United States Government Accountability Office

GAO Report to Congressional Requesters

MEDICARE

Communications to 

Beneficiaries on the 

Prescription Drug 

Benefit Could Be 

Improved 

May 2006 

 

GAO-06-654 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 2006

MEDICARE

Communications to Beneficiaries on the 

Prescription Drug Benefit Could Be 

Improved 

Highlights of GAO-06-654, a report to 

congressional requesters 

On January 1, 2006, Medicare

began providing coverage for 

outpatient prescription drugs 

through its new Part D benefit. 

Beneficiaries who enroll in Part D 

may choose a drug plan from those

offered by private plan sponsors 

under contract to the Centers for 

Medicare & Medicaid Services 

(CMS), which administers the Part

D benefit. Beneficiaries have until

May 15, 2006, to enroll in the Part D 

benefit and select a plan without 

the risk of penalties. 

GAO was asked to review the 

quality of CMS’s communications 

on the Part D benefit. GAO 

examined 70 CMS publications to 

select 6 documents for review and 

contracted with the American 

Institutes for Research to evaluate

the clarity of these texts; made 500 

calls to the 1-800-MEDICARE help

line; and contracted with the 

Nielsen Norman Group to evaluate

the usability of the Medicare Web 

site. 

What GAO Recommends

GAO is recommending that the 

CMS Administrator enhance the

quality of its communications by

taking actions to improve written 

materials, its 1-800-MEDICARE 

help line, and the Medicare Web 

site. CMS said that GAO’s findings

did not present a complete and 

accurate picture of its activities. 

However, CMS said that it supports 

the goals of GAO’s 

recommendations and is already 

taking steps to implement them. 

The information given in the six sample documents that GAO reviewed 

describing the Part D benefit was largely complete and accurate, although 

this information lacked clarity. The documents were unclear in two ways. 

First, although about 40 percent of seniors read at or below the fifth-grade 

level, the reading levels of these documents ranged from seventh grade to 

postcollege. Second, on average, the six documents did not comply with 

about half of 60 common guidelines for good communication. For example, 

the documents used too much technical jargon and often did not define 

difficult terms, such as formulary. Moreover, 16 beneficiaries and advisers 

that GAO tested reported frustration with the documents’ lack of clarity and 

had difficulty completing the tasks assigned to them. Although the 

documents lacked clarity, they informed readers of enrollment steps and 

factors affecting coverage decisions and were consistent with laws, 

regulations, and agency guidance. 

Customer service representatives (CSR) responded to the 500 calls GAO 

placed to CMS’s 1-800-MEDICARE help line accurately and completely about 

two-thirds of the time. Of the remainder, 18 percent of the calls received 

inaccurate responses, 8 percent of the responses were inappropriate given 

the question asked, and about 3 percent received incomplete responses. In 

addition, about 5 percent of GAO’s calls were not answered, primarily 

because of disconnections. Accuracy and completeness rates of CSRs’ 

responses varied significantly across the five questions GAO asked. For 

example, while CSRs provided accurate and complete responses to calls 

about beneficiaries’ eligibility for extra help 90 percent of the time, the 

accuracy rate for calls concerning the drug plan that would cost the least for 

a specified beneficiary was 41 percent. For this question, the CSRs 

responded inappropriately for 35 percent of the calls by explaining that they 

could not identify the least costly plan without the beneficiary’s personal 

information—even though CSRs had the information needed to answer the 

question. The time GAO callers waited to speak with CSRs also varied, 

ranging from no wait time to over 55 minutes. For 75 percent of the calls—

374 of the 500—the wait was less than 5 minutes. 

The Part D benefit portion of the Medicare Web site can be difficult to use. 

GAO’s test of the site’s overall usability—the ease of finding needed 

information and performing various tasks—resulted in scores of 47 percent 

for seniors and 53 percent for younger adults, out of a possible 100 percent. 

While there is no widely accepted benchmark for usability, these scores

indicate that using the site can be difficult. For example, the prescription 

drug plan finder was complicated to use and some of its key functions, such 

as “continue” and “choose a drug plan,” were often not visible on the page 

without scrolling down. www.gao.gov/cgi-bin/getrpt?GAO-06-654.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Leslie G. 

Aronovitz at aronovitzl@gao.gov or (312) 

220-7600. 
Contents 

Letter 1

Results in Brief 5

Conclusions 8

Recommendations for Executive Action 9 

Agency Comments and Our Evaluation 9 

Appendix I Briefing on Medicare Part D 13 

Appendix II Objectives, Scope, and Methodology 61 

Appendix III Comments from the Centers for Medicare & 

Medicaid Services 67 

Appendix IV GAO Contact and Staff Acknowledgments 83 

Tables 

Table 1: Sample of Six Selected Documents 62 

Table 2: Questions and Criteria Used to Evaluate Accuracy 64 

Page i GAO-06-654 Medicare Part D Communications
Abbreviations 

AIR American Institutes for Research 

CMS Centers for Medicare & Medicaid Services 

CSR customer service representative 

MMA Medicare Prescription Drug, Improvement, and 

 Modernization Act of 2003 

NN/g Nielsen Norman Group

SHIP State Health Insurance Assistance Program 

SMOG Simplified Measure of Gobbledygook

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Page ii GAO-06-654 Medicare Part D Communications
United States Government Accountability Office

Washington, DC 20548 

May 3, 2006

Congressional Requesters

In the most significant change to the Medicare program since its inception, 

the Medicare Prescription Drug, Improvement, and Modernization Act of 

2003 (MMA)1 established an outpatient prescription drug benefit in 

Medicare, known as the Part D benefit. Coverage for this new benefit 

began on January 1, 2006. Until this time, Medicare, the federal program 

that finances health care benefits for about 42 million elderly and disabled 

beneficiaries, had not generally provided coverage for outpatient 

prescription drugs. Beneficiaries may choose a Part D plan2

 from multiple 

plans offered by private sponsors3

 under contract to the Centers for 

Medicare & Medicaid Services (CMS),4

 the agency that is responsible for 

administering the Medicare program, including the Part D benefit. These 

plans differ in the drugs they cover and the pharmacies they use. In 

addition, the costs to the enrollee for the monthly premium, the annual

deductible, and co-payments for covered drugs vary by plan. As of 

April 20, 2006, more than 30 million of Medicare’s 42 million beneficiaries 

were enrolled in a Part D plan or had other outpatient prescription drug 

coverage. Beneficiaries have until May 15, 2006, to select a plan without 

the risk of penalties in the form of higher premiums. 

Given the newness and complexity of the Part D benefit, it is critical that 

beneficiaries and their advisers, including members of their families, 

understand the available options so that beneficiaries can make informed 

decisions on whether to enroll in Part D, and if so, which drug plan to 

choose. Beneficiaries need to compare drug plans in light of their 

anticipated prescription drug needs and existing arrangements for paying 

 1

Pub. L. No. 108-173, § 101, 117 Stat. 2066, 2071-2152 (to be codified at 42 U.S.C. §§ 1395w101—1395w-152). MMA redesignated the previous part D of title XVIII of the Social 

Security Act as part E and inserted a new part D after part C.

2

For Part D standard coverage, Medicare pays on average 75 percent of prescription drug 

costs up to $2,250, after a $250 deductible. Beneficiaries then pay their next $2,850 in drug 

costs. If their drug costs exceed this amount, Medicare will pay about 95 percent of their 

additional costs for the rest of the calendar year. 

3

Drug plan sponsors include insurance companies and other private organizations. 

4

CMS is an agency in the Department of Health and Human Services. 

Page 1 GAO-06-654 Medicare Part D Communications
for these drugs. In addition to comparing costs and drug coverage, 

beneficiaries need to consider whether the plans they are comparing have

contracted with a local or mail-order pharmacy that will provide a 

convenient means of filling their prescriptions. 

