type: other

jurisdiction: US

text: b' ~~~\n #\'\n\n\n\n\nDepartment of Health and Human Services\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\n MARKETING PRACTICES OF\n SOUTH FLORIDA HMOs SERVING\n MEDICARE BEN EFICIARI ES\n\n\n\n\n VlCES\n\n\n\n\n Richard P. Kusserow\n INSPECTOR GENERAL\n\n NOVEMBER 1~1\n\x0c #\'\n\n\n\n\nDepartment of Health and Human Services\n OFFICE OF\n INSPECTO R GENERAL\n\n\n\n\n MARKETING PRACTICES OF\n SOUTH FLORIDA HMOs SERVING\n MEDICARE BENEFICIARIES\n\n\n\n\n V1CF3\n\n\n\n\n Richard P. Kusserow\n INSPECTOR GENERAL\n\n \'.t ~claa OEI- 04-91-00630\n\x0c EXECUTIVE SUMMAR Y\n\nPURPOSE\n\nThis report describes marketing practices of risk-contracted health maintenance\norganizations (HMOs) serving Medicare beneficiaries in South Florida.\n\nBACKGROUND\n\nIn most geographic areas , Medicare beneficiaries obtain medical care through a fee-\nfor-service program. However , in some places , beneficiaries may obtain Medicare\ncovered medical care in two ways.\n\nRegular Fee-for-Service Medicare Program - Beneficiaries choose each of their own\nhealth care providers. Medicare payments are based on each allowed service the\nbeneficiary receives.\n\nPrepaid Health Plans - Beneficiaries enroll in health organizations which manage their\nmedical care. Under these plans , Medicare pays a predetermined amount per\nbeneficiary enrollee.\n\nThe most common types of prepaid health plans are risk-contracted HMOs. Such\nHMOs are considered " at financial risk" because they agree to provide a beneficiary\ntotal medical care for a set amount each month. Beneficiaries are required to obtain\nall their medical care through providers affiliated with an HMO , except during (1) an\nemergency, and (2) periods when care is urgently needed and the beneficiary is out of\nthe HMO service area.\n\nIn the fall of 1990 , newspapers in South Florida ran articles alleging marketing abuses\nby HMOs. The articles indicated Medicare beneficiaries are sometimes\ninappropriately enrolled and not adequately informed of the requirement that all\nmedical care must be received from HMO-affiliated providers. Concerned about the\nsituations described in these articles , the Administrator of the Health Care Financing\nAdministration (HCFA) requested the Inspector General to examine the marketing\npractices and enrollment patterns of South Florida HMOs. This report deals with\nmarketing practices. Enrollment patterns are described in a separate report\n(OEI- 04-91- 00640).\n\nTo analyze marketing practices , we relied on data collected from sampled beneficiaries\nwho enrolled in one of the six South Florida HMOs in 1990 , HMO marketing\nmaterials , and HMO officials.\n\x0cFINDINGS\n\nOn the positive side , we found that:\n\n Almost three- fourths of the beneficiaries themselves initiate contact with the\n HMO and ask about joining. However , this number varies by HMO.\n\n Few beneficiaries feel pressured by sales staff.\n\n Most of the beneficiaries know they are enrolling in an HMO and can only use\n providers affiliated with the HMO. However , this number also varies by HMO.\n\nOn the other hand , some instances of inappropriate marketing practices do occur.\nSome HMOs fail to adequately monitor sales staff, leaving beneficiaries vulnerable to\ninappropriate marketing practices. We found that:\n\n Eight percent of the beneficiaries say salespersons made unannounced visits to\n their homes asking them to enroll in an HMO.\n\n Nine percent of the beneficiaries say they had not known they were enrolling in\n an HMO when they signed the application. Another 10 beneficiaries could not\n HMO.\n be interviewed because they maintained they had not been in an\n\n\n Ten percent of the beneficiaries were unaware they could only use HMO\n providers.\n\n Seventeen percent of the beneficiaries were unaware they could "back-out" if\n they changed their minds after signing the application.\n\n Some beneficiaries have been vulnerable to unethical sales practices.\n\nRECOMMENDATIONS\n\nThe following recommendations target Medicare prepaid health care program\nvulnerabilities , as well as addressing troublesome situations encountered during this\ninspection of South Florida HMOs.\n\n The HCFA should establish standards for sales force training and monitoring,\n and hold HMOs accountable for maintaining those standards.\n\n The HCFA should establish a policy limiting enrollment to one " open season\n (opportunity to enroll) per year.\n\n\n frequent enrollment change. \n\n The HCF A should establish an on-line system to identify and review cases of\n\x0c In the three-county Miami service area , HCF A should test the efficacy of a\n third party handling HMO enrollment actions.\n\n The HCF A should impose a " cooling off\' period allowing beneficiaries to\n reconsider HMO enrollment decisions before enrollment applications are\n processed.\n\nCOMMENTS\n\nComments on the draft report were received from HCF A and the Assistant Secretary\nfor Planning and Evaluation (ASPE). Both agencies agree that HCFA should identify\nand review frequent enrollment changes , and HCFA believes they now have that\ncapability. While ASPE supported the concept of a "cooling off\' period for Medicare\nenrollees , HCF A thinks a " cooling off\' period is not needed.\n\nNeither agency concurred with the other recommendations. We will defer our\ncomments on their responses until the OIG completes its national study on HMO\ndisenrollments (OEI- 06-91- 00730).\n\nThe comments of HCF A and ASPE can be found in appendix E. Where appropriate\nwe made the technical changes they suggested.\n\n\n\n\n III\n\x0c . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . ..\n . .. .. .. .. .... . . . . . . .\n\n\n\n\n TABLE OF CONTENTS\nEXECUTIVE SUMMARY\n\nIN1RODUCfION ................................................\n\n\n\n\n Scope .\n\n Purpose ..................................................... \n\n Background ..................................................\n\n ...................................................... 4\n\n Methods .....................................................\n\n\nFINDINGS ...................................................... 6\n\n Most Beneficiaries Initiate Contact with the HMO to Enroll.\n\n However , the Percent Varies by HMO .............................. 6\n\n\n Few Beneficiaries Feel Pressured\n bySalesStaff .................................................\n\n\n Most Beneficiaries Understand HMO\n Requirements Before They Enroll.\n\n However, this Varies by HMO ...................................\n\n\n Some HMOs Fail to Adequately Monitor Sales\n Staff, Leaving Beneficiaries Vulnerable to\n Inappropriate Marketing Practices .................................\n\n\n Some Beneficiaries Have Been Vulnerable\n to Unethical Sales Practices .....................................\n\n\nRECOMMENDATIONS\n\nAPPEND !XES\n\n Appendix A: Methods and Sample Selection ....................... A-\n\n Appendix B: Responses to Telephone\n Survey of Beneficiaries ................................... B-\n\n\n Appendix C: Responses to Face- to-Face\n InterviewswithBeneficiaries ............................... C-\n\n Appendix D: Analysis of Survey Respondents vs. Nonrespondents ....... D-\n\n Appendix E: Comments on the Draft Report .... E-\n\x0c INTRODUCTION\xe2\x82\xac\nPURPOSE\n\nThis report describes marketing practices of risk-contracted health maintenance\norganizations (HMOs) serving Medicare beneficiaries in South Florida.\n\nBACKGROUND\n\nIn the fall of 1990 , newspapers in South Florida ran articles alleging marketing abuses\nby HMOs. The articles indicated Medicare beneficiaries are sometimes\ninappropriately enrolled and not adequately informed of the requirement that all\nmedical care must be received from HMO-affiliated providers. Monitoring reports\nfrom HCF A also noted problems with marketing materials and practices of some\nSouth Florida HMOs.\n\nResponding to these concerns , the Administrator of the Health Care Financing\nAdministration (HCFA) requested that the Inspector General conduct an inspection of\nmarketing practices of HMOs serving Medicare beneficiaries in South Florida.\ninspection of beneficiaries who repeatedly change their enrollments among South\nFlorida HMOs was conducted at the same time. (OEI- 04-91- 00640)\n\nThe Medicare Program\n\nMedicare is a Federal health insurance program for individuals age 65 and older and\nfor certain categories of disabled people. Authorized in 1965 by title XVIII of the\nSocial Security Act , Medicare serves over 33 million beneficiaries nationwide. Within\nthe Department of Health and Human Services , HCF A is responsible for\nadministering the Medicare Program.\n\nMethod of Service\n\nIn most geographic areas , Medicare beneficiaries obtain medical care through a fee-\nfor-service program. However , in some places , there are two ways in which\nbeneficiaries may obtain medical care covered by Medicare.\n\nRegular Fee-for-Service Coverage - Beneficiaries choose their own physicians\nhospitals , and other medical care providers. The beneficiary pays the Medicare\npremiums , deductibles for inpatient and outpatient care , and 20 percent of the\nallowable charge for covered physician and other outpatient services.\n\nPrepaid Health Plans - Beneficiaries enroll in Medicare-contracted health\n Beneficiaries continue to pay\norganizations which manage their medical care.\nMedicare premiums. They may also have to pay the plan a monthly premium and/or\n\x0ca copayment for each service received. However, they do not pay the deductibles or\n20 percent of physician and outpatient charges required under the fee- for-service\nprogram. As a result , these beneficiaries do not need Medicare supplemental policies.\n\nA beneficiary can be in only one program at a time. He/she cannot combine fee- for-\nservice and prepaid health plans.\n\nThe most common types of Medicare prepaid health plans are risk-contracted HMOs.\nThese HMOs are considered " at financial risk" because they agree to provide a\nbeneficiary s total medical care for a set amount paid monthly by Medicare.\n\nThese HMOs serve beneficiaries who live within a defined geographic area. They are\nresponsible for providing the full range of Medicare services. They may offer other\nbenefits not covered by Medicare , such as prescription drugs.\n\nMter joining an HMO , the beneficiary selects a primary care physician (PCP)\naffiliated with the plan. All medical care is managed by that PCP. The PCP either\nprovides the services needed or refers the beneficiary to appropriate specialists or\nother health care providers.\n\n\n\nThe HMO network of providers may be either HMO employees working in an HMO-\nowned facility or private physicians contracting with the HMO to provide services to\nthe members. Some HMOs use a combination.\n\nBeneficiaries are required to obtain all their medical care through the providers\naffiliated with the HMO , except for emergency and out-of-area urgently needed care.\n\nIn an emergency, beneficiaries can receive care anywhere. The HMO will pay for the\ncare , even if the provider is not affiliated with the HMO. The HMO also will pay for\nurgently-needed care a beneficiary receives when out of the HMO\' s service area.\nNeither the HMO nor Medicare will pay for non-emergency or non-urgent care\nobtained outside the HMO without prior approval of the HMO. The beneficiary is\nresponsible for those charges.\n\n\nUniqueness of Miami HMO Market\n\nThe HMO market in the three-county Miami area is unique in the number of elderly\nand the number of risk-contract HMOs.\n\nNationally, persons over age 65 comprise 13 percent of the population. In the three-\ncounty Miami area , approximately 18 percent of the population is over the age of 65.\nIn 2 of the 3 counties , over 20 percent of the population is over 65. Some live in\n\x0cFlorida full- time. Others live there only part of the year , and reside in other States\nthe rest of the time.\n\n\nIn most locations , only one or two HMOs are available to Medicare beneficiaries. In\nthe Miami area , five risk-contract HMOs currently serve beneficiaries. Approximately\n33 percent of the elderly are enrolled in one of those HMOs. Two additional HMOs\nhave applied to serve beneficiaries in the Miami area and will be granted contracts if\nthey meet HCF A requirements. Since the benefits HMOs offer are quite similar\nmarketing of the programs is highly competitive.\n\nThe HMOs Serving Beneficiaries in South Florida\n\nSix HMOs currently serve beneficiaries in South Florida. For the purpose of this\nstudy, the Humana Medical Plan serving the Miami area and the plan serving the\nTampa area were treated as two separate HMOs. Although the Humana corporate\npolicies are the same for both areas , the marketing practices may differ. In Tampa\nHumana is the only risk-contracted HMO available. In Miami , Humana has\ncompetition from four other such plans serving Medicare beneficiaries.\n\nThe six HMOs serving beneficiaries in South Florida are:\n\n Humana Medical Plan (Tampa);\n\n Humana Medical Plan (Miami);\n\n CAC- RAMSA Y;\n\n Av-Med Health Plan;\n\n Health Options of South Florida; and\n\n CareFlorida.\n\nNone of these HMOs charge an HMO monthly premium. They all charge copayments\nfor some services not covered by the regular Medicare program , such as dental care.\nOnly two , Health Options and Av- Med , charge copayments for physician services.\n\nThe HMOs vary in their methods of operation:\n\n Health Options and Av- Med provide services solely through contracted\n physicians and providers.\n\n\n\n\n Demographic data from county planning departments in Dade , Broward , and Palm Beach Counties\nand the u.S. Department of Commerce; Bureau of the Census.\n\x0c CAC has a combination of HMO-owned medical centers and contracted private\n physicians. The CAC regional offices coordinate patients \' care and referrals\n made by PCPs. The corporate office pays the specialists for the services they\n render.\n\n Humana also has a combination of HMO-owned medical centers and\n contracted private physicians and physician groups. Humana has risk contracts\n with all its contracted PCPs. The HMO provides each PCP (or PCP group) a\n set amount each month per HMO patient. The PCP controls and pays for all\n care the beneficiary receives , whether through the PCP or specialists.