"," ~
( t-
DEPARTMENT OF HEALTH &. HUMAN SERVICES Office of Inspector General
'..'..
""'J.'l''.Y...I.C.JEOS'OS~ OCT 1 7 2007 Washington, D.C. 20201
TO: Kerry Weems
Acting Administrator
Centers for Medicare & Medicaid Services
Daniel R. Levinson~ : ~
FROM:
Inspector General
SUBJECT: Memorandum Report: Medicare Part 0 Prescription Drug Plan Sponsor
lnternet Web Sites: Content and Accessibility, OEI-06-06-00340
In November 2006, we notified the Centers for Medicare & Medicaid Services (CMS)
"Medicare Part D Coverage Determinations"
that we were beginning a study of 
(OEI-06-06-00340). Shortly afterward, the Offce ofInspector General (OIG) learned
that the Governent Accountability Office had undertaken a similar study. To avoid
duplication, OIG decided not to pursue the study at that time. However, in preparing to
perform the study, OIG identified issues with Medicare Part D Prescription Drug Plan
(PDP) sponsors' Internet Web sites that warranted further review.
This memorandum report provides information about Medicare Part D PDP sponsors'
Internet Web sites' compliance with Federal regulations regarding content and
accessibility. OIG examined the Web sites of all 84 POP sponsors offering drug plans
within the 50 States and the District of Columbia in 2007. i
Federal regulations require that all POP sponsors have Web sites that include specific
content about receipt and use of Medicare benefits.2 Further, each Federal department
and agency is required to ensure that individuals with disabilities have comparable access
to information as those individuals without disabilities.3 Additionally, the Medicare
Marketing Guidelines require Part D Plans to maintain Web sites that are compliant with
accessibility standards for people with disabilities.4
i We excluded POP sponsors with service areas only in Puerto Rico and U. S. territories and we did not
include Medicare Advantage Prescription Drug Plans.
242 CFR  423.128(d)(2).
3 Section 508 of  the Rehabilitation Act (29 U.S.c.  794d), as amended by the Workforce Investment Act
of 1998 (P.L. 105-220),  508(a)(I)(A)(ii).
4 CMS, "Medicare Marketing Guidelines for: Medicare Advantage Plans, Medicare Advantage Prescription
Drug Plans, Prescription Drug Plans, and 1876 Cost Plans." Available online at
http://www . c ms. h hs. go viP rescr i pti 0 n D rii gCovContra/Do wn load s/F ina IMarketingG 1I ide Ii n es. pd f. Accessed
August 16, 2006.    
 
 
Page 2  Kerry Weems 
 
 
We found that 33 percent of the 84 PDP sponsors Web sites we reviewed did not contain 
all federally required content.  The most commonly omitted information pertained to 
enrollee disenrollment rights and responsibilities, the potential for PDP contract 
termination, and information related to the formulary.  Using two electronic tools that 
allow page-level testing of Web-based information and applications, we also found that 
85 percent of sponsor Web sites did not meet at least one of the Federal requirements for 
Web site accessibility. These problems could affect access to  content by Medicare 
beneficiaries. 
 
BACKGROUND 
 
Medicare Part D:  Prescription Drug Benefit 
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 created 
the Part D program to provide access to prescription drug coverage for individuals 
eligible for Medicare.5  Beneficiaries have two options. The first option is to enroll in a 
PDP for their drug coverage and receive all other benefits through traditional Medicare 
fee-for-service. The second option is to enroll in a Medicare Advantage Prescription 
Drug Plan (MA-PD) and receive all Medicare benefits, including drug coverage, through 
managed care.6  Most of the beneficiaries enrolled in Medicare Part D as of May 2007 
(17 million of 25.4 million) were enrolled in PDPs.7     
 
Part D plan sponsors are nongovernmental entities under contract with CMS to offer 
prescription drug benefits through PDPs, MA-PDs, PACE plans, or cost plans offering 
qualified prescription drug coverage.8  9  In early 2007, there were 1,875 PDPs in the 
United States distributed among 84 plan sponsors.10  11   The number of Medicare 
beneficiaries enrolled in particular PDPs varies considerably.  Four plan sponsors have 
more than a million enrollees each, 23 plan sponsors have between 100,000 and 999,999 
enrollees each, and 57 plan sponsors have fewer than 100,000 enrollees each.12  
 
Each Part D plan sponsor is required to have mechanisms for providing information to 
current and prospective enrollees.  These mechanisms must include a toll-free customer 
                                                 