As part of its responsibilities, CMS has undertaken outreach and education 

efforts to provide beneficiaries and their advisers with the information 

they need about Part D through various media, including written 

documents, the 1-800-MEDICARE help line,5

 and the Medicare Web site.6

As of December 2005, CMS has produced more than 70 written documents 

to explain Part D to beneficiaries. Medicare & You—the beneficiary 

handbook—is the most widely available of these documents and was sent 

directly to beneficiaries in October 2005. Other CMS documents are 

targeted to specific groups of beneficiaries, such as dual-eligible 

beneficiaries7

 and beneficiaries with Medicare Advantage or Medigap 

policies.8

 Since March 1999, CMS has administered its nationwide 

1-800-MEDICARE help line to answer beneficiaries’ questions about the 

Medicare program. As of December 2005, about 7,500 customer service 

representatives (CSR) were handling calls on the help line, which operates 

24 hours a day, 7 days a week, and is run by two CMS contractors. Calls 

are answered by an automated system and are routed to a CSR for specific 

questions, including those about Part D. CMS provides CSRs with detailed 

scripts to use in answering the questions. CSRs type in related keywords 

to generate a list of suggested scripts for a given question, select the script

they consider best suited to the question, and read excerpts or the entire 

script. Call center contractors write the scripts, and CMS checks them for 

accuracy and completeness. CSRs can also consult other information 

sources, such as the Medicare Web site. CMS does not allow CSRs to offer 

individualized guidance to callers, including advice in choosing a drug 

 5

In December 2004, we reported on the information being provided to beneficiaries through

the Medicare help line on eligibility, enrollment, and benefits. (See GAO, Medicare:

Accuracy of Responses from the 1-800-MEDICARE Help Line Should Be Improved, 

GAO-05-130 (Washington, D.C.: Dec. 8, 2004).) 

6

The Medicare Web site is www.medicare.gov.

7

Dual-eligible beneficiaries are Medicare beneficiaries who are also eligible for Medicaid—

the federal-state health program for low-income individuals—and receive full Medicaid 

benefits for services not covered by Medicare. 

8

Medicare Advantage replaced the Medicare+Choice managed care program and expanded 

the availability of private health plan options to Medicare beneficiaries. Medigap policies

provide supplemental health coverage sold by private insurers to help pay for Medicare 

cost-sharing requirements, as well as for some services not provided by Medicare. 

Page 2 GAO-06-654 Medicare Part D Communications
plan. CMS’s Medicare Web site provides information about all aspects of 

the Medicare program. The Web site contains basic information about the 

Part D benefit; suggests factors for beneficiaries to consider when 

choosing a plan; describes situations common to beneficiaries with 

guidance on next steps to take in deciding whether to enroll and what plan 

to choose; lists frequently asked questions; and allows users to view, print, 

or order publications. In addition, the site contains information on cost, 

coverage, and convenience of individual plans. There is also a tool that 

allows beneficiaries to enroll directly in the plan they have chosen. 

CMS has also arranged for State Health Insurance Assistance Programs 

(SHIP) to provide Part D information on request to Medicare beneficiaries 

and their advisers. Currently, CMS provides grants to the 54 SHIPs—one in 

each state, the District of Columbia, the Virgin Islands, Puerto Rico, and 

Guam. State SHIPs provide subgrants to over 1,300 local organizations to 

assist SHIPs in their efforts. In total, SHIPs rely on over 12,000 trained 

counselors, most of whom are volunteers, to provide free counseling and 

assistance via telephone and face-to-face sessions, public education 

presentations and programs, and media activities.

Widespread confusion among beneficiaries about the costs and coverage 

under the new benefit has been reported by the media and others. For 

example, according to an October 2005 survey by a research organization,

some beneficiaries are unaware of the penalties for late enrollment and 

others did not realize that beneficiaries had to sign up for the benefit.9

 In 

light of your interest in ensuring that Medicare beneficiaries receive the 

information they need to make informed decisions, you asked us to 

examine the quality of the information being provided on the Part D 

benefit. In this report, we examined 

• the extent to which CMS’s written documents describe the Part D benefit 

in a clear, complete, and accurate manner; 

• the effectiveness of CMS’s 1-800-MEDICARE help line in providing 

accurate, complete, and prompt responses to callers inquiring about the 

Part D benefit; 

• whether CMS’s Medicare Web site presents information on the Part D 

benefit in a usable manner; and 

 9

The Henry J. Kaiser Family Foundation, The Medicare Drug Benefit: Beneficiaries 

Perspectives Just Before Implementation, http://kff.org/kaiserpolls/med111005nr.cfm

(downloaded Apr. 26, 2006). 

Page 3 GAO-06-654 Medicare Part D Communications
• how CMS has used SHIPs to respond to the needs of Medicare 

beneficiaries for information on the Part D benefit. 

We briefed your staff regarding the results of our review on 

April 19, 2006. Appendix I contains information we provided during our 

briefing to your staff. 

To evaluate CMS’s written documents describing the Part D benefit, we 

examined 70 relevant CMS publications and selected a sample of six 

documents for in-depth review. These documents represent a variety of 

document types, content, and target audiences and include Section 6 of 

the Medicare & You beneficiary handbook, which discusses Part D. To 

assess the clarity of the sample documents, we contracted with the 

American Institutes for Research (AIR), a firm with experience in 

evaluating written documents. AIR evaluated the texts by using three 

standard readability tests;

10 60 commonly recognized good 

communications practices; and user testing with 11 Medicare beneficiaries 

and 5 advisers to beneficiaries, all of whom were asked to perform 

18 specified tasks related to enrollment, coverage, costs, penalty, and 

informational resources and provide feedback about their experiences. To

evaluate completeness, we reviewed the sample documents to determine if 

they included sufficient information for the beneficiaries to identify 

(1) their next steps in deciding whether to enroll and what plan to choose 

and (2) important factors, such as penalty provisions, that could affect 

their coverage decisions. To evaluate accuracy, we reviewed the sample 

documents for consistency with MMA, regulations, and CMS guidance. 

To assess the accuracy, completeness, and promptness of the help line 

responses, we made 500 calls to 1-800-MEDICARE, posing one of five 

questions about Part D in each call so that each question was asked 

100 times. To develop the questions, we considered topics listed on the 

Medicare Web site and topics addressed in scripts frequently accessed by

CSRs. To develop our criteria for evaluating the accuracy and 

completeness of CSRs’ responses, we used three resources: (1) the 

prescription drug finder tool on the Medicare Web site, (2) the 1-800-

MEDICARE scripts, and (3) input from CMS officials. We also recorded 

 10The three tests were the Flesch-Kincaid Grade Level, the SMOG (Simplified Measure of

Gobbledygook) Reading Grade Level, and the Fry Readability Estimate. These tests use 

such measures as sentence length and the number of syllables in a selection of text to 

arrive at a reading level, which is expressed in terms of school grade level. 

Page 4 GAO-06-654 Medicare Part D Communications
the length of each call, including wait times, and the time it took to be 

connected to a CSR. 

To assess whether the Medicare Web site presents information on the Part

D benefit in a usable manner, we contracted with the Nielsen Norman 

Group (NN/g), a firm with expertise in Web design. NN/g conducted three 

evaluations: (1) it calculated an overall usability score for the site—

considering factors such as site navigation, customer support, and 

presentation of online forms—to reflect the ease of finding necessary 

information and performing various tasks; (2) it determined the usability 

of 137 detailed aspects of the Web site, including aspects of Web design, 

online tools, and writing style; and (3) it tested the ability of seven 

participants (five beneficiaries and two advisers to beneficiaries) to 

complete a total of 34 user tests to determine the ease of performing a 

variety of Web-related tasks, such as browsing the site and determining 

how to join a plan. We also reviewed the results of CMS’s analysis of its 

Web site’s compliance with requirements that federal government Web 

sites be accessible to people with disabilities. 

Finally, to examine how CMS has used SHIPs to meet the information 

needs of beneficiaries regarding Part D, we obtained information about 

SHIPs, their funding, changes made in response to the new benefit, and the 

impact of Part D on the demand for SHIP services. In addition, we 

interviewed CMS officials who monitor SHIP activities as well as SHIP 

coordinators in the five states with the largest populations of Medicare 

beneficiaries—California, Florida, New York, Pennsylvania, and Texas. 

We performed our work from November 2005 through May 2006 in 

accordance with generally accepted government auditing standards. For 

more information on our methodology, see appendix II. 

The sample of CMS’s written documents we reviewed describing the Part 

D benefit to Medicare beneficiaries and their advisers were largely 

complete and accurate, but the information these documents presented 

lacked clarity. The documents were unclear in two ways. First, about 40 

percent of seniors read at or below the fifth-grade level, but the reading 

levels of the documents ranged from seventh grade to postcollege. As a 

result, documents at these levels are not completely clear and

understandable for many seniors. Second, on average, the six documents 

did not comply with about half of the 60 commonly recognized guidelines

for good communications. For example, although the documents included 

concise and descriptive headings, they used too much technical jargon and 

Results in Brief 

Page 5 GAO-06-654 Medicare Part D Communications
often did not define difficult terms, such as formulary.11 The 11 

beneficiaries and 5 advisers we tested reported frustration with the 

documents’ lack of clarity as they encountered difficulties in 

understanding and attempting to complete 18 specified tasks. For 

example, none of these beneficiaries and only 2 of the advisers were able 

to complete the task of computing their projected total out-of-pocket costs 

for a plan that provided Part D’s standard coverage. Only 1 of the 18 tasks 

was completed by all beneficiaries and advisers. Even those who were 

able to complete a given task expressed confusion and frustration as they 

worked to comprehend the relevant text. Although the sample documents

lacked clarity, the information presented in them was generally complete. 