\n\n CareFlorida uses only contracted private physicians to provide care. Thirteen\n PCP groups are under a risk contract and 240 PCPs are not at risk. Some of\n those under a risk contract do their own advertising and have their own\n salespersons. Some industry people refer to this type arrangement as a "mini-\n HMO.\n\nSCOPE\n\nWe examined the marketing practices of the six risk-contracted HMOs serving\nMedicare beneficiaries in the counties of Dade , Broward , Palm Beach , Hillsborough\nPinellas , and Pasco.\n\nAlthough these HMOs may serve beneficiaries in other areas , we included only the\nSouth Florida operations in this inspection.\n\nMedicare enrollment and service areas for the six HMOs currently serving\nbeneficiaries in South Florida are:\n\n\n\n NAME MEDICARE COUNTIES\n ENROLlEES * SERVED\n\n Humana Medical Plan 722 Pinellas , Hillsborough , Pasco (Tampa area)\xe2\x82\xac\n Humana Medical Plan 100 503 Dade , Broward , Palm Beach (Miami area)\xe2\x82\xac\n CAC- RAMSA Y 090 Dade , Broward\n\n Av-Med Health Plan 138 Dade, Broward , Palm Beach\xe2\x82\xac\n Health Options of\n\n South Florida 300 Dade , Broward\n\n CareFlorida 484 Dade , Broward , Palm Beach\xe2\x82\xac\n\n Number of Medicare members as of February \n 1991 according to the HMOs.\n\x0cMETHODS\n\nWe obtained information for this study from various sources , including:\n\n a review of HCFA regulations to determine Federal requirements for HMOs;\n\n a review of the marketing materials used by each HMO to determine if they\n meet HCF A requirements;\n\n discussions with officials representing each HMO to learn each company\n policies and practices;\n\n a telephone survey of 601 randomly selected Medicare beneficiaries to ascertain\n their experiences in joining an HMO; and\n\n face- to- face interviews with 22 beneficiaries who had 15 or more multiple\n enrollments in HMOs to determine their reasons for changing HMOs.\n\nTelephone Survey\n\n\n\nWe drew a sample of 833 beneficiaries from a universe of 37 423 beneficiaries who\nenrolled in one of the South Florida HMOs between January and October 1990. This\nwas their first , and only, enrollment in an HMO.\n\nThe survey was conducted January 7- , 1991. A total of 601 of the 833 beneficiaries\nwere interviewed , yielding an overall response rate of 72 percent.\n\nAnother 10 beneficiaries were contacted , but could not be interviewed. They\nmaintained they had not been in an HMO and could not answer questions about\nenrollment.\n\nFace-to-Face Interviews\n\nThrough their data base , the HCF A Region IV office identified 26 beneficiaries who\nhad each enrolled in different HMOs 15 or more times since becoming eligible for\nMedicare. Because of HCF A\' s concern about multiple enrollments , we included these\nbeneficiaries in our study. Staff conducted face- to-face interviews with 22 of the 26\nduring January 28- , 1991 to determine their reasons for multiple enrollments.\n\nAppendix A describes in greater detail the data collection methods used in this\ninspection. Appendix B contains the telephone survey instrument and response\nfrequencies , by HMO. Appendix C contains the survey instrument and response\nfrequencies to the face- to- face interviews with beneficiaries. The analysis of\nnonrespondents is found in appendix D.\n\x0c FINDINGS\xe2\x82\xac\n\nMOST BENEFICIARIES INITIATE CONTACf WITH THE HMO TO ENROLL\nHOWEVER, THE PERCENT VARIES BY HMO.\n\nOur interviews with 601 HMO enrollees showed that almost three-fourths (72 percent)\nof the beneficiaries say they themselves had contacted the HMO about joining.\n\nAlthough 25 percent of the beneficiaries say the HMO approached them about\njoining, the number varies widely by HMO. For example , 10 percent of the\nbeneficiaries in Av- Med say the HMO contacted them , whereas 41 percent in\nCareFlorida say they were contacted by the HMO.\n\nThree percent of the beneficiaries do not remember who initiated the contact.\n\nHow do the beneficiaries hear about the HMO?\n\nAbout half of the beneficiaries in the survey indicate they first heard about their\nHMOs through friends or relatives. Others learned of the HMOs through\nadvertisements on television , in newspapers , and in the mail. Only a few first heard\nabout their HMOs from senior citizen groups, the Social Security office , or other\nsources. Approximately 2 percent had previously been in the HMO and simply\nconverted to the Medicare component when they turned 65.\n\nAdvertising methods vary by HMO and are determined usually by the HMO\' s size and\nmarketing budget. All have used television, radio , and newspaper advertising at one\ntime or another.\n\n\n\nSome HMOs also conduct mass mail-outs of brochures. They purchase lists of elderly\npersons within a given zip code and send them information about the HMO.\n\nPresentations to groups of senior citizens and participation in "health fairs " are other\nmarketing methods frequently used. Humana and CAC , which have HMO-owned\ncenters , often have " open houses " offering free health screening tests, refreshments\nand tours of the facilities.\n\nHumana relies most heavily on television ads. The smaller HMOs use less expensive\nmethods , such as mail-outs and presentations. Advertising by CAC is almost\nexclusively in Spanish, while the other HMOs primarily advertise to English-speaking\naudiences.\n\x0c HMOs USE SEVERAL METHODS TO ADVERllSE\n Humana Humana Health Care\n CAC Av-Med\n Miami Tampa Options Florida\n Television Yes Yes Yes Yes Yes\n Radio Yes\n Newspapers Yes Yes Yes\n Mass Mailings Yes Yes Yes\n Open Houses Yes Yes Yes\n Phone Solicitation Yes\n\nWhat happens after the beneficiary contacts the HMO?\n\nWhen beneficiaries call the HMO to inquire about joining, they are encouraged to let\na salesperson come to their home and explain the program requirements. In most\ninstances , that is what occurs , and the salesperson completes an application if the\nbeneficiary requests to join. However, some beneficiaries prefer that the HMO mail\nthem the additional information and the application, and not send a salesperson.\n\nWhere HMOs initiate contact, how do they identify prospective enroUees?\n\nEach of the six HMOs we reviewed solicited Medicare beneficiaries through a door- to-\ndoor process--although such solicitation violates HCF A regulation. Of the 601\nbeneficiaries we interviewed , 150 told us an HMO salesperson had initially contacted\nthem for enrollment. Thirty-four percent of the 150 said the HMO salesperson came\nto their homes , soliciting their enrollment in an HMO. Thus , about eight percent of\nthe 601 we interviewed received unannounced visits from HMO salespersons asking\nthem to enroll.\n\nSalespersons used various sources to identify potential beneficiaries for HMO\nenrollment. The sources included relatives , friends , and doctors. About 64 percent of\nthe 150 beneficiaries solicited by the HMOs we reviewed said they did not know how\nthe HMO salesperson obtained their names. All of the HMOs included in our\nanalysis reported that their salespersons obtain leads for potential enrollees from\ncurrent members and functions such as open houses or presentations on the HMO.\n\n\nFEW BENEFICIARIES FEEL PRESSURED BY SALES STAFF.\n\nOnly four percent of the beneficiaries say they felt pressured to join the HMO. Most\nbeneficiaries who felt pressured cite persistence of the salesperson. Some say the\nsalespersons kept calling them. Other beneficiaries say the salesperson repeatedly\n\x0cextolled the benefits of the plan in a poor economy. Two beneficiaries were told\nenrollment in an HMO would not affect their way of getting medical care , and one\nwas told her enrollment would help the salesperson.\n\nTwo beneficiaries say the salespersons misrepresented the agencies with which they\nwere affiliated.\xe2\x82\xac\n\nWho are the salespersons wlw visit beneficiaries?\n\nThe types of salespersons who market HMOs vary by plan. Most are either (1) HMO\nemployees who market only the HMO , or (2) private independent insurance\nsalespersons who market the HMO in addition to other products , such as Medicare\nsupplemental policies. Florida law requires that all HMO salespersons be licensed as\ninsurance agents.\n\nIn Miami , Humana has 140 salespersons employed by the HMO and 12 independent\nagents. In Tampa , Humana has a sales force of 75 employees.\n\nThe CAC plan has a sales force of 25- 30 employees.\n\nHealth Options , which is owned by Blue CrosslBlue Shield , has contracted with 40\nsenior citizens who market the HMO and sell other Blue CrosslBlue Shield products.\n\nCareFlorida employs six full- time salespersons. They also use 60- 70 independent\nagents , although only 15 of them are said to generate significant business. Some of\ntheir 13 risk-contracted PCPs also have sales staffs of independent agents.\n\nAv- Med has 7 salespersons employed by the HMO and 15 independent agents.\n\nWhat type of training do salespersons receive?\n\nAlthough HCF A has no requirement for training salespersons , each HMO provides\nsome training for new staff.\xe2\x82\xac\n\nHumana has the most extensive sales force training. Initially, each salesperson\nreceives 30 hours of classroom training. He/she is tested and must score 72 (out of a\npossible 100) overall , and must correctly answer an essay question about " lock-\nDuring the salesperson s first two weeks on the job , management observes five\npresentations. The salesperson is retested every six months and must score 77 overall\nand 100 on the " lock- " question.\n\n\n\n\n Lock- " refers to a requirement that all medical care must be received from HMO-affiliated\nproviders.\n\x0cHealth Options provides eight or more hours of formal training for new salespersons\nand quarterly training for all the sales force. Health Options also tests its salespersons\nonce a quarter.\n\nThe sales staff of CAC receive two to three days of formal training.\n\nBoth CareFlorida and Av- Med provide less formal training for their sales staffs.\n\nAlthough only Humana and Health Options have formal retraining, all HMOs have\nregular meetings with their sales staff. The meetings are scheduled as follows:\n\n\n HMO SALES STAFF MEET REGULARLY\n Weekly Twice Monthly Monthly\n HUMAN A MIAMI\n Yes\n HUMAN A TAMPA Yes\n CAC Yes\n HEALTH OPTIONS Yes\n AV- MED Yes\n CAREFLORIDA\n Employees Yes\n Independent Agents\n (Includes some\n PCP-based agents) Yes\n Independent Agents\n From 3 PCPs Yes\n\nHow are sales staffs paid?\n\nAll HMOs pay salespersons a commission for each beneficiary enrolled. The amount\nper person enrolled increases with the number of enrollees per month. For example\nthe HMO may pay the salesperson $60 for each of the first 20 enrollees in a month\nand $75 for additional enrollees that month. The dollar amounts vary by HMO , as do\nthe commission policies.\n\nThe CAC pays a retention fee of $2. 00 for every month a beneficiary remains enrolled\nin the HMO. CAC believes this provides an incentive for sales staff to remain with\nthe HMO and keep beneficiaries they have enrolled in the plan. When a salesperson\nmoves to another HMO , he/she may persuade members to change to the other plan.\nHumana and Health Options pay salespersons a lump sum amount after a beneficiary\nhas been enrolled a specified number of months. Humana pays $25 after a\nbeneficiary has been enrolled for 13 months. Health Options pays $5 after six months.\n\x0cCareFlorida staggers commission payments to its independent agents. Half is paid\nwhen the beneficiary enrolls. One- fourth is paid when the beneficiary has been\nenrolled three months , and the remaining fourth is paid when the beneficiary has been\nenrolled six months. CareFlorida does not pay a commission for the third time a\nbeneficiary enrolls within 12 months.\n\nHumana , CAC , and Av-Med revoke commissions if the beneficiary disenrolls within 90\ndays.\n\nThe following chart illustrates the differences in sales staff pay structures among the\nHMOs.\n\n HMO COMPENSAll0N POUCIES DIFFER\n\n Humana Hurnana Health Care Florida\n CAC Av-Med\n Miami Tampa Options Employee Independent\n SALES COMPENSATION\n\n Payment for enrolling 250 250 $1,500 662 800 875 $1,590\n 30 beneficiaries\xe2\x82\xac\n Penalty for early outs 90 Days 90 days 90 days None 90 days None None\n Bonus " for longevity Yes Yes Yes Yes Yes\n Bonus " on 30 enrol- $750 $750 080 $150 500\n lees staying 18 months\xe2\x82\xac\n Total payment on 30 $3, 000 000 $2, 580 812 $1,800 875 090\n enrollees staying 18 mo.\n\n Quotas: Employees None None None\n Indep. Agents None None None None None None\n\nHow do HMOs monitor their salespersons \' activities?\n\nThe HCF A has no specific requirement for monitoring enrollment practices of HMO\nsalespersons. The HMOs we reviewed , however , have several methods for identifying\nand curtailing inappropriate enrollment practices by their sales staff. Some have also\nimplemented processes for discouraging and correcting improper practices.\n\nFirst , HMOs are required by Florida law to conduct an enrollment verification.\nGenerally, HMO employees other than salespersons are expected to call potential\nenrollees before processing their ap plication and ensure that they: (1) know they are\njoining and HMO and (2) understand the " lock- " concept. Potential enrollees who\ndo not understand are either provided further information or referred to the\n\x0cmarketing department for further explanation before enrollment. One of the six\nHMOs we reviewed , Humana , also telephones beneficiaries about 10 days after their\nenrollment to answer questions and ensure that they have received membership\nmaterials.\n\nSecond , each HMO receives beneficiary complaints and appeals which provide\ninformation on enrollment practices of salespersons.\n\nThird , two HMOs , Humana and CAC, kept records on salespersons who appeared to\nhave provided inadequate or erroneous information to potential enrollees. Humana\nreferred such cases to a private company for investigation. Where such investigations\nconfirmed inappropriate practices , Humana took disciplinary action , including\nwarnings , retraining, and termination. One HMO , Health Options , did not keep\nrecords on claims of inappropriate enrollments by salespersons , stating that such\npractices were so few, records were not warranted.