Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
MEDICARE MANAGED CARE 
Goals of National Marketing Guide 
JUNE GIBBS BROWN 
Inspector General 
FEBRUARY 2000 
OEI-03-98-00270  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's Philadelphia Regional Office prepared this report under the direction of Robert A. Vito, 
Regional Inspector General, and Linda M. Ragone, Deputy Regional Inspector General.  Principal 
OEI staff included: 
REGION  HEADQUARTERS 
Isabelle Buonocore, Project Leader  Stuart Wright, Program Specialist 
Erika Q. Lang, Lead Program Analyst  Tricia Davis, Program Specialist 
Lauren McNulty, Program Analyst 
To obtain copies of this report, please call the Philadelphia Regional Office at (215) 861-4551. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E   S U M M A R Y  
PURPOSE 
This report describes how well the Medicare Managed Care National Marketing Guide 
met its established goals in its first year of implementation. 
BACKGROUND 
The Health Care Financing Administration (HCFA) has authority to establish how 
managed care health plans with Medicare contracts provide information to beneficiaries. 
The health plans are required to submit marketing materials to HCFA regional offices for 
review and approval before distribution.  Marketing materials include pre-enrollment 
materials (e.g., advertisements and sales brochures) and member materials (e.g., 
membership rules and notices of change in benefits).  The HCFA regional staff keep track 
of their marketing-material reviews. 
In November 1997, the Medicare Managed Care National Marketing Guide was issued 
as an operational tool for health plans and HCFA reviewers.  It includes Federal marketing 
requirements and instructions regarding the review process.  The goals of this National 
Marketing Guide are to (1) expedite the review process, (2) reduce re-submissions of 
material prior to approval, (3) ensure uniform review across the nation, and, most 
importantly, (4) provide Medicare beneficiaries with current, accurate, consumer friendly 
material that will help them make informed health-care choices.  The following 
operational elements of the National Marketing Guide were designed to help HCFA 
reviewers and health plans meet the four goals: (1) lead regional offices, (2) model 
member material, (3) checklists for member materials, (4) language chart, (5) Use and File 
System (this system allows health plans that consistently meet Federal requirements to 
distribute sales materials without prior approval), and (6) Product Consistency Team. 
We surveyed all HCFA staff responsible for reviewing marketing materials and 
representatives from 150 managed care plans.  We also obtained data from HCFA regional 
offices that had systems to track marketing-material reviews. 
FINDINGS 
Goals of the National Marketing Guide Were Not Completely Met in the First Year 
of Implementation 
1 
Goals of National Marketing Guide  OEI-03-98-00270  However, Some Aspects of the Review Process Improved Due to the National 
Marketing Guide.  Marketing guidelines were clearer, and creating and reviewing marketing 
materials became easier. 
Of the Operational Elements, the Use and File System and Checklists for Member 
Materials Were Not Well Understood or Applied Uniformly 
Marketing-Material Reviews Were Not Tracked Consistently Across HCFA 
Regions 
Both HCFA Reviewers and Managed Care Plan Representatives Felt 
Improvements Are Needed.  They felt operational elements need clarification, model member 
materials should be more sensitive to beneficiary needs, and there should be training on how to 
use the National Marketing Guide. 
RECOMMENDATIONS 
Our findings from this report and our review of marketing materials for a companion 
report, Medicare Managed Care: 1998 Marketing Materials (OEI-03-98-00271), provide 
evidence that the Medicare Managed Care National Marketing Guide, while improving 
some aspects of the marketing-material review process, was not very successful at meeting 
its most important goal.  That goal is to provide Medicare beneficiaries with accurate and 
consumer friendly marketing materials.  Inaccurate and confusing materials may affect 
beneficiaries ability to make informed health-care choices. 
We recommend that HCFA: 
<	 update the National Marketing Guide.  The National Marketing Guide should further 
clarify which information is specifically prohibited or required in marketing materials. 
The National Marketing Guide should provide model materials that are accurate and 
easy to read.  It should clarify policy and operational instructions regarding the lead and 
local regional office responsibilities, the Use and File System (which allows plans to 
distribute sales material without prior approval), and the health plans use of checklists 
for member materials.  It should also ensure that checklists for member materials contain 
all the required information. 
<	 standardize and mandate use of member materials.  The HCFA should work toward 
standardizing as many types of member materials as possible.  Managed care plans 
should be required to use these materials when communicating with their enrolled 
Medicare beneficiaries. 
2 
Goals of National Marketing Guide  OEI-03-98-00270  <	 develop standard review instruments.  These review instruments should be used by 
HCFA staff in determining if marketing materials (both pre-enrollment and member) 
contain all required information and do not contain prohibited information. 
<	 establish a quality control system.  The HCFA should periodically review a nationwide 
sample of previously approved marketing materials (both pre-enrollment and member) to 
determine if they meet Federal marketing guidelines. 
<  track marketing-material reviews consistently and uniformly across all regions. 
<	 conduct meetings to review Federal marketing requirements with managed care 
plans that continually submit materials not in compliance with the requirements. 
<	 provide training on the use of the National Marketing Guide for HCFA reviewers 
and managed care plans. 
AGENCY COMMENTS 
The Health Care Financing Administration (HCFA) reviewed our companion reports and 
concurred with our recommendations.  The agency is updating the National Marketing 
Guide and plans to promote better understanding of the Use and File System.  As of 2000, 
contracting health plans must use a standardized Summary of Benefits.  In the future, 
beneficiary notifications such as the Evidence of Coverage will be standardized, and their 
mandatory use will be phased in.  In 2001, the agency will have a new and comprehensive 
instrument for collecting benefit data and reviewing marketing materials.  In addition, the 
Product Consistency Team will meet monthly and uncover and correct inconsistencies in 
operational or policy interpretations of standardized materials.  As to quality control, the 
agency will verify that all final versions of beneficiary notices are the same as versions 
HCFA approved, and will review samples of printed marketing materials.  The HCFA is 
also taking steps to address the tracking of marketing material reviews, monitoring of 
contractor performance, and training of staff.  Appendix C contains the full comments. 
We appreciate the comprehensiveness of HCFAs comments.  We believe the agencys 
stated efforts can result in comparable and understandable materials which beneficiaries 
need to make informed health-care choices.  We are hopeful that the updated National 
Marketing Guide will include clarification of lead and local regional office responsibilities, 
and clarification as to whether health plans must submit checklists along with the member 
materials they submit for HCFAs review.  With regard to the Product Consistency Team, 
the past team was not fully able to realize the objectives stated in the agency comments 
(uncovering and correcting inconsistencies; updating the National Marketing Guide as 
needed).  We are hopeful that the new team has the tools and authority needed to 
accomplish these important objectives. 
3 
Goals of National Marketing Guide  OEI-03-98-00270  T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

FINDINGS

Goals of National Marketing Guide not completely met . . . . . . . . . . . . . . . . . . . . . . . . 11

Improvements due to National Marketing Guide  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12

Certain operational elements not understood or applied uniformly  . . . . . . . . . . . . . . . .  14

Marketing-material reviews not tracked consistently . . . . . . . . . . . . . . . . . . . . . . . . . . .  15

Improvements still needed  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19

APPENDICES

A: Opinions of Plan Representatives: Estimates and Confidence Intervals . . . . . . . . . . .  22

B: Opinions of How Well Goals of National Marketing Guide Were Met . . . . . . . . . . .  31

C: Comments from the Health Care Financing Administration  . . . . . . . . . . . . . . . . . . .  33