The documents informed readers of next steps in determining whether to 

enroll and what plan to choose, and of important factors that could affect 

their coverage decisions. The information in the sample documents was 

also generally accurate when evaluated for consistency with MMA, 

implementing regulations, and agency guidance. 

Responses to the 500 calls we placed to CMS’s 1-800-MEDICARE help line 

regarding the Part D benefit were frequently accurate and complete. 

However, we nonetheless received a substantial number of responses that 

were inaccurate, incomplete, or inappropriate and that sometimes 

involved an extensive wait before we could speak to a CSR. CSRs 

answered 67 percent of the calls accurately and completely. Of the 

remainder, 18 percent of the calls received inaccurate responses, 8 percent

of the responses were inappropriate given the question asked, and about 3 

percent received incomplete responses. In addition, about 

5 percent of our calls were not answered, primarily because of 

disconnections.12 Accuracy and completeness rates of CSRs’ responses 

varied significantly for the five questions we asked. For example, for the 

question on whether a beneficiary qualifies for extra help, CSRs provided 

an accurate and complete response 90 percent of the time. However, for a 

question concerning which drug plan would cost the least for a beneficiary 

with certain specified prescription drug needs, the accuracy rate was 41 

percent. CSRs inappropriately responded 35 percent of the time that this 

question could not be answered without personal identifying 

information—such as the beneficiary’s Medicare number or date of birth—

even though the CSRs could have answered our question using CMS’s 

 11A formulary is a list of prescription drugs covered by a health plan. 

12The percentages related to the responses we received to our 500 calls exceed 100 percent 

because of rounding. 

Page 6 GAO-06-654 Medicare Part D Communications
Web-based prescription drug plan finder tool. The amount of time we 

waited to speak with a CSR also varied, ranging from no wait time to over 

55 minutes. For 75 percent of the calls—374 of the 500—we waited less 

than 5 minutes. For the remainder of the calls, 62 were answered in less 

than 15 minutes, 39 calls were answered in from 15 minutes to less than 25

minutes, and 25 led to a wait of 25 minutes or more. 

We found that the Part D benefit portion of the Medicare Web site can be

difficult to use. In our evaluation of overall usability—the ease of finding 

needed information and performing various tasks—we found usability 

scores of 47 percent for seniors and 53 percent for younger adults, out of a 

possible 100 percent. While there is no widely accepted benchmark for 

usability, these scores indicate that using the site can be difficult. For 

example, tools such as the drug plan finder were complicated to use, and 

forms that collect information online from users were difficult to correct if 

the user made an error. In our evaluation of the usability of 137 detailed

aspects of the Part D portion of the site, including features of Web design 

and online tools, we found that 70 percent of these aspects could be 

expected to cause users confusion. For example, key functions of the 

prescription drug plan finder tool, such as the “continue” and “choose a 

drug plan” buttons, were often not visible on the page without scrolling 

down. In our evaluation of the ability of seven participants to collectively 

complete 34 user tests, we found that on average, participants were able to

proceed slightly more than halfway through each test. In addition, CMS 

evaluated whether its Web site complied with pertinent federal 

requirements regarding accessibility for people with disabilities in March 

2006. Although CMS has established features to make information on its 

Web site accessible to disabled users, it found that two requirements were 

not met, making it difficult for the visually impaired to use. A CMS official 

told us that the agency made the appropriate corrections on April 20, 2006.

Because of time constraints, we did not verify that these corrections were 

made. 

CMS relies on SHIPs to play a significant role in providing counseling and 

education on the Part D benefit to Medicare beneficiaries. CMS increased 

SHIP funding from $12 million for the 2003 SHIP grant year13 to 

$31.7 million for the 2005 grant year. CMS kept funding relatively high for 

the 2006 grant year—$30 million—to ensure that SHIPs continued to play 

an important role in educating beneficiaries about Part D. The number of 

 13A SHIP grant year begins on April 1 of the year the funds become available. 

Page 7 GAO-06-654 Medicare Part D Communications
beneficiaries served by SHIPs has also increased. During the 2004 SHIP 

grant year, SHIPs served approximately 2.52 million people. During the 

first 9 months of the 2005 SHIP grant year—when CMS was gearing up its 

outreach and education on Part D—SHIPs served approximately 

3.3 million individuals, an increase of nearly 770,000 from the prior full 

grant year. CMS attributes the increase in demand for SHIP services—as 

reflected in increases in the number of calls, face-to-face assistance, and 

referrals from the 1-800-MEDICARE help line—to beneficiaries’ need for 

assistance on Part D. The average number of calls per month referred from 

the help line to SHIPs, for example, increased from about 16,000 referrals

for May through September 2005 to an average of about 43,000 for October 

and November 2005, about the time Part D enrollment began. According to

CMS officials, this increased demand can be attributed to callers seeking 

advice on choosing a drug plan. Unlike CSRs on the help line, SHIP 

counselors can offer individualized guidance to callers on enrollment and 

plan selection. SHIP coordinators in the five states we contacted 

confirmed that there was a substantial increase in the demand for their 

services because of the new Part D benefit. For example, the California 

SHIP served over 120,000 people in January 2006, compared to about 

35,000 served in all of 2005. 

Within the past 6 months, millions of Medicare beneficiaries have been 

making important decisions about their prescription drug coverage and 

have needed access to information about the new Part D benefit to make 

appropriate choices. CMS faced a tremendous challenge in responding to 

this need and, within short time frames, developed a range of outreach and 

educational materials to inform beneficiaries and their advisers about 

Part D. To disseminate these materials, CMS largely added information to 

existing resources, including written documents, such as Medicare & You; 

the 1-800-MEDICARE help line; the Medicare Web site; and support for 

SHIPs. However, CMS has not ensured that its communications to 

beneficiaries and their advisers are provided in a manner that is 

consistently clear, complete, accurate, and usable. Six months have passed 

since these materials were first made available to beneficiaries, and their 

limitations could result in confusion among those seeking to make 

coverage decisions. Although the initial enrollment period for Part D will 

end on May 15, 2006, CMS will continue to play a pivotal role in providing 

beneficiaries with information about the drug benefit during the year and

in subsequent enrollment periods. CMS has an opportunity to enhance its 

communications on the Part D benefit. This would allow beneficiaries and

their advisers to be better prepared when deciding whether to enroll in the 

benefit, and if enrolling, which drug plan to choose. 

Conclusions 

Page 8 GAO-06-654 Medicare Part D Communications
In order to improve the Part D benefit education and outreach materials 

that CMS provides to Medicare beneficiaries, we are recommending that

the CMS Administrator take the following four actions: 

• Ensure that CMS’s written documents describe the Part D benefit in a 

manner that is consistent with commonly recognized communications 

guidelines and that is responsive to the intended audience’s needs. 

• Determine why CSRs frequently do not search for available drug plans if

the caller does not provide personal identifying information. 

• Monitor the accuracy and completeness of CSRs’ responses to callers’ 

inquiries and identify tools targeted to improve their performance in

responding to questions concerning the Part D benefit, such as additional 

scripts and training. 

• Improve the usability of the Part D portion of the Medicare Web site by 

refining Web-based tools, providing workable site navigation features and

links, and making Web-based forms easier to use and correct.

We received written comments on a draft of this report from CMS (see 

app. III). CMS said that it did not believe our findings presented a 

complete and accurate picture of its Part D communications activities. 

CMS discussed several concerns regarding our findings on its written 

documents and the 1-800-MEDICARE help line. However, CMS did not 

disagree with our findings regarding the Medicare Web site or the role of

SHIPs. CMS also said that it supports the goals of our recommendations

and is already taking steps to implement them, such as continually 

enhancing and refining its Web-based tools. 

CMS discussed concerns regarding the completeness and accuracy of our 

findings in terms of activities we did not examine, as well as those we did. 

CMS stated that our findings were not complete because our report did 

not examine all of the agency’s efforts to educate Medicare beneficiaries 

and specifically mentioned that we did not examine the broad array of 

communication tools it has made available, including the development of 

its network of grassroots partners throughout the country. We recognize 

that CMS has taken advantage of many vehicles to communicate with 

beneficiaries and their advisers. However, we focused our work on the 

four specific mechanisms that we believed would have the greatest impact 

on beneficiaries—written materials, the 1-800-MEDICARE help line, the 

Medicare Web site, and the SHIPs. In addition, CMS stated that our report 

is based on information from January and February 2006, and that it has 

undertaken a number of activities since then to address the problems we 

identified. Although we appreciate CMS’s efforts to improve its Part D 

Recommendations for 

Executive Action 

Agency Comments 

and Our Evaluation 

Page 9 GAO-06-654 Medicare Part D Communications
communications to beneficiaries on an ongoing basis, we believe it is 

unlikely that the problems we identified in this report could have been 

corrected yet given their nature and scope. 