5  Medicare Prescription Drug, Improvement, and  Modernization Act  of 2003, P. L. 108-173. 

6 CMS, Final Rule, Medicare Prescription  Drug Benefit, 70 FR 4194 (Jan. 28, 2005).  

7 CMS, CMS Medicare Advantage, Cost, PACE, Demo, and Prescription Drug Plan  Organizations; 

Monthly Report by Contract,  May 2007.  Available online at 
 
http://www.cms.hhs.gov/MCRAdvPartDEnrolData/MEC/itemdetail.asp?filterType=none&filterByDID=
99&sortByDID=2&sortOrder=descending&itemID=CMS1199141&intNumPerPage=10.  Accessed  

June 17, 2007. 

8 A  PACE is a Program of  All-Inclusive Care of the Elderly.  42 CFR  460.6. 
 
9 42 CFR   423.4.
 
10 J. Hoadley, E.  Hargrave, K.  Merrell, J. Cubanski, and T. Neuman. Benefit Design and Formularies of 

Medicare Drug Plans:  A Comparison of  2006 and 2007 Offerings.  Kaiser Family Foundation, 2006.  

Available online at http://www.kff.org/medicare/7589.cfm. Accessed June 9, 2007. 

11 A plan sponsor may have  one contract and offer multiple plans or have  several contracts and offer 

multiple plans. 

12  See footnote 7. 
     
 
 
Page 3  Kerry Weems 
 
 
call center, an Internet Web site, and the provision of information in writing, upon 
request.13   Our review focuses on one of the required mechanisms, Internet Web sites.14  
 
Content Requirements for Web Sites 
Each Part D plan sponsors Web site must include the information listed below about 
prescription drug coverage under the PDP (see Appendix A for a more detailed 
description):15  
 
 	  service area; 
 	  benefits; 
 	  ways of obtaining more information on cost-sharing requirements;  
 	  formulary; 
   addresses of network pharmacies;  

   out-of-network coverage; 

 	  grievances, reconsideration, exceptions, coverage determination, and appeal rights 
and procedures; 
 	  quality assurance policies and procedures; 
 	  disenrollment rights and responsibilities; and 
 	  potential for contract termination.  
 
Additionally, Part D plan sponsors must submit all of their marketing materials 
(including Web sites) to CMS for review of content and approval for distribution.16    
Part D plan sponsors must also demonstrate to CMS that a portion of marketing resources 
is allocated to marketing to the disabled and beneficiaries aged 65 and over.17  
 
Accessibility Requirements for Web Pages 
Web pages that make up PDP sponsor Web sites must meet certain criteria to ensure that 
individuals with disabilities have comparable access to information about PDPs.  Federal 
regulation establishes 16 specific accessibility requirements for Web-based information 
and applications (see Appendix B).18  These requirements focus on enabling assistive 
technology tools designed for persons with disabilities and are particularly critical for 
Web sites designed specifically for Medicare beneficiaries, such as PDP sponsor Web 
sites. In 2000, sensory disabilities, such as blindness, deafness, or a severe vision or 
                                                 
13 42 CFR   423.128(d). 

14 A Web site is  a set of interconnected  Web pages.   A Web page is an individual  document in  Hypertext 
 
Markup Language (HTML) contained in the  Web site.  Available online at  www.techterms.com. Accessed 

July 30, 2007. 

15 42 CFR   423.128(b). 

16 42 CFR   423.50. 

17 42 CFR   423.50(f)(viii)(2)(i). 

18 36 CFR   1194.22. 
    
 
 
Page 4  Kerry Weems 
 
 
hearing impairment, affected approximately 14 percent of the civilian 
noninstitutionalized population aged 65 years and older.19 20    
 
Compliance with 4 of the 16 accessibility requirements can be assessed automatically, 
using commercially available electronic tools.21  The four requirements are:   
 
(1) Text equivalents. A nontext element conveys meaning through pictures (images, 
graphics) or sound (audio clips). Federal regulations require that text equivalents 
accompany every nontext element.22  For example, an image indicating a navigational 
action should also have appropriate text, such as Move to the next screen.23  This is 
necessary because speech synthesizers and Braille displays use the text description to 
explain the meaning of the image.24  25  When audio clips convey instructions or 
information, a text equivalent, such as a transcript, must be provided to ensure that the 
information is available to those with auditory impairments.26    
 
(2) Frames.  Frames must be titled with text that facilitates frame identification and 
navigation.27  Frames provide a way of dividing a computer screen into distinct areas.  
They also can be obstacles for users with disabilities if the frames are not easily 
identifiable to assistive technology. For example, one use of frames is to provide 
navigational bars that remain in a fixed position while the content is displayed on another 
                                                 
19 U.S. Census Bureau, Census 2000  Summary File 3 (SF-3) - Sample Data.  Table P41:   Age by  Types 

of Disability for the Civilian  Noninstitutionalized Population 5 Years and Over With Disabilities [19].  

