Medicare:

HCFA Should Release Data to Aid Consumers, Prompt Better HMO Performance

HEHS-97-23: Published: Oct 22, 1996. Publicly Released: Oct 31, 1996.

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Pursuant to a congressional request, GAO reviewed the marketing, education, and enrollment practices of health maintenance organizations (HMO) participating in the Medicare risk-contract program, focusing on whether: (1) the Health Care Financing Administration (HCFA) provides Medicare beneficiaries with sufficient information about Medicare HMO; and (2) available HCFA data could be used to caution beneficiaries about HMO that perform poorly.

GAO found that: (1) HCFA does not provide beneficiaries any of the comparative consumer guides that federal government and many employer-based health insurance programs routinely provide to their employees and retirees; (2) Medicare beneficiaries seeking similar information face a laborious, do-it-yourself process which includes calling to request area HMO names and telephone numbers, calling each HMO to request marketing materials, and attempting to compare plans from HMO brochures that may not use the same format or standardized terminology; (3) HCFA collects volumes of information that could be packaged and distributed to help consumers choose between competing Medicare HMO and also compiles data regarding HMO disenrollment rates, enrollee complaints, and certification results; (4) HCFA is developing comparison charts that will contain information on the benefits and costs for all Medicare HMO, but plans to post the charts in electronic format on the Internet rather than distribute them to beneficiaries; and (5) HCFA provision of information on HMO disenrollment rates may be particularly useful in helping beneficiaries to distinguish among competing HMO, since beneficiaries could then ask HMO representatives questions and seek additional information before making an enrollment decision.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: CMS does not currently have plans to analyze and publicly distribute HMO rates of inquiries and complaints. However, since the recommendation was made, CMS has instituted beneficiary satisfaction surveys and made summary results available on Medicare's website, and in the Medicare & You handbook distributed to beneficiaries. Unlike inquiry and complaint rates, the survey results can indicate the level of beneficiary satisfaction or dissatisfaction with particular aspects of an HMO, and thus better facilitate informed comparisons of available Medicare managed care options.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to annually analyze, compare, and distribute widely HMO rate of inquiries and complaints per thousand enrollees.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: The Balanced Budget Act of 1997, incorporates GAO's recommendation by specifically citing disenrollment rates under the types of quality and performance indicators to be provided Medicare beneficiaries to promote informed choice. HCFA officials said they may begin publishing comparative disenrollment rates as early as spring 1999, via HCFA's website. HCFA is still considering what rates to publish, and how to present the information.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to annually analyze, compare, and distribute widely HMO voluntary disenrollment rates, including cancellations, disenrollment within 3 months, disenrollment after 12 months, total disenrollment, retroactive disenrollment, and rate of return to fee for service.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: HCFA mails annually to each beneficiary a comprehensive handbook that includes comparative information on health plans available in the beneficiary's service area. Also, comparative charts are available over the Internet. Beneficiaries can also request comparative data on health plans via HCFA's 1-800-MEDICARE hot-line.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to widely publicize the availability of the charts to all beneficiaries in markets served by Medicare HMO and ensure that beneficiaries considering an HMO are notified of the charts' availability.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: The Balanced Budget Act of 1997, incorporated GAO's recommendation by mandating that the Secretary of HHS provide to beneficiaries standard and clear comparative information on available choices. Recently, HCFA began disseminating comparative charts via the Internet. It has contracted to mail similar charts to beneficiaries beginning in late 1998.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to produce benefit and cost comparison charts with all Medicare options available for each market area.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Not Implemented

    Comments: Medicare health plans produce three key documents related to their covered benefits, the summary of benefits, evidence of coverage, and annual notice of change. CMS now requires plans to use a standard summary of benefits. The agency has established model language and formats, which HMOs may choose to adopt, for the remaining two documents. HMOs that produce documents using the models without modification are entitled to an agency review of those documents within 10 days, otherwise the agency's review may take up to 45 days. In 2002, CMS revised the model evidence of coverage based on input from beneficiaries, beneficiary organizations, representatives of the managed care industry, and others.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to require that all literature distributed by Medicare HMO follow standard formats.

    Agency Affected: Department of Health and Human Services

  6. Status: Closed - Implemented

    Comments: HCFA required plans to use a standardized Summary of Benefits in the fall of 1999, for the contract year 2000. The Summary of benefits included a matrix of benefits using standard categories, language and order. The document was provided to all potential members and all current members. This format will be used in the fall of 2000, for contract year 2001, however, it will be a more automated product.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to require standard formats and terminology for important aspects of HMO informational materials for beneficiaries, including benefits descriptions.

    Agency Affected: Department of Health and Human Services

  7. Status: Closed - Not Implemented

    Comments: CMS has not yet automated the collection of HMO monitoring visit results and does not have a plan for distributing summary information from monitoring visits. However, since this recommendation was made, CMS has collected and distributed other performance information that can help beneficiaries compare HMOs. For example, CMS requires HMOs to participate in surveys of members and former members. HMOs must report selected performance measures relevant to the Medicare population, such as influenza immunization rates. CMS includes summary statistics from the surveys, and reported performance measures on Medicare's website and in the Medicare & You handbook distributed to beneficiaries.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to annually analyze, compare, and distribute widely HMO summary results of HCFA monitoring visits.

    Agency Affected: Department of Health and Human Services

 

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