Medicare Part D: Prescription Drug Plan Sponsor Call Center Responses Were Prompt, but Not Consistently Accurate and Complete
Published: 2006-06-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established a voluntary outpatient prescription drug benefit, known as Medicare Part D. Private sponsors have contracted with the Centers for Medicare & Medicaid Services (CMS) to provide this benefit and are offering over 1,400 stand-alone prescription drug plans (PDP). Depending on where they live, beneficiaries typically have a choice of 40 to 50 PDPs, which vary in cost and coverage. MMA required each PDP sponsor to staff a toll-free call center, which serves as a key source of the information that beneficiaries need to make informed choices among PDPs. GAO examined (1) whether PDP sponsors provide prompt, courteous, and helpful service to Medicare beneficiaries and others and (2) the extent to which PDP sponsor call centers provide accurate and complete information to Medicare beneficiaries and other callers. To address these objectives, we made 900 calls to 10 of the largest PDP sponsor call centers during March 2006, posing one of five questions about their Part D plans during each call. We tracked the amount of time it took to reach a customer service representative (CSR), the number of calls that did not reach a CSR, and the appropriateness and clarity of CSRs' language. We developed criteria for determining accurate and complete responses based on CMS information.
section_title: What GAO Found
paragraphs: Call center service was generally prompt and courteous, and many CSRs offered helpful suggestions and information. GAO reached a representative in less than 1 minute for 46 percent of the calls CSRs fielded and in less than 5 minutes for 96 percent of the calls fielded. While GAO did not reach CSRs for 4 percent of the calls it placed, mainly because of disconnections, GAO found that 98 percent of CSRs with whom GAO spoke were easy to understand, polite, and professional. In addition, many CSRs provided helpful suggestions related to GAO's questions, such as details about a mail-order option to obtain drugs or lower-cost drugs. However, CSRs at 10 of the largest PDP sponsor call centers did not consistently provide accurate and complete responses to GAO's five questions, which GAO developed using information from CMS and other sources. GAO obtained accurate and complete responses to about one-third of the 864 calls for which GAO reached a CSR. The overall accuracy and completeness rate for each call center ranged from 20 to 60 percent. CSRs were unable to answer 15 percent of the questions posed, primarily those related to plan costs. Furthermore, CSRs within the same call center sometimes provided inconsistent answers. For example, in response to questions about PDP cost comparisons for specified sets of drugs, CSRs at 3 call centers told GAO that it was against the sponsors' policies to identify any of their plans as lowest cost. However, other CSRs at each of these call centers did not cite this policy and did identify a plan as lowest cost. In commenting on a draft of this report, CMS criticized the analysis as based on inaccurate, incomplete, and subjective methods that limit the report's relevance and validity. GAO maintains that its methods are sound and its findings are accurate. CMS officials told GAO at a May 2006 meeting that CSRs should have been able to accurately answer the questions GAO posed.

section_title: Letter
paragraphs: The Medicare Prescription Drug, Improvement, and Modernization Act of  The Medicare Prescription Drug, Improvement, and Modernization Act of  2003 (MMA) established a voluntary outpatient prescription drug benefit,  2003 (MMA) established a voluntary outpatient prescription drug benefit,  known as Medicare Part D, beginning January 1, 2006. Seventy-nine  known as Medicare Part D, beginning January 1, 2006. Depending on where they live, Medicare  CMS-designated PDP regions.
Because  other sources about a sponsor’s PDPs, or enroll in a PDP.
Pub. L. No. 108-173, § 101, 117 Stat. 2066, 2071-2152 (to be codified at 42 U.S.C. §§ 1395w- 101—1395w-152).
Although beneficiaries may obtain drug coverage through either stand-alone PDPs or  Medicare Advantage (Medicare’s private health plan option) drug plans, this report  addresses only stand-alone PDP sponsor call centers. About 90 percent of Medicare  beneficiaries are enrolled in traditional Medicare, rather than Medicare Advantage.  Therefore, most beneficiaries will be making choices among stand-alone PDPs.
Other sources of information about Part D and specific PDPs include sponsors’ Web sites,  and CMS’s Medicare.gov Web site and 1-800-MEDICARE toll-free help line. annual open-enrollment period, sponsor call centers will continue to play a  significant role in informing current and prospective enrollees.
