600 or aronovitzl@gao.gov. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this report. GAO staff who 
made major contributions to this report are listed in appendix IV. 

Signed By:

Leslie G. Aronovitz: 
Director: 
Health Care:

List of Requesters:

The Honorable John D. Dingell: 
Ranking Minority Member: 
Committee on Energy and Commerce: 
House of Representatives:

The Honorable Henry A. Waxman: 
Ranking Minority Member: 
Committee on Government Reform: 
House of Representatives:

The Honorable Charles B. Rangel: 
Ranking Minority Member Committee on Ways and Means: 
House of Representatives:

The Honorable Sherrod Brown: 
Ranking Minority Member: 
Subcommittee on Health Committee on Energy and Commerce: 
House of Representatives:

The Honorable Pete Stark: 
Ranking Minority Member: 
Subcommittee on Health Committee on Ways and Means: 
House of Representatives:

[End of section]

Appendix I: Briefing on Medicare Part D: 

Medicare Part D: CMS Communications to Beneficiaries Could Be Improved:

Briefing for Congressional Staff Updated:

Contents:

* Purpose and Objectives:

* Objective 1: Written Documents:

* Objective 2: 1-800-MEDICARE Help Line:

* Objective 3: Medicare Web Site:

* Objective 4: State Health Insurance Assistance Programs:

Purpose and Objectives:

* The Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 (MMA) established the new Part D outpatient prescription drug 
benefit.

* The Centers for Medicare & Medicaid Services (CMS) is responsible for 
overseeing this new benefit. CMS has taken steps to inform 
beneficiaries and their advisers about Part D using written documents, 
a toll-free help line, and an Internet Web site. CMS also gives State 
Health Insurance Assistance Programs (SHIP) funds to provide 
information about the Medicare program, including Part D.

* We assessed information that CMS provides to Medicare beneficiaries 
to educate them about Part D. Specifically, we assessed:

1. The extent to which CMS's written documents describe the Part D 
benefit in a clear, complete, and accurate manner.

2. The effectiveness of CMS's 1-800-MEDICARE help line in providing 
accurate, complete, and prompt responses to callers inquiring about the 
Part D benefit.

3. Whether the Medicare Web site presents information on the Part D 
benefit in a usable manner.

4. How CMS has used SH I Ps to respond to the needs of Medicare 
beneficiaries for information on the Part D benefit.

Objective 1: Written Documents Methodology:

* We performed in-depth review of a sample of six CMS documents 
describing the Part D benefit. The sample was selected to represent a 
variety of document types, content, and target audiences.

* We contracted with the American Institutes for Research (AIR) to 
assess the clarity of sample documents.

Sample documents: Medicare & You (Section 6: Medicare Prescription Drug 
Coverage);
Target audience: All beneficiaries.

Sample documents: Things to Think about When You Compare Plans; 
Target audience: All beneficiaries.

Sample documents: Frequently Asked Questions about: Retiree 
Prescription Drug Coverage & the New Medicare Prescription Drug 
Coverage;
Target audience: Beneficiaries with employer or union coverage.

Sample documents: The Auto-Enrollment Notice;
Target audience: Dual-eligible beneficiaries[a].

Sample documents: Quick Facts about Medicare's New Coverage for 
Prescription Drugs for People with a Medicare Health Plan with 
Prescription Drug Coverage;
Target audience: Beneficiaries with Medicare Advantage [B].

Source: GAO.

Sample documents: Do You Have a Medigap Policy[c] with Prescription 
Drug Coverage?; 
Target audience: Beneficiaries with Medigap. 

[a] Dual-eligible beneficiaries are Medicare beneficiaries who receive 
full Medicaid benefits for services not covered by Medicare.

[b] Medicare Advantage replaces the Medicare+Choice managed care 
program and expands the availability of private health plan options to 
Medicare beneficiaries.

[c] Medigap policies provide supplemental health coverage sold by 
private insurers to help pay for Medicare cost-sharing requirements, as 
well as for some services not provided by Medicare.

[End of table]

* To determine the clarity of the sample of Part D written documents 
describing the Part D benefit, AIR:

- evaluated text by sentence length and the number of syllables using 
three standard readability tests Flesch-Kincaid, SMOG, and Fry:

- assessed the design and organization of the documents based on 60 
commonly recognized written communications guidelines, including those 
to aid senior readers; and:

* tested the usability of sample documents with 16 participants-1 1 
Medicare beneficiaries, including 1 disabled beneficiary who was under 
65, and 5 advisers to beneficiaries.

- Everyone was asked to perform 18 specified tasks related to 
enrollment, coverage, costs, penalty, and informational resources. They 
were also asked to provide feedback about their experiences.

- Although the size of the group was small, research shows that as few 
as 5 individuals can provide meaningful insights into common problems.

* To evaluate completeness, we reviewed the sample documents to 
determine if they included sufficient information to identify (1) next 
steps in determining whether to enroll and what plan to choose and (2) 
important factors, such as penalty provisions, that could affect 
coverage decisions.

* To evaluate accuracy, we reviewed the sample documents for 
consistency with laws, regulations, and CMS guidance. 

Objective 1: Written Documents-Documents Lack Clarity:

* Readability assessment: Sample documents explaining the Part D 
benefit are written at a reading level that is difficult for many 
seniors.

- Reading levels for the sample documents were challenging for at least 
the 40 percent of seniors, who read at or below the 5th grade level.

* Reading level estimates for the sample texts[Footnote 1] ranged from 
7th grade to postcollege level.

* Reading levels remain challenging for at least 40 percent of seniors 
even after adjusting for 26 multisyllabic words, such as Medicare, 
Medicare Advantage, and Social Security Administration. After the 
adjustment, the estimated reading level ranged from 8th to 12th grade.

* Document design and organization assessment: The sample documents 
demonstrated adherence to about half of the 60 commonly recognized 
written communications guidelines, on average.

- Desirable features: The documents;

* were written with a respectful and polite tone, 

* were free of cliches and slang,

* contained useful contact information,

* included concise and descriptive headings, and:

* generally followed graphic and formatting guidelines.

- Undesirable features: The documents;

* used too much technical jargon,

* often did not define difficult terms,

* included sentences and some paragraphs that were too long, and:

* did not use sufficient summaries to assist the reader in identifying 
key points.

* Usability assessment: Beneficiaries and advisers to beneficiaries 
were frustrated by the documents' lack of clarity and often could not 
complete the 18 assigned tasks.

- One of the 18 assigned tasks was completed by all beneficiaries and 
advisers.

- Eleven of the 18 assigned tasks were completed by at least half of 
the beneficiaries and advisers.

- Four of the 18 assigned tasks were completed by 2 or fewer of the 11 
beneficiaries.

- Nine of the 18 assigned tasks, were completed by 2 or fewer of the 5 
advisers.

* Some of the tasks that proved difficult included:

- computing projected total out-of-pocket costs for a plan that 
provided Part D's standard coverage (successfully completed by none of 
the 11 beneficiaries and 2 of the 5 advisers),

- evaluating whether it was possible to enroll in Medicare Part D and 
keep drug coverage from a retiree health plan (successfully completed 
by 2 beneficiaries and 2 advisers), and:

- determining the course of action for dual-eligibles who are 
automatically enrolled in a plan that does not cover all drugs used 
(successfully completed by 4 beneficiaries and 1 adviser).

- Participants described documents as too wordy, confusing, and hard to 
follow.

- Participants struggled with technical terms, such as "classes of 
commonly prescribed drugs" and "formulary," which is a list of drugs 
covered by a plan.

- Even when most participants were able to complete the tasks, they 
expressed confusion and frustration.  

Objective 1: Written Documents-Documents are Generally Complete:

* Our analysis showed that the sample documents were generally complete 
and informed readers of next steps in determining whether to enroll and 
what plan to choose as well as important factors that could affect 
their coverage decisions. For example:

- All documents reviewed provided sources of assistance and relevant 
contact information, which could aid in identifying next steps for 
coverage decisions.

- All documents reviewed provided the dates of the start of initial 
program enrollment and coverage.

* However, our analysis also identified a few exceptions where the 
documents did not mention some important issues. For example:

- Medicare & You noted that drug plan information may change, but made 
no mention of possible changes on the pages beneficiaries would use to 
compare coverage and select a plan. Such information is needed because 
drug plans can change their covered drugs and prices.

- The documents did not provide sufficient information about the 
cumulative effect of the penalty for missing the initial enrollment 
deadline.

* Our analysis showed that the sample documents were generally accurate 
and that the text was consistent with MMA, implementing regulations, 
and agency guidance.

* However, we noted a few misleading statements in Medicare & You. For 
example:

- The document implied that if a beneficiary's doctor applied for an 
exception it would be granted, whereas exceptions to the formulary are 
granted at each plan sponsor's discretion.

- The document outlined the minimum requirements for standard coverage 
by Part D plans. However, it did not indicate that few plans offer this 
exact coverage and that beneficiaries should be prepared to compare 
plans with varying premiums, co-payments, and covered drugs to choose 
plans that best suit them.

Objective 2: 1-800-MEDICARE Help Line Methodology:

* We placed 500 calls to 1-800-MEDICARE, posing one of five questions 
in each call, so that each question was asked 100 times. To develop the 
questions, we considered topics listed on the Medicare Web site and 
obtained help line reports that listed the scripts that customer 
service representatives (CSR) frequently accessed to respond to 
callers' questions.

