text: Background Medicare Coverage Options Beneficiaries have several Medicare options from which to select, which can have important consequences for their out-of-pocket expenses and access to care. These decisions include the following: What type of coverage? The first coverage decision faced by Medicare beneficiaries is choosing between original Medicare or MA. Original Medicare includes coverage for Medicare Part A services, such as inpatient hospital stays, and for Medicare Part B services, such as outpatient hospital care and physician office visits. Under MA—the private plan alternative to original Medicare—beneficiaries enroll in MA plans that generally must provide coverage for all the services included under original Medicare, and may also offer extra benefits. MA plans generally establish a network of health care providers to provide services to enrolled beneficiaries. Add prescription drug coverage? Beneficiaries in original Medicare and those in certain MA plans may also choose whether to add prescription drug coverage (Medicare Part D). Prescription drug plans are administered by private insurance companies that contract with CMS. Beneficiaries in original Medicare obtain drug coverage by purchasing a separate prescription drug plan (PDP), while those in MA generally obtain coverage by selecting a MA plan that offers prescription drug benefits. MA prescription drug plans and separate PDPs vary in the amount beneficiaries need to pay and in the drugs that are covered. Add supplemental coverage? Beneficiaries in original Medicare can also purchase Medicare supplemental insurance—known as Medigap plans—offered by private insurance companies. These plans help pay for Medicare’s required cost sharing and some out-of-pocket costs not covered under original Medicare, such as emergency health care during international travel. Figure 1 illustrates the decisions beneficiaries have to make when selecting their Medicare coverage options. Medicare Cost and Access Considerations Two research studies we reviewed indicate that cost is a key consideration for Medicare beneficiaries when selecting Medicare coverage. Beneficiaries may want to know what their likely out-of-pocket costs will be monthly, annually, or both. Beneficiaries may also want to know what their costs may be if they have a change in health status, such as by experiencing an illness. Beneficiaries may be responsible for several specific types of health care costs, including the following: Premiums—Beneficiaries generally make monthly payments to purchase coverage. Medicare Part A generally does not require beneficiaries to pay a premium. Part B premiums are established by statutory formula and are means-tested so that beneficiaries with higher incomes pay higher premiums. The premiums charged by MA plans and Part D plans are established by each plan and can vary widely. Beneficiaries in original Medicare who opt to purchase Medigap will also pay a monthly premium for coverage, with the amount of the premium varying across the 10 standardized plans and by the different companies offering these plans. Cost sharing—Beneficiaries are typically responsible for paying a portion of the costs for the services they receive as either a copayment or coinsurance. A copayment is a fixed dollar amount for each doctor visit, medical service, or medication. With coinsurance, a beneficiary pays a percentage of the allowed charge for each health care service or medication. Deductibles—Beneficiaries must pay out-of-pocket a specified annual amount of expenses before Medicare will begin paying for approved services or medications. MA plans establish out-of-pocket maximums or set limits on the amount a beneficiary will have to spend a year. In contrast, original Medicare has no limit on beneficiary out-of-pocket costs. In 2019, two Medigap plans provide maximum out-of-pocket limits, and beneficiaries with these plans do not have to pay costs above the limits. The same two research studies identified access to particular health care providers as another key consideration for beneficiaries when selecting Medicare coverage. Beneficiaries in original Medicare may see any doctor or use any facility that accepts Medicare payment, and referrals are not needed to see specialists. In contrast, MA beneficiaries must typically use the MA plan’s network of health care providers, including doctors, hospitals, and outpatient facilities, and referrals are generally needed to see specialists. Further, beneficiaries in MA plans that allow access to out-of-network providers may be required to pay more when receiving services from such providers. MA provider networks can change during the year and from year to year. Medicare Plan Finder (MPF) According to CMS officials, MPF was launched in 1998 in response to the Balanced Budget Act of 1997, which required the Department of Health and Human Services—the agency responsible for overseeing CMS—to maintain