You were interested in the quality of the service and information provided  to beneficiaries by PDP sponsor call centers, as inaccurate or misleading  benefit information could lead beneficiaries to choose a PDP that does not  meet their needs. In this report, we examined (1) whether PDP sponsors  provide prompt, courteous, and helpful service to Medicare beneficiaries  and others accessing their toll-free call centers, and (2) the extent to  which PDP sponsors provide accurate and complete information to  Medicare beneficiaries and other callers.
To address these objectives, we made 900 calls to 10 of the largest PDP  sponsor call centers, all of which operate in 30 or more PDP regions and  offer two or three PDPs per region. As of April 27, 2006, each of these  sponsors served at least 100,000 beneficiaries. Each of our 10 sponsors has  one toll-free call center, which we contacted from March 2 through   March 31, 2006. We posed one of five questions about their Part D plans  during each call, asking each question a total of 180 times—18 times to  each of the 10 PDP sponsors. We developed scenarios with zip codes and  fictional relatives for each of the questions. To make them sound realistic  and provide needed information, we specified additional details, such as  drug dosage and frequency information, lack of current drug coverage,  low-income subsidy eligibility, and preference for retail purchasing, if  asked.
In developing our five questions, we examined those addressed by the  Frequently Asked Questions section of CMS’s Medicare.gov Web site. We  also reviewed materials from policy analysts that identified information  critical to making a choice among competing plans. In addition, we spoke  with representatives of beneficiary advocacy groups about the types of  information beneficiaries need to consider when selecting a PDP plan.  Finally, we asked CMS officials what types of information they required or  expected call center customer service representatives (CSR) to be able to  provide the public and developed our questions from this information.  Although CMS does not have requirements regarding the specific types of  information CSRs must be able to provide, agency officials told us that  CSRs should be able to accurately answer questions about the relative  costs of a sponsor’s PDPs, the availability of a plan for beneficiaries  eligible for Medicare’s low-income subsidy, actions that beneficiaries  could take if their drugs are not covered by the plan, and types of  restrictions plans use to manage their formularies.
To evaluate the extent to which sponsor call centers provided prompt,  courteous, and helpful service during our calls, we analyzed information  on the amount of time it took to reach a CSR and the number of calls for  which we could not reach a CSR. In addition, our callers noted if they had  concerns about the appropriateness and clarity of CSRs’ language. In such  cases, we evaluated whether the CSR was difficult to understand, impolite,  or unprofessional. We also noted any helpful suggestions or information  provided to the caller.
We developed criteria for accurate and complete responses for each  question from information provided on CMS’s Web-based PDP finder tool  on Medicare.gov and information that CMS has approved for use by its   1-800-MEDICARE CSRs (see table 1). Excluding calls for which we did not  reach a CSR, we report results on the accuracy and completeness of  information obtained during the remaining calls. We considered an  answer accurate and complete if the CSR’s response met all of our criteria  and we considered an answer incomplete if the CSR’s response met one,  but not both of our criteria. We considered an answer inaccurate if the  CSR’s response did not meet any of our criteria. If the CSR stated that they  did not know or could not provide an answer, we classified the call as “no  answer provided.”
The results from our 900 calls are limited only to those calls and are not  generalizable to the population of calls routinely made to sponsor call  centers by beneficiaries and other callers. Although the five questions we  posed are among the most critical questions regarding PDP comparison,  they do not encompass all of the questions callers might ask. We did not  contact PDP sponsors other than posing questions to the call centers. In  addition, we did not examine other issues related to the performance of  call centers, such as CSR qualifications and training, nor did we evaluate  CMS oversight of sponsor call centers. We conducted our work from  February 2006 through June 2006 in accordance with generally accepted  government auditing standards.
subsections: section_title: Background
paragraphs: Medicare Part D coverage is provided through private sponsors that offer a  choice of PDPs with different costs and coverage. The largest sponsors  offer PDPs to beneficiaries throughout the United States and generally  have experience in providing Medicare coverage and with call center  operations.
subsections: section_title: Key Features of Medicare Part D
paragraphs: Under Part D, each PDP may offer the standard prescription drug benefit  or coverage that is different, but at least actuarially equivalent, to the  standard benefit. According to the Medicare Payment Advisory  Commission, for 2006, 9 percent of PDPs offer the standard benefit,   48 percent offer a basic plan that has the same actuarial value as the  standard benefit but with a different design, and 43 percent offer enhanced  coverage that exceeds the standard benefit. Therefore, the specific  premium, deductible, and copayment or coinsurance amounts, as well as  the coverage gap—the period during which beneficiaries must pay   100 percent of their drug costs—of each PDP may vary.