* Calls were randomly placed at different times of the day and on 
different days of the week from January 17 to February 7, 2006, to 
match the daily and hourly pattern of calls reported by 1-800-MEDICARE 
in October 2005.

* To evaluate the accuracy and completeness of CSRs' responses to our 
five questions, we used three resources:

- the prescription drug finder tool on the Medicare Web site,

- the 1-800-MEDICARE scripts prepared by CMS and contractors for CSRs 
to use in responding to callers' questions, and:

- input from CMS officials on the criteria we used to evaluate 
responses.

* To evaluate the promptness of the help line in answering calls, we 
recorded the length of time it took to connect to a CSR for each call.

* CSRs' responses were scored in one of five categories based on 
specific criteria we developed:

- Accurate and Complete - responses met our defined criteria; 

- Inappropriate - responses reflected the need for personal beneficiary 
information, which was not actually required to answer the question;

- Inaccurate - responses did not meet our defined criteria; 

- Incomplete - responses partially met our defined criteria; 

- Unanswered - calls did not receive responses from CSRs. 

Table:

Question: 1. What drug plan can a beneficiary get that will cover all 
of his/her [specified] drugs at a [specified] pharmacy; have a mail-
order option; and cost the least amount annually with [or without] a 
deductible?;
Criteria: An accurate and complete response would identify the 
prescription drug plan that has the lowest estimated annual cost for 
the drugs the beneficiary uses.

Question: 2. Can a beneficiary who is in a nursing home and not on 
Medicaid sign up for a prescription drug plan?; 
Criteria: An accurate and complete response would indicate that such a 
beneficiary can choose whether to enroll in a Medicare prescription 
drug plan.

Question: 3. Can a beneficiary enroll in the Medicare prescription drug 
program and keep his/her current Medigap policy?;
Criteria: An accurate and complete response would inform the caller 
that enrolling for the prescription drug benefit would depend on 
whether the beneficiary's Medigap plan was creditable- that is, whether 
the coverage it provided was at least as good as Medicare's standard 
prescription drug coverage-or noncreditable. The CSR response would 
also mention that the beneficiary's Medigap plan should have sent 
him/her information that outlines options.

Question: 4. What options does a beneficiary, who has retiree health 
insurance with prescription drug coverage that is not as good as the 
Medicare prescription drug coverage, have as it relates to the Medicare 
benefit?;
Criteria: An accurate and complete response would indicate that a 
beneficiary has two options: (1) keep current health plan and join the 
prescription drug plan later with a penalty; or (2) drop current 
coverage and join a Medicare drug plan.

Question: 5. How do I know if a beneficiary qualifies for extra help?; 
Criteria: An accurate and complete response would refer the beneficiary 
to the Social Security Administration. 

Source: GAO.

[End of table] 

Objective 2: 1-800-MEDICARE Responses Often Accurate and Complete, but 
Some Not:

* We found that the 1-800-MEDICARE help line provided accurate and 
complete answers to 334 of our 500 calls, a rate of about 67 percent. 
In addition, it provided accurate but incomplete answers for about 3 
percent of our calls.

Figure: Distribution of Unanswered Calls and Accurate and Complete, 
Inaccurate, Incomplete, and Inappropriate Responses[a]:

[See PDF for image]

Source: GAO.

[a] Percentages exceed 100 because of rounding. 

[End of figure] 

Objective 2: 1-800-MEDICARE-Variation in Results for Individual 
Questions: 

* The accuracy and completeness of responses to our five questions 
varied significantly, from 41 percent to 90 percent.

- Q1 - 41 percent 
- Q2 - 79 percent 
- Q3 - 66 percent 
- Q4 - 58 percent 
- Q5 - 90 percent 
- Average for all questions-67 percent:

Figure: Distribution of Unanswered Calls and Accurate and Complete, 
Inaccurate, Incomplete, and Inappropriate Responses by Question: 

[See PDF for image]

Source. GAO. 

[End of figure]

* CSRs answered some questions better than others. For example:

- CSRs accurately and completely answered question 5 (whether a 
beneficiary qualifies for extra help), which had a specific script, 90 
percent of the time.

- CSRs accurately and completely answered question 2 (whether a 
beneficiary in a nursing home, who was not on Medicaid, could sign up 
for the drug benefit) 79 percent of the time even though there was no 
specific script for the question.

- CSRs' responses for question 3 (whether a beneficiary with a Medigap 
policy could enroll in the drug benefit) were accurate and complete 66 
percent of the time. Many of the responses were inaccurate because they 
did not provide adequate information about creditable and noncreditable 
coverage.

- The accuracy and completeness rate for question 4 (about retiree 
health insurance) was 58 percent. Many of the responses were inaccurate 
because the CSRs did not follow the available script or provide 
sufficient information about the implications of the beneficiary's 
decision.

- CSRs' responses to question 1 (which requires CSRs to use the 
prescription drug plan finder Web tool) were accurate and complete less 
than 50 percent of the time. The rate is largely caused by CSRs' 
inappropriate responses35 out of 100 times that they were unable to 
answer the question without personal identifying information, such as 
the beneficiary's Medicare number or date of birth.

* We did not obtain answers for 23 of the calls we placed because of 
unintentional disconnections, intentional disconnections, or an 
inoperative Web tool.

- Unintentional disconnections occurred when the system inadvertently 
disconnected the call (19 calls).

- Intentional disconnections were programmed by the telephone company 
when wait times were projected to exceed 20 minutes (3 calls).

- The prescription drug plan finder Web tool used by CSRs was not 
operative at the time of our call (1 call).

Objective 2: 1-800-MEDICARE-Variation in Wait Times:

* The amount of time we had to wait to speak with a CSR varied 
significantly, ranging from no wait to more than 55 minutes.

- About 75 percent of calls were connected in less than 5 minutes.

- For calls where we waited more than 5 minutes to speak to a CSR, the 
wait time ranged from 5 minutes to over 55 minutes.

* Sixty-two calls were on hold from 5 to 14 minutes, 59 seconds;

* Thirty-nine calls were on hold from 15 to 24 minutes, 59 seconds;

* Twenty-five calls were on hold 25 minutes or more.

- For both intentional and unintentional disconnections, we often 
waited more than 5 minutes before the disconnection occurred. In one 
case, we were placed on hold for 54 minutes before being disconnected.

Objective 3: Medicare Web Site Methodology:

* To evaluate the usability of the Part D benefit portion of the 
Medicare Web site, we contracted with Nielsen Norman Group (NN/g), a 
firm with expertise in Web design.

* In addition, we reviewed CMS's efforts to comply with section 508 of 
the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794d).

- Section 508 requires that all federal Web sites be designed to make 
information and services fully available to individuals with 
disabilities.

- Our review included an examination of CMS's March 2006 report 
assessing the compliance of its Medicare Web site with this federal 
requirement and discussions with CMS officials.

* NN/g performed the following three separate evaluations:

- Evaluation one: NN/g calculated an overall score of the site's 
usability, to reflect the ease of finding necessary information and 
performing various tasks. For this calculation, NN/g considered various 
factors, such as site navigation, customer support, and presentation of 
online forms.

- Evaluation two: NN/g evaluated in detail the usability of 137 
detailed aspects of the Part D benefit portion of the Web site. Topics 
included:

* Web design (e.g., home page, navigation, search function, graphics, 
and organization);

* tools (e.g., plan finder);

* writing style (e.g., tone, content, legibility, and readability);

* accessibility (e.g., availability of site version for the blind); 
and; 
 
* languages (e.g., links for users who have difficulty reading English).

- Evaluation three: NN/g conducted a total of 34 user tests to 
determine the ease of performing a variety of Web-related tasks, such 
as browsing the site, making a change in address, finding plan 
information under certain scenarios, comparing Medigap and Part D drug 
coverage, and determining how to join a plan.

* NN/g asked five Medicare beneficiaries who were not disabled and two 
advisers to beneficiaries to perform one or more user tests each using 
the Web site.

* At the end of the user tests, the seven participants were asked to 
provide feedback about their experiences.

Objective 3: Medicare Web Site Difficult to Use:

* Based on NN/g evaluations, we concluded that the Part D benefit 
portion of the Medicare Web site can be challenging to use.

- For evaluation one, the calculated usability scores indicate a need 
for improvement. The usability score was 47 percent for seniors and 53 
percent for younger adults. While there is no widely accepted benchmark 
for usability, these scores indicate that using the site can be 
difficult. For example, tools such as the drug plan finder were 
complicated to use, and forms that collect information online from 
users were difficult to correct if the user made an error.

- Evaluation two showed that the Part D benefit portion of the Web site 
was difficult to use. About 70 percent of the 137 detailed aspects of 
the site were presented in a manner that could be expected to cause a 
medium or high level of confusion. For example,

* important functions in the plan finder tool the "continue" and 
"choose a drug plan" buttons are often not visible on the page;

* plan finder tool defaults to generic drugs, complicating users' 
search for drug plans covering brand-name drugs;

* information to assist navigation was often not helpful for example, 
text labels associated with links were not always functioning; and:

* the writing style presented some challenges for example, material was 
written at the 11th grade level.