4 
Goals of National Marketing Guide  OEI-03-98-00270  I N T R O D U C T I O N  
PURPOSE 
This report describes how well the Medicare Managed Care National Marketing Guide 
met its established goals in its first year of implementation. 
BACKGROUND 
Marketing Regulations 
Title XVIII of the Social Security Act (Part D, Section 1876[c][3][C]) provided the 
Health Care Financing Administration (HCFA) authority to establish how managed care 
health plans with Medicare contracts provide information to beneficiaries.  Regulations 
which list prohibited marketing activities are in Title 42 of the Code of Federal 
Regulations (Section 422.80).  Prohibited are activities that (1) discriminate against 
beneficiaries with poor health, (2) mislead or confuse beneficiaries, or (3) misrepresent the 
health plan or HCFA.  These same regulations also require managed care plans to submit 
all marketing materials to HCFA for review and approval at least 45 days before planned 
distribution. 
Marketing Materials 
Marketing materials include a wide range of materials used to communicate with 
beneficiaries before and after enrollment in a managed care plan.  Pre-enrollment materials 
are essentially sales materials and include newspaper, radio, and television advertisements; 
summaries of benefits; application forms; telemarketing scripts; and slide presentations. 
Post-enrollment materials, more commonly called member materials, include letters 
confirming enrollment and disenrollment; notices about a change in providers, benefits, or 
premiums; letters with claim information; lists of covered and non-covered services; co
payment schedules; and subscriber agreements.  Subscriber agreements contain member 
rights as well as member and plan responsibilities.  Some subscriber agreements also list 
covered and non-covered services. 
Medicare beneficiaries are exposed to marketing materials through different media, 
including literature, billboards, radio, television, informational meetings, and the Internet. 
Regardless of the medium used, managed care plans must get approval from HCFA prior 
to distributing the information. 
5 
Goals of National Marketing Guide  OEI-03-98-00270  National Marketing Guide 
The Medicare Managed Care National Marketing Guide, hereinafter called the National 
Marketing Guide, became effective November 17, 1997.  Its main users are managed care 
plan staff who create marketing materials and HCFA staff who review the materials.  Prior 
to the National Marketing Guides implementation, the main reference for Federal 
marketing guidelines was the Health Maintenance Organization/Competitive Medical 
Plan Manual, issued March 1991. 
The National Marketing Guide incorporates Federal marketing requirements, represents 
HCFA's official position on marketing policy, and contains operational instructions.  It 
explains requirements for different types of materials and media.  Some instructions are 
voluntary, and others are mandatory.  The HCFA policy is that certain information must 
be conveyed to Medicare beneficiaries.  However, format and the addition of other types 
of information are left to the discretion of the health plans. The National Marketing Guide 
is meant to address concerns about what had been the slow pace of HCFA's review 
process; the inconsistent interpretation of Federal marketing guidelines by HCFA 
reviewers; and the misleading or incorrect statements in marketing materials that were 
reaching Medicare beneficiaries even after going through the review process. 
The goals of the National Marketing Guide, as listed in the preamble, are as follows: 
1.  expedite the review process; 
2. 	 conserve resources by avoiding multiple submissions and reviews of a 
piece prior to final approval; 
3.  ensure uniform marketing review across the nation; and, most importantly, 
4. 	 provide Medicare beneficiaries with current, accurate, consumer friendly, 
managed care marketing information that will assist them in making 
informed health-care choices. 
Operational Elements 
Below are operational elements of the National Marketing Guide which have the potential 
to help HCFA and managed care plans meet the four goals mentioned above. 
Lead regional offices.  A HCFA lead regional office reviews materials designed for use in 
more than one region.  Prior to the National Marketing Guide, every HCFA regional 
office reviewed all materials intended for use in its geographic area.  Managed care plans 
with service areas crossing regional boundaries complained that HCFA regional offices 
interpreted marketing guidelines differently, and what was approved in one region was 
denied in another region.  This led to revisions and re-submissions of materials for HCFA's 
review.  Now, managed care plans serving more than one region are assigned a lead 
6 
Goals of National Marketing Guide  OEI-03-98-00270  regional office to review their cross-regional materials.  However, materials created for 
use in only one region are reviewed by the HCFA office in that region. 
Model member materials.  Member materials are pieces used by managed care plans to 
communicate with enrolled Medicare beneficiaries regarding their status in the plan, their 
benefits, rules and regulations of the plan, and other matters.  The HCFA created model 
materials covering many of these topics (e.g., model subscriber agreement, model 
disenrollment letter) and included them in the National Marketing Guide.  Model pieces 
with content that does not change substantially from year to year, such as a model 
disenrollment letter, may be distributed by managed care plans without HCFAs prior 
review and approval. 
Checklists.  The HCFA created checklists for several types of member materials and 
included them in the National Marketing Guide.  Managed care plans must submit these 
checklists with the corresponding member materials to the reviewer, showing that all 
required information is included. 
Language chart.  The National Marketing Guide contains a chart of marketing language 
that managed care plans "Must Use/Can't Use/Can Use" when talking about certain 
concepts/subjects in sales materials.  Use of the language chart can protect beneficiaries 
from misleading statements in advertising.  Moreover, the chart standardizes language for 
certain concepts, making the creation and review of sales materials easier.  Use of the 
standard language can also help beneficiaries become familiar with the concepts. 
Use and File System.  This operational element of the National Marketing Guide is a 
way to expedite the review process and reward managed care plans that demonstrate they 
can be relied upon to meet Federal marketing requirements.  Plans that meet the Use and 
File criteria may distribute sales materials without prior review and approval from HCFA, 
but they must send copies of those materials to HCFA to be kept on file.  The criteria are: 
(1) the plan has had a Medicare contract for at least 18 months; (2) only sales materials 
are eligible; (3) at least 10 pieces of sales material were submitted for review in a calendar 
quarter; and (4) 95 percent of the quarters sales materials were error free. 
Product Consistency Team.  This Team is made up of HCFA central office and regional 
staff.  It is responsible for (1) internally assuring consistency in the application of 
marketing guidelines, and (2) drafting updates to the National Marketing Guide.  The 
work of the Product Consistency Team can lead to more uniform reviews of marketing 
materials, expediting the review process, and even reducing re-submissions of marketing 
materialsthree of four goals of the National Marketing Guide. 
7 
Goals of National Marketing Guide  OEI-03-98-00270  Future of the National Marketing Guide 
Updates to the National Marketing Guide are disseminated in the form of operational 
policy letters.  In Operational Policy Letter #79, issued February 4, 1999, HCFA stated 
that in the future, the National Marketing Guide will become a chapter of the Medicare + 
Choice Manual.  Until that time, interim changes to the National Marketing Guide will 
continue to be made through operational policy letters, and they are available on the 
Internet at HCFAs managed care home page. 
The HCFA Reviewers 
Staff in HCFA regional offices are responsible for various aspects of overseeing contracts 
between Medicare and managed care plans, including review of marketing materials and 
keeping track of the reviews.  In 1998, a total of 96 staff members were conducting 
reviews.  According to the review staff, the review of marketing materials is only one of 
their duties, but for some staff it is the most time-consuming.  In 1998, the median number 
of hours per week spent on reviews was 10 hours, with some reviewers spending as many 
as 35 hours. 
Reviewers must determine whether marketing materials meet regulatory requirements, 
accurately reflect the health plan's Medicare contract, and accurately describe benefits. 
Consequently, the review of materials can be extremely complex to perform, requiring 
attention to numerous details.  In the last quarter of calendar year 1998, most of the same 
staff responsible for conducting reviews were also responsible for implementing the new 
Medicare + Choice program.  The Medicare + Choice program increases the types of 
health plans HCFA staff must oversee. 
Recent Developments in the Review Program 
In August 1999, HCFA issued an operational policy letter which contains new and 
updated models of enrollment and disenrollment letters.  The HCFA also created a 
standard form called the Summary of Benefits.  All plans are required to use this form in 
fiscal year 2000 when describing their benefits to beneficiaries. 
Currently, HCFA is conducting a pilot study to determine the effectiveness of having an 
outside contractor review marketing materials.  The HCFA has also contracted an 
evaluation of the Medicare managed care marketing regulatory program to determine the 
programs strengths and weaknesses. 
Studies by the Office of Inspector General 
Medicare managed care has been the focus of many Office of Inspector General (OIG) 
studies.  We have covered such topics as HCFA oversight of managed care plans, 
8 
Goals of National Marketing Guide  OEI-03-98-00270  grievance and appeal issues, physician and beneficiary perspectives, beneficiary 