In addition, MMA and CMS regulations require plan formularies—the list  of drugs a PDP covers—to meet certain standards, but within these  standards, the drugs that are covered and the utilization management tools  that are used to control costs may vary. If beneficiaries’ drugs are not on  their PDP’s formulary, rather than paying full (retail) price for them,  beneficiaries may switch to a similar drug that is on the formulary.  Beneficiaries may also request that the plan make an exception to the  formulary and cover their drugs. If the PDP denies that request, CMS  regulations require that beneficiaries generally be able to appeal the  decision to the sponsor.
Although certain drugs may be on a PDP’s formulary, they may be subject  to one or more of several utilization management tools—the most  common of which are prior authorization, quantity limits, step therapy,  and generic substitution. For drugs subject to prior authorization,  beneficiaries need approval from their PDP before they can fill their  prescription and for drugs subject to quantity limits, the plan limits the  amount of the drug it covers over a certain period of time. For drugs  subject to step therapy, the PDP requires that the beneficiary first try a  less expensive drug for their condition before it will cover the  beneficiary’s prescribed drug. Finally, generic substitution means that  when there is a generic substitute available, the PDP will automatically  provide the generic, unless the beneficiary’s doctor specifically orders the  brand-name drug.
To help cover costs under Part D, Medicare provides subsidies to certain  low-income beneficiaries. For example, Medicare beneficiaries for whom  Medicaid pays their Medicare Part B premium automatically receive the  full low-income subsidy. This subsidy provides the beneficiary with  reduced copayment amounts, covers any deductible, provides drug  coverage during the coverage gap, and helps pay their PDP premium, up to  a certain amount. Other Medicare beneficiaries, however, must apply for  the low-income subsidy through the Social Security Administration, and  may receive only a partial subsidy.
section_title: Characteristics of PDP Sponsors
paragraphs: For 2006, 79 sponsors are offering over 1,400 PDPs, each of which has  been approved by CMS to ensure that it meets established standards. Ten  of these sponsors are offering PDPs in all 34 PDP regions, and they  account for nearly 62 percent of PDPs nationwide. The largest PDP  sponsors are either in the commercial insurance or pharmacy benefit  management and services sectors and generally have prior experience  with call center operations. In addition, the largest PDP sponsors all have  some prior experience with Medicare. Most offered a Medicare  prescription drug discount card or partnered with a company and most  offer Medicare Advantage plans.
section_title: CSRs Generally Provided Prompt, Courteous, and Helpful Service
paragraphs: Almost all of the calls we placed were answered by a CSR with minimal  delay. A limited number of calls were not answered by CSRs, mainly due  to disconnections. Further, we found that most CSRs with whom we spoke  were easy to understand, polite, and professional, and many provided  helpful suggestions and information.
Call centers generally provided prompt service in answering our calls. The  wait time to reach a CSR was generally short—46 percent of the 864 calls  CSRs fielded were answered in less than 1 minute and 96 percent of the  calls were answered in less than 5 minutes (see fig. 1). Only 9 calls   (1 percent) were answered in 10 minutes or more, with the longest wait  time being 25 minutes (1 call). For a small number of calls—36 of the 900  calls we placed (4 percent)—we did not receive an answer to our  questions because we did not reach a CSR. For almost all of these calls  (33), this occurred because we were disconnected.
CSRs generally provided courteous service. Our callers noted that many  were helpful and friendly, and we found that CSRs were easy to  understand, polite, and professional in 98 percent of the calls. In addition,  if a CSR did not know or could not answer a question, many provided  additional resources for obtaining the answer, most commonly during  calls on the low-income subsidy (question 3). While CSRs did not provide  an answer for over one-third of the calls for this question, in over   80 percent of these cases, CSRs suggested another source the caller could  contact to obtain the answer—most commonly Medicare or the Social  Security Administration.