\n\n\nMOST BENEFICIARIES UNDERSTAND HMO REQUIREMENTS BEFORE\xe2\x82\xac\nTHEY ENROlL. HOWEVER, TIllS VARIES BY HMO.\xe2\x82\xac\n\nHow do beneficiaries get information?\n\nIn most instances , beneficiaries talk to at least two HMO representatives and receive\nwritten material prior to enrolling. First , salespersons explain the program and\nprovide some written information. Then, the HMO calls beneficiaries to verify their\nintent to enroll and their understanding of " lock- in. " Mter enrollment , members are\nmailed additional written information , usually a handbook, that describes the program\nand requirements. Humana also calls the beneficiary again after 10 days and conducts\ngroup meetings for new enrollees.\n\nThe HCF A regulations require that HMOs provide prospective enrollees with written\nmaterial which fully explains program requirements and beneficiary rights. The\nmembership materials reviewed for this inspection have clear explanations of program\nrequirements , particularly " lock- in.\n\nDo beneficiaries understand the requirements before they enroll?\n\nOverall , we found that most beneficiaries knew about HMO requirements before they\njoined. However , the number who understand varies by HMO.\n\n Ninety percent knew they were enrolling in an HMO when they signed the\n application form. Most who did not know thought they were applying for\n supplemental insurance or additional benefits. Five people did not remember\n signing an application.\xe2\x82\xac\n\x0c Eighty-nine percent knew they could only use medical providers affiliated with\n the HMO (except for emergency or urgently-needed care).\n\n Seventy percent knew they must pay for care incurred outside the HMO\n (except for emergency or urgently-needed care). Ten percent do not remember\n if they had known this when they enrolled.\n\nThe proportion of beneficiaries who are knowledgeable about program requirements\nvaries by HMO of enrollment. To determine if factorsother than the HMO of\nenrollment account for this variation , age and gender of the respondents were\nconsidered. The analysis showed that understanding of the " lock- " provisions of\nHMO membership did correlate with age; that is , older respondents seem not to have\nunderstood the "lock- " provisions as well as younger people.\n\nTo adjust for these differences , the responses to three survey questions were\nstandardized by age and gender, and the response frequencies recalculated. The\nfollowing table shows that knowledge of "lock- " related program requirements still\ndiffers among enrollees in the six HMOs , even after standardization. (See page A-\nfor the method used to standardize for age and gender.\n\n BENEFICIARIES\' KNOWLEDGE OF REQUIREMENTS DIFFERS BY HMO\n Human Human Health Care\n CAC Av-Med\n Miami Tampa Options Florida\n When Signed Application:\n Did Not Know Enrolling in an\n HMO 15% 13% 26%\n Did Not Understand Lock- 11% 13% 17% 25%\n Did Not Know Could " Back\n Out" Prior to Enrollment\n Becoming Effective 21% 26% 14% 36%\n\nThis table indicates that some HMOs , such as Health Options and Humana in Tampa\nhave been more successful in imparting program information than others, such as\nCareFlorida.\n\nAt the time they applied for HMO coverage , almost 90 percent of the beneficiaries\nknew when their enrollment would be effective and how to get medical services.\nEighty- three percent knew what to do in regard to coverage for emergency treatment.\nAbout three- fourths knew how to see a specialist and to get other information they\nneeded about the HMO.\n\nAlthough 81 percent knew they could have " backed out" prior to their date of\nenrollment , only 61 percent knew how to disenroll. The marketing materials\nbeneficiaries receive prior to enrolling inform them of their ability to disenroll and\n\x0ctheir right to appeal. The procedures for these actions , however, are described in the\nhandbooks beneficiaries receive after enrolling.\n\nEnrollees of HMOs maintain their Medicare right to appeal denials of claims. They\nmay appeal denials of payments for emergency and urgently needed care received\noutside the HMO. They may also appeal refusals of service. However, only\n35 percent know how to appeal these HMO decisions.\n\nMost beneficiaries (88 percent) say they think their salespersons gave them accurate\ninformation. Only five percent say they were given inaccurate information. The\nothers either do not know if the information is accurate or they do not remember.\n\nHow do the HMOs compare in marketing approaches and operations?\n\nThe chart on the following page provides a summary of HMO operations and some\nfindings from the telephone survey of beneficiaries. Responses to the survey have\nbeen standardized to accommodate the respondents \' age and gender differences\namong the HMOs.\n\x0c SUMMARY OF HMO SURVEYS\n\n Humana Humana CAG Health Av-Med Care Florida\n Miami Tampa Options Employee Independent\nHMO SURVEY\n\nSales Staff\n\n Employees 140 25+\n\n Independent Agents 60+\n\n Contracted 40+\n\nSales Compensation\n Payment For Enrolling\n 30 Beneficiaries 250 $2,250 $1, 500 662 800 $2, 875 590\n Penalty For Early Outs 90 Days 90 Days 90 Days NONE 90 Days NONE NONE\n Bonus " For Longevity YES YES YES YES YES\n Bonus " on 30 Enrollees\n Staying 18 Months $750 $750 $1,080 $150 500\n Total Payment On 30\n Enrollees Staying 18 Mo. $3, 000 000 580 812 $1,800 785 $3,090\n Quotas: Employees NONE NONE NONE\n Indep. Agents NONE NONE NONE NONE NONE NONE\nSales Staff Training\n Initial Training 30 hr 30 hr 3 Days 8+hr Informal Informal Informal\n Retraining YES YES YES\nMarketing Approaches\n Television YES YES YES YES YES\n Radio YES YES\n Newspapers YES YES YES\n Mass Mailings YES YES YES\n Open Houses YES YES YES YES\n Phone Solicitation YES\nBENEFICIARY SURVEY RESPONSES\nAspects of Enrollment ...\nPressured to Join 2.5%\nNot Oear Enrolling in HMO 14.5% 4.4% 12. 25.\nUnaware of Lock- 11.2% 13. 16. 24.\nUnaware of Back- Out 20. 25. 14. 36.3%\nInitiation of HMO Contact\n HMO Initiated Contact 22. 35. 28.3% 16. 40.\n Sales Rep. Visited Home 7.4% 17.\nAspects of Services.......\nSeen MD Since Joining 81.7% 86.3% 82. 80. 78.3% 70.\nServices Found Later Not\n To be covered 16.3% 11.4% 10. 13. 16.\nUnable to See Needed\n Physician 11.2% 13. 7.4% 7.4%\nServices Worse Than\n Previous Care Source 15. 18. 11. 5.4% 13.3%\n\x0c , "\n\n\n\n\n\nSOME HMOs FAIL TO ADEQUATELY MONITOR SALES STAFF, lEAVING\xe2\x82\xac\nBENEFICIARIES VULNERABLE TO INAPPROPRIATE MARKETING\xe2\x82\xac\nPRACfICES.\xe2\x82\xac\n\nAlthough HMOs have changed several policies within the last few years to better\nmonitor sales staffs and curtail inappropriate practices , several HMO practices may\nstill leave beneficiaries vulnerable to inappropriate enrollment. For example , HMOs\nhave little or no control over salespersons attached to PCPs and clinics or independent\nagents. Further, HMOs sometimes compromise the integrity of enrollment verification\nby conducting the verification while salespersons are present in beneficiaries \' homes.\n\n Salespersons Attached to PCPs or Clinics\xe2\x82\xac\n\n The HMO has little control over salespersons attached to PCPs or clinics.\n When PCPs or clinics are financially responsible for all care provided to their\n enrollees (e.g. at risk" ), their interest in who is enrolled and who is not may be\n influenced by the health status of the member. Having the means to control\n enrollments and disenrollments makes it possible for PCPs to enroll\n beneficiaries while healthy, then disenroll them when sick.\n\n Also , a beneficiary may feel compelled to join an HMO if his doctor s agent (a\n PCP salesperson) approaches him about enrolling. Further, if he enrolls in an\n HMO because of his own primary physician s affiliation with it , he may be less\n likely to understand " lock- " as it relates to ancillary health care providers.\n\n CareFlorida currently uses salespersons attached to PCPs or PCP-groups.\xe2\x82\xac\n\n Use of Independent Agents\n\n\n Again , HMOs currently exercise little control over salespersons not in their\n employ. Although these agents have signed Codes of Ethics and other\n affidavits agreeing to adhere to HCF A and HMO marketing guidelines , they\n may not be as committed to follow them as an HMO employee would be.\n They do not have as much to lose if found using inappropriate marketing\n methods. These sales agents may lose their association with the HMO , but\n they would not jeopardize their eligibility to market other products.\n\n The fact that these agents market products in addition to HMOs could also\n hamper a beneficiary s understanding of " lock-in. " If the salesperson discusses\n several products , the beneficiary may not realize it is an HMO for which he/she\n has applied. Nine percent of the beneficiaries in the survey did not realize they\n had applied for an HMO when they signed the application.\n\n CareFlorida , Av- Med , and Humana in Miami currently use independent agents.\n\x0c Enrollment Verification Conducted from Beneficiary s Home\n\n Consistent with Florida law, most HMOs telephone potential enrollees for\n verification after the salesperson has left the home and submitted the\n application for processing. However, one HMO , Humana , telephones the\n HMO from the beneficiary s home immediately after taking the application.\n The HMO interviewer completes the telephone verification at that time.\n beneficiary who has felt pressured to join or does not understand the\n requirements may not be willing to tell the interviewer while the salesperson is\n present. Making the verification call several days after the application is signed\n enables a beneficiary who has changed his mind to more easily " back out"\n Although Humana calls beneficiaries again , it is 10 days after they have been\n enrolled.\n\n Also , verification conducted from the beneficiary s home may make the HMO\n vulnerable to claims of fraudulent enrollments. Since the salesperson places\n the call to the HMO , the verifier has no assurance that the individual the\n salesperson has him talk to is an actual applicant.\n\n\nSOME BENEFICIARIES HAVE BEEN VULNERABLE TO UNETHICAL SALES\nPRACfICES.\n\nSome beneficiaries are not fully aware of their actions when enrolling in or changing\nHMOs , and may be particularly vulnerable to unethical sales practices.\n\nThe HCF A Region IV office identified several blatant cases of abuse. According to\ntheir records , the five HMOs in the Miami area had enrolled 26 beneficiaries a total\nof 424 times since 1981. According to Florida newspaper articles , one of these\nbeneficiaries was reported to have been unaware that she had enrolled 16 times in at\nleast five HMOs since 1987.\n\nThe HCF A records show that all 26 of these beneficiaries were enrolled in an HMO\nplan during the period of this inspection. We conducted face- to- face interviews with\n22 of them. Four could not be located.\n\nThese beneficiaries were especially vulnerable people. Some could not read. Some\nhad no transportation. Most did not have a regular physician. Many had problems\nremembering their health coverage circumstances. Some seemed unconcerned about\nthese enrollment issues. Seventeen stated that they didn t know they would be\ndisenrolled automatically from their current HMO if they enrolled in another one.\n\nThe disorientation of such individuals can make them more susceptible to aggressive\nor unscrupulous sales representatives. In fact, 16 of the 22 people (over 70 percent)\nsaid that they had been influenced to change HMOs by sales representatives of the\n\x0cHMOs. This reason had been given by only 20 percent of the beneficiaries in a survey\nof a general sample of 136 multiple enrollees. (OEI- 04-91- 00640).\n\nThe enrollment records of these 26 individuals showed that virtually all of the multiple\nenrollments were in three HMOs in 1990. The table below shows these activities.\n\n ENROLLMENT ACllONS OF 26 BENEFICIARIES TOTALlED 86 IN 1990\n Number of Enrollment Actions In: Average Length of Enrollment\n CAC 88 Months\n CareFlorida 14 Months\n Humana 58 Months\n\n 3.49 Months\n\nEach beneficiary was shown his/her enrollment history which identified the current and\nall previous enrollments. When these beneficiaries were asked about their reasons for\nchanging, the most common answers were:\n\n convinced by an HMO representative;\n\n did not like previous HMO; and\n\n services were restricted or limited.\n\nSeveral of these beneficiaries described actions by HMO representatives which violate\nHCFA regulations and indicate abusive practices.\n\n Several beneficiaries reported that HMO representatives came to the their\n homes or communal gathering places and persuaded them to join an HMO\n while assuring them that their enrollment actions would not affect their\n Medicare coverage.\n\n One beneficiary said a " driver" picked him up to keep a medical appointment\n at his HMO. However, the driver took the beneficiary to a new HMO\n whereupon he was enrolled in that HMO plan. The beneficiary thought he was\n merely keeping his appointment with his current HMO.\n\n One beneficiary who was barely able to move said an HMO representative\n forcibly placed a pen in her hand and told her to sign the enrollment\n application. She signed.\xe2\x82\xac\n\x0c RECOMMENDA TIONS\xe2\x82\xac\nA number of HCF A policies and HMO practices leave the Medicare prepaid health\ncare program vulnerable to abuse. The following recommendations target those\nvulnerabilities , as well as addressing troublesome situations encountered during this\ninspection of South Florida HMOs.\n\n The HCFA should establish standards for sales force training and monitoring, and\n hold HMOs accountable for maintaining those standards.\n\nSouth Florida HMOs now engage salespersons in three ways:\n\n as HMO employees;\n\n as contracted agents marketing only that company s products; and\n\n as independent agents who sell a variety of insurance products in addition to\n HMO coverage.\n\nTraining and monitoring of these salespersons vary widely by HMO and by type of\nsales agent. Medicare-contracted HMOs must be accountable for the actions and\nsales practices of their agents , regardless of the manner of employment.