- For evaluation three, the 34 user tests showed that the site was a 
challenge for the seven participants to use. For example:

* For 12 of the 34 tests, participants' initial reactions were that 
they would not be able to complete the tests and wanted to quit trying.

* On average, participants were able to proceed slightly more than 
halfway through each of the 34 tests.

* When asked for feedback on their experience with using the site, the 
seven participants, on average, indicated high frustration levels and 
low satisfaction.

* To comply with section 508 of the Rehabilitation Act, CMS has 
established features to make information on its Medicare Web site 
accessible to disabled users. For example, CMS provides a "screen 
reader" version of the site for the visually impaired. This technology 
translates text and data into spoken words.

* CMS's March 2006 review of its site's compliance with section 508 
showed that two requirements were not met:

- The plan finder did not provide alternative text for all images that 
is, there was no text for the screen reader to read. Therefore, images 
could not be translated into spoken words for the visually impaired.

- The plan finder did not allow screen readers to recognize form fields 
and translate forms into spoken words. As a result, visually impaired 
users would not have been able to complete Web-based forms.

* A CMS official told us that the agency made the necessary corrections 
on April 20, 2006, but we did not verify that these corrections were 
made.

Objective 4: SHIP Methodology:

* We interviewed CMS officials and reviewed documentation they provided 
about SHIPs' role in educating beneficiaries about the Part D benefit.

* We contacted the SHIP coordinators in California, Florida, New York, 
Texas, and Pennsylvania the five states with the most Medicare 
beneficiaries. Together, these states accounted for about 35 percent of 
the country's total Medicare population in 2004.

Objective 4: SHIPs' Responses to Beneficiaries' Needs Concerning Part D:

* According to CMS, it relies on SHIPs to play a significant role in 
beneficiary counseling and education on the Part D benefit.

* In anticipation of the increased demand for SHIP services regarding 
the Part D benefit, CMS increased SHIP funding in recent years. Funding 
for the 2003 SHIP grant year[Footnote 2] was $12 million, and it 
reached $31.7 million for the 2005 grant year. CMS kept funding 
relatively high for the 2006 grant year $30 million to ensure that 
SHIPs continue to play an important role in educating beneficiaries 
about the Part D benefit.

* During the 2004 SHIP grant year, SHIPs served approximately 2.52 
million people. According to preliminary data for the first 9 months of 
the 2005 SHIP grant year when CMS was gearing up its outreach and 
education on Part D SHIPs served approximately 3.3 million individuals, 
an increase of nearly 770,000 from the prior full grant year. CMS 
attributes this increase in demand for services to beneficiaries' need 
for assistance on the Part D benefit.

* The average number of calls referred from the 1-800-MEDICARE help 
line to SHIPs has increased significantly.

- The monthly average of number of calls referred to SHIPs increased 
from 16,000 referrals for May through September 2005 to approximately 
43,000 for October and November 2005, the months around the time when 
enrollment in the Part D benefit began.

- According to CMS officials, this increased demand was influenced by 
callers seeking advice on choosing a drug plan. Unlike CSRs on the help 
line, SHIP counselors can offer individualized guidance to callers.

* Specifically, the five SHIPs we contacted experienced a large 
increase in demand for their services because of the Part D benefit.

- California served over 120,000 people in January 2006, compared to 
about 35,000 served in all of 2005.

- Florida, mostly during November and December of 2005, held at least 
six "phone bank" events where SHIP counselors were available to take 
calls on the Part D benefit during live newscasts. Florida plans to 
hold two additional phone banks as the May 15 enrollment deadline 
approaches.

- New York reported nearly doubling its formal training sessions for 
SHIP counselors in 2005, to prepare them for the demand for services 
related to the Part D benefit.

- Texas counseled 45,719 clients and conducted 523 outreach events from 
November 15, 2005the official start of the enrollment period to March 
22, 2006.

- Pennsylvania held over 3,000 enrollment events, which were attended 
by more than 130,000 people, from May 2005 to February 28, 2006.

* The SHIP officials in four of the five states we contacted indicated 
that the demand for their services related to the Part D benefit has 
declined since the benefit began in January 2006. However, each SHIP 
contacted expects a surge in demand as the May 15 enrollment deadline 
approaches.

* Since December 2005, CMS has been conducting biweekly meetings with 
its regional offices, which interact directly with SHIP offices, to 
gauge SHIPs' ability to meet the demands of beneficiaries.

Agency Comments:

We discussed our findings with CMS officials on March 13, 2006.

9 CMS officials did not comment on our findings. 

Footnotes:

[1] Estimates have a likely margin of error of [plus or minus] two 
grades. 

[2] A SHIP grant year begins on April 1 of the year the funds become 
available.

[End of section]

Appendix II: Objectives, Scope, and Methodology:

In this report, we assessed (1) the extent to which the Centers for 
Medicare & Medicaid Services' (CMS) written documents describe the 
Medicare Part D prescription drug benefit in a clear, complete, and 
accurate manner; (2) the effectiveness of CMS's 1-800-MEDICARE help 
line in providing accurate, complete, and prompt responses to callers 
inquiring about the Part D benefit; (3) whether CMS's Medicare Web site 
presents information on the Part D benefit in a usable manner; and (4) 
how CMS has used State Health Insurance Assistance Programs (SHIP) to 
respond to the needs of Medicare beneficiaries for information on the 
Part D benefit. To obtain information on CMS's efforts to educate 
beneficiaries about Part D, we interviewed agency officials responsible 
for Part D written documents, the 1-800-MEDICARE help line, the 
Medicare Web site, and SHIPs. Following our briefing of congressional 
staff on April 19, 2006, the briefing slides were updated to reflect 
CMS's reported correction to the Medicare Web site to comply with 
section 508 of the Rehabilitation Act of 1973.[Footnote 14] We 
determined that the data used were sufficiently reliable for the 
purposes of this report.

Written Documents:

To assess the clarity, completeness, and accuracy of written documents, 
we compiled a list of all available CMS-issued Part D benefit 
publications intended to inform beneficiaries and their advisers and 
selected a sample of 6 from the 70 CMS documents available, as of 
December 7, 2005, for in-depth review, as shown in table 1. The sample 
Part D documents were chosen to represent a variety of publication 
types, such as frequently asked questions and fact sheets available to 
beneficiaries about the Part D drug benefit. We selected documents that 
targeted all beneficiaries or those with unique drug coverage concerns, 
such as dual-eligibles and beneficiaries with Medigap.[Footnote 15]

Table 1: Sample of Six Selected Documents:

Document: Medicare & You, Section 6: Medicare Prescription Drug 
Coverage; 
Target audience: All beneficiaries.

Document: Things to Think about When You Compare Plans; 
Target audience: All beneficiaries.

Document: Frequently Asked Questions about: Retiree Prescription Drug 
Coverage & the New Medicare Prescription Drug Coverage; 
Target audience: Beneficiaries with employer or union coverage.

Document: Introduction to the Auto-Enrollment Notice; 
Target audience: Dual-eligible beneficiaries[A].

Document: Quick Facts about Medicare's New Coverage for Prescription 
Drugs for People with a Medicare Health Plan with Prescription Drug 
Coverage; 
Target audience: Beneficiaries with Medicare Advantage[B].

Document: Do You Have a Medigap Policy with Prescription Drug 
Coverage?; 
Target audience: Beneficiaries with Medigap. 

Source: GAO.

[A] Dual-eligible beneficiaries are Medicare beneficiaries who receive 
full Medicaid benefits for services not covered by Medicare.

[B] Medicare Advantage replaced the Medicare+ Choice managed care 
program and expanded the availability of private health plan options to 
Medicare beneficiaries.

[End of table]

To evaluate clarity, we contracted with the American Institutes for 
Research (AIR)--a firm with experience in evaluating written material. 
AIR evaluated the texts of the six sample documents using three 
methodologies:

1. three standard readability tests;[Footnote 16]

2. 60 commonly recognized written communications guidelines, including 
practices to aid senior readers; and:

3. user testing with 11 Medicare beneficiaries and 5 advisers to 
beneficiaries, who performed 18 specified tasks related to enrollment, 
coverage, cost, penalty, and information resources and provided 
feedback about their experiences.

We reviewed the sample documents for completeness to determine whether 
they contained sufficient information to allow the beneficiaries to 
identify (1) their next steps in determining whether to enroll and what 
plan to choose and (2) important factors, such as penalty provisions, 
that could affect their coverage decisions. To identify those important 
factors associated with the Part D benefit, we reviewed relevant laws, 
regulations, and 1-800-MEDICARE scripts prepared for customer service 
representatives (CSR) to read to callers and obtained information from 
advocacy groups. To evaluate the accuracy of information, we reviewed 
the sample materials for compliance with laws, regulations, and CMS 
guidance.

The 1-800-MEDICARE Help Line:

To determine the accuracy and completeness of information provided 
regarding the Part D benefit, we placed a total of 500 calls to the 1- 
800-MEDICARE help line. We posed one of five questions about Part D in 
each call, so that each question was asked 100 times. Each question was 
pretested before we finalized its wording. We randomly placed calls at 
different times of the day and different days of the week from January 
17 to February 7, 2006. Our calling times were chosen to match the 
daily and hourly pattern of calls reported by 1-800-MEDICARE in October 
2005. We informed CMS officials that we would be placing calls; 
however, we did not tell them the questions we would ask or the 
specific dates and times that we would be placing our calls.