MA plan information on the internet, among other things. According to CMS, MPF is a primary CMS resource for beneficiaries to compare costs and coverage of different Medicare health and prescription drug coverage options in their area, including comparing original Medicare to MA plans, and Part D plans. As illustrated in figure 2, the MPF landing page—the first web page users see when accessing MPF— includes a section where beneficiaries start the process of searching for and comparing coverage options (see A in fig. 2), and a section providing links to additional decision support tools for beneficiaries (see B in fig. 2). Beneficiaries begin searching in MPF by entering their zip code and following a 4-step process that moves them through different MPF website pages. Step 1—Basic search: Beneficiaries provide responses to requested information, including identifying whether they have Medicare coverage and whether they would like to add prescription drug coverage to their search. Step 2—Enter drugs: Beneficiaries may add a list of prescription drugs, along with the dosage and dosing frequency, to identify which plans cover these drugs and the cost sharing amount under each plan. Step 3—Select pharmacies: Beneficiaries select up to two pharmacies that they prefer for obtaining their medications. Step 4—Refine plan results: Beneficiaries see a list of available coverage options—original Medicare, MA plans, and separate PDPs—based on the zip code they entered. Beneficiaries can filter these search results by variables such as monthly premium or deductible amounts, and then they can sort those results by variables such as lowest estimated annual costs or lowest plan deductible. Beneficiaries can then select up to three choices, view specific coverage and cost details for each, and do a detailed side-by-side comparison of each. The plan results page shows this comparison and includes beneficiaries’ estimated annual out-of- pocket costs for each coverage option they choose to review. The additional decision support tools available on the MPF landing page that beneficiaries may use to help select their Medicare health and drug coverage include the following: 1. Help with Your Medicare Choices, which uses filtering questions to help new beneficiaries understand their Medicare coverage choices; 2. Estimate Medicare Costs, which helps beneficiaries compare the average estimated costs of original Medicare options, such as original Medicare with a prescription drug plan and a Medigap plan, to the costs of MA with prescription drug coverage; and 3. Find and Compare Medigap Policies, which helps beneficiaries find information on the different standardized Medigap plans offered by zip code. Since its inception, MPF has undergone many modifications as new parts were added to the Medicare program, such as the addition of Medicare Part D. According to CMS officials, the agency has also taken steps to make additional changes to improve the website, including technology updates to improve system stability and performance, such as page load times and error rates. In addition, CMS seeks feedback from stakeholders, such as the customer service representatives at the 1-800- MEDICARE help line, SHIP personnel, and others, which according to agency officials, has resulted in additional changes. Changes have included allowing beneficiaries to log into their Medicare account to access some of their existing data, such as their prescription drugs, and the addition of a help feature that can connect beneficiaries to 1-800- MEDICARE customer service representatives for live help. Stakeholders and Research Indicated Medicare Plan Finder Is Difficult to Use and Provides Incomplete Information, and CMS Is Redesigning It to Make Improvements Challenges Navigating and Understanding Information in Medicare Plan Finder Make It Difficult for Beneficiaries to Use, According to Stakeholders and Research Stakeholders, research studies, and SHIP directors responding to our survey generally indicated that MPF is difficult for beneficiaries to navigate and understand. All 13 stakeholder groups we interviewed reported that MPF is challenging for Medicare beneficiaries to use. Specifically, most stakeholders cited difficulty navigating as beneficiaries click through multiple complex pages in order to find and compare coverage options. For example, two stakeholders noted that beneficiaries must answer questions about their current Medicare health and drug coverage and then go through a series of pages and steps before they can view detailed information on their coverage options. One of these stakeholders also told us that MPF navigation is cumbersome because users cannot jump directly to certain pages or sections that address their needs, such as viewing the availability of preferred pharmacies. One of the stakeholders we interviewed also noted the lack of prominent instructions on how to use MPF contributed to difficulties