CMS raised two concerns with our examination of a sample of written 

materials. First, it criticized our use of readability tests to assess the clarity 

of the six sample documents we reviewed. For example, CMS said that 

common multisyllabic words would inappropriately inflate the reading 

level. However, we found that reading levels remained high after adjusting 

for 26 multisyllabic words a Medicare beneficiary would encounter, such 

as Social Security Administration. CMS also pointed out that some experts 

find such assessments to be misleading. Because we recognize that there

is some controversy surrounding the use of reading levels, we included 

two additional assessments to supplement this readability analysis—the 

assessment of design and organization of the sample documents based on

60 commonly recognized communications guidelines and an examination 

of the usability of six sample documents, involving 11 beneficiaries and 5

advisers. 

Second, CMS expressed concern about our examination of the usability of 

the six sample documents. The participating beneficiaries and advisers 

were called on to perform 18 specified tasks, after reading the selected

materials, including a section of the Medicare & You handbook. CMS 

suggested that the task asking beneficiaries and advisers to calculate their 

out-of-pocket drug costs was inappropriate because there are many other 

tools that can be used to more effectively compare costs. We do not 

disagree with CMS that there are a number of ways beneficiaries may 

complete this calculation; however, we nonetheless believe that it is 

important that beneficiaries be able to complete this task on the basis of 

reading Medicare & You, which, as CMS points out, is widely disseminated 

to beneficiaries, reaching all beneficiary households each year. In addition,

CMS noted that it was not able to examine our detailed methodology 

regarding the clarity of written materials—including assessments 

performed by one of our contractors concerning readability and document 

design and organization. We plan to share this information with CMS, once 

our report has become public. 

Finally, CMS took issue with one aspect of our evaluation of the 

1-800-MEDICARE help line. Specifically, CMS said the 41 percent accuracy 

rate associated with one of the five questions we asked was misleading, 

because, according to CMS, we failed to analyze 35 of the 100 responses. 

However, we disagree. This question addressed which drug plan would 

cost the least for a beneficiary with certain specified prescription drug 

Page 10 GAO-06-654 Medicare Part D Communications
needs. We analyzed these 35 responses to this question and found the 

responses to be inappropriate. The CSRs would not provide us with the 

information we were seeking because we did not supply personal 

identifying information, such as the beneficiary’s Medicare number or date 

of birth. We considered such responses inappropriate because the CSRs 

could have answered this question without personal identifying 

information by using CMS’s Web-based prescription drug plan finder tool. 

Although CMS said that it has emphasized to CSRs, through training and 

broadcast messages, that it is permissible to provide the information we 

requested without requiring information that would personally identify a 

beneficiary, in these 35 instances, the CSR simply told us that our question

could not be answered. CMS also said that the bulk of these inappropriate 

responses were related to our request that the CSR use only brand-name 

drugs. This is incorrect—none of these 35 responses were considered 

incorrect or inappropriate because of a request that the CSR use only 

brand-name drugs—as that was not part of our question. 

As arranged with your offices, unless you publicly announce the contents 

of this report earlier, we plan no further distribution of it until 30 days 

after its date. At that time, we will send copies of this report to the 

Secretary of Health and Human Services, the Administrator of the Centers 

for Medicare & Medicaid Services, and other interested parties. We will 

also make copies available to others on request. In addition, the report will 

be available at no charge on the GAO Web site at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact me 

at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix IV. 

Leslie G. Aronovitz 

Director, Health Care 

Page 11 GAO-06-654 Medicare Part D Communications
List of Requesters 

The Honorable John D. Dingell 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

The Honorable Henry A. Waxman 

Ranking Minority Member 

Committee on Government Reform 

House of Representatives 

The Honorable Charles B. Rangel 

Ranking Minority Member 

Committee on Ways and Means 

House of Representatives 

The Honorable Sherrod Brown 

Ranking Minority Member 

Subcommittee on Health

Committee on Energy and Commerce 

House of Representatives 

The Honorable Pete Stark 

Ranking Minority Member 

Subcommittee on Health

Committee on Ways and Means 

House of Representatives 

Page 12 GAO-06-654 Medicare Part D Communications
Appendix I: Briefing on Medicare Part D Appendix I: Briefing on Medicare Part D 

1

Medicare Part D: CMS 

Communications to Beneficiaries 

Could Be Improved

Briefing for Congressional Staff

Updated

Page 13 GAO-06-654 Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 14 GAO-06-654

2

Contents

• Purpose and Objectives

• Objective 1: Written Documents

• Objective 2: 1-800-MEDICARE Help Line

• Objective 3: Medicare Web Site

• Objective 4: State Health Insurance

Assistance Programs

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 15 GAO-06-654

3

Purpose and Objectives

• The Medicare Prescription Drug, Improvement, and Modernization 

Act of 2003 (MMA) established the new Part D outpatient 

prescription drug benefit. 

• The Centers for Medicare & Medicaid Services (CMS) is responsible 

for overseeing this new benefit. CMS has taken steps to inform

beneficiaries and their advisers about Part D using written 

documents, a toll-free help line, and an Internet Web site. CMS also

gives State Health Insurance Assistance Programs (SHIP) funds to

provide information about the Medicare program, including Part D.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 16 GAO-06-654

4

Purpose and Objectives (continued)

• We assessed information that CMS provides to Medicare

beneficiaries to educate them about Part D. Specifically, we 

assessed: 

1. The extent to which CMS’s written documents describe the Part

D benefit in a clear, complete, and accurate manner.

2. The effectiveness of CMS’s 1-800-MEDICARE help line in 

providing accurate, complete, and prompt responses to callers

inquiring about the Part D benefit.

3. Whether the Medicare Web site presents information on the 

Part D benefit in a usable manner. 

4. How CMS has used SHIPs to respond to the needs of Medicare

beneficiaries for information on the Part D benefit.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 17 GAO-06-654

5

Objective 1: Written Documents Methodology 

• We performed in-depth review of a

sample of six CMS documents

describing the Part D benefit. The 

sample was selected to represent a 

variety of document types, content, and

target audiences.

• We contracted with the American

Institutes for Research (AIR) to assess

the clarity of sample documents.

a

Dual-eligible beneficiaries are Medicare beneficiaries 

who receive full Medicaid benefits for services not

covered by Medicare.

b

Medicare Advantage replaces the Medicare+Choice

managed care program and expands the availability of

private health plan options to Medicare beneficiaries.

c

Medigap policies provide supplemental health coverage

sold by private insurers to help pay for Medicare costsharing requirements, as well as for some services not

provided by Medicare.

Dual-eligible

beneficiariesa

The Auto-Enrollment Notice

Beneficiaries

with Medicare

Advantageb

Quick Facts about Medicare’s New 

Coverage for Prescription Drugs for

People with a Medicare Health Plan

with Prescription Drug Coverage

Beneficiaries

with Medigap

Do You Have a Medigap Policyc with

Prescription Drug Coverage?

Beneficiaries

with employer or

union coverage

Frequently Asked Questions about:

Retiree Prescription Drug Coverage &

the New Medicare Prescription Drug

Coverage

Things to Think about When You All beneficiaries

Compare Plans

Medicare & You (Section 6: Medicare All beneficiaries

Prescription Drug Coverage)

Six sample documents Target audience

Source: GAO.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 18 GAO-06-654

6

Objective 1: Written Documents Methodology 

(continued)

• To determine the clarity of the sample of Part D written documents

describing the Part D benefit, AIR

• evaluated text by sentence length and the number of syllables 

using three standard readability tests—Flesch-Kincaid, SMOG,

and Fry;

• assessed the design and organization of the documents based on 

60 commonly recognized written communications guidelines, 

including those to aid senior readers; and 

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 19 GAO-06-654

7

Objective 1: Written Documents Methodology 

(continued)

• tested the usability of sample documents with 16 participants—11 

Medicare beneficiaries, including 1 disabled beneficiary who was

under 65, and 5 advisers to beneficiaries. 

• Everyone was asked to perform 18 specified tasks related to

enrollment, coverage, costs, penalty, and informational 

resources. They were also asked to provide feedback about 

their experiences.

• Although the size of the group was small, research shows that 

as few as 5 individuals can provide meaningful insights into 

common problems. 