\n\nThe HCF A should develop standards for the content , duration and frequency of\ntraining of sales agents , and should require HMOs to certify that those standards are\nbeing upheld. Appropriate training of new salespersons must apply equally to\nindependent agents and HMO marketing staff. Periodic sales meetings should be held\nto impart information on new HCF A regulations and policies. Such meetings should\nalso be used to correct aberrant sales practices detected by the HMOs.\n\nSalespersons should be tested to assure that they understand all germane Medicare\nrules , HMO services , and restrictions , as well as individual company policies.\nSalespersons should be retrained as necessary and retested periodically. The HMOs\nshould maintain records of each agent\' s participation in training and performance on\ntests.\n\nThe HCF A should require that each HMO maintain records on and investigate\nenrollee complaints about sales staff. Where a determination is made that individual\nagents have been involved in inappropriate marketing and enrollment activities , such\nas " cold calls " to Medicare beneficiaries \' homes , HCF A should require that disciplinary\nmeasures be taken.\n\x0c The HCFA should establish a policy limiting enroUment to one "open season\n (opportunity to enroU) per year.\n\n\nPresently, HCF A rules allow Medicare beneficiaries to change their health insurance\xe2\x82\xac\ncoverage as frequently as every month. Disenrollment from prior coverage \xe2\x82\xac\nautomatic when the new enrollment occurs. This policy allows beneficiaries to change\xe2\x82\xac\nplans without thoughtful consideration of the pros and cons of their actions. The\xe2\x82\xac\npolicy also encourages an aggressive approach to sales , since it allows a new sale to\xe2\x82\xac\neach enrollee every 30 days.\n\n\nThis policy clearly undermines HCF A\' s commitment to managed health care. It also\nincreases the likelihood of confusion among beneficiaries over coverage issues , and\nmay jeopardize the well-being of those who have not made thoughtful decisions.\nBased on health insurance industry norms, HCF A should establish an annual " open\nseason " so that changes in coverage may be made only once a year. The effective\ndate of change should be no sooner than 30 days after a new plan/form of coverage is\nselected by the beneficiary.\n\nTo safeguard that beneficiaries are not disadvantaged by enrollment decisions contrary\nto their best interests , HCF A should allow disenrollment "for cause " between open\nseason periods. The HCFA should develop the criteria for determining whether\nsufficient " cause " is established.\n\n The HCFA should establish an on-line system to identify and review cases of\xe2\x82\xac\n frequent enrollment change.\n\nThe HCF A\' s automated systems are capable of identifying individual Medicare\nbeneficiaries who have applied for HMO enrollment at the point each new enrollment\nbegins. The agency should capitalize on this capability by:\n\n determining an appropriate threshold for number of changes acceptable over a\n specified period of time (e. , two per year) or minimum time between new\n enrollments (e.g. , 6 months);\n\n automatically scanning new enrollments for beneficiaries who exceed those\xe2\x82\xac\n thresholds;\xe2\x82\xac\n\n alerting the new HMO-of-enrollment to these cases , with adequate beneficiary\xe2\x82\xac\n identification information;\n\n requiring the HMO to explain and document the circumstances surrounding the\n sale and application for enrollment; and\n\n developing corrective actions and penalties for HMOs found to have\xe2\x82\xac\n inappropriately enrolled Medicare beneficiaries.\xe2\x82\xac\n\x0cWe note that HCFA has already taken preliminary steps to develop such a system.\nWe endorse the agency s early efforts in this regard. The refinements outlined above\nare recommended to strengthen and standardize HCF A\' s monitoring of excessively\nfrequent HMO enrollment change.\n\nThe system recommended here would be obviated by implementation of\xe2\x82\xac\nRecommendation #2 above or Recommendation #4 below.\n\n In the three-county Miami service area, HCFA should test the efficacy of a third\xe2\x82\xac\n party handling HMO enroUment actions.\xe2\x82\xac\nA major vulnerability of the present system is that an HMO sales agent can sign up\nMedicare beneficiary in his/her home at the time of the sales presentation.\nBeneficiaries may not object to this practice in many instances, since it is convenient.\nHowever, in cases where the beneficiary is intimidated by the sales agent, he/she may\nsign-up just to get the sales person to leave.\n\n\nAlthough the HMOs included in this review do have procedures for verifying that\nbeneficiaries understand certain provisions of HMO coverage , this may not be\nadequate protection against inappropriate sales practices. We note in this report that\none HMO allows the verification call to be made while the salesperson is still present\nin the beneficiary s home.\n\nThe best safeguard for an informed choice by the beneficiary is to ensure that the\ndecision to enroll in a new HMO is made independent of the sales person and even of\nthe HMO.\n\nWe recommend that HCFA contract , on a 2 to 3 year pilot basis , with a third party to\nprovide HMO enrollment services. One possible enrollment agent is the Social\nSecurity Administration (SSA) District Offices (DO). In each DO in the Miami area\nHCF A could fund a position or part of a position for a service representative to advise\nnew enrollees on their decisions , and process the enrollments. An SSA service\nrepresentative would be able to provide objective , balanced information on health\ncoverage to the beneficiary, and answer applicants \' questions stemming from the sales\npresentation.\n\nThis proposal is consistent with Secretary Sullivan s Program Direction which calls for\na more expansive role for SSA district offices in integrating SSA and other health and\nhuman services.\xe2\x82\xac\n\nIf an arrangement cannot be made with SSA, HCF A might contract for this service\nwith a private contractor in the Miami area. Such services could possibly be provided\nunder the auspices of senior citizen or other neighborhood service centers. Assuming\nproper guidelines are provided to the contractor , this recommendation would obviate\nRecommendations #2 and #3 above.\n\x0c The HCFA should impose a "cooling off\' period allowing beneficiaries to\n reconsider HMO enrollment decisions before enrollment applications are processed.\n\nFlorida law now requires that , after an individual has applied to enroll in an HMO , a\nverification phone call must be made by the HMO to ascertain the applicant\'\nunderstanding of the " lock- " feature of HMO enrollment , and assure that he/she\naffirms his enrollment decision. This consumer protection step would seem a good\nmodel for HCF A to adopt , with application nationally, to cover Medicare beneficiary\nenrollments in prepaid health plans.\n\nTo further refine Florida s model , HCF A should require that enrollment verification\ntake place no sooner than 72 hours after the beneficiary has signed his/her application\nto enroll. This " cooling-off\' period is consistent with consumer contract protection in\nmany States.\n\x0c APPENDIX A\xe2\x82\xac\n METHODS AND SAMPLE SELECfION\n\n\nInformation for this inspection was obtained from:\n\n a review of HCFA regulations to determine Federal requirements for HMOs;\n\n a review of the marketing materials used by each HMO to determine if they\n meet HCF A requirements;\n\n discussions with officials representing each HMO to learn each company\n policies and practices;\n\n a telephone survey of 601 randomly selected Medicare beneficiaries to ascertain\n their experiences joining an HMO; and\n\n face- to-face interviews with 22 beneficiaries who had 15 or more multiple\n enrollments to determine their reasons for changing HMOs frequently.\n\nReview of H CF A Regulations\n\nThe HCF A regulations relating to HMO requirements were examined to compare\nwith HMO practices. Monitoring requirements for HCF A site visits and reports of\nHCF A visits to each of the HMOs were also reviewed.\n\nReview of HMO Marketing Requirements\n\nMarketing and membership materials from each HMO were examined for compliance\nwith HCF A requirements. Particular attention was paid to each HMO\' s explanation\nof " lock- " instructions for obtaining emergency and urgently-needed care , and\nprocedures for filing complaints and appeals.\n\nDiscussions with HMO Officials\n\nSite visits were made to all to verify their marketing policies and procedures.\n HMOs\n\nDiscussions were held with HMO officials such as Chief Operating Officers and\nMedicare Compliance Directors. In each location , Marketing Directors and Customer\nService Managers were always included in the discussions.\n\x0cTelephone Survey of Beneficiaries\xe2\x82\xac\n\nThe survey universe consisted of 37 423 beneficiaries who enrolled in one of the six\nselected South Florida HMOs between January and October 1990. This was their\nfirst , and only, enrollment in an HMO. Eighty-two percent of them were still\nmembers as of November 1. Eighteen percent had disenrolled and returned to the\nregular fee- for-service Medicare program.\n\n\nA stratified sample of 839 of these beneficiaries was selected. The sample was\nreduced to 833 because 6 beneficiaries were deceased.\n\nThe survey was conducted between January 7 and 25 , 1991. A letter was sent to each\nperson in the sample explaining the purpose of the survey. Each was asked to provide\nhis/her telephone number by returning a postcard enclosed with the letter. Phone\nnumbers were also obtained from Directory Assistance and directories that list\ntelephone numbers by street addresses.\n\nPostcards were sent to beneficiaries for whom no telephone numbers could be found\xe2\x82\xac\nand to beneficiaries who could not be reached after calling their homes at least three\xe2\x82\xac\ntimes. Those beneficiaries were asked to call a toll-free telephone number so an\xe2\x82\xac\nappointment to conduct the survey could be arranged.\n\n\nFrom the sample of 833 beneficiaries , 601 interviews were conducted yielding an\noverall response rate of 72 percent.\n\nThe sample and response rate from each HMO was as follows:\xe2\x82\xac\n\n HMO\xe2\x82\xac NUMBER IN SAMPLE NUMBER OF RESPONSE RA 1E\n RESPONSES\n Humana - Miami 210\xe2\x82\xac 135\xe2\x82\xac\n Humana - Tampa\xe2\x82\xac\n CAC\xe2\x82\xac 132\xe2\x82\xac\n Av- Med\xe2\x82\xac 133\xe2\x82\xac\n Health Options\n 132\xe2\x82\xac 103\xe2\x82\xac\n CareFlorida\xe2\x82\xac 131\xe2\x82\xac\n 833\xe2\x82\xac 601\xe2\x82\xac\n\n\nTo compute overall findings for the report , responses to the questionnaire were\nweighted according to each HMO\' s proportion of the universe. The unweighted\nactual frequencies of responses, however , are shown in appendix B.\n\n\n\n A -\xe2\x82\xac\n\x0cIn addition to the 601 beneficiaries interviewed , another 10 beneficiaries were\ncontacted , but could not be interviewed. They maintained they had not been in an\xe2\x82\xac\nHMO and could not answer questions about enrollment. HCF A records indicate all\xe2\x82\xac\n10 had been in HMOs , and that , as of November 1 , 1990, 5 were still enrolled. The\xe2\x82\xac\nenrollments were distributed fairly evenly among the HMOs:\xe2\x82\xac\n\n two in Humana- Miami;\xe2\x82\xac\n\n one in Humana- Tampa;\xe2\x82\xac\n\n two in CAC;\xe2\x82\xac\n\n one in Av- Med;\xe2\x82\xac\n\n two in Health Options; and\xe2\x82\xac\n\n two in CareFlorida.\xe2\x82\xac\n\nStandardization of Responses\xe2\x82\xac\n\nDue to differences in the age and gender distribution of enrollees among the HMOs\xe2\x82\xac\nthe proportions of respondents answering each question were standardized to\xe2\x82\xac\neliminate differences that might be attributable solely to the age and gender of an\xe2\x82\xac\nenrollee. Using the total population of respondents as the referent group, the direct\nmethod of standardization was used. ! Within the two genders , three age groups were\ncreated: under 65 years of age , 65 to 74 years of age , and 75 years of age or older.\nThe six categories , with the appropriate weights are:\xe2\x82\xac\n\n Age Group Sex Weight\n -c::: 65 Yrs. Male 070\n Female 073\n\n 65- 74 Yrs. Male 297\n Female 0.347\n\n 75 + Yrs. Male 085\n Female 128\n\nThe responses in tables on pages 12 and 14 present standardized proportions.\xe2\x82\xac\n\n\n\n\n Harold A Kahn and Christopher T. Sempos Statistical Methods in Epidemiology. Oxford\xe2\x82\xac\nUniversity Press , 1989\n\n\n A -\xe2\x82\xac\n\x0cFace-to-Face Interviews\n\nThe HCF A Region IV office identified 26 beneficiaries whom HMOs had enrolled\ntotal of 424 times in the last 10 years. Face- to-face interviews were conducted with\nthese beneficiaries.\n\nWe interviewed 21 of the 26 beneficiaries and the spouse of a recently deceased\nbeneficiary. We were unable to locate the remaining four beneficiaries. The\ninterviews were performed between January 28 and 31 , 1991. The response rate was\n85 percent. Appendix C contains the survey instrument and response frequencies.\n\x0c APPENDIX\n RESPONSES TO TELEPHONE SURVEY\n OF BENEFICIARIES\n\nThe answers shown below in capital letters were not read to respondents. No prompts\nof possible answers were given to respondents.\n\n The first number listed shows the frequency of responses for the 601\n respondents to the survey. Numbers in parenthesis reflect the unweighted\n percent of responses overall and within each HMO. The sum of the individual\n percentages may not equal 100 percent due to independent rounding.\n\n Not all respondents answered every question.\n\n Legend: H(M) Humana - Miami\n H(T) Humana - Tampa\n CAC Comprehensive American Care\n Av-Med Av- Med Health Plan\n Health Op Health Options\n CFL CareFlorida\n\n How did you first hear about (Name of HMO)?\n (Respondents could mention more than one means.