satisfaction, enrollment and service access problems, and the use of disenrollment rates as 
performance indicators. 
We have also addressed managed care marketing within the last three years.  In 
Medicare's Oversight of Managed Care (OEI-01-96-00191), we found that while HCFA 
had increased the number of staff responsible for managed care oversight, some staff 
lacked managed care experience.  The HCFA staff needed certain skills to evaluate various 
aspects of health plan operations, including marketing.  We recommended that HCFA 
develop a more comprehensive training program for staff who oversee managed care 
plans.  In Medicare HMO Appeal and Grievance Processes (OEI-07-94-00280), we 
found that many health maintenance organizations had marketing materials and operating 
procedures with incorrect or incomplete information on appeal and grievance processes. 
We recommended that HCFA (1) work with the health plans to standardize appeal and 
grievance language in marketing materials and operating procedures, and (2) take a more 
active approach in monitoring the plans. 
As a companion to this report, we are issuing, Medicare Managed Care: 1998 Marketing 
Materials (OEI-03- 00271).  We found that few marketing materials submitted by 
managed care plans and approved by HCFA in 1998 were in full compliance with Federal 
guidelines, and nearly half the materials were not consumer friendly.  The findings from 
the companion reports were used to develop the recommendations contained in both 
reports. 
SCOPE AND METHODOLOGY 
Our purpose in this study was to determine how well the National Marketing Guide met 
its goals in the first year (November 1997 through November 1998).  We collected data 
between September 1998 and March 1999 and completed analysis in June 1999. 
Survey of HCFA Reviewers and Managed Care Plan Representatives 
In December 1998, we sent self-administered questionnaires to all 96 HCFA regional staff 
who were responsible for reviewing and approving managed care marketing materials and 
who had been employed longer than 4 months.  Ninety percent (86 of 96) responded. 
We also sent self-administered questionnaires to a simple random sample of managed care 
health plan representatives responsible for risk-based Medicare contracts in 1998.  Of the 
346 risk-based contracts in 1998, we sampled 150.  Eighty-seven percent of sampled plan 
representatives (131 of 150) responded.  (Appendix A contains the confidence intervals 
related to their opinions.)  These respondents informed us their plans had been submitting 
9 
Goals of National Marketing Guide  OEI-03-98-00270  marketing materials to HCFA for as little as 10 months to as long as 16 years; 3 years was 
the median. 
All respondents provided demographic information and opinions about how well the 
National Marketing Guide worked and what improvements are needed.  A few questions 
in the survey required a finite response (e.g., demographic questions), but most had a 
range of choices to express opinions.  Two open-ended questions addressed (1) 
improvements needed and (2) anything else the respondent wanted to say about the 
National Marketing Guide. 
Collection of Tracking Information From HCFA Regional Offices 
We asked each HCFA regional office for data from their tracking of marketing-material 
reviews so that we could determine the volume of reviews, review time-frames, review 
outcomes (approvals and denials), number of re-submitted materials, and number of plans 
in the Use and File System.  We obtained 1997 and 1998 data from regions that kept 
tracking systems so that we could compare data before and after implementation of the 
National Marketing Guide. 
____________ 
This study was conducted in accordance with the Quality Standards for Inspections issued 
by the Presidents Council on Integrity and Efficiency. 
10 
Goals of National Marketing Guide  OEI-03-98-00270  F I N D I N G S  
Goals of the National Marketing Guide were not completely 
met 
Less than half of the managed care plan representatives and HCFA reviewers felt the 
National Marketing Guide worked very well or well toward meeting three of its goals: 
reducing material re-submissions, ensuring uniform reviews across the nation, and 
providing beneficiaries with useful information.  While 64 percent of the HCFA reviewers 
felt the National Marketing Guide worked very well or well at the goal to expedite the 
review process, the majority of managed care plan representatives felt it was not as 
successful at meeting that goal. The HCFA reviewers were generally more positive than 
the managed care plan representatives about the effectiveness of the National Marketing 
Guide.  (Appendix B contains HCFA reviewer and plan representative opinions of how 
well each goal was met.) 
Goal 1 - Expedite the review process 
As stated above, the HCFA reviewers felt more strongly than plan representatives that, as 
a whole, the National Marketing Guide worked very well or well at expediting the review 
process.  In fact, reviewers felt the National Marketing Guide was most successful at 
achieving this goal.  Both respondent groups felt the language chart was the most 
instrumental of the operational elements in meeting this goal.  Seventy-two percent of 
reviewers and 60 percent of plan representatives said the language chart worked very well 
or well.  Reviewers felt more strongly than plan representatives that model member 
materials expedited the review process.  A large percentage of both plan representatives 
(74 percent) and HCFA reviewers (44 percent) did not know how well the Use and File 
System met this goal.  On the negative side, 19 percent of HCFA reviewers felt the lead 
regional office concept did not work well at expediting the review process. 
Goal 2 - Reduce re-submissions of marketing material 
Managed care plan representatives felt the National Marketing Guide made the most 
substantial improvement in the goal to reduce material re-submissions.  Thirty-nine 
percent of the plan representatives felt it worked very well or well.  As with the first goal, 
the highest percentage of managed care plan representatives (66 percent) thought the 
language chart was the most successful in reaching this goal.  The next highest percentage 
of plan representatives (41 percent) felt the same way about model member materials. 
The HCFA reviewers agreed that the same two operational elements worked best at 
reducing re-submissions, but the percentage of reviewers was lower (44 and 43 
11 
Goals of National Marketing Guide  OEI-03-98-00270  percent respectively for the language chart and model materials).  However, roughly 20 
percent of HCFA reviewers felt the lead regional office concept and checklists for member 
materials did not work well. 
Goal 3 - Ensure uniform review across the nation 
Thirty-nine percent of HCFA reviewers felt the National Marketing Guide worked very 
well or well at ensuring uniform review across the nation.  A fourth of the respondents 
from both groups felt it worked less than well, and 18 percent of the plan representatives 
felt it had not achieved this goal at all.  The language chart was the operational element 
that was the most successful at reaching this goal.  Twenty-five percent of plan 
representatives said the lead regional offices worked very well or well.  Thirty-two percent 
of HCFA reviewers felt the Product Consistency Team worked very well or well. 
Goal 4 - Provide Medicare beneficiaries with useful information 
Thirty-eight percent of HCFA reviewers compared to 24 percent of plan representatives 
felt the National Marketing Guide worked very well or well at providing beneficiaries 
with useful information (i.e., materials that will help them make informed health-care 
choices).  Nineteen percent of plan representatives felt the National Marketing Guide was 
not successful in meeting this goal.  Of the operational elements, the language chart 
worked best according to 45 percent of HCFA reviewers and 42 percent of plan 
representatives.  While a majority of plan representatives felt the model member materials 
worked less than well at meeting this goal, 34 percent of HCFA reviewers felt model 
materials worked well. 
However, some aspects of the review process improved due 
to the National Marketing Guide 
The majority of respondents agreed the review process had improved since the National 
Marketing Guide was issued.  More than three-quarters of both respondent groups felt 
marketing guidelines were clearer; 82 percent of plan representatives felt creating 
materials became easier; and 68 percent of HCFA reviewers thought reviewing materials 
became easier.  Eighty-three percent of HCFA reviewers also felt they became more 
consistent in language they allowed and did not allow in materials. 
Overall, HCFA reviewers felt more strongly than managed care plan representatives that 
the review process had improved and that marketing materials were more accurate and 
useful for beneficiaries.  For example, 81 percent of reviewers compared to 59 percent of 
plan representatives said final marketing materials contain more accurate information. 
12 
Goals of National Marketing Guide  OEI-03-98-00270  Table 1 below shows whether managed care plan representatives and HCFA reviewers 
agreed or disagreed with statements about the National Marketing Guides early impact. 
Table 1. Respondent Opinions Concerning National Marketing Guides Early Impact 
OPINIONS 
STATEMENTS OF  Type of  Strongly  Somewhat Somewhat  Strongly  Dont 
EARLY IMPACT  Respondent  n*  agree  agree  disagree  disagree  know 
Managed care plan  127  12%  69%  16%  0%  3% 
Marketing guidelines are clearer. 
HCFA  83  19%  58%  7%  5%  11% 
Lead regional offices improved  Managed care plan  125  22%  30%  7%  3%  37% 
review process for health plans with 
HCFA  83  21%  33%  13%  7%  27% 
cross-regional materials. 
Creating/reviewing marketing  Managed care plan  127  18%  64%  13%  1%  4% 
materials is easier. 
HCFA  83  25%  43%  15%  5%  12% 
Submitting/receiving marketing  Managed care plan  128  12%  58%  19%  6%  6% 
materials is easier. 
HCFA  80  14%  41%  21%  5%  19% 
HCFA reviews marketing materials  Managed care plan  127  17%  37%  21%  16%  9% 
in shorter time frames. 
HCFA  82  17%  37%  22%  11%  13% 
HCFA comments on reviewed  Managed care plan  127  6%  39%  32%  8%  16% 