To select the five questions, we considered topics identified in the 
Medicare Web site's frequently asked questions. In addition, we 
considered topics most frequently addressed by 1-800-MEDICARE CSRs 
based on help line reports. To evaluate the accuracy of CSRs' responses 
to our five questions, we used three resources: (1) the prescription 
drug plan finder tool on the Medicare Web site, (2) 1-800-MEDICARE 
scripts, and (3) input obtained from CMS officials on the criteria we 
used for evaluating CSR responses. Table 2 lists the questions we asked 
and the criteria we used to evaluate the accuracy of responses.

Table 2: Questions and Criteria Used to Evaluate Accuracy:

Question: 1. What drug plan can a beneficiary get that will cover all 
of his/her [specified] drugs at a [specified] pharmacy; have a mail- 
order option; and cost the least amount annually with [or without] a 
deductible?; 
Criteria: An accurate and complete response would identify the 
prescription drug plan that has the lowest estimated annual cost for 
the drugs the beneficiary uses.

Question: 2. Can a beneficiary who is in a nursing home and not on 
Medicaid sign up for a prescription drug plan?; 
Criteria: An accurate and complete response would indicate that a 
beneficiary can choose whether to enroll in a Medicare prescription 
drug plan.

Question: 3. Can a beneficiary enroll in the Medicare prescription drug 
program and keep his/her current Medigap policy?; 
Criteria: An accurate and complete response would inform the caller 
that enrolling for the prescription drug benefit would depend on 
whether the beneficiary's Medigap plan was creditable--that is, whether 
the coverage it provided was at least as good as Medicare's standard 
prescription drug coverage-or noncreditable. The CSR response would 
also mention that the beneficiary's Medigap plan should have sent 
him/her information that outlined options.

Question: 4. What options does a beneficiary, who has retiree health 
insurance with prescription drug coverage that is not as good as the 
Medicare prescription drug coverage, have as it relates to the Medicare 
benefit?; 
Criteria: An accurate and complete response would indicate that a 
beneficiary has two options: (1) keep current health plan and join the 
prescription drug plan later with a penalty or (2) drop current 
coverage and join a Medicare drug plan.

Question: 5. How do I know if a beneficiary qualifies for extra help?; 
Criteria: An accurate and complete response would refer the beneficiary 
to the Social Security Administration. 

Source: GAO.

[End of table]

When placing our calls, we identified ourselves as a beneficiary's 
relative, but did not provide CSRs with specific identifying 
information, such as a Medicare beneficiary number or date of birth. 
During our calls, CSRs were not aware that their responses would be 
included in a research study. We recorded the length of each call, 
including wait times, and the time it took before being connected to a 
CSR. We evaluated the accuracy and completeness of the responses by 
CSRs to the 500 calls by determining whether key information was 
provided.

The results from our 500 calls are limited to those calls and are not 
generalizable to the universe of calls made to the help line. The 
questions we asked were limited to matters concerning the Part D 
benefit and do not encompass all of the questions callers might ask.

Medicare Web Site:

We contracted with the Nielsen Norman Group (NN/g)--a firm with 
expertise in Web design--to assess the usability of the Part D 
information available on the Medicare Web site. This study consisted of 
three separate evaluations. First, NN/g compared the site's compliance 
with established usability guidelines to determine a usability score to 
reflect the ease of finding necessary information and performing 
various tasks. Specifically, to determine the usability scores, NN/g 
evaluated various aspects of the Web site using industry-recognized 
"good" Web design practices, as indicated by the contractor, and the 
collective body of knowledge from NN/g internal reports and experts, or 
NN/g usability guidelines.[Footnote 17]

Second, NN/g determined the degree of difficulty associated with 137 
detailed aspects of Web site design for the Part D portion of the site. 
The 137 aspects fall into the following general categories:

* overall Web design (e.g., home page, navigation, search function, 
graphics, and overall organization);

* tools (e.g., plan finder);

* writing style (e.g., content, tone, legibility, and readability);

* accessibility (e.g., availability of a version of the Web site for 
the blind); and:

* languages (e.g., availability of languages other than English).

NN/g determined the difficulty level in using each of the 137 aspects. 
NN/g noted aspects that had good design and would not be expected to 
cause confusion. For those aspects with a design that would be expected 
to cause confusion, NN/g ranked the associated difficulty level as 
high, medium, or low.[Footnote 18]

Third, NN/g performed a qualitative evaluation on January 20 and 23, 
2006, to test the ability of five Medicare beneficiaries and two 
beneficiary advisers to perform specified tasks related to Medicare 
beneficiaries using the Web site and to obtain feedback about 
participants' experiences. While the results are not statistically 
valid, these users provided important insights into the usability of 
the Medicare Web site. Participants were asked to "think out loud" as 
they worked through their tasks, while an NN/g facilitator observed 
their behavior and took notes. NN/g gave each task a score. At the end 
of their sessions, NN/g asked participants for input regarding their 
confidence in the answers they obtained from the Web site, and their 
overall satisfaction and frustration levels associated with using the 
site.

Finally, we obtained the results of CMS's March 2006 review of its Web 
site's compliance with section 508 of the Rehabilitation Act of 1973, 
as amended. This law requires federal agencies to make the information 
on their Web sites accessible to people with disabilities. We also 
discussed the results of this review with agency officials and followed 
up with them to determine the status of CMS's corrective actions.

State Health Insurance Assistance Programs:

To determine the role of SHIPs in helping Medicare beneficiaries 
understand Part D, we interviewed CMS officials who monitor SHIPs' 
activities. We also reviewed information that we obtained from CMS 
officials and other sources on the program, its funding, changes made 
in response to the introduction of Part D, and the impact of Part D on 
the demand for SHIP services. In addition, we interviewed SHIP 
officials in California, Florida, New York, Texas, and Pennsylvania-- 
the five states with the largest Medicare populations--to obtain 
information on the experience of their SHIPs with Part D.

We conducted our work from November 2005 through May 2006 in accordance 
with generally accepted government auditing standards.

[End of section]

Appendix III: Comments from the Centers for Medicare & Medicaid 
Services: 

Department Of Health & Human Services: 

Centers for Medicare & Medicaid Services:

200 Independence Avenue SW: 
Washington, DC 20201:

TO: Leslie G. Aronovitz:
Director: 
Health Care:

FROM: Mark B. McClellan, M.D., PhD: 
Administrator:

SUBJECT: Government Accountability Office's (GAO) Draft report, 
"Medicare: Communications to the Beneficiaries on the Prescription Drug 
Benefit Could Be Improved" (GAO-06-654):

The Centers for Medicare & Medicaid Services has reviewed the findings 
in the GAO report entitled MEDICARE: Communications to Beneficiaries on 
the Prescription Drug Benefit Could Be Improved (GAO-06-654) regarding 
CMS communications on the Part D benefit. Having clear and effective 
communication about Medicare's new prescription drug coverage is one of 
the Agency's critical priorities. We have worked very hard to ensure 
that Medicare beneficiaries have the information they need to make 
decisions about enrolling in a drug plan that works for them. We are 
pleased that the millions of beneficiaries who have enrolled in Part D 
are experiencing very high rates of satisfaction with their coverage. 
Each week, tens of thousands of beneficiaries are enrolling in Part D, 
which gives them real savings and protections for the future.

While we greatly appreciate the feedback from your report and have 
already worked to implement your recommendations, we do not believe 
that your findings present a complete or accurate picture of the Part D 
communication activities. We understand that the report is based on 
studies of particular aspects of some of our communications tools at 
one point in time three months ago, in January and early February 2006. 
In addition to the many "continuous improvement" activities we have 
undertaken to address startup issues in the drug benefit since that 
time, there are much more extensive internal and external evaluations 
of our communications activities completed before, during, and after 
that time which have different conclusions, as we note below. These 
evaluations have used well-established methods which have been clearly 
documented and reviewed; in contrast, you have not yet responded to our 
requests for information on the methods you have applied. Additionally, 
your report does not address the unique breadth and depth of CMS 
activities to educate and to reach out to people with Medicare and the 
community that supports them in their health care decisions. From the 
outset, it was clear that no single source of information would be 
adequate or preferred by all of our beneficiaries. Consequently, we 
have expanded the range of tools available and vastly expanded our 
local partnerships to help beneficiaries use them, partnering with more 
than ten thousand diverse public and private organizations around the 
country in this effort.

Importantly, the report does not look at this broad array of 
communication tools to help Medicare beneficiaries consider their drug 
plan options. For example, the report dismisses all of the tools used 
by our customer service representatives and our website for 
beneficiaries that provide personalized identifying information to 
enable us to provide them with personally customized service. The vast 
majority of our callers provide such personal identification, yet these 
tools were not evaluated. In fact, the report misleadingly states that 
we provided the right information on a lower share of cases because 
some customer service representatives sought to get this personal 
information to serve the beneficiary more quickly and effectively. 
Where GAO did actually get information on drug costs, as thousands of 
callers get every day, customer service representatives provided 
accurate information at a much higher rate. As another example, GAO 
evaluated whether beneficiaries could calculate their out-of-pocket 
drug costs in the standard Medicare benefit by hand, using only the 
Medicare and You handbook, but very few beneficiaries have opted to use 
the handbook in this way because: (1) there are far better tools 
available for quickly and automatically calculating drug costs on the 
web, on the phone, and through our partner organizations, and (2) over 
90 percent of our beneficiaries are choosing plans with benefits other 
than the standard plan, because they prefer features like zero 
deductibles, flat copays, and coverage in the "donut hole." 
Beneficiaries are overwhelmingly using other tools to make effective 
cost comparisons. 