Available online at http://factfinder.census.gov/servlet/DTTable?_bm=y&-geo_id=01000US&
ds_name=DEC_2000_SF3_U&-_lang=en&-mt_name=DEC_2000_SF3_U_P041&-format=&-

CONTEXT=dt. Accessed July 23, 2006.  
 
20 The Census Bureau  determined  disability status through responses to questions about the existence of 

long-lasting conditions such as blindness, deafness, severe vision  or  hearing impairment; physical, mental, 

or emotional conditions lasting more than  6  months; and conditions that substantially limit one or more 

basic physical activities.  Available online at  

http://www.census.gov/acs/www/Downloads/2005/usedata/Subject_Definitions.pdf#page=31 and 

http://www.census.gov/dmd/www/pdf/d-61b.pdf. Accessed July 26, 2007. 

21 The four requirements that can be checked  automatically are 36 CFR  1194.22(a), (i), (m), and  (n).   All 

other Federal  requirements require manual checks. 

22 36 CFR   1194.22(a). 

23 United States Access Board, Web-Based Intranet and Internet Information and Applications (1194.22), 

2001.  Available online at http://www.access-board.gov/sec508/guide/1194.22.htm. Accessed  

September 15,  2006. 

24 Ibid. 

25  W. Chisholm, G. Vanderheiden, and  I. Jacobs, Web Content Accessibility Guidelines 1.0, 1999. 

Available online at http://www.w3.org/TR/1999/WAI-WEBCONTENT-19990505. Accessed 

September 14,  2006. 

26 J. Ellison, Assessing the Accessibility of Fifty United States Government  Web Pages:  Using Bobby to 
 
Check on Uncle Sam, 2004.  Volume 9 (7).  Available online at 
 
http://www.firstmonday.org/issues/issue9_7/ellison/index.html. Accessed May 8,  2007. 

27 36 CFR   1194.22(i). 
    
 
 
Page 5  Kerry Weems 
 
 
area of the screen.  Users with disabilities may have difficulty navigating the page if the 
different areas are not clearly defined by including text titles on the frames.28  
 
(3) Links to plug-ins or applets. When a Web page requires an applet, a plug-in, or some  
other application to enable a user to interpret page content, the page must provide a link 
to the necessary plug-in or applet.29  Some PDP sponsors Web site home pages use file 
formats that require plug-ins or applets that are downloaded and installed on the 
enrollees computer.  For example, a Web page containing links to materials in Adobe 
Acrobats Portable Document Format (PDF) must also provide a link to the plug-in 
needed to read the PDF file.30  Some Web pages may use applets to create such design 
features as scrolling text. The user must be able to operate the applet either by mouse or 
by keyboard.  If not, the information is inaccessible to persons with visual disabilities 
who rely upon a screen reader and keyboard to navigate the site.  The lack of an applet 
link could also affect persons with motor disabilities who must rely upon assistive 
devices to navigate a keyboard.31  32    
 
(4) Online forms.  Online forms must be designed so that people using assistive 
technology may access information, field elements, and functionality that are required for 
completion and submission of the forms.33  For example, if an input box on a form is 
intended for receiving a users last name, the words last name (or some similar text) 
should appear near that input box or should be associated with it.34    
 
Internet Usage 
The use of the Internet by older adults and persons with disabilities as a mechanism to 
obtain health-related information has expanded in recent years.  The most recent figures 
available on Internet usage indicate that about 8.5 million adults aged 65 years and older 
in the United States (25 percent of all seniors) report using the Internet to access 
                                                 
28 United States Access Board, Web-Based Intranet and Internet Information and Applications (1194.22), 

2001.  Available online at http://www.access-board.gov/sec508/guide/1194.22.htm. Accessed  

September 15,  2006. 

29 36 CFR   1194.22(m). 