\n\n\n FROM FRIEND OR RELATIVE: 316\xe2\x82\xac\n H(M) H(1) CAC Av- Med Health Op CFL\xe2\x82\xac\n\n\n TELEVISION ADVERTISING: 96\xe2\x82\xac\n H(M) H(1) CAC Av- Med Health Op CFL\xe2\x82\xac\n\n\n HMO SALESPERSON CAME TO HOME:\xe2\x82\xac\n H(M) H(1) CAC Av- Med Health Op CFL\xe2\x82\xac\n\n\n NEWSPAPER ADVERTISING: 47\xe2\x82\xac\n H(M) H(1) CAC Av- Med Health Op CFL\xe2\x82\xac\n\n\n ADVERTISEMENTS IN THE MAIL: 28\xe2\x82\xac\n H(M) H(1) CAC Av- Med Health Op CFL\xe2\x82\xac\n\n\n FROM DOCTOR\' S OFFICE: 21\xe2\x82\xac\n H(M) H(1) CAC Av- Med Health Op CFL\xe2\x82\xac\n\x0c RADIO ADVERTISING: 17\n\n H(M) H(T) CAC Av- Med Health Op CFL\n\n\n\nAT SENIOR CITIZEN\' S GROUP: 8\n\nH(M) H(T) CAC Av- Med Health Op CFL\n\n\n\nFROM SOCIAL SECURITY OFFICE: 4\nH(M) H(T) CAC Av- Med Health Op CFL\n\n\nOTHER: 112\nH(M) H(T) CAC Av-Med Health Op CFL\n\n\n\n\n Did you call (Name of HMO) to get information, or did (Name of\n HMO) contact you to ask you to enroll?\nBENEFICIARY INITIAlED CONTACf: 433 (72%)\n H(M) H(T) CAC Av- Med Health Op CFL\n100(74%) 62(66%) 55(68%) 78(85%) 83(81 %) 55(57%)\nHMO INITIAlED CONTACf: 150 (25%)\n H(M) H(T) CAC Av-Med Health Op CFL\n30(22%) 31(33%) 24(30%) 9(10%) 17(17%) 39(41%)\n\nBENEFICIARY DOES NOT REMEMBER: 17 (3%)\n H(M) H(T) CAC Av- Med Health Op CFL\n5(4%) 1(1%) 1(1%) 5(5%) 3(3%) 2(2%)\n\n Number Not Responding: 1 (0. 1%)\n H(M)\n H(T) CAC Av- Health Op\n 1(1%) Med CFL\n\n\n How did the HMO contact you?\n\n (Asked only of the 150 who said the HMO contacted them.\n\n\n\n H(M) H(T) CAC Av-\nSALESPERSON\n\n\n\n10(33%) 10(32%) 7(29%)\n STOPPED BY HOME : 57 (38%)\n Med\n 2(22%)\n Health Op\n 11(65%)\n CFL\n 17(44%)\n\n\n H(M) H(T) CAC Av-Med\nSALESPERSON CONTACTED BENEFICIARY BY PHONE : 51 (34%)\n Health Op\n CFL\n\n12(40%) 13(42%) 8(33%) 5(56%) 3(18%) 10(26% )\n\nSALESPERSON STOPPED BY A " GROUP GArnERING PLACE" (like a Senior Citizen\n\n H(T) CAC Av-Med Health Op CFL\nCenter): 3 (2%)\n H(M) 1(3%)\n 1(3%) 1(3%)\n\x0c H(M) H(T) CAC Av-Med\nSALESPERSON CONTACfED\n\n\n\n7(23%) 7(23%) 9(38%) 2(22%)\n BY OTHER MEANS : 39 (26%)\n Health Op\n 3(18%)\n CFL\n 11(28%)\n\n\na. Do you know how the salesperson got your name?\n(Asked only of the 150 who said the HMo contacted them.\n\nNO: 87 (58%)\n H(M) H(T) CAC Av- Med Health Op CFL\n19(63%) 25(81%) 9(38%) 6(67%) 8(47%) 20(51%)\n\nYES: 52 (35%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 9(30) 5(16%) 10(42%) 3(33%) 7(41%) 18(46%)\n\n Number Not Responding: 11 (7%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 2(7%) 1(3%) 5(21%) 2(12%) 1(3%)\n\n\nb. Where?\n(Asked only of the 52 who answered YES to 3.\n\n\n H(M) H(T) FROM FRIEND OR RELATIVE\n CAC Av-Med Health Op\nSALESPERSON GOT NAME\n\n\n\n 3(33%) 3(60%) 1(10%) 2(67%) 2(29%)\n : 13 (25%)\n CFL\n 2(11%)\n\n\n H(M) H(T) 2(20%)\nSALESPERSON GOT NAMES DOcrOR\n CAC Av-Med Health Op\n 1(14%)\n FROM BENEFICIARY\' : 7 (13%)\n CFL\n 4(22%)\n\n\n H(M) H(T) CAC Av-Med\nSALESPERSON GOT NAME\n\n\n\n 2(22%) 1(20%) 2(20%)\n FROM MEDICARE : 5 (10%)\n Health Op CFL\n\n\n\n H(M) H(T) CAC Av-Med\nSALESPERSON GOT NAME\n\n\n\n 1(11%) 1(20%)\n FROM SOCIAL SECURITY: 4 (8%)\n Health Op CFL\n 2(11 %)\n\n\n H(M) H(T) 5(50%)\n 3(33%) CAC Av-Med\nSALESPERSON GOT NAME\n\n\n\n 1(33%)\n FROM OTHER SOURCE : 23 (44%)\n Health Op\n 4(57%)\n CFL\n 10(56%)\n\n\nWhere did the salesperson say he or she was from?\nTHE HMO: 504 (84%)\n H(M)\n120(89%) 84(89%)\n H(T) CAC\n 62(77%)\n Av- Med\n 83(90%)\n Health Op\n 77(75%)\n CFL\n 78(81 %)\n\n\n H(M) H(T)\nTHE GOVERNMENT: 2 (0.3%)\n CAC Av-Med Health Op CFL\n\x0c 1(1%) 1(1%)\n\nSALESPERSON DID NOT SAY: 7 (1%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(1%) 2(2%) 1(1 %) 3(3%)\n\nBENEFICIARY DOES NOT REMEMBER: 31 (5%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\xe2\x82\xac\n10(7%) 4(4%) 5(6%) 1(1 %) 7(7%) 4(4%)\xe2\x82\xac\n\n Number Not Responding: 57 (9%)\n H(M) H(T) CAC Av-Med Health Op CFL\xe2\x82\xac\n5(4%) 6(6%) 12(15%) 6(7%) 18(17%) 10(10%)\xe2\x82\xac\n\n\nWho filled out the application form?\xe2\x82\xac\nSALESPERSON: 323 (54%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\n80(59%) 61(65%) 42(52%) 40(43%) 37(36%) 63(66%)\n\nBENEFICIARY: 188 (31%)\n H(M) H(T) CAC Av- Med Health Op CFL\n39(29%) 20(21 %) 15(19%) 40(43%) 52(50%) 22(23%)\n\nFRIEND OR RELATIVE: 24 (4%)\n H(M) H(T) CAC Av- Med Health Op CFL\xe2\x82\xac\n 3(2%) 4(4%) 5(6%) 4(4%) 4(4%) 4(4%)\xe2\x82\xac\n\nDOCTOR\' S OFFICE: 5 (1%)\n H(M) H(T) CAC Av- Med Health Op CFL\xe2\x82\xac\n 2(2%) 3(3%)\xe2\x82\xac\n\nSOCIAL SECURITY OFFICE: 2 (0.3%)\n\n H(M) H(T) CAC Av- Med Health Op CFL\xe2\x82\xac\n 1(1 %) 1(1 %)\xe2\x82\xac\n\nOTHER: 28 (5%)\n H(M) H(T) CAC Av-Med Health Op CFL\n5(4%) 4(4%) 11(14%) 4(4%) 2(2%) 2(2%)\n\nBENEFICIARY DOES NOT REMEMBER: 28 (5%)\n H(M) H(T) CAC Av- Med Health Op CFL\n8(6%) 5(5%) 3(4%) 3(3%) 8(8%) 1(1%)\n\n Number Not Responding: 3 (0.4%)\n H(M) H(T) CAC Av- Med Health Op CFL\xe2\x82\xac\n 2(2%) 1(1 %)\xe2\x82\xac\n\n\na. When you signed the application, was it clear to you that you were emolling\xe2\x82\xac\nin a Health Maintenance Organization?\xe2\x82\xac\nYES: 525 (87%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\xe2\x82\xac\n\n\n B - 4\xe2\x82\xac\n\x0c122(90% ) 88(94%) 67(83%) 80(87%) 97(94%) 71(74% )\n\nNO: 66 (11%)\n H(M) H(T)\n13(10%) 5(5%)\n CAC\n 11(14%)\n Av- Med Health Op CFL\n 10(11%) 5(5%) 22(23%)\n\n\n H(M) H(T) CAC\nBENEFICIARY DOES NOT REMEMBER SIGNING APPLICATION: 5 (1%)\n\n 1(1%)Av- Med Health Op 3(3%)\n CFL\n 1(1%)\n H(M) H(T)\n Number Not Responding: 5 (1\n CAC Av-\n 1(1%) 2(2%) Med\n 1(1%)\n Health Op\n 1(1%)\n CFL\n\n\n\nb. Do you recall what you thought you were signing?\n (Asked only of the 66 who answered NO to 6.\n\nNO: 18 (27%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 5(38%) 6(55%) 1(10%) 6(27%)\n\nYES: 46 (70%)\n H(M) H(T) CAC Av-Med Health Op CFL\n6(46%) 5(100%) 5(45%) 9(90%) 5(100%) 16(73%)\n\n Number Not Responding: 2 (3%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\n2(15%)\n\n\nc. What did you think you were signing?\n (Asked only of the 46 who answered YES to 6.\n\nAPPLICATION FOR SUPPLEMENTAL INSURANCE: 15 (33%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(17%) 1(20%) 2(40%) 3(33%) 3(60%) 5(31%)\n\nAPPLICATION FOR ADDITIONAL BENEFITS: 8 (17%)\n H(M) H(T) CAC Av- Med Health Op CFL\n3(50%) 1(20%) 2(22%) 2(13%)\nFORM FOR MEDICARE/GOVERNMENT: 7 (15%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(20%) 3(60%) 2(22%) 1(6%)\n\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(20%) 3(60%) 2(22%)\nOTHER: 5 (11%)\n H(M) H(T) CAC Av- Med Health Op CFL\n1(17%) 1(20%) 3(19%)\n\n\n H(M)\n1(17%)\n H(T) CAC Av-\n 1(20%)\n Number Not Responding: 11 (24%)\n Med\n 2(22%)\n Health Op\n 2(40%)\n CFL\n 5(31%)\n\n\n B - 5\n\n\x0cWhen you signed the application, did you know that unless it was an\xe2\x82\xac\nemergency, or you were outside the service area and urgently needed care, you\ncould only go to (Name of HMO\' s) doctors, hospitals, and medical providers?\nYEs: 527 (88%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 120(89%) 88(94%) 68(84%) 78(85%) 98(95%) 75(78%)\n\nNO: 69 (11%)\n H(M) H(T) CAC Av- Med Health Op CFL\n15(11%) 6(6%) 10(12%) 13(14%) 4(4%) 21(22%)\n\n Number Not Responding: 5 (1%)\n H(M) H(T) CAC Av- Med Health Op CFL\xe2\x82\xac\n 3(4%) 1(1 %) 1(1%)\xe2\x82\xac\n\n\nWhen enrolled in the HMO, did the salesperson ask if you:\xe2\x82\xac\na. Were in good health?\nYEs: 282 (47%)\n H(M) H(T) CAC Av- Med Health Op CFL\n76(56%) 50(53%) 31(38%) 36(39%) 45(44%) 44(46%)\n\nNO: 181 (30%)\n H(M) H(T) CAC Av-Med Health Op CFL\n31(23%) 23(24%) 39(48%) 24(26%) 33(32%) 31(32%)\n\nBENEFICIARY DOES NOT REMEMBER: 127 (21 %)\n H(M) H(T) CAC Av- Med Health Op CFL\n28(21 %) 21(22%) 9(11%) 29(32%) 19(18%) 21(22%)\n\n Number Not Responding: 11 (2%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 2(2%) 3(3%) 6(6%)\n\n\nb. Had health problems?\xe2\x82\xac\nYES: 246 (41%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\n66(49%) 47(50%) 27(33%) 37(40%) 37(36%) 32(33%)\n\nNO: 229 (38%)\n H(M) H(T) CAC Av- Med Health Op CFL\n43(32%) 28(30%) 44(54%) 28(30%) 42(41%) 44(46%)\n\nBENEFICIARY DOES NOT REMEMBER: 117 (19%)\n H(M) H(T) CAC Av- Med Health Op CFL\n26(19%) 19(20%) 8(10%) 26(28%) 18(17%) 20(21 %)\n\n Number Not Responding: 9 (1%)\n H(M) H(T) CAC Av- Med Health Op CFL\xe2\x82\xac\n\n\n B - 6\xe2\x82\xac\n\x0c 2(2%) 1(1%) 6(6%)\n\n\nc. Were being treated by a doctor?\nYEs: 252 (42%)\n H(M) H(T) CAC Av- Med Health Op CFL\n67(50%) 49(52%) 27(33%) 35(38%) 34(33%) 40(42%)\n\nNO: 201 (33%)\n H(M) H(T) CAC Av- Med Health Op CFL\n41(30%) 20(21%) 38(47%) 26(28%) 41(40%) 35(36%)\n\nBENEFICIARY DOES NOT REMEMBER: 138 (23%)\n H(M) H(T) CAC Av- Med Health Op CFL\n27(20%) 25(27%) 14(17%) 30(33%) 21(20%) 21(22%)\n\n Number Not Responding: 10 (2%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 2(2%) 1(1%) 7(7%)\n\n\nd. Needed medical services at the time?\nYES: 177 (29%)\n H(M) H(T) CAC Av- Med Health Op CFL\n48(36%) 30(32%) 19(23%) 23(25%) 25(24%) 32(33%)\n\nNO: 263 (44%)\n H(M) H(T) CAC Av-Med Health Op CFL\n60(44%) 37(39%) 45(56%) 27(29%) 52(50%) 42(44%)\n\nBENEFICIARY DOES NOT REMEMBER: 140 (23%)\n H(M) H(T) CAC Av- Med Health Op CFL\n26(19%) 27(29%) 15(19%) 31(34%) 19(18%) 22(23%)\n\n Number Not Responding: 21 (3%)\xe2\x82\xac\n H(M) H(T) CAC Av-Med Health Op CFL\n1(1%) 2(2%) 11(12%) 7(7%)\n\n\nDid the salesperson push you or pressure you to join (Name of HMO)?\nYES: 21 (3%)\n H(M) H(T) CAC Av- Med Health Op CFL\n5(4%) 5(5%) 2(2%) 4(4%) 5(5%)\n\nNO: 564 (94%)\n H(M) H(T) CAC Av-Med Health Op CFL\n130(96%) 88(94%) 73(90%) 87(95%) 95(92%) 91(95%)\n\n Number Not Responding: 16 (3%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(1 %) 6(7%) 1(1%) 8(8%)\n\n\n\n B - 7\n\n\x0c10. Were you offered any incentives, like a gift, to join (Name of HMO)?\n YEs: 0\n H(M) H(1) CAC Av-Med Health Op CFL\n\n\n NO: 589 (98%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 135(100%) 94(100%) 76(94%) 91(99%) 97(94%) 96(100%)\n\n Number Not Responding: 12 (2%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 5(6%) 1(1 %) 6(6%)\n\n\n11. I\'m going to read to you some methods a salesperson might use to try to get\n people to join an HMO. Did the salesperson that signed you up use any of\n these?\n\n a. Keep encouraging you to join even if you said you were not interested?\n YEs: 20(3%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 7(7%) 3(4%) 1(1%) 2(2%) 7(7%)\n\n NO: 540 (90%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 132(98%) 85(90%) 67(83%) 86(93%) 89(86%) 81(84%)\n\n BENEFICIARY DOES NOT REMEMBER: 22 (4%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 3(2%) 1(1 %) 4(5%) 3(3%) 3(3%) 8(8%)\n\n Number Not Responding: 19 (3%)\xe2\x82\xac\n H(M) H(1) CAC Av- Med Health Op CFL\n 1(1 %) 7(9%) 2(2%) 9(9%)\n\n\n b. Promise to leave as soon as you signed?\n\n YES: 37 (6%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 5(4%) 9(10%) 6(7%) 4(4%) 8(8%) 5(5%)\n\n NO: 487 (81%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 123(91 %) 74(79%) 47(58%) 81(88%) 78(76%) 84(88%)\n\n BENEFICIARY DOES NOT REMEMBER: 41 (7%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 7(5%) 6(6%) 11(14%) 4(4%) 6(6%) 7(7%)\n\n Number Not Responding: 36 (6%)\xe2\x82\xac\n H(M) H(1) CAC Av- Med Health Op CFL\n\n\n\n B-8\n\x0c 5(5%) 17(21 %) 3(3%) 11(11 %)\n\n\nc. Tell you it would be more difficult to sign up if you waited until later?\nYEs: 24 (4%)\n H(M) H(T) CAC Av-Med Health Op CFL\n4(3%) 8(9%) 3(3%) 5(5%) 4(4%)\n\nNO: 518 (86%)\n H(M) H(T) CAC Av- Med Health Op CFL\n123(91 %) 77(82%) 67(83%) 83(90%) 83(81 %) 85(89%)\n\nBENEFICIARY DOES NOT REMEMBER: 39 (6%)\n H(M) H(T) CAC Av- Med Health Op CFL\n8(6%) 7(7%) 7(9%) 4(4%) 6(6%) 7(7%)\n\n Number Not Responding: 20 (3%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 2(2%) 7(9%) 2(2%) 9(9%)\n\n\n Tell you it would be hard to get medical care if you did not join?\nYES: 8 (1%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(1%) 3(3%) 1(1 %) 3(3%)\n\nNO: 546 (91%)\n H(M) H(T) CAC Av- Med Health Op CFL\n129(%%) 88(94%) 66(81 %) 87(95%) 91(88%) 85(89%)\n\nBENEFICIARY DOES NOT REMEMBER: 28 (5%)\n H(M) H(T) CAC Av- Med Health Op CFL\n5(4%) 2(2%) 8(10%) 3(3%) 2(2%) 8(8%)\n\n Number Not Responding: 19 (3%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(1%) 7(9%) 2(2%) 9(9%)\n\n\ne. Is there anything else you would like to say about the methods the\nsalesperson used to try to get you to sign up?\nYES: 88 (15%)\n H(M) H(T) CAC Av- Med Health Op CFL\n23(17%) 26(28%) 12(15%) 7(8%) 11(11%) 9(9%)\n\nNO: 490 (82%)\n H(M) H(T) CAC Av- Med Health Op CFL\n112(83%) 67(71%) 58(72%) 83(90%) 83(81 %) 87(91%)\n\n Number Not Responding: 23 (4%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 1(1%) 11(14%) 2(2%) 9(9%)\n\n\n B-9\n\x0c12.\t After you signed the application, did you know you could change your mind\n and " back out" before the enrollment took effect?\n\n YEs: 480 (80%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 104(77%) 86(91%) 58(72%) 75(82%) 93(90%) 64(67%)\n\n NO: 109 (18%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 29(21 %) 6(6%) 20(25%) 14(15%) 8(8%) 32(33%)\n\n Number Not Responding: 12 (2%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\n 2(1%) 2(2%) 3(4%) 3(3%) 2(2%)\n\n\n\n13. At the time you signed up, did you know:\n\n a. The date your enrollment would take effect?\n YEs: 511 (85%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 115(85%) 87(93%) 68(84%) 78(85%) 92(89%) 71(74%)\n\n NO: 34 (6%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 12(9%) 3(3%) 1(1 %) 7(8%) 2(2%) 9(9%)\n\n BENEFICIARY DOES NOT REMEMBER: 44 (7%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 7(5%) 2(2%) 9(11 %) 4(4%) 6(6%) 16(17%)\n\n Number Not Responding: 12 (2%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(1%) 2(2%) 3(4%) 3(3%) 3(3%)\n\n\n b. How to get medical services?\n YES: 523 (87%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 119(88%) 83(88%) 63(78%) 83(90%) 94(91 %) 81(84%)\n\n NO: 43 (7%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 10(7%) 6(6%) 8(10%) 3(3%) 5(5%) 11(11%)\n\n BENEFI CIAR Y DOES NOT REMEMBER: 22 (4%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 5(4%) 3(3%) 7(9%) 2(2%) 1(1 %) 4(4%)\n\n\n\n\n B - 10\n\x0c Number Not Responding: 13 (2%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(1 %) 2(2%) 3(4%) 4(4%) 3(3%)\n\n\nc. What you should do in emergency situations?\nYEs: 482 (80%)\n H(M) H(T) CAC Av- Med Health Op CFL\n117(87%) 76(81%) 62(77%) 69(75%) 87(84%) 71(74%)\n\nNO: 76 (13%)\n H(M) H(T) CAC Av- Med Health Op CFL\n15(11%) 12(13%) 8(10%) 13(14%) 9(9%) 19(20%)\n\nBENEFICIARY DOES NOT REMEMBER: 29 (5%)\n H(M) H(T) CAC Av- Med Health Op CFL\n2(1%) 4(4%) 8(10%) 6(7%) 4(4%) 5(5%)\n\n Number Not Responding: 14 (2%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\n 1(1%) 2(2%) 3(4%) 4(4%) 3(3%) 1(1%)\n\n\nd What to do if you needed to see a specialist?