In fact, the drug plan finder element of the website has received 164.6 
million page views between November 15, 2005 and April 26, 2006. The 
Frequently Asked Questions (FAQ) section of www.medicare.gov has been 
accessed more than one million times since January l, 2006. CMS has 
also responded to more than 19,000 emails received through the FAQ 
section, with 93% of them being resolved satisfactorily in the first 
response.

Finally, there is no attention in the report at all to major aspects of 
our communications activities and expenditures, such as the expansion 
of our community based education and outreach efforts through an 
extensive network of grassroots partners across the country. This 
significant emphasis on reaching people where they live, work, play and 
pray is a key component of our success in reaching millions of people 
with Medicare and those who work on their behalf. No mention is made of 
the specialized campaigns targeting African American, Hispanic, 
American Indians, Asian American and Pacific Islander and in low income 
communities. These campaigns utilize new partnerships, employ materials 
in other languages and specialized paid media campaigns. These targeted 
campaigns within the broader campaign allow us to reach all segments of 
the Medicare population, including those who might benefit from the low 
income subsidy and those with language and other cultural barriers to 
accessing information.

We believe that there have been a number of key elements to our 
successful education campaign. First, we recognized early on that we 
would need to supplement our proven traditional communications tools, 
including the Medicare & You Handbook, the 1-800-MEDICARE line, and the 
State Health Insurance Assistance Programs (SHIPs) with additional 
advanced technology and grassroots resources, as well as use earned and 
paid media opportunities. Second, we determined that the provision of 
personalized assistance and one-on-one counseling was the key 
ingredient to success. This necessitated our building a grassroots 
network of traditional and non-traditional partners who were willing to 
be trained to provide the one-on-one counseling. We strongly believe 
this is important for beneficiaries to make confident decisions about 
their Part D plan. We knew we would have to develop a grassroots 
capacity and local networks to supplement the CMS regional structure to 
provide the necessary education and enrollment assistance at the 
community level. This would involve reaching out, not just to our 
traditional partners such as the SHIPs, but to all the groups and 
organizations that have contact with our beneficiaries on a daily basis 
"where they work, where they play, and where they pray."

We appreciate any and all ideas for improving our communications 
efforts, and we take very seriously the four tasks that GAO recommends 
to improve CMS' education efforts. We support the goal of these tasks 
and have already taken many steps to meet them.

Ensure that CMS's written documents describe the Part D benefit in a 
manner that is consistent with commonly recognized communications 
guidelines and that is responsive to the intended audience needs. - CMS 
employs a wide variety of consumer research techniques, simple language 
best practices, and independent evaluations in both English and in 
Spanish documents to ensure the readability and usefulness of our 
educational materials including those describing Part D. These tests 
have demonstrated that CMS written documents follow best practice 
guidelines for written communications with the intended audiences. 
These techniques and practices are summarized in Attachment A.Because 
of the importance of this topic, we are always interested in improving 
our written products. We look forward to an opportunity to review what 
GAO used in its review and will compare them to the evaluation methods 
we are already using, as soon as GAO is willing to provide the 
methodological details.

Determine why CSRs frequently do not search for available drug plans if 
the caller does not provide personal identifying information. -As 
discussed with the GAO reviewers, CMS has instructed CSRs, in cases 
where that information is unavailable, to perform a search that 
provides general information on the plan options available to the 
beneficiary. Our web tools have always been set up to support such 
"unauthenticated" searches as well.

1-800 MEDICARE CSRs do have the ability to conduct a general search for 
callers who do not have their Medicare number. If the person provides 
personal information, the authenticated search, other information that 
may influence their decision is pulled into the search, e.g., low 
income subsidy status or coverage through a retiree drug subsidy. 
Because this path provides more robust and specific results, CMS has 
encouraged CSRs to stress the importance of an authenticated 
Prescription Drug Plan Finder search to callers. The importance of 
authenticated searches is stressed in the CSR training materials and 
scripts. We have placed warnings throughout the training materials 
about the downside of proceeding without the personalized information 
and CSRs do suggest that the person call back when they have it.

Even so, we know that there are occasions in which someone may not want 
to provide this information, or another caller may be inquiring on 
behalf of a beneficiary and not have the information, or a reporter or 
analyst may be calling for information. It has been emphasized to CSRs 
that non-authenticated general information is to be shared if the 
caller is unable to provide specific information that would enable a 
more detailed search. An example of relevant CSR instructions follows. 
"If a caller indicates they are calling for someone else and just wants 
general information on plans available in their area, you do not need 
to personalize the search if the caller does not want to. You can 
provide general plan information and send a personalized booklet if 
requested." CMS has a comprehensive quality review process on calls and 
we will continue to monitor calls to ensure that CSRs are pursuing the 
general search when appropriate.

At the same time, we believe that GAO presents this finding in a way 
that is incorrect and misleading. We believe that the 41 % accuracy 
rate unfairly portrayed how accurately CMS answers questions on drug 
plan options without beneficiary personal identification information, 
when the GAO failed to analyze 35 out of the 41 responses. In 
actuality, when the responses are analyzed, correct answers are 
actually being provided a majority of the time. Further, the bulk of 
the responses characterized as "inaccurate" were related to the test 
caller's request that the CSR use only brand name drugs (i.e., no 
generic drug substitution). This request is highly unusual in our call 
experience as generic versions of a drug are identical in their 
clinical effects. However, we have subsequently modified the web tool 
used by our CSRs to make it easier to override the generic drug 
substitution logic in the tool.

Monitor the accuracy and completeness of CSRs responses to callers' 
inquiries and identify tools targeted to improve their performance in 
responding to questions concerning the Part D benefit, such as 
additional scripts and training.-We have worked hard to ensure 
beneficiaries have access to accurate and clear information when they 
call 1-800-Medicare. Our ongoing monitoring program, which evaluates a 
random sample of hundreds of actual calls received each month, has 
found that calls to 1-800-MEDICARE in 2006 have been answered 
accurately 93 percent of the time. The high accuracy rate is reflected 
in high rates of overall satisfaction from 1-800-MEDICARE callers, 
which averaged 84 to 85 percent in February and March.

Improve the usability of the Part D portion of the Medicare website by 
refining web-based tools, providing workable navigation features and 
links, and making web-based forms easier to use and correct. - CMS is 
continually enhancing and refining their web-based tools to provide 
Medicare beneficiaries and their caregivers the information needed to 
compare, choose and enroll in a prescription drug plan that best meet 
their needs. We summarize some of our recent enhancements below. Online 
enrollment has been highly successful, as evidenced by the 3 million 
beneficiaries who have enrolled in the prescription drug plans using 
CMS' web-based drug plan finder. Our partner organizations have used 
the web tools to assist millions more with their enrollment-related 
needs. The high level of online enrollment and use by partners 
indicates that many people have found that this resource is useful and 
effective for undertaking the most important step of enrolling in a 
drug plan, and we are pleased that thousands more are using it every 
day.

We cannot emphasize enough CMS' commitment to continuously improve the 
communications with beneficiaries and other constituents. We want our 
websites to continue to be recognized as benchmarks for excellence. 
Attachment A outlines improvements that we have made to the website 
since the GAO review and we believe demonstrate our continued 
commitment to excellence.

All of our communications methods, in conjunction with our far-reaching 
grassroots efforts, have helped provide the important information about 
Part D needed by beneficiaries, providers and partners to ensure the 
Medicare drug program is a success. In fact, the vast majority of 
beneficiaries are using their coverage to save money and get protection 
for the future: actual premiums and drug costs are much lower than had 
been expected because of strong competition, and because beneficiaries 
are using the enrollment tools to choose plans that save them more 
(over 73 percent of beneficiaries are enrolling in plans stand-alone 
prescription drug plans with premiums below the average); the drug 
plans are successfully filling over three million prescriptions a day; 
and each week hundreds of thousands of beneficiaries are enrolling in 
the new program.

Tab A attached provides additional details about our communications 
materials and approaches. Also attached are technical comments for your 
consideration in Tab B. We will use the findings of the GAO report 
going forward as we continue our commitment to ensure that Medicare 
beneficiaries have the information they need to make informed health 
care decisions.

Tab A:

Detailed Information About Part D Education And Outreach:

Over the past two years, we have dedicated significant resources to the 
development and implementation of an extensive education and outreach 
campaign surrounding Medicare prescription drug coverage, including a 
variety of beneficiary publications and materials, the 1-800-MEDICARE 
helpline, the Medicare Prescription Drug Plan Finder web tool on 
www.medicare.gov, personalized assistance via the State Health 
Insurance Assistance Program (SHIP) counseling program, and local 
enrollment events. All of these initiatives are rooted in a foundation 
of continuous quality improvement that involves identifying the 
information that needs to be conveyed, using consumer research to 
determine the most effective messages and vehicles, preparing materials 
accordingly, and measuring material effectiveness. This thorough, 
comprehensive and careful process ensures that all of our educational 
materials are as accurate, clear and informative as possible.

