Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

FEBRUARY 2000 

OEI-03-98-00270 

MEDICARE MANAGED CARE 

Goals of National Marketing Guide 
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 
EXECUTIVE SUMMARY 

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 

Goals of National Marketing Guide 1 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. 

Goals of National Marketing Guide 2 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 HCFA’s comments. We believe the agency’s 

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 HCFA’s 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. 

Goals of National Marketing Guide 3 OEI-03-98-00270 
TABLE OF CONTENTS 

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

Goals of National Marketing Guide 4 OEI-03-98-00270 
INTRODUCTION 

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; copayment 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. 

Goals of National Marketing Guide 5 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 Guide’s 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 

Goals of National Marketing Guide 6 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 HCFA’s 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 quarter’s 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 

materials–three of four goals of the National Marketing Guide. 

Goals of National Marketing Guide 7 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 HCFA’s 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 

program’s 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, 

Goals of National Marketing Guide 8 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 

Goals of National Marketing Guide 9 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 President’s Council on Integrity and Efficiency. 

Goals of National Marketing Guide 10 OEI-03-98-00270 
FINDINGS 

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 

Goals of National Marketing Guide 11 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. 

Goals of National Marketing Guide 12 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 Guide’s early impact. 

Table 1. Respondent Opinions Concerning National Marketing Guide’s Early Impact 

STATEMENTS OF 

EARLY IMPACT 

Type of 

Respondent n* 

OPINIONS 

Strongly Somewhat Somewhat Strongly 

agree agree disagree disagree 

Don’t 

know 

Marketing guidelines are clearer. 

Managed care plan 127 12% 69% 16% 0% 3% 

HCFA 83 19% 58% 7% 5% 11% 

Lead regional offices improved 

review process for health plans with 

cross-regional materials. 

Managed care plan 125 22% 30% 7% 3% 37% 

HCFA 83 21% 33% 13% 7% 27% 

Creating/reviewing marketing 

materials is easier. 

Managed care plan 127 18% 64% 13% 1% 4% 

HCFA 83 25% 43% 15% 5% 12% 

Submitting/receiving marketing 

materials is easier. 

Managed care plan 128 12% 58% 19% 6% 6% 

HCFA 80 14% 41% 21% 5% 19% 

HCFA reviews marketing materials 

in shorter time frames. 

Managed care plan 127 17% 37% 21% 16% 9% 

HCFA 82 17% 37% 22% 11% 13% 

HCFA comments on reviewed 

marketing materials are more 

objective. 

Managed care plan 127 6% 39% 32% 8% 16% 

HCFA 82 18% 46% 16% 4% 16% 

HCFA reviewers are more 

consistent in interpreting guidelines. HCFA 

Managed care plan 128 12% 38% 21% 17% 12% 

79 35% 44% 8% 0% 13% 

HCFA reviewers are more 

consistent in language they allow. 

Managed care plan 128 9% 48% 20% 16% 7% 

HCFA 82 39% 44% 6% 1% 10% 

HCFA reviewers are more 

consistent in language they do not 

allow. 

Managed care plan 128 9% 61% 18% 6% 6% 

HCFA 82 39% 44% 5% 2% 10% 

Final marketing materials contain 

more accurate information. 

Managed care plan 126 10% 49% 31% 0% 10% 

HCFA 82 27% 54% 5% 5% 10% 

Final marketing materials are more 

consumer friendly. 

Managed care plan 126 4% 26% 41% 20% 9% 

HCFA 81 16% 51% 16% 6% 11% 

Final marketing materials are more 

likely to help Medicare beneficiaries 

make informed health-care choices. HCFA 

Managed care plan 127 4% 31% 39% 13% 13% 

82 17% 45% 16% 6% 16% 

Source: OIG survey, conducted December 1998 

n = number of respondents answering survey question 

Goals of National Marketing Guide 13 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 quarter’s 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 

Criteria that Must Be Met for Use and File Privilege Criterion 

Percentage of 

Plans Aware of 

Consider Criterion 

Percentage of 

Reviewers who 

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 quarter’s 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 Guide’s goals (see Appendix B). 

Goals of National Marketing Guide 14 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 HCFA’s 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 

material’s 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. 

Goals of National Marketing Guide 15 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 resubmit 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 guidelines—whether 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 

Goals of National Marketing Guide 16 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. 

Goals of National Marketing Guide 17 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. 