\n\nYES: 454 (76%)\n H(M) H(T) CAC Av- Med Health Op CFL\n101(75%) 66(70%) 57(70%) 79(86%) 94(91%) 57(59%)\n\nNO: 95 (16%)\n H(M) H(T) CAC Av- Med Health Op CFL\n27(20%) 20(21 %) 12(15%) 6(7%) 4(4%) 26(27%)\n\nBENEFICIARY DOES NOT REMEMBER: 38 (6%)\n H(M) H(T) CAC Av- Med Health Op CFL\n6(4%) 6(6%) 9(11%) 3(3%) 2(2%) 12(13%)\n\n Number Not Responding: 14 (2%)\xe2\x82\xac\n H(M) H(T) CAC Av- Med Health Op CFL\n1(1%) 2(2%) 3(4%) 4(4%) 3(3%) 1(1%)\n\n\ne. How to get other information you needed?\nYES: 426 (71 %)\n H(M) H(T) CAC Av- Med Health Op CFL\n98(73%) 70(74%) 53(65%) 72(78%) 86(83%) 47(49%)\n\nNO: 98 (16%)\n H(M) H(T) CAC Av- Med Health Op CFL\n21(16%) 12(13%) 11(14%) 12(13%) 13(13%) 29(30%)\n\nBENEFICIARY DOES NOT REMEMBER: 61 (10%)\n H(M) H(T) CAC Av- Med Health Op CFL\n\n\n B - 11\n\n\x0c 13(10%) 10(11%) 14(17%) 4(4%) 1(1%) 19(20%)\n\n Number Not Responding: 16 (3%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 3(2%) 2(2%) 3(4%) 4(4%) 3(3%) 1(1%)\n\n\n f. How to disenroII, or "get out" of the HMO?\n YEs: 368 (61%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 80(59%) 60(64%) 48(59%) 55(60%) 74(72%) 51(53%)\n\n NO: 175 (29%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 43(32%) 24(26%) 21(26%) 27(29%) 24(23%) 36(38%)\n\n BENEFICIARY DOES NOT REMEMBER: 45 (7%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 11(8%) 8(9%) 9(11 %) 6(7%) 3(3%) 8(8%)\n\n Number Not Responding: 13 (2%)\n H(M) H(1) CAC Av-Med Health Op CFL\n 1(1 %) 2(2%) 3(4%) 4(4%) 2(2%) 1(1%)\n\n\n g. How to appeal decisions (Name of HMO) makes concerning your medical\n care?\n YES: 219 (36%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 43(32%) 39(41%) 23(28%) 35(38%) 51(50%) 28(29%)\n\n NO: 259 (43%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 68(50%) 39(41 %) 28(35%) 38(41%) 36(35%) 50(52%)\n\n BENEFICIARY DOES NOT REMEMBER: 109 (18%)\n H(M) H(1) CAC Av-Med Health Op CFL\n 23(17%) 14(15%) 26(32%) 15(16%) 14(14%) 17(18%)\n\n Number Not Responding: 14 (2%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 1(1%) 2(2%) 4(5%) 4(4%) 2(2%) 1(1%)\n\n\n14.\t In addition to the things I just mentioned, is there anything you later learned\n about being in an HMO that you wished you had known before you signed up?\n YES: 100 (17%)\n H(M) H(1)\n 27(20%) 19(20%)\n CAC\n 9(11 %)\n Av- Med\n 16(17%)\n Health Op CFL\n 16(16%) 13(14%)\n\n NO: 483 (80%)\n H(M) H(1) CAC Av- Med Health Op CFL\n\n\n B - 12\n\x0c 106(79%) 73(78%) 66(81 %) 72(78%) 84(82%) 82(85%)\n\n\n H(M)\n 2(1%)\n H(T) 6(7%)\n 2(2%)\n Number Not Responding: 18 (3%)\n CAC Av- Med\n 4(4%)\n Health Op\n 3(3%)\n CFL\n 1(1%)\n\n\n15.\xe2\x82\xac Before you signed up for (Name of HMO), or at the time you signed up, did\n the salesperson give you a Member s Handbook or other written material that\n explained how the HMO worked?\n YES, SALESPERSON LEFf SUCH MATERIAL: 443 (74%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 114(84%) 80(85%) 57(70%) 71(77%) 73(71 %) 48(50%)\n\n SALESPERSON DID NOT LEAVE MATERIAL, BUT IT\n WAS MAILED: 83 (14%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 10(7%) 8(9%) 9(11%) 14(15%) 16(16%) 26(27%)\n\n\n\n 4(3%) H(T) 2(2%)\n SALESPERSON DID NOT LEAVE ANY MATERIAL: 19 (3%)\n H(M) 3(3%) CAC Av-Med Health Op\n 2(2%)\n CFL\n 8(8%)\n\n SALESPERSON LEFf SOME MATERIAL, BUT BENEFICIARY DOES NOT\n\n H(M) H(T) 3(4%)\n REMEMBER WHAT IT WAS: 15 (2%)\n\n 2(1%) CAC Av-Med Health Op CFL\n 10(10%)\n\n BENEFICIARY DOES NOT REMEMBER IF RECEIVED ANY\n\n\n 3(2%) H(T) 2(2%)\n MATERIAL: 13 (2%)\n H(M) 1(1%) CAC Av-Med\n 2(2%) Health Op\n 2(2%)\n CFL\n 3(3%)\n\n\n H(M)\n 2(1%)\n H(T) 8(10%)\n 2(2%)\n Number Not Responding: 28 (5%)\n CAC Av- Med\n 5(5%)\n Health Op\n 10(10%)\n CFL\n 1(1%)\n\n\n16.\xe2\x82\xac Were you later mailed a notification of the date your enrollment in (Name of\n HMO) began?\n YES: 512 (85%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 111(82%) 81(86%) 66(81 %) 78(85%) 95(92%) 81(84%)\n\n NO: 22 (4%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 7(5%) 3(3%) 2(2%) 2(2%) 1(1 %) 7(7%)\n\n\n H(M) H(T)\n BENEFICIARY DOES NOT REMEMBER: 51 (8%)\n CAC Av-Med\n 14(10%) 9(10%) 9(11%) 8(9%)\n Health Op\n 4(4%)\n CFL\n 7(7%)\n\n Number Not Responding: 16 (3%)\xe2\x82\xac\n\n\n B - 13\n\n\x0c H(M) H(T) CAC Av- Med Health Op CFL\n 3(2%) 1(1%) 4(5%) 4(4% ) 3(3%) 1(1%)\n\n\n17.\t Thinlrin g about the things the salesperson told you about (Name of HMO),\n would you say the salesperson gave you accurate information?\n YEs: 504 (84%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 120(89%) 88(94%) 63(78%) 76(83%) 87(84%) 70(73%)\n\n NO: 34 (6%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 6(4%) 3(3%) 7(9%) 6(7%) 2(2%) 10(10%)\n\n DO NOT KNOW: 18 (3%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 5(4%) 2(2%) 3(3%) 8(8%)\n\n OTHER RESPONSES: 20 (3%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 2(1%) 1(1%) 2(2%) 2(2%) 8(8%) 5(5%)\n\n BENEFICIARY DOES NOT REMEMBER: 5 (1%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 3(4%) 1(1%) 1(1 %)\n\n Number Not Responding: 20 (3%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 2(1 %) 2(2%) 4(5%) 4(4%) 6(6%) 2(2%)\n\n\n\n18.\t When the salesperson talked to you about enrolling in (Name of HMO), did he\n or she explain that when you are in an HMO...\n a. Unless it was an emergency, you needed to get (Name of HMO)\'s\n permission before you went to doctors or hospitals not part of (Name of\n HMO)?\n YES: 428 (71 %)\n H(M) H(T) CAC Av-Med Health Op CFL\n 101(75%) 72(77%) 49(60%) 67(73%) 74(72%) 65(68%)\n\n NO: 87 (14%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 20(15%) 12(13%) 15(19%) 11(12%) 11(11%) 18(19%)\n\n BENEFICIARY DOES NOT REMEMBER: 59 (10%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 12(9%) 7(7%) 10(12%) 10(11%) 9(9%) 11(11%)\n Number Not Responding: 27 (4%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 2(1 %) 3(3%) 7(9%) 4(4%) 9(9%) 2(2%)\n\n\n\n B - 14\n\x0c b. H you did notget (Name of HMO)\'s permission, and it was not an\xe2\x82\xac\n emergency, you would have to pay for visits to doctors and hospitals that are\xe2\x82\xac\n not affiliated with (Name of HMO)?\n YEs: 399 (66%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 100(74%) 67(71%) 45(56%) 66(72%) 62(60%) 59(61%)\n\n NO: 112 (19%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 18(13%) 17(18%) 17(21%) 13(14%) 20(19%) 27(28%)\n\n BENEFICIARY DOES NOT REMEMBER: 63 (10%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 15(11 %) 7(7%) 12(15%) 9(10%) 12(12%) 8(8%)\n\n Number Not Responding: 27 (4%)\n H(M) H(T) CAC Av-Med Health Op CFL\xe2\x82\xac\n 2(1%) 3(3%) 7(9%) 4(4%) 9(9%) 2(2%)\xe2\x82\xac\n\n\n c. Medicare would be paying (Name of HMO) for your medical care and\xe2\x82\xac\n would not make payments directly to doctors?\xe2\x82\xac\n YES: 399 (66%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 93(69%) 69(73%) 48(59%) 70(76%) 65(63%) 54(56%)\n\n NO: 106 (18%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 23(17%) 13(14%) 16(20%) 10(11%) 18(17%) 26(27%)\n\n BENEFICIARY DOES NOT REMEMBER: 68 (11%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 17(13%) 9(10%) 10(12%) 7(8%) 11(11%) 14(15%)\n\n Number Not Responding: 28 (5%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 2(1 %) 3(3%) 7(9%) 5(5%) 9(9%) 2(2%)\n\n19. Since you have been in (Name of HMO), have there been times when you\n needed to see a doctor, but haven t been able to?\n\n YES: 56 (9%)\n H(M) H(T) CAC Av-Med Health Op CFL\n 14(10%) 13(14%) 6(7%) 7(8%) 9(9%) 7(7%)\n\n NO: 529 (88%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 119(88%) 79(84%) 71(88%) 80(87%) 92(89%) 88(92%)\n Number Not Responding: 16 (3%)\n H(M) H(T) CAC Av- Med Health Op CFL\n 2(1%) 2(2%) 4(5%) 5(5%) 2(2%) 1(1 %)\n\n\n\n B - 15\xe2\x82\xac\n\x0c20.\xe2\x82\xac Since you have been enrolled in (Name of HMO), have you been told that\n some services you wanted were not covered?\n YEs: 80 (13%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 21(16%) 13(14%) 8(10%) 15(16%) 15(15%) 8(8%)\n\n NO: 503 (84%)\n H(M) H(1) CAC Av- Med Health Op CFL\n 111(82%) 79(84%) 69(85%) 72(78%) 86(83%) 86(90%)\n\n Number Not Responding: 18 (3%)\n H(M) H(1) CAC Av-Med Health Op CFL\n 3(2%) 2(2%) 4(5%) 5(5%) 2(2%) 2(2%)\n\n\n21. How would you compare the care you have received while in (Name of HMO)\n with the medical care you received before you joined? Would you say the care\n you have received while in (Name of HMO) is?\n\n H(M) H(1)\n BEITER THAN YOUR PREVIOUS CARE: 116 (19%)\n\n 30(22%) 13(14%) 18(22%) 16(16%)\n CAC Av-\n Med Health Op\n 16(15%)\n CFL\n 23(24%)\n\n\n H(M) H(1)\n ABOUT THE SAME AS YOUR PREVIOUS CARE: 245 (41%)\n CAC Av-Med\n 41(30%) 47(50%) 31(38%) 46(50%) 50(49%)\n Health Op CFL\n 30(31%)\n\n\n H(M) H(1)\n NOT AS GOOD AS YOUR PREVIOUS CARE: 73 (12%)\n\n 20(15%) 18(19%) 9(11%) 5(5%)\n CAC Av-Med Health Op\n 8(8% )\n CFL\n 13(14%)\n\n\n H(M) H(1)\n BENEFICIARY CAN\'T OR WON\' T COMPARE CARE: 147 (24%)\n\n 41(30%) 14(15%) 18(22%) 20(22%)\n CAC Av-Med Health Op\n 27(26%)\n CFL\n 27(28%)\n\n\n H(M)\n 3(2% )\n H(1) 5(6%)\n 2(2%)\n Number Not Responding: 20 (3%)\n CAC Av- Med\n 5(5%)\n Health Op\n 2(2%)\n CFL\n 3(3%)\n\n\n\n\n B - 16\n\n\x0c APPENDIX C\n\n RESPONSES TO FACE-TO-FACE INTERVIEWS WITII BENEFICIARIES\xe2\x82\xac\n\nThe following are the results of face- to-face interviews with 22 of 26 beneficiaries who\xe2\x82\xac\nwere identified by HCF A as having enrolled in HMOs an excessive number of times.\xe2\x82\xac\nFour beneficiaries could not be located. Each beneficiary was shown his/her HMO\xe2\x82\xac\nenrollment history which identified the current and all previous enrollments.\xe2\x82\xac\n\nRESULTS: PERSONS INTERVIEWED:\xe2\x82\xac\n\n BENEFICIARIES\xe2\x82\xac\n RESPONSffiLE PARTY: Spouse\xe2\x82\xac\n\n\nI would like to ask you some questions about your experiences with Health\xe2\x82\xac\nMaintenance Organizations.\xe2\x82\xac\n\n\n1. Are you a year-round Florida resident or do you live in Florida only part of the year?\xe2\x82\xac\n\n RESPONSES 22 - LIVE IN FLORIDA YEAR- ROUND\xe2\x82\xac\n\n\n2. Are you currently enrolled in an HMO?\xe2\x82\xac\n\n RESPONSES 1 - NO - (GO TO #4)\xe2\x82\xac\n 19 - YES\xe2\x82\xac\n 2 - DON\'T KNOW\xe2\x82\xac\n3. In which HMO are you (currently) enrolled?\xe2\x82\xac\n\n RESPONSES 10 - Humana Gold Plus Plan (Dade , Broward , & Palm Beach)\xe2\x82\xac\n 5 - CAC- RAMSAY\xe2\x82\xac\n 5 - CareFlorida\xe2\x82\xac\n 2 - DON\'T KNOW\xe2\x82\xac\n\n Show and briefly explain to the beneficiary his/her HMO enrollment histo\xe2\x82\xac\n\n4. Do you remember signing an application form to enroll in these HMO plans?\xe2\x82\xac\n\n RESPONSES . 5 - NO\xe2\x82\xac\n 17 - YES\xe2\x82\xac\n\n\n\n C - 1\xe2\x82\xac\n\x0c5. What were the reasons you changed from each of these plans (PLANS IDENTIFIED\n IN QUESTION #4)to another?\n\n REASONS 7 - DOES NOT KNOW WHY\n 11 - HMO REPRESENTATIVE CONVINCED BENEFICIARY\n TO CHANGE\n 4 - UNHAPPY WITH SERVICES OF HMO\n\n6. Did any of these plans make a special offer; give you a free gift; or give you money to\n enroll in their plan?\n\n RESPONSES 4 - BENEFICIARY DOESN\'T REMEMBER\n 18 - NO\n\n\n7. When you signed the application form, was it clear that by enrolling in this new\n HMO, you would be automatically disenrolled from your current HMO? (PROVIDE\n ILLUSTRATION TO BENEFICIARY BASED ON HIS/HER HMO\n ENROLLMENT HISTORY AND INDICATE HMO BY NAME)\n\n RESPONSES 8 - BENEFICIARY DOESN\'T REMEMBER\n 5 - YES , IT WAS CLEAR\n 9 - NO , IT WAS NOT CLEAR\n\nSome people give the following reasons for changing health care plans. Have you ever\nchanged plans because of any of these reasons?\n\n\n8. Because you needed to see a doctor more often than your plan would allow?\xe2\x82\xac\n\n RESPONSES 5 - BENEFICIARY DOESN\'T REMEMBER\n 16 - NO\n YES\n\n9. Have you ever changed plans because you needed services of a specialist and those\n services were not available in your plan?\n\n RESPONSES 4 - BENEFICIARY DOESN\'T REMEMBER\n 18 - NO\n YES\n\n\n10. Have you ever changed plans because you wanted to use a specific doctor and he/she\xe2\x82\xac\n was not in your plan?\xe2\x82\xac\n\n\n\n C - 2\xe2\x82\xac\n\x0c RESPONSES 4 - BENEFICIARY DOESN\'T REMEMBER\xe2\x82\xac\n 16 - NO\xe2\x82\xac\n 2 - YES\xe2\x82\xac\n\n11. Have you ever changed plans because your doctor left the plan and you wanted to\xe2\x82\xac\n continue with that doctor?\xe2\x82\xac\n\n RESPONSES 4 - BENEFICIARY DOESN\' T REMEMBER\xe2\x82\xac\n 15 - NO\xe2\x82\xac\n YES\xe2\x82\xac\n\n\n12. Have you ever changed plans because your doctor advised you to change to another\xe2\x82\xac\n plan?\xe2\x82\xac\n\n RESPONSES 3 - BENEFICIARY DOESN\'T REMEMBER\xe2\x82\xac\n 16 - NO\xe2\x82\xac\n YES\xe2\x82\xac\n\n13. an HMO sales representative advised you to\xe2\x82\xac\n Have you ever changed plans because\n\n join a new plan? (NOTE: A SALESMAN COULD ADVISE AN ENROLLEE TO\n\n JOIN HIS PLAN JOIN ANOTHER PLAN IN ORDER TO DISENROLL A\xe2\x82\xac\n BENEFICIARY. \xe2\x82\xac\n\n\n\n\n RESPONSES 5 - BENEFICIARY DOESN\'T REMEMBER\xe2\x82\xac\n 1- NO\xe2\x82\xac\n 16 - YES\xe2\x82\xac\n (A) \xe2\x82\xac What HMO did that salesman represent?\xe2\x82\xac\n\n RESPONSES\xe2\x82\xac\n\n 16 - BENEFICIARY DOESN\'T REMEMBER\xe2\x82\xac\n\n (B)\xe2\x82\xac Do you know the salesman s name?\xe2\x82\xac\n\n RESPONSES\xe2\x82\xac\n\n 16 - NO\xe2\x82\xac\n\n (C)\xe2\x82\xac Which plan did he/she suggest you to enroll in?\xe2\x82\xac\n\n RESPONSES\xe2\x82\xac\n\n 16 - BENEFICIARY DOESN\' T REMEMBER\xe2\x82\xac\n\n\n\n\n C - 3\xe2\x82\xac\n\x0c14. Have you ever changed plans because a\n friend or relative suggested that you join a\n different plan?\n\n RESPONSES 4 - BENEFICIARY DOESN\'T REMEMBER\xe2\x82\xac\n 17 - NO\xe2\x82\xac\n YES\xe2\x82\xac\n\n\n15. Have you ever changed plans because you didn t like the plan you were in?\xe2\x82\xac\n\n RESPONSES 4 - BENEFICIARY DOESN\' T REMEMBER\n 12 - NO\n 6 - YES\n (A) IF YES, Which plan did you dislike and why?\n\n RESPONSES\xe2\x82\xac\n\n 6 - BENEFICIARY DOESN\' T REMEMBER\n\n16. Have you changed health care plans for any other reason we did not mention?\xe2\x82\xac\n\n RESPONSES 7 - BENEFICIARY DOESN\'T REMEMBER\xe2\x82\xac\n 15 - NO\xe2\x82\xac\n\n\n17. Do you plan to change from (CURRENT HMO PLAN) to another plan?