marketing materials are more 
HCFA  82  18%  46%  16%  4%  16% 
objective. 
HCFA reviewers are more  Managed care plan  128  12%  38%  21%  17%  12% 
consistent in interpreting guidelines. 
HCFA  79  35%  44%  8%  0%  13% 
HCFA reviewers are more  Managed care plan  128  9%  48%  20%  16%  7% 
consistent in language they allow. 
HCFA  82  39%  44%  6%  1%  10% 
HCFA reviewers are more  Managed care plan  128  9%  61%  18%  6%  6% 
consistent in language they do not 
HCFA  82  39%  44%  5%  2%  10% 
allow. 
Final marketing materials contain  Managed care plan  126  10%  49%  31%  0%  10% 
more accurate information. 
HCFA  82  27%  54%  5%  5%  10% 
Final marketing materials are more  Managed care plan  126  4%  26%  41%  20%  9% 
consumer friendly. 
HCFA  81  16%  51%  16%  6%  11% 
Final marketing materials are more  Managed care plan  127  4%  31%  39%  13%  13% 
likely to help Medicare beneficiaries 
HCFA  82  17%  45%  16%  6%  16% 
make informed health-care choices. 
Source: OIG survey, conducted December 1998 
n = number of respondents answering survey question 
13 
Goals of National Marketing Guide  OEI-03-98-00270  Certain operational elements were not well understood or 
implemented uniformly 
Use and File System 
We found that some plan representatives and HCFA reviewers did not know, or had 
misconceptions, about the Use and File System.  At the time of our survey, only 12 
percent of plans (16 of 131) had the Use and File privilege.  Plan representatives and 
HCFA reviewers had different conceptions about the criteria for gaining the Use and File 
privilege.  Plans must be in the Medicare program at least 18 months to be considered for 
Use and File privilege, and only sales materials are eligible.  The plan must submit at least 
10 pieces of sales material in a calendar quarter, and 95 percent of the quarters sales 
materials must be error free.  While plans with the Use and File privilege may distribute 
sales materials without prior approval, they must send HCFA copies of the materials to be 
kept on file.  Table 2 below shows the percentage of plan representatives aware of each 
criterion, and the percentage of HCFA reviewers who considered each criterion when 
determining whether plans should receive the Use and File privilege. 
Table 2. Awareness and Consideration of Use and File Criteria 
Percentage of  Percentage of 
Plans Aware of  Reviewers who 
Criteria that Must Be Met for Use and File Privilege  Criterion  Consider Criterion 
Plan must be in Medicare program for at least 18 months  76%  51% 
Only sales materials are eligible  70%  35% 
At least 10 pieces must be submitted in a calendar quarter  58%  44% 
95% of calendar quarters sales materials must be approved  87%  64% 
Source: OIG survey, conducted December 1998 
In order for HCFA to identify plans for the Use and File privilege, the reviews of plans 
marketing material must be tracked.  However, 25 percent of HCFA reviewers said their 
regional office did not track reviews for this purpose, and 17 percent said they did not 
know if their office required tracking.  In many regions, reviewers did not agree on 
whether their office required tracking for Use and File purposes.  Fifty percent of managed 
care plan representatives thought they must ask HCFA to track them, 25 percent thought 
HCFA tracks automatically, and 25 percent did not know how tracking is initiated.  Some 
plan representatives commented that the Use and File System is not available in their 
region,  and this was echoed in comments of some reviewers.  The lack of awareness and 
inconsistent implementation of the Use and File System may explain why very high 
percentages of respondents did not know how well the Use and File System worked at 
meeting the National Marketing Guides goals (see Appendix B). 
14 
Goals of National Marketing Guide  OEI-03-98-00270  Checklists for member materials 
More than half of managed care plan representatives (68 of 126) and a third of HCFA 
reviewers (28 of 82) said plans do not need to submit member-material checklists to 
HCFA because checklists are solely for the plans use.  According to the National 
Marketing Guide, if plans create a member piece that requires HCFAs review and 
approval, then both the member piece and corresponding checklist must be submitted. 
The checklist helps expedite the review because it shows that all the necessary information 
is included in the member piece. 
Given the lack of understanding about the use of checklists, it is not surprising that 50 
percent of plan representatives and 41 percent of HCFA reviewers thought the checklists 
worked less than well or not well at expediting the review process (see Appendix B). 
Marketing-material reviews were not tracked consistently 
across HCFA regions 
As of November 1998, only 7 of 10 HCFA regional offices were keeping track of their 
marketing-material reviews.  However, of the seven regional offices with tracking systems, 
most did not require reviewers to enter data.  Moreover, many reviewers who entered data 
did not do so consistently or uniformly.  Various types of inconsistencies led to incomplete 
data in the systems.  For example, very few reviewers noted when a piece was a 
re-submission.  Some reviewers did not enter the received date, the material type, or the 
materials unique identifier.  Without consistent and uniform tracking, reviewers may not, 
for example, be able to determine whether plans have met criteria for the Use and File 
privilege.  One Use and File criterion is that 95 percent of a plan's sales materials in a 
calendar quarter are error free.  If material type is not tracked consistently and uniformly, 
one cannot accurately determine whether this criterion is met. 
Only two regional offices consistently and uniformly tracked marketing materials for Use 
and File purposes.  Two additional regional offices tracked reviews for Use and File 
purposes only if managed care plans requested to be tracked.  (One of these two regions 
requires the plan to file a formal application and demonstrate that all criteria have been 
met.)  The remaining six regions either did not use their existing tracking system for Use 
and File purposes, or did not track marketing materials consistently for any purpose. 
The HCFA has the potential to track marketing materials nationally in its Managed Care 
Information System.  One of the databases in this system was designed in 1997 specifically 
for tracking marketing-material reviews.  Some regional offices were using the database 
when we collected data for this study.  However, the data was not input consistently or 
uniformly so as to permit valid regional or national reporting. 
15 
Goals of National Marketing Guide  OEI-03-98-00270  Tracking has the potential to help HCFA identify (1) the number and type of marketing 
materials submitted, (2) material approval rates, (3) review time-frames, (4) material 
re-submission rates, and (5) plan eligibility for the Use and File privilege.  Tracking can 
help regions and central office determine whether the review process is becoming more 
efficient.  It can also help identify managed care plans with a history of having to re-
submit material.  Since tracking was done inconsistently and data sent to us from most 
regions was incomplete, we could not analyze the data to identify national statistics.  Nor 
could we use it to determine whether certain goals of the National Marketing Guide were 
met (e.g., reduce the number of material re-submissions). 
Both HCFA reviewers and managed care plan 
representatives felt improvements are needed 
Sixty-three percent of managed care plan representatives (77 of 123) and 76 percent of 
HCFA reviewers (60 of 79) felt the National Marketing Guide needs improvement. 
Below are summaries of respondent comments wherein they described problems and made 
suggestions regarding the National Marketing Guide and its operational elements. 
Marketing guidelines need more consistent interpretation 
Managed care plan representatives and HCFA reviewers who wrote comments repeatedly 
raised the issue of inconsistent interpretation of guidelineswhether the topic at hand was 
the lead regional office concept, model member materials, the language chart, or the 
National Marketing Guide as a whole.  Some HCFA reviewers said the solution to 
inconsistency is to standardize materials and make their use mandatory.  One of our survey 
questions asked respondents if they favored that approach with certain materials, e.g., 
disenrollment letters.  Ninety-five percent of HCFA reviewers (82 of 86) and 54 percent of 
the managed care plan representatives (70 of 130) favored that approach. 
Some respondents wrote that HCFA and plan staffs needed training on how to use the 
National Marketing Guide.  More specific comments were that organized training for 
HCFA staff is weak and inconsistent, and training is needed for new employees and to 
address the new Medicare + Choice program. 
National Marketing Guide needs timely updates and expansion 
Both respondent groups said timely updates of the National Marketing Guide are needed 
to reflect current market conditions and the new Medicare + Choice program.  They also 
commented that parts of the National Marketing Guide are vague, incomplete, or hard to 
use.  They wanted policy clarifications, more wording choices in the language chart, and 
more types of model materials and checklists.  They felt the layout and writing style should 
16 
Goals of National Marketing Guide  OEI-03-98-00270  be improved to make it easier to use, and updates should be made with replacement pages 
instead of operational policy letters. 
A relatively small number of plan representatives compared to HCFA reviewers thought 
the "Must Use/Can't Use/Can Use" language chart should be improved.  But their 
concerns were similar.  A specific recommendation was to expand the chart to include 
more concepts, examples of violations, and suggested/required language.  Respondents 
also recommended making the chart easier to use and updating it to include Medicare + 
Choice terminology. 
Model materials need to be more beneficiary sensitive, and more types of 
models are needed 
Respondents from both groups commented that current model materials are not 
"beneficiary sensitive."  They described models as cold, technical, complex, wordy, and 