navigating the four steps. Finally, in our interviews two stakeholders also noted that navigation is difficult because beneficiaries are uncertain of the information needed to make different comparisons or identify specific plans. For example, the ability to filter and sort plan information does not appear until later in the plan search process, where users are refining plan results. This makes it hard for users to narrow options specific to their needs because they first must go through all the options presented. Specifically, beneficiaries will first see a list of plans available in their zip code—on average 24 plans—and then must narrow down that list before they can compare up to three selected plans. A 2018 report conducted jointly by two advocacy groups cited difficulties locating the filter and sort functions in MPF, which contributed to navigation problems. CMS user testing conducted on MPF found that overall beneficiaries are confused about how to find a MA plan on MPF. For example, this testing showed that some users had difficulties with the steps for refining plan results because they overlooked or ignored the filters. A 2017 CMS study noted that MPF navigation is difficult and is better suited for specialist users who assist beneficiaries in determining their coverage options, such as 1-800 MEDICARE customer service representatives and SHIP counselors. Further, CMS officials said the study found that beneficiaries would benefit if navigation through the site were more tailored to the tasks they were undertaking. Our survey of SHIP directors, who provide assistance to Medicare beneficiaries and therefore are familiar with MPF usability, also found that it is difficult for beneficiaries to navigate and find information. Specifically, 73 percent (29 of 40) of the SHIP directors who responded to our survey reported that it is difficult or very difficult for beneficiaries to find information in MPF. While SHIP directors reported that it is easier for SHIP counselors to find information, they noted that some also experience difficulty. Eighteen percent (7 of 40) SHIP directors reported that it is difficult for SHIP counselors to find information in MPF. (See fig. 3.) In addition to website navigation, it is also difficult for beneficiaries to understand the information in MPF, according to stakeholders, research studies, and SHIP directors responding to our survey. All seven beneficiary advocacy groups interviewed reported that beneficiaries find it challenging to understand information in MPF. For example, some stakeholders noted that beneficiaries do not always understand terminology, such as the differences between cost sharing, copayment, and out-of-pocket costs. Most stakeholders also noted that beneficiaries struggle to understand cost estimates and interpret how much they will have to pay. CMS user testing of MPF in 2018 found that beneficiaries were overwhelmed by the number and complexity of options from which they had to choose. According to a 2018 research study conducted by two advocacy groups, the website explains health coverage terminology poorly and does not use plain language. As a result, users with low health insurance literacy may not understand, for example, the cost differences between generic versus brand-name drugs. Sixty-five percent (26 of 40) of the SHIP directors we surveyed reported that the information in MPF is difficult or very difficult for beneficiaries to understand, while 23 percent (9 of 40) reported that it is difficult for SHIP counselors to understand information (see fig. 4). SHIP directors identified health coverage terminology as a challenge, with 38 percent (15 of 40) reporting that MPF does a poor or very poor job explaining health coverage terminology, such as non-network providers, drug formularies, and drug tiers to beneficiaries. According to Stakeholders, Medicare Plan Finder Provides Incomplete Information on Costs and Coverage, Making it Difficult to Compare Medicare Options MPF provides incomplete estimates of beneficiaries’ costs under original Medicare, making it difficult to compare coverage options, according to stakeholders and SHIP directors responding to our survey. The cost estimates on the plan results pages are incomplete because they do not include the effect of Medigap—which helps cover beneficiaries’ cost sharing responsibilities under original Medicare. As a result, beneficiaries who want to use MPF to compare original Medicare with a Medigap plan to specific MA plans are unable to do so. Most—4 of 7—beneficiary advocacy group stakeholders that we interviewed noted that beneficiaries must leave MPF to obtain information about Medigap plans, such as the specific benefits covered under those plans and their estimated costs. Six of seven beneficiary advocacy groups that we interviewed noted that MPF’s incomplete information on estimated beneficiary costs is a concern because beneficiaries need this