30 J. Ellison, Assessing the Accessibility of Fifty United States Government  Web Pages:  Using Bobby to 
 
Check on Uncle Sam, 2004.  Volume 9 (7).  Available online at
  
http://www.firstmonday.org/issues/issue9_7/ellison/index.html. Accessed May 8,  2007. 

31 L. R. Kasday, D.  N. Bryen, and P. R. Bohman, Web Browsing Challenges, Strategies, and Tools for 

People With  Motor Disabilities and Users of AAC Technologies, 20012003.  Available online at 

http://www.webaim.org/projects/whitepaper.htm. Accessed June  29, 2007.  Web  Accessibility In Mind, 

Motor Disabilities:  Assistive Technologies.  Available online at 

http://www.webaim.org/articles/motor/assistive.php. Accessed June 29, 2007. 

32 Keynote NetMechanic, Building  Web Sites That Comply with Section  508  Accessibility Guidelines.  

Available online at http://www.netmechanic.com/accessibility/accessibility-requirements.shtml. Accessed 

August 2, 2007. 

33 36 CFR   1194.22(n). 

34  W. Chisholm, G. Vanderheiden, and  I. Jacobs, Web Content Accessibility Guidelines 1.0, 1999.  

Available online at http://www.w3.org/TR/1999/WAI-WEBCONTENT-19990505. Accessed  

September 14,  2006. 
    
 
 
Page 6  Kerry Weems 
 
 
information.35  Forty-seven percent of those seniors used the Internet as a source of 
information on health services or practices and 32 percent for information on government 
services or agencies.36    
 
According to one survey, approximately 38 percent of persons with disabilities indicated 
that they used the Internet. Within this group, 87 percent said that they had searched for 
at least one health-related topic.37  Prior to the implementation of Part D, persons living 
with disabilities were reportedly just as likely as other Americans to use the Internet to 
search for drug information, underscoring the importance of comparable access to Web-
based information.38  
 
METHODOLOGY 
 
We examined the Web sites of all 84 PDP sponsors offering drug plans within the  
50 States and the District of Columbia in 2007.39  Each plan sponsor is required to have a 
Web site containing information about all of its PDPs.  To identify Web site addresses for 
PDP sponsors, we used Medicare.gov, which lists each PDP and associated Web site.   
Additionally, we verified that the Web address provided on Medicare.gov was the same 
address that was included in information provided to enrollees by comparing online 
versions of the Summary of Benefits and Evidence of Coverage to the Medicare.gov 
address.40  We calculated the proportion of beneficiaries enrolled in each PDP using 
enrollment figures reported by CMS as of May 2007.41  We conducted the review during 
April and May 2007. 
 
We reviewed each Web site to determine whether the required content was available.  We  
began by reviewing the plan sponsors home page, which is the starting page or front 
page of a Web site.42  When required content was not available on the home page, we  
reviewed other documents available through links from the home page.  We considered 
                                                 
35 U.S. Census Bureau, Current Population Survey.  Table  9B.  Purpose of Internet  Use for People 18  
Years and Over Using the Internet Anywhere, by Selected Characteristics:  October 2003.  Available online 
at http://www.census.gov/population/socdemo/computer/2003/tab098.xls. Accessed July 23, 2007.   
36 Ibid. 
37 Pew Internet & American Life Project, Internet Health Resources, July 16, 2003.  Available online at 
http://www.pewinternet.org/pdfs/PIP_Health_Report_July_2003.pdf.  Accessed August 24, 2007. 
38 Pew Internet & American Life Project, Prescription  Drugs Online, October  10, 2004.  Available online  
at http://www.pewinternet.org/pdfs/PIP_Prescription_Drugs_Online.pdf.  Accessed August 24, 2007. 
39 We  excluded PDP sponsors with  service areas only in Puerto Rico and U.S. territories and we did not  
include  Medicare Advantage Prescription Drug  Plans. 
40 CMS requires PDPs to  provide the Evidence of Coverage and Summary of Benefits via the PDP 
Web page and in hard copy form, according to the Medicare Marketing Guidelines  for:  Medicare 
Advantage Plans, Medicare Advantage Prescription Drug  Plans, Prescription Drug Plans,  and 1876 Cost 
Plans.  Second  revision, July 25, 2006.  Available online at 
http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/FinalMarketingGuidelines.pdf. Accessed 
August 16, 2006. 
41  See footnote 7 on p. 2.  
42 Available online at www.techterms.com. Accessed July 30, 2007.     
 