confusing.  They felt models should be written at a more appropriate reading level, and 
terms should have the same definitions across all models. 
Respondents also wanted more types of models.  There were recommendations for model 
member handbooks, enrollment forms, summaries of benefits, and point-of-service 
options.  Another suggestion was to have more than one model per topic to allow for plan 
variations. 
Several operational elements need clarification 
Both HCFA reviewers and plan representatives believed that the lead regional office, 
checklist for member material, and Use and File information in the National Marketing 
Guide needs clarification. 
Some HCFA reviewers had concerns regarding responsibility, authority, and coordination 
between the lead regions and other regions where cross-regional materials are used. 
Numerous managed care plan representatives also wrote comments on this subject.  They 
agreed with reviewers that lead and local regional roles need clarification.  Some also said 
that because materials with varying local information have to be reviewed by both the lead 
and local regional offices, the review process has become cumbersome and too time 
consuming. 
Some plan representatives reiterated they did not understand how to use checklists 
contained in the National Marketing Guide.  Some complained that HCFA reviewers 
require language in member materials that is not on checklists.  However, one reviewer 
said checklists do not always contain all the information that is required.  Reviewers 
wanted checklists to contain more details, include all pieces of information that plans are 
required to have in their materials, and be available for more types of materials. 
17 
Goals of National Marketing Guide  OEI-03-98-00270  Both managed care plan representatives and HCFA reviewers commented on the lack of 
understanding about the Use and File System.  A few managed care plan representatives 
stated they need technical assistance or feedback from their HCFA regional office. 
Some respondents reported that the criteria for the system should be changed or 
strengthened.  Others felt that while the concept is good the system is too cumbersome to 
implement and track.  Several respondents believed there should be national standards and 
procedures for the system, including a mandatory spot check of materials distributed under 
the Use and File privilege and a periodic review of those materials to ensure that plans can 
retain the Use and File privilege. 
Product Consistency Team needs better administration 
With regard to the Product Consistency Team, the HCFA reviewers said they wanted 
better dissemination of the team's decisions, strengthening of the team's authority, and 
improvement in the team's management. 
18 
Goals of National Marketing Guide  OEI-03-98-00270  R E C O M M E N D A T I O N S  
Our findings from this report and our review of marketing materials for a companion 
report, Medicare Managed Care: 1998 Marketing Materials (OEI-03-98-0071), provide 
evidence that the Medicare Managed Care National Marketing Guide, while improving 
some aspects of the marketing-material review process, was not very successful at meeting 
its most important goal.  That goal is to provide Medicare beneficiaries with accurate and 
consumer friendly marketing materials.  Inaccurate and confusing materials may affect 
beneficiaries ability to make informed health-care choices. 
We recommend that HCFA: 
<	 update the National Marketing Guide.  The National Marketing Guide should further 
clarify which information is specifically prohibited or required in marketing materials. 
The National Marketing Guide should provide model materials that are accurate and 
easy to read.  It should clarify policy and operational instructions regarding the lead and 
local regional office responsibilities, the Use and File System (which allows plans to 
distribute sales material without prior approval), and the health plans use of checklists 
for member materials.  It should also ensure that checklists for member materials contain 
all the required information. 
<	 standardize and mandate use of member materials.  The HCFA should work toward 
standardizing as many types of member materials as possible.  Managed care plans 
should be required to use these materials when communicating with their enrolled 
Medicare beneficiaries. 
<	 develop standard review instruments.  These review instruments should be used by 
HCFA staff in determining if marketing materials (both pre-enrollment and member) 
contain all required information and do not contain prohibited information. 
<	 establish a quality control system.  The HCFA should periodically review a nationwide 
sample of previously approved marketing materials (both pre-enrollment and member) to 
determine if they meet Federal marketing guidelines. 
<<  track marketing-material reviews consistently and uniformly across all regions. 
<	 conduct meetings to review Federal marketing requirements with managed care 
plans that continually submit materials not in compliance with the requirements. 
<	 provide training on the use of the National Marketing Guide for HCFA reviewers 
and managed care plans. 
19 
Goals of National Marketing Guide  OEI-03-98-00270  AGENCY COMMENTS 
The Health Care Financing Administration (HCFA) reviewed this report and the 
companion report on 1998 marketing materials and concurred with our recommendations. 
We summarized the agencys comments below, however, the full comments are in 
Appendix C. 
<	 update the National Marketing Guide.  The agency is updating the National Marketing 
Guide, including checklists and model letters.  They are also clarifying what is allowed 
and prohibited in marketing materials.  As they believe the Use and File System is an 
important tool, they plan to develop materials to promote a better understanding of its 
operation. 
<	 standardize and mandate use of member materials.  Work toward standardizing 
certain materials has already begun.  As of contract year 2000, health plans contracting 
with HCFA must use a standardized Summary of Benefits.  In the future, beneficiary 
notifications such as the Evidence of Coverage will be standardized, and their mandatory 
use will be phased in. 
<	 develop standard review instruments.  The agencys goal is to have a new and 
comprehensive data collection instrument, called the Plan Benefit Package, fully 
implemented in contract year 2001.  This instrument will have multiple uses, including a 
standardized way to collect descriptions of benefits from health plans.  The instrument can 
then be used to review health plan marketing materials.  In the meantime, a modified 
version of a prior data collection instrument will be used.  In addition, the Product 
Consistency Team, comprised of representatives from all ten HCFA regional offices, will 
meet monthly.  Through ongoing dialogue, the team is expected to uncover and correct 
any inconsistencies in operational or policy interpretations of standardized materials. 
<	 establish a quality control system.  The HCFA has established procedures for verifying 
that all final versions of beneficiary notices are the same as the versions HCFA approved. 
They also plan to review a sample of actual printed marketing materials from a random 
sample of health care organizations.  The agency has also established a quality control 
system in their pilot study of the effectiveness of contracting the marketing material 
review to a single national contractor.  Moreover, the Product Consistency Team will be 
critical to overall quality control efforts. 
<	 track marketing-material reviews consistently and uniformly across all regions. The 
HCFA regional offices will be required to track receipt and approval of all marketing 
materials when the new Health Plan Management System becomes operational in 2000. 
The Managed Care Information System, which is currently used by a number of the 
regional offices, will become part of the new system. 
20 
Goals of National Marketing Guide  OEI-03-98-00270  <	 conduct meetings to review Federal marketing requirements with managed care 
plans that continually submit materials not in compliance with the requirements. 
The HCFA is in the process of updating a contractor performance monitoring protocol. 
The revised protocol will require HCFA reviewers who find a pattern of noncompliant 
marketing submissions to take action, including meeting with managed care plans.  As the 
agency continues to review its marketing material review program, it will determine 
additional steps that need to be taken, including sanctioning. 
<	 provide training on the use of the National Marketing Guide for HCFA reviewers 
and managed care plans.  The HCFA currently includes a marketing session in their 
annual training program for reviewers.  They plan to expand the program to address the 
needs of contracting health plans.  In addition, they expect Product Consistency Team 
meetings will promote better understanding of the National Marketing Guide. 
OIG RESPONSE 
We appreciate the comprehensiveness of HCFAs comments.  We believe the agencys 
stated efforts can result in comparable and understandable materials which beneficiaries 
need to make informed health-care choices.  We are hopeful that the update of the National 
Marketing Guide will include clarification of lead and local regional office responsibilities, 
and clarification as to whether health plans must submit checklists along with the member 
materials they submit for HCFAs review.  These two elements of the guidelines were not 
specifically mentioned in the agency comments regarding various elements of the guidelines 
that would be updated. 
We have one other concern regarding the Product Consistency Team.  The agency states 
they will be relying on the team to play a critical role in quality control, to uncover and 
correct inconsistencies in operational or policy interpretations of standardized materials, 
and to update the National Marketing Guide as needed.  The past team was not fully 
effective in these areas, and we are hopeful that the new team has the tools and authority 
needed to accomplish these important objectives. 
21 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
OPINIONS OF PLAN REPRESENTATIVES:

ESTIMATES AND CONFIDENCE INTERVALS

As mentioned in this reports introduction, we surveyed a sample of 150 risk-based 
managed care plans out of a total of 346.  Eighty-seven percent (131 of 150) responded. 
In our findings section, we cite the percentage of plans having certain opinions.  The 
precision of our estimates about these opinions, based on a 95 percent confidence level, are 
shown in the tables of this appendix.  The calculations were computed using standard 
statistical formulas for a simple random sample.  The report pages containing the findings 
are noted in parentheses after the table title. 
22 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
Table 1. 	Plan representative opinions of how well operational elements worked toward 
Goal 1 - Expedite the review process (pp. 11 - 12 ) 
Percentage of  95% Confidence 
Operational Elements  Opinions  Plan Reps  Interval 
Very well  3.10  2.26 
Well  28.68  5.90 
National Marketing Guide as a whole 
Somewhat well  53.49  6.50 
Not well  10.08  3.93 
Dont know  4.65  2.75 
Very well  17.19  4.94 
Well  17.97  5.03 
Lead regional offices 
Somewhat well  16.41  4.85 
Not well  6.25  3.17 
Dont know  42.19  6.46 
Very well  6.20  3.14 
Well  30.23  5.99 
Model member material 
Somewhat well  42.64  6.45 
Not well  13.95  4.52 
Dont know  6.98  3.32 
Very well  10.08  3.93 
Well  16.28  4.81 
Checklists for member material 
Somewhat well  37.98  6.33 
Not well  11.63  4.18 
Dont know  24.03  5.57 
Very well  17.05  4.90 
Well  43.41  6.46 
Language chart 
Somewhat well  24.03  5.57 
Not well  10.85  4.06 
Dont know  4.65  2.75 
Very well  8.66  3.70 
Well  4.72  2.79 
Use and File System 
Somewhat well  5.51  3.00 
Not well  7.09  3.37 
Dont know  74.02  5.76 
Very well  0.78  1.14 
Well  10.08  3.93 
Product Consistency Team 
Somewhat well  13.18  4.41 
Not well  12.40  4.30 
Dont know  63.57  6.27 
23 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
Table 2.Plan representative opinions of how well operational elements worked toward Goal 2 - Reduce re-
submissions of marketing material (pp. 11 - 12) 
Percentage of  95% Confidence 
Operational Elements  Opinions  Plan Reps  Interval 
Very well  6.15  3.12 
Well  33.08  6.11 
National Marketing Guide as a whole 
Somewhat well  45.38  6.47 
Not well  12.31  4.27 
Dont know  3.08  2.24 
Very well  5.47  2.98 
Well  19.53  5.19 
Lead regional offices 
Somewhat well  24.22  5.61 
Not well  5.47  2.98 
Dont know  45.31  6.52 
Very well  10.77  4.03 
Well  30.00  5.95 
Model member material 
Somewhat well  38.46  6.32 
Not well  14.62  4.59 
Dont know  6.15  3.12 
Very well  5.38  2.93 
Well  26.92  5.76 
Checklists for member material 
Somewhat well  43.08  6.43 
Not well  6.92  3.30 
Dont know  17.69  4.96 
Very well  16.15  4.78 
Well  50.00  6.49 
Language chart 
Somewhat well  27.69  5.81 
Not well  4.62  2.73 
Dont know  1.54  1.60 
Very well  9.30  3.79 
Well  3.10  2.26 
Use and File System 
Somewhat well  6.20  3.14 
Not well  6.20  3.14 
Dont know  75.19  5.63 
Very well  1.54  1.60 
Well  4.62  2.73 
Product Consistency Team 
Somewhat well  6.15  3.12 
Not well  16.15  4.78 
Dont know  71.54  5.86 
24 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
Table 3.Plan representative opinions of how well operational elements worked toward Goal 3 - Ensure 
uniform review across the nation (pp. 11 - 12) 
Percentage of  95% Confidence 
Operational Elements  Opinions  Plan Reps  Interval 
Very well  3.08  2.24 
Well  18.46  5.04 
National Marketing Guide as a whole 
Somewhat well  26.92  5.76 
Not well  17.69  4.96 
Dont know  33.85  6.15 
Very well  15.63  4.75 
Well  8.59  3.67 
Lead regional offices 
Somewhat well  25.00  5.67 
Not well  3.13  2.28 
Dont know  47.66  6.54 
Very well  4.62  2.73 
Well  16.92  4.87 
Model member material 
Somewhat well  34.62  6.18 
Not well  6.92  3.30 
Dont know  36.92  6.27 
Very well  4.62  2.73 
Well  13.08  4.38 
Checklists for member material 
Somewhat well  29.23  5.91 
Not well  8.46  3.61 
Dont know  44.62  6.46 
Very well  8.46  3.61 
Well  23.08  5.47 
Language chart 
Somewhat well  26.92  5.76 
Not well  6.92  3.30 
Dont know  34.62  6.18 
Very well  6.98  3.32 
Well  3.10  2.26 
Use and File System 
Somewhat well  5.43  2.95 
Not well  5.43  2.95 
Dont know  79.07  5.30 
Very well  1.54  1.60 
Well  2.31  1.95 
Product Consistency Team 
Somewhat well  6.15  3.12 
Not well  13.85  4.49 
Dont know  76.15  5.53 
25 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
Table 4.Plan representative opinions of how well operational elements worked toward Goal 4 - Provide 
Medicare beneficiaries with useful information (pp. 11 - 12) 
Percentage of  95% Confidence 
Operational Elements  Opinions  Plan Reps  Interval 
Very well  5.38  2.93 
Well  19.23  5.12 
National Marketing Guide as a whole 
Somewhat well  40.00  6.36 
Not well  18.46  5.04 
Dont know  16.92  4.87 
Very well  2.33  1.97 
Well  12.40  4.30 
Lead regional offices 
Somewhat well  24.81  5.63 
Not well  6.98  3.32 
Dont know  53.49  6.50 
Very well  6.11  3.10 
Well  12.98  4.35 
Model member material 
Somewhat well  52.67  6.46 
Not well  12.98  4.35 
Dont know  15.27  4.65 
Very well  4.62  2.73 
Well  15.38  4.69 
Checklists for member material 
Somewhat well  38.46  6.32 
Not well  8.46  3.61 
Dont know  33.08  6.11 
Very well  12.31  4.27 
Well  30.00  5.95 
Language chart 
Somewhat well  32.31  6.07 
Not well  9.23  3.76 
Dont know  16.15  4.78 
Very well  2.33  1.97 
Well  6.98  3.32 
Use and File System 
Somewhat well  9.30  3.79 
Not well  3.88  2.52 
Dont know  77.52  5.44 
Very well  0.77  1.13 
Well  4.62  2.73 
Product Consistency Team 