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 20 GAO-06-654

8

Objective 1: Written Documents Methodology 

(continued)

• To evaluate completeness, we reviewed the sample documents to 

determine if they included sufficient information to identify (1) next

steps in determining whether to enroll and what plan to choose and 

(2) important factors, such as penalty provisions, that could affect

coverage decisions.

• To evaluate accuracy, we reviewed the sample documents for

consistency with laws, regulations, and CMS guidance.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 21 GAO-06-654

9

Objective 1: Written Documents—Documents

Lack Clarity 

• Readability assessment: Sample documents explaining the Part D 

benefit are written at a reading level that is difficult for many seniors.

• Reading levels for the sample documents were challenging for at 

least the 40 percent of seniors, who read at or below the 5th grade 

level.

• Reading level estimates for the sample texts1 ranged from 7th

grade to postcollege level. 

• Reading levels remain challenging for at least 40 percent of 

seniors even after adjusting for 26 multisyllabic words, such as

Medicare, Medicare Advantage, and Social Security

Administration. After the adjustment, the estimated reading level 

ranged from 8th to 12th grade. 

1Estimates have a likely margin of error of ± two grades.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 22 GAO-06-654

10

Objective 1: Written Documents—Clarity

(continued)

• Document design and organization assessment: The sample 

documents demonstrated adherence to about half of the 60 

commonly recognized written communications guidelines, on 

average. 

• Desirable features: The documents

• were written with a respectful and polite tone,

• were free of clichés and slang, 

• contained useful contact information, 

• included concise and descriptive headings, and 

• generally followed graphic and formatting guidelines.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 23 GAO-06-654

11

Objective 1: Written Documents—Clarity

(continued)

• Undesirable features: The documents

• used too much technical jargon,

• often did not define difficult terms,

• included sentences and some paragraphs that were too long, 

and 

• did not use sufficient summaries to assist the reader in 

identifying key points. 

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 24 GAO-06-654

12

Objective 1: Written Documents—Clarity

(continued)

• Usability assessment: Beneficiaries and advisers to beneficiaries

were frustrated by the documents’ lack of clarity and often could not 

complete the 18 assigned tasks.

• One of the 18 assigned tasks was completed by all beneficiaries

and advisers.

• Eleven of the 18 assigned tasks were completed by at least half of 

the beneficiaries and advisers.

• Four of the 18 assigned tasks were completed by 2 or fewer of the 

11 beneficiaries.

• Nine of the 18 assigned tasks, were completed by 2 or fewer of 

the 5 advisers.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 25 GAO-06-654

13

Objective 1: Written Documents—Clarity

(continued)

• Some of the tasks that proved difficult included

• computing projected total out-of-pocket costs for a plan that 

provided Part D’s standard coverage (successfully completed by

none of the 11 beneficiaries and 2 of the 5 advisers),

• evaluating whether it was possible to enroll in Medicare Part D 

and keep drug coverage from a retiree health plan (successfully

completed by 2 beneficiaries and 2 advisers), and 

• determining the course of action for dual-eligibles who are 

automatically enrolled in a plan that does not cover all drugs used 

(successfully completed by 4 beneficiaries and 1 adviser).

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 26 GAO-06-654

14

Objective 1: Written Documents—Clarity

(continued)

• Participants described documents as too wordy, confusing, and hard 

to follow.

• Participants struggled with technical terms, such as “classes of

commonly prescribed drugs” and “formulary,” which is a list of drugs

covered by a plan.

• Even when most participants were able to complete the tasks, they 

expressed confusion and frustration. 

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 27 GAO-06-654

15

Objective 1: Written Documents—Documents 

Are Generally Complete

• Our analysis showed that the sample documents were generally

complete and informed readers of next steps in determining whether

to enroll and what plan to choose as well as important factors that 

could affect their coverage decisions. For example:

• All documents reviewed provided sources of assistance and

relevant contact information, which could aid in identifying next

steps for coverage decisions.

• All documents reviewed provided the dates of the start of initial 

program enrollment and coverage.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 28 GAO-06-654

16

Objective 1: Written Documents—

Completeness (continued)

• However, our analysis also identified a few exceptions where the

documents did not mention some important issues. For example: 

• Medicare & You noted that drug plan information may change, but 

made no mention of possible changes on the pages beneficiaries

would use to compare coverage and select a plan. Such

information is needed because drug plans can change their

covered drugs and prices. 

• The documents did not provide sufficient information about the 

cumulative effect of the penalty for missing the initial enrollment 

deadline.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 29 GAO-06-654

17

Objective 1: Written Documents—Documents 

Are Generally Accurate

• Our analysis showed that the sample documents were generally

accurate and that the text was consistent with MMA, implementing

regulations, and agency guidance. 

• However, we noted a few misleading statements in Medicare & You.

For example:

• The document implied that if a beneficiary’s doctor applied for an 

exception it would be granted, whereas exceptions to the 

formulary are granted at each plan sponsor’s discretion.

• The document outlined the minimum requirements for standard

coverage by Part D plans. However, it did not indicate that few 

plans offer this exact coverage and that beneficiaries should be

prepared to compare plans with varying premiums, co-payments,

and covered drugs to choose plans that best suit them.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 30 GAO-06-654

18

Objective 2: 1-800-MEDICARE Help Line 

Methodology

• We placed 500 calls to 1-800-MEDICARE, posing one of five

questions in each call, so that each question was asked 100 times. 

To develop the questions, we considered topics listed on the 

Medicare Web site and obtained help line reports that listed the

scripts that customer service representatives (CSR) frequently

accessed to respond to callers’ questions.

• Calls were randomly placed at different times of the day and on

different days of the week from January 17 to February 7, 2006, to 

match the daily and hourly pattern of calls reported by

1-800-MEDICARE in October 2005.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 31 GAO-06-654

19

Objective 2: 1-800-MEDICARE Help Line 

Methodology (continued)

• To evaluate the accuracy and completeness of CSRs’ responses to 

our five questions, we used three resources:

• the prescription drug finder tool on the Medicare Web site, 

• the 1-800-MEDICARE scripts prepared by CMS and contractors

for CSRs to use in responding to callers’ questions, and 

• input from CMS officials on the criteria we used to evaluate 

responses.

• To evaluate the promptness of the help line in answering calls, we 

recorded the length of time it took to connect to a CSR for each call.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 32 GAO-06-654

20

Objective 2: 1-800-MEDICARE Help Line 

Methodology (continued)

• CSRs’ responses were scored in one of five categories based on

specific criteria we developed: 

• Accurate and Complete – responses met our defined criteria

• Inappropriate – responses reflected the need for personal 

beneficiary information, which was not actually required to answer 

the question

• Inaccurate – responses did not meet our defined criteria

• Incomplete – responses partially met our defined criteria

• Unanswered – calls did not receive responses from CSRs

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 33 GAO-06-654

21

Objective 2: 1-800-MEDICARE Help Line 

Methodology (continued)

An accurate and complete response

would indicate that such a beneficiary can 

choose whether to enroll in a Medicare

prescription drug plan.

2. Can a beneficiary who is in a 

nursing home and not on

Medicaid sign up for a 

prescription drug plan?

An accurate and complete response

would identify the prescription drug plan

that has the lowest estimated annual cost

for the drugs the beneficiary uses.

1. What drug plan can a 

beneficiary get that will cover all 

of his/her [specified] drugs at a

[specified] pharmacy; have a 

mail-order option; and cost the

least amount annually with [or 

without] a deductible? 

Question Criteria

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 34 GAO-06-654

22

Objective 2: 1-800-MEDICARE Help Line 

Methodology (continued)

An accurate and complete response would 

inform the caller that enrolling for the prescription 

drug benefit would depend on whether the 

beneficiary’s Medigap plan was creditable—that 

is, whether the coverage it provided was at least 

as good as Medicare’s standard prescription 

drug coverage—or noncreditable. The CSR 

response would also mention that the 

beneficiary’s Medigap plan should have sent

him/her information that outlines options.

3. Can a beneficiary 

enroll in the Medicare

prescription drug program

and keep his/her current 

Medigap policy?

Question Criteria

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 35 GAO-06-654

23

Objective 2: 1-800-MEDICARE Help Line 

Methodology (continued)

An accurate and complete response

would indicate that a beneficiary has two 

options: (1) keep current health plan and 

join the prescription drug plan later with a 

penalty; or (2) drop current coverage and 

join a Medicare drug plan.

4. What options does a 

beneficiary, who has retiree 

health insurance with

prescription drug coverage that

is not as good as the Medicare

prescription drug coverage, 

have as it relates to the 

Medicare benefit? 

An accurate and complete response

would refer the beneficiary to the Social

Security Administration.