 
Page 7  Kerry Weems 
 
 
the content available if it was present on the home page or elsewhere on the Web site.  
We did not assess the quality of the information or the policies and procedures described 
on the Web site.   
 
We also reviewed each sponsors home page to assess the Web site for compliance with 
Federal requirements regarding accessibility.  We used two electronic tools that enable 
page-level testing of Web-based information and applications:  WebXactTM and Cynthia 
SaysTM.43 44   Both tools determine compliance with the same four Federal accessibility 
requirements using automated procedures.  Our assessment was limited to those four  
requirements (i.e., text equivalents, frames, links to plug-ins or applets, and online 
forms).45  The primary assessment tool was WebXactTM.  We used Cynthia SaysTM when 
the structure or design of a page prohibited an assessment by WebXactTM.  Although 
neither of the programs measures the full range of accessibility and usability issues, both 
identify basic design errors that could impede access to Web page content.  If either of 
the programs identifies errors, it is reasonable to conclude that accessibility problems 
exist.46  47    
 
In addition to examining the four accessibility requirements on the 84 PDP sponsors 
home pages, we examined specific Web pages that contained information related to 
grievances, coverage determinations, and appeal rights for each PDP sponsor.  Many 
Web sites included this information only through links to files in PDF.  For these sites, 
we used WebXactTM and Cynthia SaysTM to determine whether the required link to the 
plug-in program was available on the page containing information on grievances, 
coverage determinations, and appeal rights.   
 
To determine whether any change in accessibility occurred over time, we compared 2006 
and 2007 PDP sponsor home pages.  We found that 68 PDP plan sponsors within the  
50 States and the District of Columbia had contracts in both 2006 and 2007.  We  
conducted reviews of the 2006 home pages using WebXactTM and Cynthia SaysTM 
between September and November 2006. 
 
                                                 
43  WebXactTM is an  updated  version of the free online tool BobbyTM, an accessibility evaluation tool  used in 
 
many earlier studies on Web page accessibility.  Cynthia SaysTM functions in a similar fashion, although it 

may not identify as many Web page accessibility errors as WebXactTM (Ellison, 2004).  The free  online  

service WebXactTM is no longer available, as of July 15, 2007. 

44  W. Chisholm, G. Vanderheiden, and  I. Jacobs, Web Content Accessibility Guidelines 1.0, 1999.  

Available online at http://www.w3.org/TR/1999/WAI-WEBCONTENT-19990505. Accessed  

September 14,  2006. 

45  36  CFR  1194.22(a), (i), (m), and (n).  
 
46 P. T. Jaeger, The  Importance of Accurately Measuring the Accessibility of the Federal Electronic 

Government:  Developing the Research  Agenda, Information  Technology and Disabilities, 9(1). 2003.  

Available online at http://www.rit.edu/~easi/itd/itdv09n1/jaeger.htm. Accessed May  9,  2007. 

47 J. Ellison, Assessing the Accessibility of Fifty United States Government  Web Pages:  Using Bobby to 
 
Check on Uncle Sam, 2004.  Volume 9 (7).  Available online at
  
http://www.firstmonday.org/issues/issue9_7/ellison/index.html. Accessed May 8,  2007. 

       
 
 
Page 8  Kerry Weems 
 
 
This study was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency and the Executive Council 
on Integrity and Efficiency.  
     
 
 
Page 9  Kerry Weems 
 
 
RESULTS 
 
Thirty-Three Percent of Web Sites Reviewed Did Not Contain All Required Content  
Twenty-eight of the 84 PDP sponsors Web sites did not contain all required content (see 
Table 1). These 28 plan sponsors serve 39 percent of all PDP enrollees.  The most 
commonly omitted information pertained to enrollee disenrollment rights and 
responsibilities, the potential for PDP contract termination, and information related to the 
formulary.   
 