Somewhat well  12.31  4.27 
Not well  12.31  4.27 
Dont know  70.00  5.95 
26 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
Table 5. Percentage of plans that Strongly agreed with positive statements of impact (p. 13) 
95% Confidence 
Early Impact of National Marketing Guide  Percentage*  Interval 
Marketing guidelines were clearer.  11.81  4.24 
Lead region concept improved review process for chain organizations.  22.40  5.52 
Creating marketing material was easier.  18.11  5.06 
Submitting marketing materials was easier.  11.72  4.21 
HCFA reviewed marketing material in shorter time frames.  17.32  4.97 
HCFA comments on marketing material were more objective.  5.51  3.00 
HCFA reviewers were more consistent in interpreting guidelines.  11.72  4.21 
HCFA reviewers were more consistent in language they allowed.  9.38  3.82 
HCFA reviewers were more consistent in language they did not allow.  9.38  3.82 
Final marketing material contained more accurate information.  10.32  4.01 
Final marketing material was more consumer friendly.  3.97  2.58 
Final marketing material was more likely to help Medicare beneficiaries 
make informed health-care choices.  3.94  2.56 
* Plans that answered Strongly agree 
Table 6. Percentage of plans that Somewhat agreed with positive statements of impact (p. 13) 
95% Confidence 
Early Impact of National Marketing Guide  Percentage*  Interval 
Marketing guidelines were clearer.  69.29  6.06 
Lead region concept improved review process for chain organizations.  30.40  6.09 
Creating marketing material was easier.  63.78  6.32 
Submitting marketing materials was easier.  57.81  6.46 
HCFA reviewed marketing material in shorter time frames.  37.01  6.35 
HCFA comments on marketing material were more objective.  39.37  6.42 
HCFA reviewers were more consistent in interpreting guidelines.  38.28  6.36 
HCFA reviewers were more consistent in language they allowed.  47.66  6.54 
HCFA reviewers were more consistent in language they did not allow.  60.94  6.39 
Final marketing material contained more accurate information.  49.21  6.60 
Final marketing material was more consumer friendly.  26.19  5.80 
Final marketing material was more likely to help Medicare beneficiaries 
make informed health-care choices.  30.71  6.06 
* Plans that answered Somewhat agree 
27 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
Table 7. Percentage of plans that Somewhat disagreed with positive statements of impact (p. 13) 
95% Confidence 
Early Impact of National Marketing Guide  Percentage*  Interval 
Marketing guidelines were clearer.  15.75  4.79 
Lead region concept improved review process for chain organizations.  7.20  3.42 
Creating marketing material was easier.  13.39  4.47 
Submitting marketing materials was easier.  18.75  5.11 
HCFA reviewed marketing material in shorter time frames.  21.26  5.38 
HCFA comments on marketing material were more objective.  31.50  6.10 
HCFA reviewers were more consistent in interpreting guidelines.  21.09  5.34 
HCFA reviewers were more consistent in language they allowed.  19.53  5.19 
HCFA reviewers were more consistent in language they did not allow.  17.97  5.03 
Final marketing material contained more accurate information.  30.95  6.10 
Final marketing material was more consumer friendly.  41.27  6.50 
Final marketing material was more likely to help Medicare beneficiaries 
make informed health-care choices.  39.37  6.42 
* Plans that answered Somewhat disagree 
Table 8. Percentage of plans that Strongly disagreed with positive statements of impact (p. 13) 
95% Confidence 
Early Impact of National Marketing Guide  Percentage*  Interval 
Marketing guidelines were clearer.  0.00  0.00 
Lead region concept improved review process for chain organizations.  3.20  2.33 
Creating marketing material was easier.  0.79  1.16 
Submitting marketing materials was easier.  5.47  2.98 
HCFA reviewed marketing material in shorter time frames.  15.75  4.79 
HCFA comments on marketing material were more objective.  7.87  3.54 
HCFA reviewers were more consistent in interpreting guidelines.  17.19  4.94 
HCFA reviewers were more consistent in language they allowed.  16.41  4.85 
HCFA reviewers were more consistent in language they did not allow.  5.47  2.98 
Final marketing material contained more accurate information.  0.00  0.00 
Final marketing material was more consumer friendly.  19.84  5.26 
Final marketing material was more likely to help Medicare beneficiaries 
make informed health-care choices.  13.39  4.47 
* Plans that answered Strongly disagree 
28 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
Table 9. Percentage of plans that Didnt know about impact (p. 13) 
95% Confidence 
Early Impact of National Marketing Guide  Percentage*  Interval 
Marketing guidelines were clearer.  3.15  2.30 
Lead region concept improved review process for chain organizations.  36.80  6.39 
Creating marketing material was easier.  3.94  2.56 
Submitting marketing materials was easier.  6.25  3.17 
HCFA reviewed marketing material in shorter time frames.  8.66  3.70 
HCFA comments on marketing material were more objective.  15.75  4.79 
HCFA reviewers were more consistent in interpreting guidelines.  11.72  4.21 
HCFA reviewers were more consistent in language they allowed.  7.03  3.35 
HCFA reviewers were more consistent in language they did not allow.  6.25  3.17 
Final marketing material contained more accurate information.  9.52  3.87 
Final marketing material was more consumer friendly.  8.73  3.72 
Final marketing material was more likely to help Medicare beneficiaries 
make informed health-care choices.  12.60  4.36 
* Plans that answered Dont know