\xe2\x82\xac\n\n RESPONSES 4 - BENEFICIARY DOESN\'T REMEMBER\xe2\x82\xac\n 17 - NO\xe2\x82\xac\n YES\xe2\x82\xac\n\n\n18. Would you like to tell us anything else regarding why you have changed HMOs?\n\n RESPONSES 18 - NO FURTHER COMMENT WAS MADE\xe2\x82\xac\n YES\xe2\x82\xac\n\n\n\n\n C - 4\xe2\x82\xac\n\x0c APPENDIX D\xe2\x82\xac\n ANALYSIS OF RESPONDENTS VS. NONRESPONDENTS\xe2\x82\xac\n\n\nMuch of the information regarding marketing practices of South Florida HMOs was\xe2\x82\xac\ngathered directly from Medicare beneficiaries who had recently enrolled in those\xe2\x82\xac\nHMOs. A statistically representative sample of the recent-enrollee population was\xe2\x82\xac\nselected to be interviewed by phone.\xe2\x82\xac\n\nA response rate of 72 percent was achieved. However, the possibility of a\xe2\x82\xac\nnonresponse bias must be considered. That is , it must be assured that the survey\xe2\x82\xac\nresults would have been the same if theentire sample had been interviewed.\xe2\x82\xac\n\nSince it is not possible to know how those not interviewed would have responded to\xe2\x82\xac\nthe questions , certain assumptions must be made , based on what is known about the\xe2\x82\xac\nnonrespondents.\xe2\x82\xac\n\nThe data base from which the sample was drawn contains certain demographic\xe2\x82\xac\ninformation for each individual , notably gender and age. With these data elements , it\xe2\x82\xac\nis then possible to compare the demographic characteristics of nonrespondents to\xe2\x82\xac\nrespondents.\xe2\x82\xac\n\nIf the characteristics are different , it is necessary to determine whether these\xe2\x82\xac\ncharacteristics correlate with certain responses from the individuals interviewed.\xe2\x82\xac\nAssuming the same correlations exist for the nonrespondents, it can be determined\xe2\x82\xac\nwhether survey results would have been different if all individuals in the sample had\xe2\x82\xac\nresponded.\xe2\x82\xac\n\n ARIABLES ANALYZED\xe2\x82\xac\n\nFor this analysis , three characteristics of individuals in the sample were used: age\xe2\x82\xac\ngender , and HMO in which the individual is/was enrolled. The frequencies of these\xe2\x82\xac\ncharacteristics in the respondent nonrespondent\xe2\x82\xac\n group were compared against the\n\ngroup.\xe2\x82\xac\n\nWhere frequencies differed among the two groups (and it might be suspected that\xe2\x82\xac\ndifferent survey results would be found if all persons in the sample had been\xe2\x82\xac\ninterviewed), it was determined if any of these three characteristics affected responses\xe2\x82\xac\nto our interview questions.\xe2\x82\xac\n\n\nThree questions on the survey instrument were chosen for comparison of responses:\xe2\x82\xac\n\n\n\n\n D - 1\xe2\x82\xac\n\x0cQ #2. Did you call ( Name of HMO ) to get information , or did ( Name of HMO\n contact you to ask you to enroll?\n\n Possible\n answers: Beneficiary initiated contact\n HMO initiated contact\n Beneficiary does not remember\xe2\x82\xac\n\n\nQ #6. When you signed the application form , was it clear to you that you were\n enrolling in a Health Maintenance Organization?\n\n Possible\xe2\x82\xac\n answers: Yes\xe2\x82\xac\n\n Beneficiary does not remember signing application\xe2\x82\xac\n\n\nQ #7. When you signed the application form , did you know that unless it was an\n emergency, or you were outside the service area and urgently needed care , you\n could only go to (Name of HMO)\'s doctors , hospitals , and medical providers?\n\n Possible\xe2\x82\xac\n answers: Yes\xe2\x82\xac\n\n\n\nANALYSIS BY GENDER\xe2\x82\xac\n\nThe analysis by gender showed no indication of nonresponse bias.\n\nExamining the proportions of males and females in the overall sample , in the\nrespondent group, and in the nonrespondent group, no significant difference was\xe2\x82\xac\nfound:\n\n TABLE 1\n Male Female\n Number Percent Number Percent\n Sample (n = 833) 372 45% 460 55%\n Respondents (n = 601) 271 45% 329 55%\n Nonrespondents (n = 232) 103 44% 129 56%\n\n\n\n\n D - 2\xe2\x82\xac\n\x0c --- ---\n\n\n\n\nEven if males and females \n did answer questions differently, it can be assumed that the\xe2\x82\xac\nsurvey results would not have been different if the nonrespondents had been\xe2\x82\xac\ninterviewed.\xe2\x82\xac\n\n\nANALYSIS BY AGE\xe2\x82\xac\n\nThe analysis by age revealed no indication of nonresponse bias.\xe2\x82\xac\n\nThe proportions of individuals age 73 or younger and those age 74 or older were\xe2\x82\xac\ndetermined for the overall sample , the respondent group, and the nonrespondent\xe2\x82\xac\ngroup. It nonrespondents was slightly lower\xe2\x82\xac\n was found that the percentage of younger\n\nthan the percentage of younger respondents\xe2\x82\xac\n\n TABLE \xe2\x82\xac\n\n\n 73 or \n Younger 74 or Older\xe2\x82\xac\n Number\xe2\x82\xac Percent Number Percent\xe2\x82\xac\n Sample (n = 833) 612\xe2\x82\xac 73% 221 26%\xe2\x82\xac\n Respondents (n = 601) 451\xe2\x82\xac 75% 150 25%\xe2\x82\xac\n Nonrespondents (n = 232) 161\xe2\x82\xac 69% 31%\xe2\x82\xac\n\nGiven these differences , the survey responses to the three questions were examined to\xe2\x82\xac\ndetermine if individuals in the younger group answered differently than those in the\xe2\x82\xac\nolder group. We found that for two of the questions, responses differed only slightly\xe2\x82\xac\nby age:\xe2\x82\xac\n\n TABLE \xe2\x82\xac\n\n\n #2. Did you call (Name o HMO to get information, or did (Name o HMO\xe2\x82\xac\n contact you to ask you to enroll?\xe2\x82\xac\n 73 or Younger 74 or Older\xe2\x82\xac\n (n = 451) (n = 150)\n\n\n Number Percent Number Percent\xe2\x82\xac\n Beneficiary Initiated Contact 327 72% 106 71%\xe2\x82\xac\n HMO Initiated Contact 111 25% 26%\xe2\x82\xac\n Beneficiary Does Not\xe2\x82\xac\n Remember\xe2\x82\xac\n Response Missing\xe2\x82\xac\n\n\n\n\n D - 3\xe2\x82\xac\n\x0c TABLE 4\n #7.\xe2\x82\xac When you signed the application form, did you know that unless it was an\xe2\x82\xac\n emergency, or you were outside the service area and urgently needed care, you\n could only go to (Name of HMO)\' s doctors, hospitals, and medical providers?\n 73 or Younger 74 or Older\n (n = 451) (n = 150)\n\n Number Percent Number Percent\xe2\x82\xac\n Yes 393 87% 133 89%\xe2\x82\xac\n 12% 10%\xe2\x82\xac\n Response Missing\n\nRegarding the third question used in our nonresponse analysis , it was found that age\xe2\x82\xac\nof the respondent did relate to the answers given. Younger respondents more\nfrequently reported that it was clear to them that they were joining an HMO when\nthey signed the application form:\n\n\n\n TABLE 5\n\n Q#6. When you signed the application form, was it clear to you that you were\xe2\x82\xac\n enrolling in a Health Maintenance Organization?\xe2\x82\xac\n 73 or Younger 74 or Older\n (n = 451) (n 150)\n Number Percent Number Percent\n Yes 402 89. 123 82.\n 15.3%\xe2\x82\xac\n Beneficiary Does Not 1.3%\n Remember\n Response Missing 1.3%\n\n\n\n\n D - 4\xe2\x82\xac\n\x0cAssuming that the nonrespondents might answer this question as did their age- group\xe2\x82\xac\npeers in the respondent group, the responses were recalculated to include the\xe2\x82\xac\nnonrespondents. The result was compared to our original finding:\n\n TABLE 6\xe2\x82\xac\n Actual Respondents The Entire Sample\n (n = 601)\xe2\x82\xac (n = 833)\xe2\x82\xac\n Answered:\xe2\x82\xac Might Have Answered:\n Number Percent\xe2\x82\xac Number Percent\xe2\x82\xac\n Yes (It was clear)\xe2\x82\xac 525 87.3%\xe2\x82\xac 725 87.\xe2\x82\xac\n No (It was not clear)\xe2\x82\xac 10.\xe2\x82\xac 11.0%\xe2\x82\xac\n Beneficiary Does Not Remember\xe2\x82\xac\n Response Missing\n\nThe actual response to this question and the potential response (after rounding) were\xe2\x82\xac\nalmost identical.\n\n\nANALYSIS BY HMO\xe2\x82\xac\n\nSimilarly, a comparison of response rates for each of the five HMOs showed no\nevidence of bias.\n\n\n\n\n D - 5\xe2\x82\xac\n\x0c APPENDIX E\xe2\x82\xac\n COMMENTS TO DRAFT REPORT\n\n\nComments on the draft report were received from HCF A and the Assistant Secretary\nfor Planning and Evaluation (ASPE). Both agencies agree that HCFA should identify\nand review frequent enrollment changes , and HCF A believes they now have that\ncapability. While ASPE supported the concept of a "cooling off\' period for Medicare\nenrollees , HCF A thinks a " cooling off\' period is not needed.\n\nNeither agency concurred with the other recommendations. We will defer our\ncomments on their responses until the OIG completes its national study on HMO\ndisenrollments (OEI- 06-91- 00730).\n\nWe have responded to each technical change suggested by HCFA and ASPE.\n\n\n\n\n E - 1\n\n\x0c.. --"-\' ~-.-\n - \' ~.\n ,. -.-....\n \'--.r--\n (, ."\'"\n ;.;-\n --:; ~~/;\n ~=-\n .\'-,c)\n /T\n .- --.\n =:\n ~\'" ~\n ==\'\n\n\n\n\n DEPART.\'t\\ENT OF HEALTH &. HUI\'t\\AN SERVICES m \'h\xe2\x82\xac\n f1. -r\n ti"\'J1,~_\n .::::-i Washington . D. C. 20201\n\n\n MAY 2 9 1991 .c-~\\:i\n DIG-:1.S\n i:\'"- i:\'i\n -:\'1\n Dlc-or ~::5\n ""T1\n TO: Richard P. Kusserow\n Inspector General\n AIG- (");0\n ;-:1\n OGC/IG 1710\n -7" -:\'1\n FROM:\xe2\x82\xac Assistant Secretary for. EXSEC\n\n DATE SENT\n \'...J..J\n\n\n c::::\n Planning and Evaluation UJ\n\n\n\n\n SUBJECT:\xe2\x82\xac OIG Draft Reports: Marketing Practices and Enrollm~t\n Patterns for South Florida HMOs, OEI-04-91-00630 an~ :=l\n OEI-04-91-00640 -- COMMENTS\n I appreciate the opportunity to comment on the reports. In\xe2\x82\xac\n general, they appear to point more to the need for improved data\xe2\x82\xac\n collection, closer monitoring and follow-up, particularly \xe2\x82\xac\n disenrollment patterns, than for implementation of new\xe2\x82\xac\n procedures. Consequently, ~ I am inclined to disagree with certain\n of your recommendations , as noted below.\n OEI-O4-91-00630: Marketincr Practices\n HCFA to establish standards for sales force\n training and monitoring: I understand that HCFA\n has worked informally with the Group Health\n Association of America to improve marketing\n practices of HMO sales representatives nationally.\n Responsibility for oversight of marketing staff\n rests with state licensing agencies.\n t enrollment to one "open season" per year.\n This recommendation would require -legislation and.\n Limi\n\n\n\n has the appearance of a year-long lock-in which\n Congress has constantly rej ected. Moreover,\n section 6206 of OBRA-89 eliminated a coordinated\n open enrollment requirement, which had never been\n implemented, except under certain circumstances.\n Continuous open enrollment in competi ti ve markets\n allows beneficiaries to select the benefit package\xe2\x82\xac\n that best fits their needs, regardless of when\xe2\x82\xac\n that decision is reached (and, given the data on\n I S report, at most,\n page a of the \xe2\x82\xac Miami Area HMO\n sales representa~ives appear responsible for only\xe2\x82\xac\n 20 percent of changes compared with nearly three\xe2\x82\xac\n times more who expressed dissatisfaction regarding\xe2\x82\xac\n HMO physicians or services). Admittedly, this\n practice requires closer monitoring against\n abus i ve marketing practices.\n\n\n E-2\n\x0c -. . - ----- ~..\nPage 2 - Richard P. Kusserow\n Based on the preceding comment, I agree that HCFA\n should establish systems to identify and review\n cases of frequent enrollment change. Cases in\n which marketing abuses are suspected should be\n reported to state licensing agencies.\n\n Third party handling of RHO enrollment actions:\n Except for existing authority to disenroll at\n social Security District Offices, closer\n monitoring and follow-up would be preferable.\n OtherNise, responsibility for training\n salespersons and the question\n of payment for these\n services arise.\n suppor\':. the concepta "cooling off" period\n of\n\n\n for Medicare risk enrollees.\n\n OEI-O4-91-00640: Enrollment Patterns\n\n This analysis indicates the need for more data\n collection, closer monitoring and follow-up. The\n inabili ty to segregate the Miami Area enrollment\n for Humana makes it difficult to interpret the\n results.\n Editorial Comments\n\n Regarding both reports, I suggest that OIG staff\n solicit technical assistance from HCFA/Office of\n Prepaid Health Care Operations and oversight on the\n "Background" sections which distinguish fee-for-service\n from prepaid health plans.\n See, for exa~ple, the\n ttached pages.\n\n\n\n Mar--..in H. Gerry\n\nAttachments\n\n\n\n\n E - 3\n\n\x0c &. - .. .-- ,~". ....~\n . - . : ~~-:\n " ! \' :::.\n . _.-\xe2\x82\xac\n (: \'- ;.,\xe2\x82\xac ..\' .._\n \'-1 ) \\L:J 0,.. I Qc. \'e\\\'.)\n 1\'0 \xe2\x82\xac\n\n\n\n\n DEPARTMENT OF HEALTH HUMAN SERVICES ,\\=-l":i\'\n ~~1\n ~CuY\\~.~cv\\\n , .:LJ\n Health Care\n Financing Administration\n \\;FF:::: :~~F :\\ ::C \xe2\x82\xac\n\n\n\n\n:::z. Memorandum\n AUG I 5 Ig9r ; :d, f"!.\n :i.u\n "\'0\n\n Date\n Gail R. Wilensky, Ph. D , -1) )\n From Administrator r V\'-"\xe2\x82\xac\n\n\n\n Subject\n OIG Draft Re orts: " Marketing Practices and Enrollment Patterns for South\n Florida H1Y10s " (OEI- O4- 91- 00630 and OEI- 04- 91- 00640)\n\n Inspector General\xe2\x82\xac\n Office of the Secretary\xe2\x82\xac\n\n\n\n We have reviewed the above referenced draft reports evaluating Health\xe2\x82\xac\n Maintenance Organization (HMO) marketing practices for South Florida and HwfO\xe2\x82\xac\n enrollment patterns in the Miami area. As an overall comment on each of the\n above reports , we view the findings as generally positive in that they dispel many of\n the erroneous preconceptions about the marketing and enrollment practices of\xe2\x82\xac\n Medicare-contracting HMOs in the South Florida area.\xe2\x82\xac\n\n Given the positive nature of the reports, we do not believe that the findings as\n reported in the two reports warrant all of the changes in the Medicare HMO\n program suggested by OIG. However, we agree with one of your recommendations.\n Our specific comments on the reports \' recommendations are attached for your\n consideration.\n\n Thank you for the opportunity to comment on these reports. Please advise us of\n whether you agree with our position on the reports \' recommendations at your\n earliest convenience.\xe2\x82\xac\n\n\n\n Attachment\xe2\x82\xac\n\n\n\n PDIG\xe2\x82\xac\n DIG-AS\xe2\x82\xac\n ..~DIG-EI\xe2\x82\xac\n DIG-OI\xe2\x82\xac\n AIG-MP \xe2\x82\xac\n\n OGC/W\xe2\x82\xac\n EX3Ee \xe2\x82\xac . \\1\' -... .