Handbook and other written materials:

CMS has produced and disseminated an unprecedented number of written 
communication products on Medicare prescription drug coverage. These 
materials meet their intended goal of quickly and easily providing 
action-oriented information on a variety of topics related to Part D. 
Written materials exist in the form of booklets, brochures, fact sheets 
and letters. Some key communication products are available in Braille 
and audiotape, and many have been translated into alternate languages 
to increase accessibility to information.

Medicare & You Handbook:

* The Handbook is an important information source for all Medicare 
beneficiaries on the Medicare program and their medical and drug 
coverage. Each year, all beneficiary households receive a copy and we 
know from our consumer research that beneficiaries keep it to use as a 
reference source. Our customer surveys of beneficiaries who read the 
Medicare & You 2006 Handbook, conducted in January-February 2006, 
showed that 72 percent were "very" or "somewhat satisfied" with the 
Handbook.

* For 2006, we updated the Medicare & You Handbook to reflect 
information on the new Medicare prescription drug coverage by including 
a summary of the new coverage and information on how it can help 
Medicare beneficiaries in different situations. In addition, we 
reorganized the Handbook to help Medicare beneficiaries decide whether 
and how to choose among alternative plans. For example, a prominently 
highlighted box on the inside cover of the Handbook serves to remind 
beneficiaries that they need to make a choice about prescription drug 
coverage for 2006. Beneficiaries are directed to the specific Handbook 
section that provides more details on how to select a prescription drug 
plan.

* The Medicare & You Handbook has been designed to assist beneficiaries 
in deciding how to choose a plan based on cost, coverage, convenience 
and peace of mind both now and in the future. In addition to general 
information, the Handbook includes information for beneficiaries based 
upon their current prescription drug coverage status.

* CMS uses a series of steps before, during, and after printing the 
Medicare & You Handbook to ensure accuracy. Some steps may be combined 
or omitted as appropriate for other targeted publications and deadlines 
for publication.

* Before printing the Handbook, CMS conducts multiple rounds of 
internal review by program staff experts in components throughout CMS. 
CMS also subjects the Handbook to expert review by external 
organizations. CMS solicits comments from an extensive list of advocacy 
groups, academic partners, industry trade organizations, Congressional 
staff, and other interested stakeholders. CMS writers/editors do the 
final proofing. Finally, the CMS Office of External Affairs/Graphics 
reviews the Handbook. CMS provides a final desktop publishing 
troubleshooting check to ensure that materials include only the files 
(such as logos, photos, and fonts) that CMS has legal rights to use.

* During the printing process, CMS reviews printer "blueline" copies. 
CMS reviews first proofs from the printer to ensure the publication 
layout is accurate. CMS has an opportunity to correct printer errors 
(generally something that was altered in the transfer from electronic 
file to print plate) or make author's alterations (errors previously 
missed) before printing begins. Specially trained CMS and/or GPO staff 
go on-site to the print contractor to conduct quality assurance 
inspections of the publication, checking for errors as the Handbook is 
being printed.

* After printing, CMS carefully monitors and investigates reports of 
errors in publications, including tracking related feedback from 
representatives at 1-800-MEDICARE. CMS corrects publications, as 
needed, and issues updated electronic files and/or errata sheets to 
accompany printed publications.

* CMS is very concerned about the readability of our publications. We 
have to balance the often competing goals of explaining technical 
information about Medicare coverage in clear and simple language while 
ensuring its accuracy. We go to great lengths to explain terms that 
beneficiaries need to understand to address readability concerns. For 
example, all publications include phone numbers and web sites, in case 
people need more information. CMS has found that this contact 
information is nearly universally identified and understood by 
beneficiaries.

* GAO noted readability test score findings as evidence that our 
written documents lacked clarity. CMS doesn't routinely perform 
readability tests like the Fry, SMOG, FOG or Flesch-Kincaid on 
completed publications. Our writers may use these tests as tools during 
the drafting process to provide a rough estimate of the readability 
level and identify elements such as passive sentences, which can be 
readily improved. These kinds of tests rely largely on counting 
syllables per word, words per sentence, and sentences per paragraph to 
determine a "grade level" readability score which we do not find to be 
a useful parameter in gauging "readability" of Medicare materials 
because there are terms that may be unfamiliar to the Medicare 
population. As such, we go to great lengths to explain concepts that 
may be readily understood. For example, "Medicare," "deductible," 
"formulary" and "prescription" are all multi-syllabic words that would 
inflate scores in these types of reading tests. However, they are terms 
for which there are few or no simpler substitutes. People with Medicare 
(and in health insurance generally), commonly recognize most of these 
terms. Where they don't, as with "formulary," we use them with careful 
explanation in context, which also inflates the readability test scores 
by adding words to the sentence. Such tests would not account for this 
phenomenon and it is not usually accounted for by omitting certain 
words in the scoring process given how many terms for which we provide 
detailed explanations.

* These readability test scores are somewhat misleading and incomplete 
as a measure of the ease or difficulty of materials.

- Plain language and literary experts like Roger Shuy and the 
Georgetown University Round Table on Language and Linguistics, the 
Social Security Administration, the Maine AHEC Health Literacy Center, 
the Delegates Assembly of the International Reading Association, and 
the U.S. Securities and Exchange Commission state that individual's 
tested literacy level and their ability to read and understand 
materials written at the corresponding grade level rarely match.

- Test scores don't take into account other criteria that improve 
clarity of message, like navigational cues and graphic elements.

- It's challenging to account for multi-syllabic terms like "Medicare" 
or "prescription" that are widely-understood and/or for which there are 
no simpler alternatives.

- When appropriate, our publications provide a glossary to help 
beneficiaries understand words that may be new to them. The Medicare & 
You handbook contains such a glossary, as do our other large booklets. 
However, glossaries would mitigate the goals of brief fact sheets and 
letters, and therefore, for these types of materials, every effort is 
made to define difficult terms in context, which can inflate standard 
readability test scores.

* As an additional measure of clarity, GAO states they used 60 
"commonly recognized guidelines" to evaluate our publications. It is 
difficult to sufficiently comment on the findings without knowing these 
60 criteria, beyond the handful of examples in the report. However, it 
is important to note that to the best of our knowledge, these 
guidelines were compiled from multiple sources for the purposes of this 
evaluation and are not commonly recognized as a set. We look forward to 
the opportunity to review these guidelines and their relationship to 
our publications in the future, to assess where improvements might be 
made.

* To evaluate and improve the usability of Medicare publications, CMS 
hires contractors to conduct research with beneficiaries, caregivers, 
and other people who help beneficiaries. CMS uses focus groups to help 
us understand what information is important to beneficiaries. We also 
conduct cognitive interviews to test how well beneficiaries understand 
the content in our draft publications. Our drafts are revised based on 
the feedback that we receive.

* Consumer testing for the Handbook dates back to 1998. Over the years, 
we have qualitatively tested the Handbook with over 1000 aged and 
disabled beneficiaries, caregivers, and Medicare counselors. Each year, 
the basic testing is conducted in two rounds to allow for iterative 
improvements. Lessons learned from year to year are applied to each new 
version of the book.

* Multiple methods are used to test the book. The most heavily relied 
on method is cognitive interviews where participants are given tasks 
"cold," that is without prior preparation. We've also relied on triads 
and focus groups which allow participants to generate ideas on how to 
improve the book.

* We also conduct "diary groups" where beneficiaries are asked to make 
comments on the book as they read through it at home and are then 
brought in for focus groups. Tested content developed for particular 
publications is also used in other publications as-appropriate. This 
overlap ensures consistency across CMS publications.

* Information collected from beneficiaries earlier this year indicated 
that 61 percent of respondents said the Medicare & You Handbook was 
"very easy" or "somewhat easy" to understand.

* CMS elicited feedback from more than 300 beneficiaries on Part D 
materials. The Medicare & You handbook language was tested by a testing 
contractor, BearingPoint, with over 150 beneficiaries. This testing 
helped us simplify our language and explain concepts more clearly.

* GAO used similar testing methods on a smaller scale to evaluate the 
clarity of our written materials. We are interested in reviewing the 
details of the 18 tasks that were used the interviews conducted with 
beneficiaries and beneficiary advisors, and understanding which tasks 
correlated to which tested products. GAO's report provides no details 
on the tasks that respondents completed successfully, and describes 
only three tasks that were difficult. These three indicate that the 
purpose and expectations of these publications may have been 
overlooked. The primary goal of our written communications in this 
phase was awareness - to make beneficiaries aware of the new coverage, 
aware that they needed to take some action, and aware of the resources 
available to help them make decisions. None of these publications were 
intended to independently lead a reader through such complex activities 
as computing projected out-of-pocket costs. Other feedback on our 
publications shows they are successful in meeting their intended goals.

* The National Association of Government Communicators critiqued the 
Medicare & You 2005 Handbook for the 2004 Blue Pencil Competition. The 
handbook received positive feedback in the judges' ratings. The judges 
rated the handbook in categories such as writing, editing, purpose, 
design, printing, cost effectiveness, and dissemination.

- The judges strongly agreed that the writing was clear, concise, and 
appropriate for its intended audience.

- One judge wrote, "Given the complexity of this subject, the writing 
is extremely clear and easy to understand. Technical terms are well 
explained, and needed information is easy to locate."