5. How do I know if a beneficiary

qualifies for extra help?

Question Criteria

Source: GAO.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 36 GAO-06-654

24

Objective 2: 1-800-MEDICARE Responses 

Often Accurate and Complete, but Some Not

• We found that the 1-800-

MEDICARE help line 

provided accurate and 

complete answers to 334 of

our 500 calls, a rate of 

about 67 percent. In 

addition, it provided 

accurate—but incomplete—

answers for about 3 percent 

of our calls.

a

Percentages exceed 100 because of rounding.

Distribution of Unanswered Calls and Accurate and 

Complete, Inaccurate, Incomplete, and

Inappropriate Responsesa

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 37 GAO-06-654

25

Objective 2: 1-800-MEDICARE—Variation in

Results for Individual Questions 

• The accuracy and 

completeness of responses

to our five questions varied

significantly, from 41 percent 

to 90 percent.

• Q1 – 41 percent 

• Q2 – 79 percent 

• Q3 – 66 percent 

• Q4 – 58 percent 

• Q5 – 90 percent

• Average for all 

questions—67 percent

Distribution of Unanswered Calls and Accurate

and Complete, Inaccurate, Incomplete, and 

Inappropriate Responses by Question

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 38 GAO-06-654

26

Objective 2: 1-800-MEDICARE—Variation 

(continued)

• CSRs answered some questions better than others. For example: 

• CSRs accurately and completely answered question 5 (whether a 

beneficiary qualifies for extra help), which had a specific script, 90 

percent of the time. 

• CSRs accurately and completely answered question 2 (whether a 

beneficiary in a nursing home, who was not on Medicaid, could 

sign up for the drug benefit) 79 percent of the time—even though 

there was no specific script for the question.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 39 GAO-06-654

27

Objective 2: 1-800-MEDICARE—Variation 

(continued)

• CSRs’ responses for question 3 (whether a beneficiary with a 

Medigap policy could enroll in the drug benefit) were accurate and 

complete 66 percent of the time. Many of the responses were

inaccurate because they did not provide adequate information 

about creditable and noncreditable coverage.

• The accuracy and completeness rate for question 4 (about retiree

health insurance) was 58 percent. Many of the responses were

inaccurate because the CSRs did not follow the available script or

provide sufficient information about the implications of the 

beneficiary's decision.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 40 GAO-06-654

28

Objective 2: 1-800-MEDICARE—Variation 

(continued)

• CSRs’ responses to question 1 (which requires CSRs to use the

prescription drug plan finder Web tool) were accurate and 

complete less than 50 percent of the time. The rate is largely

caused by CSRs’ inappropriate responses—35 out of 100 times—

that they were unable to answer the question without personal 

identifying information, such as the beneficiary’s Medicare number

or date of birth. 

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 41 GAO-06-654

29

Objective 2: 1-800-MEDICARE—Variation 

(continued)

• We did not obtain answers for 23 of the calls we placed because of 

unintentional disconnections, intentional disconnections, or an 

inoperative Web tool. 

• Unintentional disconnections occurred when the system

inadvertently disconnected the call (19 calls).

• Intentional disconnections were programmed by the telephone 

company when wait times were projected to exceed 20 minutes

(3 calls).

• The prescription drug plan finder Web tool used by CSRs was not 

operative at the time of our call (1 call).

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 42 GAO-06-654

30

• The amount of time we had to wait to speak with a CSR varied 

significantly, ranging from no wait to more than 55 minutes.

• About 75 percent of calls were connected in less than 5 minutes.

• For calls where we waited more than 5 minutes to speak to a CSR,

the wait time ranged from 5 minutes to over 55 minutes. 

• Sixty-two calls were on hold from 5 to 14 minutes, 59 seconds.

• Thirty-nine calls were on hold from 15 to 24 minutes,

59 seconds.

• Twenty-five calls were on hold 25 minutes or more. 

• For both intentional and unintentional disconnections, we often 

waited more than 5 minutes before the disconnection occurred. In

one case, we were placed on hold for 54 minutes before being 

disconnected.

Objective 2: 1-800-MEDICARE—Variation in

Wait Times

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 43 GAO-06-654

31

Objective 3: Medicare Web Site Methodology

• To evaluate the usability of the Part D benefit portion of the Medicare

Web site, we contracted with Nielsen Norman Group (NN/g), a firm

with expertise in Web design.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 44 GAO-06-654

32

Objective 3: Medicare Web Site Methodology

(continued)

• In addition, we reviewed CMS’s efforts to comply with section 508 of 

the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794d).

• Section 508 requires that all federal Web sites be designed to 

make information and services fully available to individuals with 

disabilities. 

• Our review included an examination of CMS’s March 2006 report

assessing the compliance of its Medicare Web site with this

federal requirement and discussions with CMS officials.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 45 GAO-06-654

33

Objective 3: Medicare Web Site Methodology

(continued)

• NN/g performed the following three separate evaluations:

• Evaluation one: NN/g calculated an overall score of the site’s

usability, to reflect the ease of finding necessary information and 

performing various tasks. For this calculation, NN/g considered

various factors, such as site navigation, customer support, and

presentation of online forms.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 46 GAO-06-654

34

Objective 3: Medicare Web Site Methodology

(continued)

• Evaluation two: NN/g evaluated in detail the usability of 137 

detailed aspects of the Part D benefit portion of the Web site. 

Topics included 

• Web design (e.g., home page, navigation, search function, 

graphics, and organization);

• tools (e.g., plan finder);

• writing style (e.g., tone, content, legibility, and readability); 

• accessibility (e.g., availability of site version for the blind); and 

• languages (e.g., links for users who have difficulty reading 

English).

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 47 GAO-06-654

35

Objective 3: Medicare Web Site Methodology

(continued)

• Evaluation three: NN/g conducted a total of 34 user tests to 

determine the ease of performing a variety of Web-related tasks,

such as browsing the site, making a change in address, finding 

plan information under certain scenarios, comparing Medigap and 

Part D drug coverage, and determining how to join a plan.

• NN/g asked five Medicare beneficiaries—who were not 

disabled—and two advisers to beneficiaries to perform one or

more user tests each using the Web site.

• At the end of the user tests, the seven participants were asked 

to provide feedback about their experiences. 

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 48 GAO-06-654

36

Objective 3: Medicare Web Site Difficult to Use 

• Based on NN/g evaluations, we concluded that the Part D benefit 

portion of the Medicare Web site can be challenging to use.

• For evaluation one, the calculated usability scores indicate a need 

for improvement. The usability score was 47 percent for seniors

and 53 percent for younger adults. While there is no widely

accepted benchmark for usability, these scores indicate that using 

the site can be difficult. For example, tools such as the drug plan 

finder were complicated to use, and forms that collect information 

online from users were difficult to correct if the user made an

error.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 49 GAO-06-654

37

Objective 3: Medicare Web Site Difficult to Use

(continued)

• Evaluation two showed that the Part D benefit portion of the Web

site was difficult to use. About 70 percent of the 137 detailed

aspects of the site were presented in a manner that could be 

expected to cause a medium or high level of confusion. For

example, 

• important functions in the plan finder tool—the “continue” and 

“choose a drug plan” buttons—are often not visible on the page;

• plan finder tool defaults to generic drugs, complicating users’

search for drug plans covering brand-name drugs;

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 50 GAO-06-654

38

Objective 3: Medicare Web Site Difficult to Use 

(continued)

• information to assist navigation was often not helpful—for 

example, text labels associated with links were not always

functioning; and

• the writing style presented some challenges—for example, 

material was written at the 11th grade level.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 51 GAO-06-654

39

Objective 3: Medicare Web Site Difficult to Use 

(continued)

• For evaluation three, the 34 user tests showed that the site was a

challenge for the seven participants to use. For example:

• For 12 of the 34 tests, participants’ initial reactions were that 

they would not be able to complete the tests and wanted to quit 

trying. 

• On average, participants were able to proceed slightly more

than halfway through each of the 34 tests.

• When asked for feedback on their experience with using the 

site, the seven participants, on average, indicated high 

frustration levels and low satisfaction.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 52 GAO-06-654

40

Objective 3: Medicare Web Site Difficult to Use 

(continued)

• To comply with section 508 of the Rehabilitation Act, CMS has

established features to make information on its Medicare Web site 

accessible to disabled users. For example, CMS provides a “screen 

reader” version of the site for the visually impaired. This technology

translates text and data into spoken words.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 53 GAO-06-654

41

Objective 3: Medicare Web Site Difficult to Use 

(continued)

• CMS’s March 2006 review of its site’s compliance with section 508 

showed that two requirements were not met: 

• The plan finder did not provide alternative text for all images—that 

is, there was no text for the screen reader to read. Therefore, 

images could not be translated into spoken words for the visually

impaired.