information for understanding and comparing their Medicare options. CMS’s other coverage decision support tools—Help with Your Medicare Choices and Estimate Medicare Costs—provide general information intended to help beneficiaries understand and compare their Medicare options. However, these tools are separate links; their information is not included on the plan results pages in MPF. The SHIP directors we surveyed also noted lack of information as a concern, with 75 percent (30 of 40) reporting that the lack of Medigap information in MPF limits the ability of beneficiaries to compare original Medicare and MA plans. Further, SHIP directors surveyed reported more general concerns with MPF’s cost estimates, with 80 percent (32 of 40) reporting that improvements are needed to better estimate total annual beneficiary costs, and 63 percent (25 of 40) of the SHIP directors reporting that MPF does a poor or very poor job comparing the costs of original Medicare to MA. Stakeholders and SHIP directors responding to our survey reported that MPF also provides incomplete information on MA plan provider networks. According to a CMS-sponsored study, determining if specific providers are in an MA plan provider network is a key factor for beneficiaries when making coverage decisions, and beneficiaries stated in user testing that they must have this information. However, to obtain information on the providers in specific MA plans, MPF users must exit the website and go to the individual plan websites. Most stakeholders—10 of 13—cited the lack of information on provider networks as a shortcoming for beneficiaries in using MPF to select a plan, with one group stating that MPF users may need to call individual plans to determine if providers are in a plan’s network. SHIP directors also cited this issue as a problem, as 85 percent (34 of 40) who responded to our survey reported that the lack of a provider directory limits MPF as a resource for beneficiaries to compare MA plans. Without provider information, beneficiaries are not able to use MPF to narrow their options to MA plans that include desired providers or make comparisons among these plans. CMS Is Redesigning MPF in an Effort to Improve its Usability and the Completeness of Cost Information According to CMS officials, the agency is redesigning MPF to make it more usable for beneficiaries and is planning to release the redesigned MPF in early August 2019. With the redesign, CMS plans to improve the navigation of MPF by providing more prominent explanations on how to use MPF; reducing the steps users must take to get to more detailed coverage information; configuring MPF so users can more easily switch between different topics inside MPF, such as switching between MA plan information and Part D plan information; and improving the filter and sort functions so users can narrow down their coverage options more quickly. CMS also plans to make information easier to understand by simplifying and reducing the volume of information on the pages and revising frequently misunderstood terms with more user-friendly language. As part of the redesign, CMS is also taking steps to provide more complete cost information in MPF to help compare coverage options, according to agency officials. CMS plans to provide more information to the redesigned MPF to help beneficiaries understand their coverage options and decide whether original Medicare or MA is right for them. CMS officials also told us in June 2019 that the redesigned MPF will allow beneficiaries to do estimated cost comparisons of MA to all their original Medicare options, such as original Medicare with a Medigap plan and a prescription drug plan. Officials also told us that CMS is incorporating the functionality of the additional decision support tools currently available on the MPF landing page—Help with Your Medicare Choices and Estimate Medicare Costs—into the redesigned MPF to help beneficiaries understand their coverage options and compare their estimated costs across these options. In June 2019, CMS officials stated these additional tools will also continue to appear as separate links on the MPF landing page. CMS officials also told us that they are currently examining how to integrate MA plan provider information, but this is not part of the redesigned MPF being released in August 2019. The officials said they are working with the plans to develop requirements to help support the integration of provider directories into future versions of MPF. According to CMS, the redesign of MPF is not finalized and CMS will continue to evaluate the extent to which the changes will make MPF easier for beneficiaries to use and whether it provides complete information for making coverage decisions. As of June 2019, CMS officials told us they are continuing to gather feedback from stakeholders, such as 1-800-MEDICARE customer service representatives and SHIP personnel, and conduct user testing on a redesigned MPF