Many CSRs also provided callers with helpful suggestions that related to  our questions. For example, during question 1 calls on the PDP  comparison for a low-utilization beneficiary, CSRs provided information  about a mail-order option to obtain drugs in 22 percent of the calls. For  question 2 on the PDP comparison for a high-utilization beneficiary, CSRs  provided the caller with information about lower-cost drugs in 41 percent  of the calls and inquired as to whether the beneficiary was eligible for the  low-income subsidy in 24 percent of the calls.
section_title: PDP Sponsor Call Centers Did Not Consistently Provide Callers with Accurate and Complete Information
paragraphs: CSRs at the 10 PDP sponsor call centers we contacted provided accurate  and complete responses to about one-third of the calls they fielded,  although the accuracy and completeness rates for each of the 10 sponsor  call centers and for each of the five questions varied. CSRs were unable to  provide an answer for 15 percent of the questions posed, primarily those  related to plan costs. In addition, we found that CSRs within the same call  centers sometimes provided inconsistent responses to our questions.
subsections: section_title: About One-Third of CSR Responses Were Accurate and Complete
paragraphs: Excluding the 4 percent of calls for which we did not reach a CSR, we  obtained accurate and complete responses to 34 percent of the calls—294  of 864—and obtained incomplete responses to another 29 percent of the  calls (see fig. 2).
The overall accuracy and completeness rates for each of the 10 PDP  sponsor call centers varied widely, ranging from 20 to 60 percent (see   fig. 3). Only 1 sponsor call center had an overall accuracy and  completeness rate of greater than 50 percent and 2 sponsor call centers  had rates of 25 percent or less. No sponsor’s call center consistently had  the highest or lowest accuracy and completeness rate for all questions. For  example, although 1 call center had the highest accuracy and  completeness rate for both question 1 (the PDP comparison for a low- utilization beneficiary) and question 2 (the PDP comparison for a high- utilization beneficiary), it had the second-lowest accuracy and  completeness rate for question 4 (nonformulary drugs).
Variation across call centers was due, in part, to differences in the  resources that CSRs said were available to them. For example:  In response to questions 1 and 2, CSRs at two call centers indicated that  they were able to compute the annual cost of the least expensive plan  because they had access to a computerized “cost calculator.” However,  CSRs at other call centers stated that they could not compute an annual  cost because they did not have access to such a resource. We located cost  calculators on the Web sites of seven sponsors, each of which had call  center CSRs who stated that they did not know or could not calculate an  annual cost.
CSRs at six different sponsor call centers stated that they could not  calculate the annual cost of the least expensive plan because they did not  have access to the retail prices of the beneficiary’s drugs. In contrast,  CSRs at two other call centers stated that they did have access to these  prices, and were able to use them in calculations.
For each of the five questions, accuracy and completeness rates varied,  but were generally low. They ranged from 14 to 60 percent (see fig. 4).
Relatively few CSRs were able to accurately identify the least costly plan  and calculate its annual cost. In addition, the annual cost estimates that  CSRs provided were often substantially different from the plans’ actual  costs. For example:    For the low-utilization beneficiary (question 1), about 1 in 3 responses  were incomplete; that is, CSRs identified the least costly plan, but either  inaccurately calculated its annual cost or stated that they could not  provide any annual cost. Over half of the CSRs that provided an inaccurate  response quoted a cost that was greater than the actual cost.
For the high-utilization beneficiary (question 2), about 3 in 10 responses  were incomplete. Among the 23 CSRs that correctly identified the least  costly plan, but gave an inaccurate annual cost, almost all provided a  quote that was less than the actual cost, and in 11 cases over $1,000 less.
About two-thirds of the CSRs were unable to accurately report whether  the sponsor offered a PDP for which a Medicare beneficiary that received  help from Medicaid would not have to pay a premium (question 3).  Specifically, CSRs fielding this call answered inaccurately 31 percent of  the time and did not provide an answer 35 percent of the time. For most of  the inaccurate answers, CSRs stated that a certain PDP would not require  a premium from the beneficiary, but, in fact, it would. Other inaccurate  responses showed a poor understanding of the low-income subsidy  benefit; for example, two CSRs incorrectly stated that the low-income  subsidy did not help offset the premium at all.
Half of the CSRs responding to question 4 incompletely described the  options available to a beneficiary taking a nonformulary drug. Of the  incomplete responses, about 4 in 5 CSRs mentioned that the beneficiary  could request an exception to have the plan cover the nonformulary drug,  but not that the beneficiary could switch to a drug that the plan covers. In  addition, 15 percent of CSR responses included neither possibility, with  many CSRs stating that the beneficiary’s only option would be to pay full  price for nonformulary drugs.