• The plan finder did not allow screen readers to recognize form

fields and translate forms into spoken words. As a result, visually

impaired users would not have been able to complete Web-based 

forms.

• A CMS official told us that the agency made the necessary

corrections on April 20, 2006, but we did not verify that these 

corrections were made. 

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 54 GAO-06-654

42

Objective 4: SHIP Methodology

• We interviewed CMS officials and reviewed documentation they

provided about SHIPs’ role in educating beneficiaries about the Part

D benefit.

• We contacted the SHIP coordinators in California, Florida, New 

York, Texas, and Pennsylvania—the five states with the most 

Medicare beneficiaries. Together, these states accounted for about 

35 percent of the country’s total Medicare population in 2004.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 55 GAO-06-654

43

Objective 4: SHIPs’ Responses to 

Beneficiaries’ Needs Concerning Part D

• According to CMS, it relies on SHIPs to play a significant role in 

beneficiary counseling and education on the Part D benefit. 

• In anticipation of the increased demand for SHIP services regarding 

the Part D benefit, CMS increased SHIP funding in recent years.

Funding for the 2003 SHIP grant year2 was $12 million, and it 

reached $31.7 million for the 2005 grant year. CMS kept funding 

relatively high for the 2006 grant year—$30 million—to ensure that 

SHIPs continue to play an important role in educating beneficiaries

about the Part D benefit.

2

A SHIP grant year begins on April 1 of the year the funds become available.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 56 GAO-06-654

44

Objective 4: SHIPs’ Responses to Part D

(continued)

• During the 2004 SHIP grant year, SHIPs served approximately 2.52

million people. According to preliminary data for the first 9 months of 

the 2005 SHIP grant year—when CMS was gearing up its outreach

and education on Part D—SHIPs served approximately 3.3 million 

individuals, an increase of nearly 770,000 from the prior full grant 

year. CMS attributes this increase in demand for services to 

beneficiaries’ need for assistance on the Part D benefit.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 57 GAO-06-654

45

Objective 4: SHIPs’ Responses to Part D

(continued)

• The average number of calls referred from the 1-800-MEDICARE

help line to SHIPs has increased significantly. 

• The monthly average of number of calls referred to SHIPs

increased from 16,000 referrals for May through September 2005 

to approximately 43,000 for October and November 2005, the 

months around the time when enrollment in the Part D benefit 

began. 

• According to CMS officials, this increased demand was influenced

by callers seeking advice on choosing a drug plan. Unlike CSRs

on the help line, SHIP counselors can offer individualized 

guidance to callers.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 58 GAO-06-654

46

Objective 4: SHIPs’ Responses to Part D

(continued)

• Specifically, the five SHIPs we contacted experienced a large 

increase in demand for their services because of the Part D benefit. 

• California served over 120,000 people in January 2006, compared

to about 35,000 served in all of 2005.

• Florida, mostly during November and December of 2005, held at 

least six “phone bank” events—where SHIP counselors were 

available to take calls on the Part D benefit during live newscasts.

Florida plans to hold two additional phone banks as the May 15 

enrollment deadline approaches.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 59 GAO-06-654

47

Objective 4: SHIPs’ Responses to Part D

(continued)

• New York reported nearly doubling its formal training sessions for

SHIP counselors in 2005, to prepare them for the demand for

services related to the Part D benefit.

• Texas counseled 45,719 clients and conducted 523 outreach 

events from November 15, 2005—the official start of the 

enrollment period—to March 22, 2006.

• Pennsylvania held over 3,000 enrollment events, which were

attended by more than 130,000 people, from May 2005 to 

February 28, 2006.

Medicare Part D Communications
Appendix I: Briefing on Medicare Part D 

Page 60 GAO-06-654

48

Objective 4: SHIPs’ Responses to Part D

(continued)

• The SHIP officials in four of the five states we contacted indicated 

that the demand for their services related to the Part D benefit has

declined since the benefit began in January 2006. However, each

SHIP contacted expects a surge in demand as the May 15 

enrollment deadline approaches. 

• Since December 2005, CMS has been conducting biweekly

meetings with its regional offices, which interact directly with SHIP

offices, to gauge SHIPs’ ability to meet the demands of beneficiaries.

Medicare Part D Communications
Appendix II: 

Methodology 

Objectives, Scope, and

Page 61 GAO-06-654

Appendix II: Objectives, Scope, and 

Methodology 

In this report, we assessed (1) the extent to which the Centers for 

Medicare & Medicaid Services’ (CMS) written documents describe the 

Medicare Part D prescription drug benefit in a clear, complete, and 

accurate manner; (2) the effectiveness of CMS’s 1-800-MEDICARE help 

line in providing accurate, complete, and prompt responses to callers 

inquiring about the Part D benefit; (3) whether CMS’s Medicare Web site 

presents information on the Part D benefit in a usable manner; and 

(4) how CMS has used State Health Insurance Assistance Programs (SHIP) 

to respond to the needs of Medicare beneficiaries for information on the 

Part D benefit. To obtain information on CMS’s efforts to educate 

beneficiaries about Part D, we interviewed agency officials responsible for 

Part D written documents, the 1-800-MEDICARE help line, the Medicare 

Web site, and SHIPs. Following our briefing of congressional staff on April 

19, 2006, the briefing slides were updated to reflect CMS’s reported 

correction to the Medicare Web site to comply with section 508 of the 

Rehabilitation Act of 1973.1

 We determined that the data used were 

sufficiently reliable for the purposes of this report. 

To assess the clarity, completeness, and accuracy of written documents, 

we compiled a list of all available CMS-issued Part D benefit publications

intended to inform beneficiaries and their advisers and selected a sample 

of 6 from the 70 CMS documents available, as of December 7, 2005, for indepth review, as shown in table 1. The sample Part D documents were 

chosen to represent a variety of publication types, such as frequently 

asked questions and fact sheets available to beneficiaries about the Part D

drug benefit. We selected documents that targeted all beneficiaries or 

those with unique drug coverage concerns, such as dual-eligibles and 

beneficiaries with Medigap.2

Written Documents 

 1

29 U.S.C. § 794d (2000). 

2

Medigap policies provide supplemental health coverage sold by private insurers to help

pay for Medicare cost-sharing requirements, as well as for some services not provided by 

Medicare. 

Medicare Part D Communications
Appendix II: Objectives, Scope, and

Methodology 

Table 1: Sample of Six Selected Documents 

Document Target audience 

Medicare & You, Section 6: Medicare Prescription 

Drug Coverage

All beneficiaries

Things to Think about When You Compare Plans All beneficiaries

Frequently Asked Questions about: Retiree 

Prescription Drug Coverage & the New Medicare 

Prescription Drug Coverage

Beneficiaries with employer or

union coverage

Introduction to the Auto-Enrollment Notice Dual-eligible beneficiariesa

Quick Facts about Medicare’s New Coverage for 

Prescription Drugs for People with a Medicare Health 

Plan with Prescription Drug Coverage 

Beneficiaries with Medicare 

Advantageb

Do You Have a Medigap Policy with Prescription Drug

Coverage? 

Beneficiaries with Medigap 

Source: GAO.

a

Dual-eligible beneficiaries are Medicare beneficiaries who receive full Medicaid benefits for services

not covered by Medicare. 

b

Medicare Advantage replaced the Medicare+ Choice managed care program and expanded the 

availability of private health plan options to Medicare beneficiaries. 

To evaluate clarity, we contracted with the American Institutes for 

Research (AIR)—a firm with experience in evaluating written material. 

AIR evaluated the texts of the six sample documents using three 

methodologies: 

1. three standard readability tests;3

2. 60 commonly recognized written communications guidelines, including

practices to aid senior readers; and 

3. user testing with 11 Medicare beneficiaries and 5 advisers to 

beneficiaries, who performed 18 specified tasks related to enrollment, 

coverage, cost, penalty, and information resources and provided 

feedback about their experiences. 

 3

The three tests were the Flesch-Kincaid Grade Level, the SMOG (Simplified Measure of

Gobbledygook) Reading Grade Level, and the Fry Readability Estimate. The tests use such 

measures as sentence length and the number of syllables in a selection of text to arrive at a

reading level, which is expressed in terms of school grade level. 