- In the area of design, another judge commented that, "Choice of font, 
typeface, and size; leading; and margins made the book attractive, 
while ensuring accessibility for users (especially seniors). Use of 
blue headings and other design elements contributed to ease of use, as 
well."

- In the category of purpose, the judges strongly agreed that the 
purpose of the handbook is clear and that the handbook gets its message 
across with well-supported topics. As an overall final comment, a judge 
wrote, "This entry is very well suited to its purpose and audience."

* CMS began preparations for the 2007 Medicare & You Handbook in late 
December 2005. To date, staff and leadership have held input meetings 
with key advocates and stakeholders, tested early draft revisions with 
beneficiaries, established a firm project plan, and instituted 
additional quality assurance and proofing processes. The Handbook is 
currently on schedule for its required mailing in the fall of this 
year, with a comprehensive external review process ending this week and 
extensive consumer testing scheduled in mid-May.

1-800-MEDICARE:

It is a top priority at CMS to ensure that beneficiaries have timely 
access to accurate information and receive satisfactory service when 
contacting 1-800-MEDICARE.

* Between 2004 and the beginning of the open enrollment period, CMS 
conducted numerous activities to prepare for the prescription drug 
benefit, including the development of a comprehensive training 
curriculum on the prescription drug benefit and the Plan Finder tool 
for Customer Service Representatives (CSRs). Since November 15, 2005, 
CMS has made continuous updates to scripts and reference materials for 
CSRs to ensure they are able to communicate accurate information to 
beneficiaries and people calling on behalf of beneficiaries.

* CMS's quality monitoring program has found that in 2006, calls to 1- 
800-MEDICARE have been accurate 93 percent of the time. This quality 
monitoring program is conducted by contractors who run the call 
centers. CMS monitors at least 4 calls per month for each of our 
thousands of CSRs to identify improvement and training opportunities.

* These are not just mystery shopping calls, which are limited to 
topics chosen by researchers, but actual calls which are representative 
of the information Medicare beneficiaries want to know. To ensure 
reliability and accuracy, all monitors score a sample of calls on a 
weekly basis and meet to review their approaches. The data is analyzed 
constantly and is used to take immediate corrective action. This work 
is overseen by a team within CMS dedicated to the quality of the 1-800-
MEDICARE call centers.

* Examples of topics receiving the highest volume of inquiries at our 
call centers include:

- How to enroll in a plan to obtain prescription drug coverage 

- Complaints about drug coverage:

- How to apply for the limited-income subsidy:

* Since the beginning of the new prescription drug benefit, CMS has 
taken many steps to help beneficiaries get the information they need to 
select a drug plan. For example, CMS acquired additional infrastructure 
including telephone lines and workstations at call center sites.

* CMS increased the number of customer service representatives (CSRs) 
from 3,000 in June 2004 to as many as 7,800 to handle beneficiary calls 
with minimal wait times.

* On average, from November 15, 2005 to April 12, 2006, callers have 
experienced wait times of less than 2 minutes, with longer waits 
sometimes occurring during peak call periods. Call volume to 1-800- 
MEDICARE peaked around 400,000 calls per day in mid-November when 
enrollment began, and again in early to mid-January. Currently, call 
volume reaches 200,000 calls per day on the highest volume day and 
levels out around 150,000 per day during the remainder of the week. 
Call volumes have continued to increase slightly since then.

* CMS recognizes that not all beneficiaries are able to use, or have 
access to, the internet, which is the platform for the useful Medicare 
Prescription Drug Plan Finder tool. As part of our outreach and 
communication efforts, CMS trained additional staff exclusively on the 
use of the Medicare Prescription Drug Plan Finder tool so that they 
could be dedicated to answering calls only about the prescription drug 
benefit and available plan options.

* We expanded responsibilities and provided additional training for 
some CSRs and advanced training for others. We required CSRs to take 
written exams and test calls for certification before allowing them to 
take live calls. All CSRs have one week of classroom training followed 
by two or three additional days of practice calls, simulation, quality 
monitoring, and follow-up coaching to ensure peak performance. Finally, 
we monitored newly-trained CSRs and those who would benefit from 
additional coaching at a higher level.

* This year, CMS implemented a 1-800 MEDICARE caller satisfaction 
survey conducted by Pacific Consulting Group, an independent 
contractor. This survey provides 1) satisfaction tracking over time and 
2) an early warning system that can point to potential service 
problems. Improvements can then be implemented relatively quickly to 
enhance caller satisfaction. These CMS customer satisfaction surveys 
indicate that the bulk of callers who interact with our CSRs, 87 
percent are satisfied with their experience. They are particularly 
pleased with how courteous and patient the CSRs are (rated at 97 
percent). These responses came not only from people with Medicare, but 
also friends or relatives calling on their behalf, who made up 34 
percent of callers during March 2006.

* Currently, 500 surveys are conducted each week with 400 callers who 
spoke with CSRs and 100 callers who used the Interactive Voice Response 
System.

The data below depict results from weekly calls for those callers that 
spoke to a CSR. The results show the percentage of respondents in the 
weeks January 16th, February 27th and March 6th that strongly or 
somewhat agree with the statements listed below. 

Table: 

Survey Metric(% agree-strongly or somewhat to the following 
statements): CSR was helpful;
Week of January 16th: 84%; 
Week of February 27th: 89%;
Week of March 6th: 88%. 

Survey Metric(% agree-strongly or somewhat to the following 
statements): CSR understood issue or concern;
Week of January 16th: 83%;
Week of February 27th: 86%;
Week of March 6th: 88%.

Survey Metric(% agree-strongly or somewhat to the following 
statements): CSR explained things to me in a way that I could 
understand;
Week of January 16th: 83%;
Week of February 27th: 86%;
Week of March 6th: 84%.

Survey Metric(% agree-strongly or somewhat to the following 
statements): I received all of the information I needed;
Week of January 16th: 67%;
Week of February 27th: 72%;
Week of March 6th: 73%.

Survey Metric(% agree-strongly or somewhat to the following 
statements): The CSR was knowledgeable;
Week of January 16th: 81%;
Week of February 27th: 86%;
Week of March 6th: 85%.

Survey Metric(% agree-strongly or somewhat to the following 
statements): I received information specific to my issue;
Week of January 16th: 75%;
Week of February 27th: 80%;
Week of March 6th: 80%.

Survey Metric(% agree-strongly or somewhat to the following 
statements): Overall I am satisfied;
Week of January 16th: 79%;
Week of February 27th: 84%;
Week of March 6th: 85%.

[End of table]

* Pharmacists are a key partner in the implementation of the Medicare 
prescription drug benefit. To ensure that pharmacists have access to 
the information they need to assist beneficiaries at the pharmacy 
counter, CMS developed a dedicated pharmacist 1-866 telephone line. 
Incoming calls through the dedicated pharmacist line are routed to the 
head of the queue at the 1-800 MEDICARE number, wait times are 
substantially lower than the overall average for beneficiaries and 
other individuals calling the 1-800-MEDICARE line. This helps to 
relieve any burden on pharmacists, and also ensures that pharmacists 
are able to assist beneficiaries immediately at the pharmacy counter.

* CMS is well-prepared to handle increased call-volume that may occur 
before the May 15tH enrollment deadline. We have increased the number 
of CSRs from 3,000 in June of 2004 to 6,000 CSRs for May enrollments. 
We have also acquired additional infrastructure including telephone 
lines and workstations at call center sites. We have refined our CSR 
scripts by reducing redundant information, indexing scripts for quick 
access, and including probing questions to help the CSRs better 
identify callers' concerns.

* Despite our efforts, some beneficiaries will wait until the deadline 
is near, but our top priority is to encourage people to enroll now and 
avoid the rush.

Medicare.gov:

* To ensure that the new Plan Finder tool was well-designed and easily 
used by beneficiaries and other individuals, CMS worked with a 
professional website development contractor, CGI Federal and a 
subcontractor, Navigation Arts.

* As the Medicare Prescription Drug Plan Finder was being designed, CMS 
engaged in multiple rounds of consumer testing to ensure its usefulness 
and simplicity. CMS conducted three rounds of in-depth interviews with 
Medicare beneficiaries to obtain feedback as drafts of the tool were 
developed throughout 2005. Final interviews that focused on messages 
tailored specifically for beneficiaries based on their insurance 
information were conducted in September 2005. CMS conducts ongoing 
consumer research to continue to improve understandability and 
usability.

* CMS also conducts thorough and ongoing analyses of possible outliers 
in data, including the Medicare Prescription Drug Plan Finder plan 
pricing data, pharmacy network, mismatched formulary identifiers (NDC 
codes), and other missing formulary data. If problems are found with a 
plan's data, information on the plan will be suppressed from the 
website until CMS works with the plan to correct its information and 
properly display it.

* We are proud to say that CMS has received a number of awards for its 
website from independent organizations. These awards include the 
"eHealthcare Leadership Award" at the Ninth Annual Internet Conference, 
the "2005 Pioneer Award" at the E-Gov Institute and Federal Computer 
Week, and the "Independent Technology Supporting Service to Our 
Country" award at the Eighth Annual Technology Gala to benefit Juvenile 
Diabetes.