model. CMS then plans to publicly launch the redesigned MPF to a subset of users in early August 2019. Once launched, CMS plans to incorporate feedback from this subset of users to confirm the core features that will be released in the redesigned MPF prior to the Medicare open enrollment period starting October 15, 2019. According to CMS officials, the development of the redesigned MPF is an incremental process that will involve continuous changes based on feedback and user testing. According to the agency, CMS will know more about how well the redesigned MPF addresses user needs after it is used by beneficiaries. Agency Comments We provided a draft of this report to the Department of Health and Human Services for review and comment. The Department of Health and Human Services provided technical comments, which we incorporated as appropriate. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the Secretary of Health and Human Services and other interested parties. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix I. Appendix I: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, Tim Bushfield, Assistant Director; Maggie G. Holihan, Analyst-in-Charge; Sylvia Diaz Jones; Anne Hopewell; Dennis A. Antonio; and Dan Ries made key contributions to this report. Also contributing were Cathy Hamann, Krister Friday, Ethiene Salgado-Rodriguez, Julie Flowers, and Jennifer Rudisill.
target: Medicare beneficiaries—more than 60 million as of 2019—have a series of decisions to make when selecting their Medicare health and prescription drug coverage. Beneficiaries must first choose between two main options for their Medicare coverage: either original fee-for-service Medicare or MA. Within these two options, beneficiaries have many additional choices, and they are permitted to change their coverage at least annually. These selections can be difficult due to the Medicare program's complexity and can have important implications for beneficiaries' out-of-pocket costs and access to providers. According to CMS, the MPF website is intended to help beneficiaries make informed decisions regarding their health care and prescription drug coverage. However, some stakeholders have raised concerns that beneficiaries experience challenges using MPF to compare their Medicare coverage options. GAO was asked to review MPF. This report examines what is known about the usability of MPF and the completeness of its information. GAO reviewed research and CMS documentation on MPF, and surveyed 51 directors of SHIP offices that have counselors who assist beneficiaries with Medicare decisions. Forty SHIP directors completed the survey, resulting in a 78 percent response rate. GAO also interviewed CMS officials and officials with 13 stakeholder groups, including seven beneficiary advocacy groups. GAO provided a draft of this report to the Department of Health and Human Services. The department provided technical comments, which GAO incorporated as appropriate. The Medicare Plan Finder (MPF) website—a primary resource for comparing Medicare coverage options—is difficult for beneficiaries to use and provides incomplete information, according to stakeholders and research studies. These sources and directors of State Health Insurance Assistance Programs (SHIP) GAO surveyed—who assist beneficiaries with their Medicare coverage choices—reported that beneficiaries struggle with using MPF because it can be difficult to find information on the website and the information can be hard to understand. For example, MPF requires navigation through multiple pages before displaying plan details, lacks prominent instructions to help beneficiaries find information, and contains complex terms that make it difficult for beneficiaries to understand information. In response to GAO's survey, 73 percent of SHIP directors reported that beneficiaries experience difficulty finding information in MPF, while 18 percent reported that SHIP counselors experience difficulty. Stakeholders and SHIP directors reported that MPF provides incomplete estimates of costs under original Medicare, making it difficult to compare original Medicare and Medicare Advantage (MA), the program's private heath plan alternative. Specifically, MPF's plan results pages do not integrate information on Medigap plans. (These plans help cover some of beneficiaries' out-of-pocket costs.) Seventy-five percent of the SHIP directors surveyed reported that the lack of Medigap information in MPF limits the ability of beneficiaries to compare original Medicare to MA. The Centers for Medicare & Medicaid Services (CMS)—the agency that administers MPF—is aware of the difficulities beneficiaries face using MPF and is planning to launch a redesigned website in August 2019. According to CMS, redesigning MPF involves multiple iterations of changes and ongoing user testing, and CMS will know more about how well the redesigned MPF addresses user needs after it is used by beneficiaries.