Page 62 GAO-06-654 Medicare Part D Communications
Appendix II: Objectives, Scope, and

Methodology 

We reviewed the sample documents for completeness to determine 

whether they contained sufficient information to allow the beneficiaries to

identify (1) their next steps in determining whether to enroll and what 

plan to choose and (2) important factors, such as penalty provisions, that 

could affect their coverage decisions. To identify those important factors 

associated with the Part D benefit, we reviewed relevant laws, regulations, 

and 1-800-MEDICARE scripts prepared for customer service 

representatives (CSR) to read to callers and obtained information from 

advocacy groups. To evaluate the accuracy of information, we reviewed 

the sample materials for compliance with laws, regulations, and CMS 

guidance. 

To determine the accuracy and completeness of information provided 

regarding the Part D benefit, we placed a total of 500 calls to the 1-800-

MEDICARE help line. We posed one of five questions about Part D in each 

call, so that each question was asked 100 times. Each question was 

pretested before we finalized its wording. We randomly placed calls at 

different times of the day and different days of the week from January 17 

to February 7, 2006. Our calling times were chosen to match the daily and 

hourly pattern of calls reported by 1-800-MEDICARE in October 2005. We 

informed CMS officials that we would be placing calls; however, we did 

not tell them the questions we would ask or the specific dates and times 

that we would be placing our calls. 

To select the five questions, we considered topics identified in the 

Medicare Web site’s frequently asked questions. In addition, we 

considered topics most frequently addressed by 1-800-MEDICARE CSRs 

based on help line reports. To evaluate the accuracy of CSRs’ responses to 

our five questions, we used three resources: (1) the prescription drug plan 

finder tool on the Medicare Web site, (2) 1-800-MEDICARE scripts, and 

(3) input obtained from CMS officials on the criteria we used for 

evaluating CSR responses. Table 2 lists the questions we asked and the 

criteria we used to evaluate the accuracy of responses. 

The 1-800-MEDICARE 

Help Line 

Page 63 GAO-06-654 Medicare Part D Communications
Appendix II: Objectives, Scope, and

Methodology 

Table 2: Questions and Criteria Used to Evaluate Accuracy 

Question Criteria

1. What drug plan can a beneficiary get that will cover all of 

his/her [specified] drugs at a [specified] pharmacy; have a 

mail-order option; and cost the least amount annually with [or 

without] a deductible? 

An accurate and complete response would identify the prescription 

drug plan that has the lowest estimated annual cost for the drugs the 

beneficiary uses. 

2. Can a beneficiary who is in a nursing home and not on 

Medicaid sign up for a prescription drug plan? 

An accurate and complete response would indicate that a beneficiary 

can choose whether to enroll in a Medicare prescription drug plan. 

3. Can a beneficiary enroll in the Medicare prescription drug

program and keep his/her current Medigap policy? 

An accurate and complete response would inform the caller that 

enrolling for the prescription drug benefit would depend on whether 

the beneficiary’s Medigap plan was creditable—that is, whether the 

coverage it provided was at least as good as Medicare’s standard 

prescription drug coverage—or noncreditable. The CSR response 

would also mention that the beneficiary’s Medigap plan should have 

sent him/her information that outlined options. 

4. What options does a beneficiary, who has retiree health 

insurance with prescription drug coverage that is not as good 

as the Medicare prescription drug coverage, have as it relates 

to the Medicare benefit? 

An accurate and complete response would indicate that a beneficiary 

has two options: (1) keep current health plan and join the prescription 

drug plan later with a penalty or (2) drop current coverage and join a 

Medicare drug plan. 

5. How do I know if a beneficiary qualifies for extra help? An accurate and complete response would refer the beneficiary to the 

Social Security Administration.

Source: GAO.

When placing our calls, we identified ourselves as a beneficiary’s relative,

but did not provide CSRs with specific identifying information, such as a 

Medicare beneficiary number or date of birth. During our calls, CSRs were 

not aware that their responses would be included in a research study. We 

recorded the length of each call, including wait times, and the time it took 

before being connected to a CSR. We evaluated the accuracy and 

completeness of the responses by CSRs to the 500 calls by determining 

whether key information was provided. 

The results from our 500 calls are limited to those calls and are not 

generalizable to the universe of calls made to the help line. The questions 

we asked were limited to matters concerning the Part D benefit and do not 

encompass all of the questions callers might ask. 

Page 64 GAO-06-654 Medicare Part D Communications
Appendix II: Objectives, Scope, and

Methodology 

We contracted with the Nielsen Norman Group (NN/g)—a firm with 

expertise in Web design—to assess the usability of the Part D information 

available on the Medicare Web site. This study consisted of three separate

evaluations. First, NN/g compared the site’s compliance with established 

usability guidelines to determine a usability score to reflect the ease of 

finding necessary information and performing various tasks. Specifically, 

to determine the usability scores, NN/g evaluated various aspects of the 

Web site using industry-recognized “good” Web design practices, as 

indicated by the contractor, and the collective body of knowledge from 

NN/g internal reports and experts, or NN/g usability guidelines.4

Medicare Web Site 

Second, NN/g determined the degree of difficulty associated with 137 

detailed aspects of Web site design for the Part D portion of the site. The 

137 aspects fall into the following general categories: 

• overall Web design (e.g., home page, navigation, search function, graphics, 

and overall organization); 

• tools (e.g., plan finder); 

• writing style (e.g., content, tone, legibility, and readability); 

• accessibility (e.g., availability of a version of the Web site for the blind); 

and 

• languages (e.g., availability of languages other than English). 

NN/g determined the difficulty level in using each of the 137 aspects. NN/g 

noted aspects that had good design and would not be expected to cause 

confusion. For those aspects with a design that would be expected to 

cause confusion, NN/g ranked the associated difficulty level as high, 

medium, or low.5

Third, NN/g performed a qualitative evaluation on January 20 and 23, 2006, 

to test the ability of five Medicare beneficiaries and two beneficiary 

advisers to perform specified tasks related to Medicare beneficiaries using

the Web site and to obtain feedback about participants’ experiences. While 

the results are not statistically valid, these users provided important 

 4

These guidelines are presented in an NN/g report called Web Usability for Senior

Citizens: 46 Design Guidelines Based on Usability Studies with People Age 65 and

Older. For this study, NN/g conducted usability tests of 17 Web sites with 44 seniors. Based

on the test findings, NN/g developed 46 design guidelines that would make Web sites more 

attractive to seniors. 

5

In addition, NN/g indicated cases where an aspect was not functioning correctly from a

Web site development standpoint by giving it a “bug” mark. 

Page 65 GAO-06-654 Medicare Part D Communications
Appendix II: Objectives, Scope, and

Methodology 

insights into the usability of the Medicare Web site. Participants were 

asked to “think out loud” as they worked through their tasks, while an 

NN/g facilitator observed their behavior and took notes. NN/g gave each 

task a score. At the end of their sessions, NN/g asked participants for input 

regarding their confidence in the answers they obtained from the Web site, 

and their overall satisfaction and frustration levels associated with using 

the site. 

Finally, we obtained the results of CMS’s March 2006 review of its Web 

site’s compliance with section 508 of the Rehabilitation Act of 1973, as 

amended. This law requires federal agencies to make the information on 

their Web sites accessible to people with disabilities. We also discussed 

the results of this review with agency officials and followed up with them 

to determine the status of CMS’s corrective actions. 

To determine the role of SHIPs in helping Medicare beneficiaries 

understand Part D, we interviewed CMS officials who monitor SHIPs’ 

activities. We also reviewed information that we obtained from CMS 

officials and other sources on the program, its funding, changes made in 

response to the introduction of Part D, and the impact of Part D on the 

demand for SHIP services. In addition, we interviewed SHIP officials in 

California, Florida, New York, Texas, and Pennsylvania—the five states 

with the largest Medicare populations—to obtain information on the 

experience of their SHIPs with Part D. 

We conducted our work from November 2005 through May 2006 in 

accordance with generally accepted government auditing standards. 

State Health 

Insurance Assistance 

Programs 

Page 66 GAO-06-654 Medicare Part D Communications
Appendix III: Comments from the Centers for Appendix III: Comments from the Centers for Medicare & Medicaid Services 

Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Medicare & Medicaid Services 

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Appendix IV: 

St

GAO Contact and 

aff Acknowledgments

Page 83 GAO-06-654

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact Leslie G. Aronovitz (312) 220-7600 or aronovitzl@gao.gov 

In addition to the contact named above, Susan T. Anthony and Geraldine 

Redican-Bigott, Assistant Directors; Ramsey L. Asaly; Enchelle Bolden; 

Laura Brogan; Shaunessye D. Curry; Chir-Jen Huang; M. Peter Juang; 

Ba Lin; Michaela M. Monaghan; Roseanne Price; Pauline Seretakis; 

Margaret J. Weber; and Craig H. Winslow made contributions to this 

report. 

Medicare Part D Communications

Acknowledgments 

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