Goals of National Marketing Guide 18 OEI-03-98-00270 
<

RECOMMENDATIONS 

Our findings from this report and our review of marketing materials for a companion 

report, Medicare Managed Care: 1998 Marketing Materials (OEI-03-98-0071), 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. 

Goals of National Marketing Guide 19 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 agency’s 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 agency’s 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. 

Goals of National Marketing Guide 20 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 HCFA’s comments. We believe the agency’s 

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 HCFA’s 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. 

Goals of National Marketing Guide 21 OEI-03-98-00270 
APPENDIX A 

OPINIONS OF PLAN REPRESENTATIVES:

ESTIMATES AND CONFIDENCE INTERVALS

As mentioned in this report’s 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. 

Goals of National Marketing Guide 22 OEI-03-98-00270 
APPENDIX A 

Table 1. Plan representative opinions of how well operational elements worked toward 

Goal 1 - “Expedite the review process” (pp. 11 - 12 ) 

Operational Elements Opinions Plan Reps 

Percentage of 

Interval 

95% Confidence 

National Marketing Guide as a whole 

Very well 3.10 ±2.26 

Well 28.68 ±5.90 

Somewhat well 53.49 ±6.50 

Not well 10.08 ±3.93 

Don’t know 4.65 ±2.75 

Lead regional offices 

Very well 17.19 ±4.94 

Well 17.97 ±5.03 

Somewhat well 16.41 ±4.85 

Not well 6.25 ±3.17 

Don’t know 42.19 ±6.46 

Model member material 

Very well 6.20 ±3.14 

Well 30.23 ±5.99 

Somewhat well 42.64 ±6.45 

Not well 13.95 ±4.52 

Don’t know 6.98 ±3.32 

Checklists for member material 

Very well 10.08 ±3.93 

Well 16.28 ±4.81 

Somewhat well 37.98 ±6.33 

Not well 11.63 ±4.18 

Don’t know 24.03 ±5.57 

Language chart 

Very well 17.05 ±4.90 

Well 43.41 ±6.46 

Somewhat well 24.03 ±5.57 

Not well 10.85 ±4.06 

Don’t know 4.65 ±2.75 

Use and File System 

Very well 8.66 ±3.70 

Well 4.72 ±2.79 

Somewhat well 5.51 ±3.00 

Not well 7.09 ±3.37 

Don’t know 74.02 ±5.76 

Product Consistency Team 

Very well 0.78 ±1.14 

Well 10.08 ±3.93 

Somewhat well 13.18 ±4.41 

Not well 12.40 ±4.30 

Don’t know 63.57 ±6.27 

Goals of National Marketing Guide 23 OEI-03-98-00270 
APPENDIX A 

Table 2.Plan representative opinions of how well operational elements worked toward Goal 2 - “Reduce resubmissions of marketing material (pp. 11 - 12) 

Operational Elements Opinions Plan Reps 

Percentage of 

Interval 

95% Confidence 

National Marketing Guide as a whole 

Very well 6.15 ±3.12 

Well 33.08 ±6.11 

Somewhat well 45.38 ±6.47 

Not well 12.31 ±4.27 

Don’t know 3.08 ±2.24 

Lead regional offices 

Very well 5.47 ±2.98 

Well 19.53 ±5.19 

Somewhat well 24.22 ±5.61 

Not well 5.47 ±2.98 

Don’t know 45.31 ±6.52 

Model member material 

Very well 10.77 ±4.03 

Well 30.00 ±5.95 

Somewhat well 38.46 ±6.32 

Not well 14.62 ±4.59 

Don’t know 6.15 ±3.12 

Checklists for member material 

Very well 5.38 ±2.93 

Well 26.92 ±5.76 

Somewhat well 43.08 ±6.43 

Not well 6.92 ±3.30 

Don’t know 17.69 ±4.96 

Language chart 

Very well 16.15 ±4.78 

Well 50.00 ±6.49 

Somewhat well 27.69 ±5.81 

Not well 4.62 ±2.73 

Don’t know 1.54 ±1.60 

Use and File System 

Very well 9.30 ±3.79 

Well 3.10 ±2.26 

Somewhat well 6.20 ±3.14 

Not well 6.20 ±3.14 

Don’t know 75.19 ±5.63 

Product Consistency Team 

Very well 1.54 ±1.60 

Well 4.62 ±2.73 

Somewhat well 6.15 ±3.12 

Not well 16.15 ±4.78 

Don’t know 71.54 ±5.86 

Goals of National Marketing Guide 24 OEI-03-98-00270 
APPENDIX A 

Table 3.Plan representative opinions of how well operational elements worked toward Goal 3 - “Ensure 

uniform review across the nation (pp. 11 - 12) 

