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Highlights

Members of Congress and state agencies have raised questions about complaints that some Medicare Advantage (MA) organizations and their agents inappropriately marketed their health plans to Medicare beneficiaries. Inappropriate marketing may include activities such as providing inaccurate information about covered benefits and conducting prohibited marketing practices. The Centers for Medicare & Medicaid Services (CMS) is responsible for oversight of MA organizations and their plans. The Government Accountability Office (GAO) was asked to examine (1) the extent to which CMS has taken compliance and enforcement actions, (2) how CMS has helped beneficiaries affected by inappropriate marketing and the problems beneficiaries have encountered, and (3) information CMS has about the extent of inappropriate marketing. To do this work, GAO reviewed relevant laws and policies; analyzed Medicare data on beneficiary complaints, compliance actions and enforcement actions; and interviewed officials from CMS and selected state departments of insurance, state health insurance assistance programs, and MA organizations.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare and Medicaid Services To improve CMS's oversight of MA organizations and its ability to appropriately target interventions, the Administrator of CMS should gather more information on the extent of inappropriate marketing and the types of problems beneficiaries experienced as a result of inappropriate marketing. As part of this effort, CMS should directly track retroactive and prospective SEPs provided for inappropriate marketing.
Closed - Implemented
2014 Update: In August 2014, CMS responded that the agency has modified its Complaint Tracking Module (CTM) to systematically gather more information on all marketing cases that involve a request for an enrollment change. The agency now tracks requests for retroactive and prospective special enrollment periods (SEPs) on a monthly basis. In addition, the agency has begun to triage requests for retroactive enrollment changes to CMS case workers rather than Call Center representatives given the potential medical and financial implications associated with these requests. Finally, the agency is conducting a reasons for disenrollment survey. These changes should give CMS a better sense of the extent of inappropriate marketing and the types of problems beneficiaries experience as a result of this marketing. 2010 Update: In July 2010 CMS informed us that the agency does not intend to directly track retroactive or prospective special election periods (SEPs). CMS stated that it believes the Complaint Tracking Module (CTM) provides a reasonable proxy for tracking SEPs, and that in conjunction with other oversight activities, the agency has the information it needs to track inappropriate marketing. We reported that the CTM was not a reliable source of information on the number of beneficiaries who received a SEP and disagree that the agency has an adequate source of information on the extent of inappropriate marketing.

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