\xe2\x82\xac\n\n\n D~TE c:!l~ \xe2\x82\xac\n\n\n\n\n E - 4\xe2\x82\xac\n\x0c , "\n\n\n\n\n\n Comments of the Health Care Financing: Administration\n on OIG Draft Reports:\n Marketing Practices and\n Enrollment Patterns for South Florida HMOs\n (OEI- O4-91- 00630 and- Of:I- 04- 91- 00640)\n\n\n\nRecommendation 1 is contained only in OEI- O4- 91- 00630. Recommendations 2\nthrough 5 are contained in both OIG reports.\n\nRecommendation\n monitoring, and hold\nHCF A should establish standards for sales force training and\nHMOs accountable for maintaining those standards.\n\nHCF A Response\n\n the general\nWe do not believe it is appropriate or necessary to presence more than HCF A\nstandards for sales activities of organizations that are already required for\ncontracts. HNfOs are currently held accountable for marketing practices that lead\nto erroneous and uninformed enrollments. Without effective sales force training\nand monitoring, an HNfO will be subject to contract\n termination, intermediate\n failures.\nsanctions, and/or civil monetary penalties for marketing and enrollment\n an tThtfO to provide a\nUnder the authority of 42 CFR ~417.428(a), which requires\n beneficiaries to make an\nwritten statement of rules " and other information for\ninformed decision about enrollment " HCF A has taken a number\n of actions to\n\ncorrect problems found at individual HMOs.\n\nIn Southern California, for example, where there have been problems with\n after-sale\n ) enrollment\nbeneficiaries not understanding lock- in, an after- the- fact (i.e.\nverification process is the norm among all HNfOs in the area, and the situation has\n Similarly, for\nimproved as a result of the efforts of the HCFA regional office.\nHumana Medical Plan of Florida, we believe that marketing practices have\n survey of beneficiaries) as\nsignificantly improved since October, 1990 (after the OIG\n office staff, in\na result of Humana s working with the HCFA regional and central\nconjunction with intensified monitoring of the Plan. HCF A was successful in its\n of certain\nefforts to encourage Humana to set up its own internal monitoring\n reports.\noperations , and we can monitor Humana through its internal\n\n\n\n\n E - 5\xe2\x82\xac\n\x0c Page 2\n\n\nWe believe the regulation of insurance and HMO sales agents is more properly a\nState function and we wish to note that many States impose requirements on HMO\nmarketing personnel and brokers. ?1orida has taken a number of steps to prevent\nmarketing abuses , including a requirement that there be certification of enrollment\nin a Medicare tllvfO by someone other than a sales agent.\n\nFinally, we do believe our civil monetary penalties (CMP) and intermediate\nsanctions authority in this area could be expanded. Currently, although CMPs and\nintermediate sanctions can be applied against entities that provide false information\nwe do not have that authority in regard to entities that engage in door- to- door\nmarketing or that offer gifts or payment of more than a nominal value to induce\nenrollment. In addition , we currently only have the authority to impose a CMP\nagainst an entity; we do not have the option of imposing a CMF against an\nindividual, such as a sales agent. Weare submitting an A- 19 to the Department\nwhich addresses these issues. We would hope that you will support our proposal.\n\nRecommendation\n\n\n(opportunity to enroll) per year.\nHCF A should establish a policy limiting enrollment to one " open season\n\n\n\nHCFA Resuonse\n\nWe do not believe that OIG findings , which show that a minority of HMO enrollees\nhave had multiple HMO enrollments , are sufficient cause to make a major policy\nchange in HCF A\' s approach to beneficiaries \' ability to choose HMO enrollment as\na Medicare option. The OIG found that switching from one plan to another, even\non a frequent basis, is not necessarily indicative of marketing or enrollment abuses\nbut rather beneficiary choice, as noted above. Where " ping- ponging" does in fact\nresult from marketing or enrollment abuses, HCF A has the means to require an\ntllvfO to cease such practices.\n\nA hallmark of the Medicare fee- for-service program is the beneficiaries \' freedom of\nchoice of providers. Beneficiaries who choose to enroll in a Medicare risk-based\nHlv!O consciously choose to receive care from only the HlV!O providers , in order to\nminimize their administrative burden and to benefit from lower out-of- pocket costs.\nUnder current law, it should be noted that they are able to exercise the choice\nbetWeen HMOs and fee- for-service at any time , if they choose to disenroll from an\nHMO. However, there are limitations under current law, if an HMO conducts only\nthe minimum 30- day required annual enrollment period.\n\n\n\n\n E-6\n\x0cPage 3\n\nHCF A has traditionally viewed the Hi\\t10 option as a choice that is available on a\nvoluntary basis to beneficiaries residing in areas where Medicare HMOs are\navailable , and we have left it up to the HJ...10s to decide whether they preferred a\npolicy of enrollment other than on a year-round , continuous basis. CuIT~ntly, only\n3 percent of Medicare beneficiaries are enrolled in Medicare risk- based HNlOs.\nHNfOs that have a capacity to conduct continuous open enrollment should be\nallowed the option of flexible enrollment periods, since it expands beneficiaries\nchoices.\n\nA legislative change would be necessary to impose a single open enrollment period.\nSince 1985 (the first year of "TEFRA" Medicare risk contracting), Congress has\nchanged the original provisions of the Social Security Act relating to Medicare\nHj\\tl0 enrollment and disenrollment. Congress mandated that Medicare risk- based\nHNfO enrollees have the right of immediate disenrollment from the HMO (to\nreplace the previous provision that could delay a disenrollment for up to\n 60 days).\nCongress also did away with a coordinated open enrollment period requirement\n(introduced in the Deficit Reduction Act of 1984). The intent of\n Congress has\nbeen consistently to give beneficiaries maximum flexibility in choosing the HNI0\noption while giving HMOs the leeway to determine the appropriate enrollment\nperiods.\n\nRecommendation\n\nHCF A should establish an on- line system to identify and review cases of frequent\nenrollment change.\n\n\nHCF A Response\n\nHCF A has developed such a capability. The Managed Care Option Information\n(MCCOY) Group Health Plan (GHP) System provides online management\ninformation reports and the capability to update beneficiary enrollments\ndisenrollments, health status indicators and residence codes. We believe this system\nsatisfies the intent and spirit of GIG\' s recommendation.\n\nRecommendation\n\nIn the three-county Miami service area, RCF A should test the efficacy of a third\n\nrqrty handling Hi\\t10 enro~lment\n actions.\n\n\n\n\n E - 7\n\n\x0c Page 4\n\n HCF A Response\n\n Ti1C efficacy of a third party enrollment process has been tested and many problems\n were found. We do not believe that the OrG\' s findings warrant anotller test\n because this problem affects a small number of beneficiaries. In the vast majority\n of cases (72 percent), the beneficiary initiated the first contact with an HM:O. A\n third party enrollment process would be more appropriate in a situation where the\n HM:O contacts the beneficiaries first, in the majority of cases.\xe2\x82\xac\n\nIf enrollments were the responsibility of a third party, such as the Social Security\nAdministration (SSA) (as GIG suggests), the level of enrollment activity in the\nMiami area would make the function a massive undertaking in terms of personnel\xe2\x82\xac\nand costs (costs currently financed through the HCF A capitation payments made to\nthe fTh10s). Unless the third party could fairly present each HM:O\' s advantages\ncompetition in the marketplace could be stifled. , HCFA would also have a new\xe2\x82\xac\nmonitoring responsibility of assuring that the third party was properly enrolling\xe2\x82\xac\nindividuals in the appropriate HMO, etc.\xe2\x82\xac\n\nThe GIG may wish to consider the findings of the General Accounting Office\n(GAG) in its evaluation of the HealthChoice demonstration project in Oregon and\nCalifornia-a demonstration of the use of a third- party broker for Medicare HM:O\nenrollment. Problems that the GAO pointed out included the questionable\nauthority for HCFA\' s financing the project, unfair treatment of HMOs (those paying\nthe broker for its services versus those that did not), inadequate Privacy Act\nsafeguards , and the erroneous impression given by the broker that it was an agent\nof the Government. Many of the GAO objections would be obviated if SSA were\nthe third party, but having SSA function as an tTh10 broker is itself problematic\nbeginning with the difficulty of getting SSA to agree to undertake such a function.\n(Please note that the SSA HMO disenrollment function was a legislative mandate.\n\nRecommendation\xe2\x82\xac\n\nHCF A should impose a " cooling off\' period allowing beneficiaries to reconsider\nHlyIO enrollment decisions before enrollment applications are processed.\n\n\nHCFA Response\xe2\x82\xac\n\nAn official " cooling off\' period is not needed. If a beneficiary does change his or\nher mind, there is usually a certain time lag between the marketing presentation\nand the time the enrollment is actually transmitted to HCF A; a timely cancellation\nis therefore possible. HCF A also permits retroactive disenrollment of beneficiaries\nfor good cause (for example , failure to fully understand lock- in) if there has not\nbeen a fully informed decision to ~nroll in an HNfO.\n\n E - 8\xe2\x82\xac\n\x0c SPECIFIC COMMENTS\xe2\x82\xac\n\n\n\nPage 5\n\nWere the 22 beneficiaries who have changed HMOs multiple times identified\nduring a review of the initial sample size of 833 beneficiaries? If not , all\nreferences to this separate sample should be segregated in a separate section of\nthe report with separate descriptions of how these individuals were chosen.\n\nOIG Response: Oarification has been added to the Methods section to show\nthat the 22 beneficiaries were not part of the random sample of 833.\n\nPage 7\n\nThe impression created by the statement "Although HCF A regulations prohibit\ndoor- to- door solicitations , 34 percent of those the HMO contacted (8 percent\nof all the beneficiaries) say salespersons stopped by their homes " is misleading.\nHCFA regulations at 42 CFR 417.428(b)(4) prohibits door- to- door solicitations;\nhowever, they do not prohibit any personal contact at home between a sales\nrepresentative and a prospective or current HMO member. Sales calls at a\nperson s home may be the result of telemarketing interest follow-up or mail-\nresponse follow-up.\n\nOIG Response: The text has been clarified to show that beneficiaries who say\nsalespersons stopped by their homes are those who say the HMO initiated the\ncontact.\n\nPage 7\n\nThe fact that " sixty-four percent of the beneficiaries the HMO contacted do not\nknow where the salespersons who contacted them got their names " is relevant\nonly if it can be shown that an at- home marketing visit was made without\nhaving been requested by the beneficiary. If the contacts were phone contacts\nor mass mailings , for example , the HMO may have obtained the person s name\nfrom any number of direct marketing sources. There is no prohibition on direct\nmarketing of this nature. However, a small number of individuals , as noted on\npage B- , stated that the salesperson got their names from Social Security or\nMedicare. SSA and HCFA do not release beneficiaries \' names; therefore , the\nstatement may indicate that the marketing representative alleged that the\nperson s name had been provided by SSA or HCF A, or the respondents may\nbe confused on this point.\n\n\n\n\n E - 9\n\n\x0c , "\n\n\n\n\nPage 8\n\nAlthough initial training may be as stated, follow-up sessions for CAC-\nRAMSAY agents occur every 2 weeks.\n\nOIG Response: No revisions made to text. When the information was verified\nwith the HMO prior to release of the Draft report, CAC-Ramsay did not\ndisagree with the wording.\n\nPage 13\n\nComments made in regard to non-marketing issues such as things about\nHMOs " disenrollees " had wished they had known before joining, " without\nsubstantiating data or further discussion should be deleted from the report.\nThe report itself conceded that "these do not relate to marketing issues.\n\nOIG Response: Section has been removed from the report.\nPage 15\n\nThe conclusions reached on page 15 and page 16 in regard to the statement\nthat " Some HMOs fail to adequately monitor sales staff, leaving beneficiaries\nvulnerable to inappropriate marketing practices " are not supported by the data\nsummarized on page 14.\n\nOIG Response: The chart on page 14 reflects general practices of the HMOs.\nPages 15 and 16 refer to specific practices.\n\nPage 15\n\nThe State of Florida has now enacted a statutory prohibition regarding the use\nof agents attached to PCP\' s and/or clinics as marketing agents.\n\nOIG Response: We understand this legislation has been enacted since our\ninspection was completed; however, the report has not been revised as there is\nno national prohibition regarding this practice.\n\nPages 16-\n\nIt would appear that the conclusion that " some beneficiaries have been\nvulnerable to unethical sales practices " is based upon the 22 beneficiaries\ndiscussed on these pages which do not appear to be part of the large sample\nstudy upon which the rest of the report is based. It is questionable why this\nshould be included in the report which is based primarily on a selected sample\nsize.\n\n\n\n E - 10\n\x0cOIG Response: The text on pages 16-18 does refer to the 22 beneficiaries\nidentified by HCFA Their experiences are included in tlris report as they\nrelate to HMO marketing practices.\n\nAppendix B\n\nRegarding item 8b ,the interviewer is required to ask a person whether or not\nthey have end-stage renal disease or have elected Medicare hospice coverage.\nIn either case , such a person would not be eligible to enroll in a Medicare\nHMO.\n\nOIG Response: This data is included in the appendix for information only. No\nconclusions were reached from the beneficiaries \' responses to questions 8a- &1.\n\n\n\n\n E - 11\n\n\x0c'