Operational Elements Opinions Plan Reps 

Percentage of 

Interval 

95% Confidence 

National Marketing Guide as a whole 

Very well 3.08 ±2.24 

Well 18.46 ±5.04 

Somewhat well 26.92 ±5.76 

Not well 17.69 ±4.96 

Don’t know 33.85 ±6.15 

Lead regional offices 

Very well 15.63 ±4.75 

Well 8.59 ±3.67 

Somewhat well 25.00 ±5.67 

Not well 3.13 ±2.28 

Don’t know 47.66 ±6.54 

Model member material 

Very well 4.62 ±2.73 

Well 16.92 ±4.87 

Somewhat well 34.62 ±6.18 

Not well 6.92 ±3.30 

Don’t know 36.92 ±6.27 

Checklists for member material 

Very well 4.62 ±2.73 

Well 13.08 ±4.38 

Somewhat well 29.23 ±5.91 

Not well 8.46 ±3.61 

Don’t know 44.62 ±6.46 

Language chart 

Very well 8.46 ±3.61 

Well 23.08 ±5.47 

Somewhat well 26.92 ±5.76 

Not well 6.92 ±3.30 

Don’t know 34.62 ±6.18 

Use and File System 

Very well 6.98 ±3.32 

Well 3.10 ±2.26 

Somewhat well 5.43 ±2.95 

Not well 5.43 ±2.95 

Don’t know 79.07 ±5.30 

Product Consistency Team 

Very well 1.54 ±1.60 

Well 2.31 ±1.95 

Somewhat well 6.15 ±3.12 

Not well 13.85 ±4.49 

Don’t know 76.15 ±5.53 

Goals of National Marketing Guide 25 OEI-03-98-00270 
APPENDIX A 

Table 4.Plan representative opinions of how well operational elements worked toward Goal 4 - “Provide 

Medicare beneficiaries with useful information (pp. 11 - 12) 

Operational Elements Opinions Plan Reps 

Percentage of 

Interval 

95% Confidence 

National Marketing Guide as a whole 

Very well 5.38 ±2.93 

Well 19.23 ±5.12 

Somewhat well 40.00 ±6.36 

Not well 18.46 ±5.04 

Don’t know 16.92 ±4.87 

Lead regional offices 

Very well 2.33 ±1.97 

Well 12.40 ±4.30 

Somewhat well 24.81 ±5.63 

Not well 6.98 ±3.32 

Don’t know 53.49 ±6.50 

Model member material 

Very well 6.11 ±3.10 

Well 12.98 ±4.35 

Somewhat well 52.67 ±6.46 

Not well 12.98 ±4.35 

Don’t know 15.27 ±4.65 

Checklists for member material 

Very well 4.62 ±2.73 

Well 15.38 ±4.69 

Somewhat well 38.46 ±6.32 

Not well 8.46 ±3.61 

Don’t know 33.08 ±6.11 

Language chart 

Very well 12.31 ±4.27 

Well 30.00 ±5.95 

Somewhat well 32.31 ±6.07 

Not well 9.23 ±3.76 

Don’t know 16.15 ±4.78 

Use and File System 

Very well 2.33 ±1.97 

Well 6.98 ±3.32 

Somewhat well 9.30 ±3.79 

Not well 3.88 ±2.52 

Don’t know 77.52 ±5.44 

Product Consistency Team 

Very well 0.77 ±1.13 

Well 4.62 ±2.73 

Somewhat well 12.31 ±4.27 

Not well 12.31 ±4.27 

Don’t know 70.00 ±5.95 

Goals of National Marketing Guide 26 OEI-03-98-00270 
APPENDIX A 

Table 5. Percentage of plans that “Strongly agreed” with positive statements of impact (p. 13) 

Early Impact of National Marketing Guide Percentage* Interval 

95% Confidence 

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) 

Early Impact of National Marketing Guide Percentage* Interval 

95% Confidence 

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 

Goals of National Marketing Guide 27 OEI-03-98-00270 
APPENDIX A 

Table 7. Percentage of plans that “Somewhat disagreed” with positive statements of impact (p. 13) 