Table 10. Percentage of plans with Use and File privilege (p. 14)

95% Confidence 
Survey Statement  Percentage*  Interval 
We have the Use and File privilege.  12.21  4.24 
* Plans that agreed with statement

Table 11. Percentage of plans aware of criteria for Use and File privilege (p. 14)

Survey Question: Was your plan aware of the following criteria for  95% Confidence 
gaining Use and File privilege?  Percentage*  Interval 
Plan must be in Medicare program for at least 18 months.  76.38  5.58 
Only sales material is eligible for distribution under Use and File 
privilege.  69.77  5.99 
At least 10 pieces of sales material must be submitted for review within 
calendar quarter.  58.27  6.48 
Within calendar quarter, 95 of sales material must be approved.  86.61  4.47 
*Plans that answered Yes 
29 
Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  A  
Table 12. Percentage of plans understanding of tracking for Use and File System (p. 14) 
95% Confidence 
Survey Statement  Percentage*  Interval 
HCFA tracks our marketing material automatically.  25.38  5.65 
We must ask HCFA to track our marketing material.  50.00  6.49 
We dont know how plans start getting their marketing material  24.62  5.59 
tracked. 
* Plans that agreed with statement 
Table 13. Percentage of plans that said it is not necessary to submit checklists (p. 15) 
95% Confidence 
Survey Statement  Percentage*  Interval 
Checklists need not be submitted. They are solely for plans use.  53.97  6.58 
* Plans that agreed with statement 
Table 14. Percentage of plans that said National Marketing Guide needs improvement (p. 16) 
95% Confidence 
Survey Question  Percentage*  Interval 
Does the National Marketing Guide as a whole need improvement?  62.60  6.46 
* Plans that answered Yes 
Table 15. Percentage of plans that favored standardizing material (p. 16) 
95% Confidence 
Survey Question  Percentage*  Interval 
Do you think that in the future plans should use a standardized HCFA 
form (its use would be mandatory) for certain material such as enrollment 
and disenrollment notices?  53.85  6.47 
* Plans that answered Yes 
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Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  B  
Opinions of How Well Goals of 
National Marketing Guide Were Met 
Table 1. How well guide & operational elements met Goal 1 - Expedite the review process 
Plan Representatives Opinions - Goal 1  HCFA Reviewers Opinions - Goal 1 
Guide &  Very  Some- Not  Dont  Very  Some- Not  Dont 
Operational  n  well  Well  what  well  know  n  well  Well  what  well  know 
Elements  well  well 
Marketing Guide 
as a whole  129  3%  29%  54%  10%  5%  85  19%  45%  27%  7%  2% 
Lead regional 
offices  128  17%  18%  16%  6%  42%  85  20%  17%  19%  19%  26% 
Model member 
materials  129  6%  30%  43%  14%  7%  85  26%  33%  31%  7%  4% 
Checklists  129  10%  16%  38%  12%  24%  85  18%  24%  27%  14%  18% 
Language chart  129  17%  43%  24%  11%  5%  85  38%  34%  20%  6%  2% 
Use and File 
System  127  9%  5%  6%  7%  74%  85  14%  15%  14%  13%  44% 
Product Con
sistency Team  129  1%  10%  13%  12%  64%  85  19%  22%  24%  11%  25% 
Table 2. How well guide & operational elements met Goal 2 - Reduce marketing material re-submissions 
Plan Representativess Opinions - Goal 2  HCFA Reviewers Opinions - Goal 2 
Guide &  Very  Some- Not  Dont  Very  Some- Not  Dont 
Operational  n  well  Well  what  well  know  n  well  Well  what  well  know 
Elements  well  well 
Marketing Guide 
as a whole  130  6%  33%  45%  12%  3%  84  14%  30%  32%  14%  10% 
Lead regional 
offices  128  6%  20%  24%  6%  45%  84  13%  12%  23%  18%  35% 
Model member 
materials  130  11%  30%  39%  15%  6%  84  18%  25%  38%  12%  7% 
Checklists  130  5%  27%  43%  7%  18%  84  11%  18%  27%  20%  24% 
Language chart  130  16%  50%  28%  5%  2%  84  18%  26%  33%  14%  8% 
Use and File 
System  129  9%  3%  6%  6%  75%  84  10%  8%  20%  16%  46% 
Product Con
sistency Team  130  2%  5%  6%  16%  72%  84  11%  18%  27%  17%  27% 
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Goals of National Marketing Guide  OEI-03-98-00270  A P P E N D I X  B  
Table 3. How well guide & operational elements met Goal 3 - Ensure uniform review across the nation 
Plan Representatives Opinions - Goal 3  HCFA Reviewers Opinions - Goal 3 
Guide &  Very  Some- Not  Dont  Very  Some- Not  Dont 
Operational  n  well  Well  what  well  know  n  well  Well  what  well  know 
Elements  well  well 
Marketing Guide 
as a whole  130  3%  19%  27%  18%  34%  84  13%  26%  24%  11%  26% 
Lead regional 
offices  128  16%  9%  25%  3%  48%  84  17%  19%  20%  12%  32% 
Model member 
materials  130  5%  17%  35%  7%  37%  84  12%  24%  27%  11%  26% 
Checklists  130  5%  13%  29%  9%  45%  84  8%  18%  25%  14%  35% 
Language chart  130  9%  23%  27%  7%  35%  84  14%  32%  17%  12%  25% 
Use and File 
System  129  7%  3%  5%  5%  79%  84  6%  13%  12%  13%  56% 
Product Con
sistency Team  130  2%  2%  6%  14%  76%  84  12%  20%  17%  13%  38% 
Table 4. 	How well guide & operational elements met Goal 4 - Provide Medicare beneficiaries with useful 
information 
Plan Representatives Opinions - Goal 4  HCFA Reviewers Opinions - Goal 4 
Guide &  Very  Some- Not  Dont  Very  Some- Not  Dont 
Operational  n  well  Well  what  well  know  n  well  Well  what  well  know 
Elements  well  well 
Marketing Guide 
as a whole  130  5%  19%  40%  19%  17%  84  8%  30%  31%  5%  26% 
Lead regional 
offices  129  2%  12%  25%  7%  54%  84  8%  12%  26%  10%  44% 
Model member 
materials  131  6%  13%  53%  13%  15%  84  8%  26%  36%  6%  24% 
Checklists  130  5%  15%  39%  9%  33%  84  5%  17%  27%  10%  42% 
Language chart  130  12%  30%  32%  9%  16%  84  14%  31%  27%  7%  20% 
Use and File 
System  129  2%  7%  9%  4%  78%  84  6%  10%  13%  8%  63% 
Product Con 45% 
sistency Team  130  1%  5%  12%  12%  70%  84  12%  17%  20%  6% 
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Goals of National Marketing Guide  OEI-03-98-00270