Finally, CSRs accurately described at least two utilization management  tools in 60 percent of our calls for question 5—the highest accuracy and  completeness rate of our five questions. Other CSRs identified, but could  not accurately describe, specific tools. For example, one CSR incorrectly  stated that quantity limits—a limit on the amount of a drug that the plan  will cover over a certain period of time—means that a pharmacy may not  have enough of a drug to fill the beneficiary’s prescription.
section_title: CSRs Did Not Provide Answers to 15 Percent of Calls, Most Often for Questions regarding Plan Costs
paragraphs: Overall, CSRs stated that they did not know or could not answer our  question for 15 percent of the calls. This was most common for the  questions related to PDP costs (the PDP comparison for a low-utilization  beneficiary, the PDP comparison for a high-utilization beneficiary, and the  low-income subsidy).
For question 2 calls regarding the PDP comparison for a high-utilization  beneficiary, 30 percent of the CSRs stated that they were unable to tell the  caller which PDP would cost the beneficiary the least annually. In  contrast, only 8 percent of CSRs provided this response for question 1 on  the low-utilization beneficiary. This difference in the percentage of calls  for which an answer was provided is likely due to the added complexity of  comparing PDPs and calculating the annual cost for a beneficiary using  eight drugs versus a beneficiary using three drugs. However, reliance on at  least five drugs is common in the Medicare population.
Question 3 regarding the low-income subsidy had the highest “no answer  provided” rate—35 percent. Of the CSRs that did not provide an answer to  this question, almost all stated that they did not know the subsidy amount  the beneficiary would receive. Because they did not recognize that  beneficiaries with both Medicare and Medicaid automatically receive the  full low-income subsidy, they could not effectively determine whether that  subsidy would cover the sponsor’s PDP premiums.
section_title: CSR Responses within Sponsor Call Centers Were Inconsistent
paragraphs: CSRs within the same call center sometimes provided inconsistent  responses to our five questions. For example, within each of six different  call centers, among CSRs who accurately identified the least costly plan  for the low-utilization beneficiary (question 1), some CSRs calculated an  accurate annual cost, some calculated an inaccurate annual cost, and  others stated that they could not calculate an annual cost. In response to  question 2 regarding the high-utilization beneficiary, different CSRs within  five call centers identified each of their sponsor’s PDPs as the least costly.  In addition, in response to questions 1 and 2, CSRs at three call centers  told us that it was against the sponsor’s policies to identify any of their  plans as having the lowest annual cost. However, other CSRs at each of  these call centers did not cite this policy and did identify a plan as having  the lowest annual cost.
In part, these inconsistencies were due to differences in CSRs’ knowledge  about their sponsor’s plans. For example, CSRs’ varying knowledge related  to the low-income subsidy question (question 3) produced contradictory  responses. Within each of the 10 sponsor call centers, different CSRs  answered accurately, inaccurately, or stated that they did not know or  could not answer the question. When asked about the options for a  beneficiary using nonformulary drugs (question 4), different CSRs within  each of 6 sponsor call centers stated that a beneficiary could either switch  to a covered drug or apply for an exception, stated only that the  beneficiary could switch to a covered drug, stated only that the beneficiary  could apply for an exception, or stated neither possibility. Among CSRs  that stated neither possibility, the specific responses differed. For  example, at 1 of the above call centers, although five CSRs answered the  question accurately, one erroneously stated that the beneficiary’s only  option was to pay full price for nonformulary drugs, and another  erroneously stated that any drugs not covered by the PDP would be  covered under Medicare Part B.
In answering question 5 on utilization management tools, different CSRs  within the same call center provided varying descriptions of the utilization  management tools PDPs use. For example, although four CSRs within one  call center provided accurate descriptions of at least two tools, three other  CSRs within this call center each provided a different, and inaccurate,  description of utilization management tools. At another call center, two  CSRs stated that they could not describe any tools without knowing the  specific drugs the beneficiary was taking—even though eight other CSRs  at that call center were able to accurately describe at least one tool  without knowing the beneficiary’s drugs.
section_title: Concluding Observations
paragraphs: Our calls to 10 of the largest PDP sponsors’ call centers show that  Medicare beneficiaries face challenges in obtaining the information  needed to make informed choices about the PDP that best meets their  needs. Call center CSRs are expected to provide answers to drug benefit  questions and comparative information about their sponsors’ PDP  offerings. Yet we received accurate and complete responses to only about  one-third of our calls. In addition, responses to the same question varied  widely, both across and within call centers. Sponsor call centers’ poor  performance on our five questions raises questions about whether the  information they provide will lead beneficiaries to choose a PDP that costs  them more than expected or has coverage that is different than expected.  Rather than consider PDP options solely on the basis of the call centers’  information, callers may benefit from consulting other information  sources available on Medicare Part D when seeking to understand and  compare PDP options.
section_title: Agency Comments and Our Evaluation
paragraphs: CMS reviewed a draft of this report and provided written comments,  which appear in appendix I.