Early Impact of National Marketing Guide Percentage* Interval 

95% Confidence 

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) 

Early Impact of National Marketing Guide Percentage* Interval 

95% Confidence 

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 

Goals of National Marketing Guide 28 OEI-03-98-00270 
APPENDIX A 

Table 9. Percentage of plans that “Didn’t know” about impact (p. 13) 

Early Impact of National Marketing Guide Percentage* Interval 

95% Confidence 

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 Don’t know

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

Survey Statement Percentage* Interval 

95% Confidence 

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 

gaining Use and File privilege? Percentage* 

95% Confidence 

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 

Goals of National Marketing Guide 29 OEI-03-98-00270 
APPENDIX A 

Table 12. Percentage of plans’ understanding of tracking for Use and File System (p. 14) 

Survey Statement Percentage* Interval 

95% Confidence 

HCFA tracks our marketing material automatically. 25.38 ±5.65 

We must ask HCFA to track our marketing material. 50.00 ±6.49 

We don’t know how plans start getting their marketing material 

tracked. 

24.62 ±5.59 

* Plans that agreed with statement 

Table 13. Percentage of plans that said it is not necessary to submit checklists (p. 15) 

Survey Statement Percentage* Interval 

95% Confidence 

Checklists need not be submitted. They are solely for plan’s use. 53.97 ±6.58 

* Plans that agreed with statement 

Table 14. Percentage of plans that said National Marketing Guide needs improvement (p. 16) 

Survey Question Percentage* Interval 

95% Confidence 

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) 

Survey Question Percentage* Interval 

95% Confidence 

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 

Goals of National Marketing Guide 30 OEI-03-98-00270 
APPENDIX 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” 

Guide & 

Operational 

Elements 

Plan Representatives’ Opinions - Goal 1 HCFA Reviewers’ Opinions - Goal 1 

n 

Very 

well Well 

Somewhat 

well 

Not 

well 

Don’t 

know n 

Very 

well Well 

Somewhat 

well 

Not 

well 

Don’t 

know 

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 Consistency 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” 

Guide & 

Operational 

Elements 

Plan Representatives’s Opinions - Goal 2 HCFA Reviewers’ Opinions - Goal 2 

n 

Very 

well Well 

Somewhat 

well 

Not 

well 

Don’t 

know n 

Very 

well Well 

Somewhat 

well 

Not 

well 

Don’t 

know 

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 Consistency Team 130 2% 5% 6% 16% 72% 84 11% 18% 27% 17% 27% 

Goals of National Marketing Guide 31 OEI-03-98-00270 
APPENDIX B 

Table 3. How well guide & operational elements met Goal 3 - “Ensure uniform review across the nation” 

Guide & 

Operational 

Elements 

Plan Representatives’ Opinions - Goal 3 HCFA Reviewers’ Opinions - Goal 3 

n 

Very 

well Well 

Somewhat 

well 

Not 

well 

Don’t 

know n 

Very 

well Well 

Somewhat 

well 

Not 

well 

Don’t 

know 

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 Consistency 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” 

Guide & 

Operational 

Elements 

Plan Representatives’ Opinions - Goal 4 HCFA Reviewers’ Opinions - Goal 4 

n 

Very 

well Well 

Somewhat 

well 

Not 

well 

Don’t 

know n 

Very 

well Well 

Somewhat 

well 

Not 

well 

Don’t 

know 

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 Consistency Team 130 1% 5% 12% 12% 70% 84 12% 17% 20% 6% 

45% 

Goals of National Marketing Guide 32 OEI-03-98-00270 
APPENDIX C 

Goals of National Marketing Guide 33 OEI-03-98-00270 
APPENDIX C 

Goals of National Marketing Guide 34 OEI-03-98-00270 
APPENDIX C 

Goals of National Marketing Guide 35 OEI-03-98-00270 
APPENDIX C 

Goals of National Marketing Guide 36 OEI-03-98-00270 
APPENDIX C 

Goals of National Marketing Guide 37 OEI-03-98-00270 
APPENDIX C 

Goals of National Marketing Guide 38 OEI-03-98-00270 
APPENDIX C 

Goals of National Marketing Guide 39 OEI-03-98-00270 
APPENDIX C 

Goals of National Marketing Guide 40 OEI-03-98-00270