* We believe that the website has been extremely successful in 
providing beneficiaries, their caregivers and CMS partners with clear, 
accurate and timely information to help them enroll in drug plans. In 
fact, CSRs at 1-800 MEDICARE have access to the Plan Finder to help 
beneficiaries find the information they need about choosing a plan, 
enrolling in a plan, or other issues related to accessing their 
prescription drug coverage. The Plan Finder also has been a critical 
tool for SHIPS and other partners, such as the ABC Coalition and 
Medicare Today, to use when conducting outreach to beneficiaries.

* Results from a web-based customer satisfaction survey conducted by 
MSInteractive, a subsidiary of Market Strategies that specializes in 
web-site satisfaction research, were very positive. This research, 
conducted in December 2005, focused only on the prescription drug plan 
finder tool.

* The survey indicated that content, interactivity, and navigability 
have the greatest impact on satisfaction. During development of the 
tool, CMS contracted with a web design firm to leverage their expertise 
on these impacts. CMS continues to focus on these areas in future 
enhancements and updates.

* The site's "appearance" and "privacy" scored highly, but had no 
impact on overall satisfaction.

- 66 percent of those who enrolled were either "somewhat" or "strongly 
satisfied" with the tool.

- 80 percent of those who enrolled would recommend the tool to a friend.

- 70 percent of users agreed with this statement, "I know more about 
the Medicare Prescription Drug Plans now that I've used this site."  

- Regular internet users had higher ratings of the site.

* In January and February 2006, Abt conducted a telephone survey of a 
random sample of beneficiaries and found that:

- 14 percent of respondents used the www.medicare.gov website to get 
information about Medicare;

- 60 percent said it was "very easy" or "somewhat easy" to understand 
the information from www.medicare.gov;

- Beneficiaries who rated their satisfaction with the information 
received from medicare.gov as "very/somewhat" satisfied outnumbered the 
"dissatisfied" beneficiaries 71 percent to 19 percent. Seven percent of 
beneficiaries were neither "satisfied nor dissatisfied."

* Overall, the drug plan finder element of the website has received 
164.6 million page views between November 15, 2005 and April 26, 2006. 
We do not have a way to differentiate whether those hits were from 
beneficiaries or their caregivers.

* To date, 3 million beneficiaries have enrolled in prescription drug 
plans using the Plan Finder. That indicates that at least that many 
people were satisfied enough with the information they received to 
undertake the most important step of enrolling in a drug plan.

* The Frequently Asked Questions (FAQ) section of www.medicare.gov has 
been accessed more than one million times since January 1, 2006. CMS 
has also responded to more than 19,000 emails received through the FAQ 
section, with 93% of them being resolved satisfactorily in the first 
response.

State Health Insurance Assistance Programs (SHIPS):

* While the SHIPs play a significant role in beneficiary counseling and 
education on Part D, CMS has also created a national grassroots network 
of more than 24,000 partners and 140 coalitions that rely on 
traditional tools to help them provide personalized counseling to 
Medicare beneficiaries every day.

* The network CMS built is diverse and committed, with members from 
every sector, including advocacy groups, government agencies, service 
clubs, faith-based organizations, benefits counselors, trained 
volunteers and healthcare professionals such as doctors and pharmacists.

* This extensive, grassroots-level partnership is truly unprecedented 
for the Medicare program. It's reaching out to people with Medicare all 
over the country... "where they live, work, play, and pray." This 
approach has helped personalize Medicare in every corner of the country.

*Preliminary data from the State Health Insurance Assistance Programs 
(SHIPs) shows that individual in-person and telephone contacts, 
presentations and meetings reached a total of 4.5 million clients, 
compared to 2.5 million in the previous grant period.

Other Selected Activities:

* The Mobile Office Tour has traveled 500,000 miles since last fall and 
approximately half of the territory covered and events have been in 
rural areas, in an attempt to reach out to a variety of beneficiaries 
and partners at the local level. We knew we would have to develop a 
grassroots capacity and local networks to supplement the CMS regional 
structure to provide the necessary education and enrollment assistance 
at the community level. This would involve reaching out, not just to 
our traditional partners such as the SHIPS, but to all the groups and 
organizations that have contact with our beneficiaries on a daily basis 
"where they work, where they play, and where they pray." We needed to 
involve individuals and institutions: family members and friends; 
current and former employers; churches and synagogues; financial 
advisors and community centers, to name but a few.

* CMS is reaching out directly to beneficiaries through an extensive 
paid and earned media campaign focusing on press and radio, both of 
which are highly localized in informing beneficiaries of special events 
in their neighborhoods.

* As we approach May 15, many members of the Cabinet whose agencies 
have helped build awareness of the prescription drug benefit through 
their own programs have joined efforts with CMS, including the United 
States Department of Agriculture, Department of Commerce, Department of 
Labor and Housing and Urban Development.

* To minimize a possible last minute rush to enroll, CMS is making a 
monumental effort to enroll beneficiaries well before the May 15tH 
deadline. In the past month, there have been 1,000 events per week 
across the country to provide beneficiaries with personalized help so 
they understand the prescription drug coverage options available to 
them and they can enroll in a plan. In our enrollment efforts, we are 
targeting beneficiaries who may qualify for the low-income subsidy and 
beneficiaries who live in rural areas. Our enrollment events are fully 
coordinated with the Social Security Administration (SSA) to assist 
beneficiaries in applying for extra help, as well as to help them 
enroll in a plan. 

[End of section]

Appendix IV: GAO Contact and Staff Acknowledgments:

GAO Contact:

Leslie G. Aronovitz (312) 220-7600 or aronovitzl@gao.gov:

Acknowledgments:

In addition to the contact named above, Susan T. Anthony and Geraldine 
Redican-Bigott, Assistant Directors; Ramsey L. Asaly; Enchelle Bolden; 
Laura Brogan; Shaunessye D. Curry; Chir-Jen Huang; M. Peter Juang; Ba 
Lin; Michaela M. Monaghan; Roseanne Price; Pauline Seretakis; Margaret 
J. Weber; and Craig H. Winslow made contributions to this report.

[End of section]

FOOTNOTES

[1] Pub. L. No. 108-173, § 101, 117 Stat. 2066, 2071-2152 (to be 
codified at 42 U.S.C. §§ 1395w-101--1395w-152). MMA redesignated the 
previous part D of title XVIII of the Social Security Act as part E and 
inserted a new part D after part C.

[2] For Part D standard coverage, Medicare pays on average 75 percent 
of prescription drug costs up to $2,250, after a $250 deductible. 
Beneficiaries then pay their next $2,850 in drug costs. If their drug 
costs exceed this amount, Medicare will pay about 95 percent of their 
additional costs for the rest of the calendar year.

[3] Drug plan sponsors include insurance companies and other private 
organizations.

[4] CMS is an agency in the Department of Health and Human Services.

[5] In December 2004, we reported on the information being provided to 
beneficiaries through the Medicare help line on eligibility, 
enrollment, and benefits. (See GAO, Medicare: Accuracy of Responses 
from the 1-800-MEDICARE Help Line Should Be Improved, GAO-05-130 
(Washington, D.C.: Dec. 8, 2004).) 

[6] The Medicare Web site is www.medicare.gov.

[7] Dual-eligible beneficiaries are Medicare beneficiaries who are also 
eligible for Medicaid--the federal-state health program for low-income 
individuals--and receive full Medicaid benefits for services not 
covered by Medicare. 

[8] Medicare Advantage replaced the Medicare+Choice managed care 
program and expanded the availability of private health plan options to 
Medicare beneficiaries. Medigap policies provide supplemental health 
coverage sold by private insurers to help pay for Medicare cost-sharing 
requirements, as well as for some services not provided by Medicare.

[9] The Henry J. Kaiser Family Foundation, The Medicare Drug Benefit: 
Beneficiaries Perspectives Just Before Implementation, [Hyperlink, 
http://kff.org/]. kaiserpolls/med111005nr.cfm (downloaded Apr. 26, 
2006). 

[10] The three tests were the Flesch-Kincaid Grade Level, the SMOG 
(Simplified Measure of Gobbledygook) Reading Grade Level, and the Fry 
Readability Estimate. These tests use such measures as sentence length 
and the number of syllables in a selection of text to arrive at a 
reading level, which is expressed in terms of school grade level. 

[11] A formulary is a list of prescription drugs covered by a health 
plan. 

[12] The percentages related to the responses we received to our 500 
calls exceed 100 percent because of rounding. 

[13] A SHIP grant year begins on April 1 of the year the funds become 
available.

[14] 29 U.S.C. § 794d (2000). 

[15] Medigap policies provide supplemental health coverage sold by 
private insurers to help pay for Medicare cost-sharing requirements, as 
well as for some services not provided by Medicare.

[16] The three tests were the Flesch-Kincaid Grade Level, the SMOG 
(Simplified Measure of Gobbledygook) Reading Grade Level, and the Fry 
Readability Estimate. The tests use such measures as sentence length 
and the number of syllables in a selection of text to arrive at a 
reading level, which is expressed in terms of school grade level.

[17] These guidelines are presented in an NN/g report called Web 
Usability for Senior Citizens: 46 Design Guidelines Based on Usability 
Studies with People Age 65 and Older. For this study, NN/g conducted 
usability tests of 17 Web sites with 44 seniors. Based on the test 
findings, NN/g developed 46 design guidelines that would make Web sites 
more attractive to seniors.

[18] In addition, NN/g indicated cases where an aspect was not 
functioning correctly from a Web site development standpoint by giving 
it a "bug" mark. 

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