Table 1: Medicare Part D Prescription Drug Plan Sponsor Web Sites That Did Not 
Contain All Federally Required Content  
Number of  
Web Sites  Percentage of 
Without  Web Sites   Percentage 
Content  Without   of Enrollees 
Contenta   (n = 84)b  Content  in PDPsc  
Disenrollment rights and responsibilities  13  15%  23% 
Potential for contract termination   13  15%  10% 
Formulary  13  15%  8% 
Quality assurance policies and  7 8 %  7%  
procedures 
 
Benefits  6  7%  7% 
Addresses of network pharmacies   5  6%  7% 
Out-of-network coverage   4  5%  <1% 
Service area   3  4%  <1% 
Grievance, reconsideration, exceptions,  3 4 %  <1%  
coverage determination, and appeal rights 
and procedures  
How to obtain more information on   2 2 %  <1%  
cost-sharing requirements 
 
Web sites that did not contain all 
28  33%  39% 
federally required content 
a 42 CFR  423.128(b).  

b OIG analysis of Web sites, April 1May 31 2007.
  
c CMS, Medicare Advantage, Cost, PACE, Demo, and Prescription Drug Plan OrganizationsMonthly Report by 
 
ContractMay 2007. 

  
Because PDP sponsors with larger plans serve more enrollees, the absence of required  
information from their Web sites potentially affects more enrollees.  For example, the 
same number of Web sites (13) lacked information about both disenrollment and     
 
 
Page 10  Kerry Weems  
 
 
formulary.  However, because of differences in the number of enrollees among those plan 
sponsors, the proportion of enrollees in plans with Web sites that fell short of required 
disenrollment information and formulary information differed between disenrollment  
(23 percent) and formulary (8 percent).  
 
One of the 84 Web sites contained only information about the PDP service area, lacking 
the other nine required content elements. When we contacted that PDP to verify the lack 
of content, a customer service representative confirmed that the information is not 
available on the Web site and offered to send a brochure with the information.    
 
Eighty-Five Percent of Sponsor Web Sites Did Not Meet at Least One of the Four 
Federal Requirements Reviewed for Accessibility  
Our review, using the electronic Web page assessment tools WebXactTM and Cynthia 
SaysTM, revealed that 71 of the 84 PDP sponsors Web site home pages had errors related 
to at least one of the accessibility requirements we reviewed (see Table 2).  For enrollees 
who have specific disabilities, PDP information on their sponsors Web sites could be 
inaccessible.    
Table 2:  Sponsor Web Site Home Pages With Errors Identified in at Least One of the 
Four Federal Requirements  Reviewed for Accessibility   
Number of Home  Percentage of 
Pages With  Home Pages 
Accessibility   With  Percentage 
Web-Based Information and  Errors  Accessibility   of Enrollees in 
Applicationa   (n = 84) b  Errors  PDPsc 
Text equivalents  53  63%  78% 
Online forms  48  57%  23% 
Links to plug-ins or applets    16  19%  9% 
Frames    2  2%  2% 
Home pages  with errors 
associated with at least one 
71  85%  98% 
Federal requirement for 
accessibility  
a 36 CFR  1194.22(a), (i), (m), and (n). 

b OIG analysis of Web sites, April 1May 31 2007.
  
c CMS, Medicare Advantage, Cost, PACE, Demo, and Prescription Drug Plan OrganizationsMonthly Report by 
 
ContractMay 2007. 

 
Additionally, we compared 2006 and 2007 PDP sponsors home pages for the 68 plan 
sponsors with contracts for both years.  We found little change in Web page accessibility.      
 
 
Page 11  Kerry Weems  
 
 
Eighty-seven percent of the home pages for 2006 had errors identified in at least one of 
the four Federal requirements we reviewed, compared to 85 percent of the 2007 home 
pages. 
 
We also analyzed Web pages with content related to grievances, coverage 
determinations, and appeal rights.  Forty-three percent of the Web pages devoted to 
coverage determination used plug-ins or applets to present information but did not 
provide links to the plug-ins or applets.  This is significantly higher than the 19 percent of 
Web sites with problems identified on their home pages, demonstrating that accessibility 
problems are not limited to PDP sponsors Web site home pages. 
 
CONCLUSION 
 
Pursuant to Federal regulations, CMS must review and approve marketing materials for  
Part D prescription drug plans, including materials provided through Part D sponsors 
Web sites. Our review found that 33 percent of the 84 PDP sponsors did not provide all 
federally required content on their Web sites.  We also found that 85 percent of the  
84 PDP sponsors home pages we reviewed did not meet at least one of the four Federal 
requirements for Web site accessibility, potentially affecting access to content by 
Medicare beneficiaries. 
 
The use of computers and the Internet is increasing among adults aged 65 and older and 
utilizing the Internet as a mechanism to provide information on prescription drug plans is 
vital.  It is important that CMS oversee these Web sites to ensure that all Medicare 
beneficiaries, including beneficiaries with disabilities, have comparable access to 
federally required content to make informed decisions about their prescription drug 
coverage. 
 
This report is being issued directly in final form because it contains no recommendations.  
If you have comments or questions about this report, please provide them within 60 days.   
 
If you have any questions about this report, please do not hesitate to call me or one of 
your staff may contact Claire Barnard at (202) 205-9523 or through e-mail 
(Claire.Barnard@oig.hhs.gov). To facilitate identification, please refer to report number 
OEI-06-06-00340 in all correspondence.     
 
 
Page 12  Kerry Weems  
 
 
Appendix A 
 
PDP Sponsor Web Site Content Requirements 
Content   Description  
Service area   Provides details of the plans service area. 
Benefits  Provides a description of the benefits offered, including  
conditions and limitations, premiums, cost sharing 
(copayments, deductibles, coinsurance, and subsidy-eligible 
individuals), and any other conditions. 
Ways of obtaining more  Provides a description of how an individual may obtain more 
information on cost-sharing   information on cost-sharing requirements, including tiered or  
requirements  other copayment levels applicable to each drug or class of 
  drug. 
Formulary  Provides information about the plans formulary, including a 
list of drugs, the manner in which the formulary functions 
(including any tiered formulary structure and utilization  
management procedures used), the process for obtaining an 
exception to a plans formulary or tiered cost-sharing 
structure, and a description of how a Part D-eligible individual 
may obtain additional information on the formulary. 
Network pharmacies  Provides addresses of network pharmacies from which 
enrollees may expect to obtain covered drugs. 
Out-of-Network coverage  Provides  information regarding access to covered Part D 
drugs at out-of-network pharmacies. 
Grievances, reconsideration,  Provides information on the procedures for timely hearing and 
exceptions, coverage   resolution for grievances, coverage determinations, and 
determination, and appeal rights  appeals. 
and procedures   
Quality assurance policies and  Provides a description of the quality assurance policies and 
procedures  procedures and the medication therapy management 
program. 
Disenrollment rights and  Provides information on enrollees disenrollment rights and 
responsibilities  responsibilities. 
Potential for contract termination   Provides information on the fact that a Part D sponsor may 
terminate or decline to renew its contract or reduce the service 
area included in its contract and on the effect of any of these 
actions on enrollees. 
Source: 42 CFR  423.128(b). 
     
 
 
Page 13  Kerry Weems  
 
 
Appendix B 
 
 
 
Federal Accessibility  Requirements for Web- Based Information 
 
36 CFR  1194.22  
Paragraph  Web-Based Information and Application 
(a)  A text equivalent for every nontext element shall be provided.   
Equivalent alternatives for any multimedia presentation shall be synchronized 
(b) 
with the presentation. 
Web pages shall be designed so that all information conveyed with color is 
(c) 
available without color. 
Documents shall be organized so that they are readable without requiring an 
(d) 
associated style sheet. 
Redundant text links shall be provided for each active region of a server-side 
(e) 
image map. 
Client-side image maps shall be provided instead of server-side image maps  
(f) 
except where the regions cannot be defined with an available geometric shape.   
(g)  Row and column headers shall be identified for data tables.   
Markup shall be used to associate data cells and header cells for data tables 
(h) 
that have two or more logical levels of row or column headers. 
Frames shall be titled with text that facilitates frame identification and 
(i) 
navigation. 
Pages shall be designed to avoid causing the screen to flicker with a frequency 
(j) 
greater than 2 Hz and lower than 55 Hz. 
A text-only page, with equivalent information or functionality, shall be provided  
to make a Web site comply with the provisions of this part when compliance 
(k) 
cannot be accomplished in any other way.  The content of the text-only page 
shall be updated whenever the primary page changes.   
When pages utilize scripting languages to display content, or to create interface 
(l)  elements, the information provided by the script shall be identified with 
functional text that can be read by assistive technology.   
When a Web page requires that an applet, a plug-in, or other application be 
(m)  present on the client system to interpret page content, the page must provide a 
link to a plug-in or an applet that complies with  1194.21 (a) through (l).   
When electronic forms are designed to be completed online, the form shall 
allow people using assistive technology to access the information, field 
(n) 
elements, and functionality required for completion and submission of the form, 
including all directions and cues. 
(o)  A method shall be provided that permits users to skip repetitive navigation links.  
When a timed response is required, the user shall be alerted and given 
(p) 
sufficient time to indicate that more time is required.   
 
Source: 36 CFR  1194.22.