In its comments, CMS characterized our analysis as based on inaccurate,  incomplete, and subjective methods that limit the report’s relevance and  validity. However, CMS went on to say that despite its view on the study’s  limitations, GAO is right to be concerned about whether beneficiaries are  getting effective service from plan call centers.
CMS asserted that our questions did not reflect the usual questions  received by PDP sponsor call centers. As noted in the draft report, we  selected topics that were addressed in the Frequently Asked Questions  section of the Medicare.gov Web site and regarded by policy experts and  beneficiary advocates as important to making an informed plan choice.  Furthermore, at a May 2006 meeting with CMS officials, the agency’s  Deputy Administrator stated that CSRs should be able to accurately  answer all of the specific questions we posed during the study.
CMS also stated that we asked for information that CSRs are not required  to provide. Specifically, for questions 1 and 2 on PDP comparisons for low  and high-utilization beneficiaries, CMS stated that it does not require  sponsor call centers to provide information on the annual costs of their  PDPs. However, while not necessarily required, agency officials had  indicated that the information we sought from CSRs was within the scope  of plan sponsor customer service efforts. In a discussion held before we  conducted our March calls, CMS officials told us that the agency had not  established any requirements regarding the specific types of information  plan CSRs must be able to provide, but that it was reasonable to expect  CSRs to give callers accurate information on the topics we included in our  review.
In addition, as noted in the draft report, some call centers were relatively  successful in providing accurate and complete answers to questions 1 and  2, indicating that call center CSRs can handle such questions  appropriately. One call center’s CSRs answered the question accurately  and completely in 88 percent of the calls for the low-utilization  beneficiary, and one call center’s CSRs responded correctly in 81 percent  of the calls for the high-utilization beneficiary. In addition, we found that 7  of the 10 PDP sponsors had cost calculators on their Web sites that could  have been used to answer these questions.
CMS commented that, to be counted as providing a complete response to  questions 1 and 2 on PDP comparisons, we expected CSRs to recommend  a specific plan to the caller, a practice that often constitutes “steering,”  which is prohibited under Medicare marketing guidance. As noted in the  draft report, our callers identified themselves as family members wishing  to assist beneficiaries in choosing a drug plan. Providing assistance to  beneficiaries—which is encouraged by CMS—generally consists of  learning the characteristics of various PDPs and assessing their relative  merits given the potential enrollee’s needs. This is clearly allowed in CMS’s  Marketing Guidelines, which distinguish between assistance based on  objective information and steering to a drug plan for financial gain.
CMS also took issue with how we counted a specific CSR response to  questions 1 and 2. The agency incorrectly claimed that a CSR’s referral to  1-800-MEDICARE was categorized as an incomplete response. As noted in  the draft report, we categorized responses as incomplete if the CSR  accurately named the lowest annual cost plan, but either inaccurately  calculated or could not provide the annual cost. If the CSR did not answer  the question and instead referred the caller to 1-800-MEDICARE for  information on PDPs, we classified the response as “no answer provided.”
CMS stated that the wording of question 3 on the low-income subsidy was  inaccurate and therefore misleading. This question specifies that the  beneficiary automatically qualifies for extra help because Medicaid pays  part of her Medicare premiums. According to CMS, the wording of  question 3 is incorrect because only Medicare pays the drug premium for  low-income beneficiaries and Medicaid would fully (not partly) pay the  Part B premium. However, CMS’s comment conflicts with the information  we obtained from its Medicare.gov Web site in developing the wording and  answer for this question. Using the Web-based PDP finder tool on this Web  site, the user can select one of several options specifying why the  beneficiary qualified for extra help. We selected the option specifying that  the beneficiary automatically qualified for extra help because they receive  “help from  State paying Medicare premiums.” We agree that only  Medicare, and not Medicaid, pays the Medicare Part D premium for low- income beneficiaries and Medicaid would fully (not partly) pay the Part B  premium. Therefore, for such a beneficiary, Medicaid would pay part of  the beneficiary’s Medicare premiums.
CMS also stated that, for certain questions, many reasonable answers were  not counted as correct. The agency cited our question regarding a  beneficiary’s options should he or she be prescribed a nonformulary drug,  and asserted that our criteria for a correct response—switching to a  covered drug or asking for an exception—was too limited. The agency  stated that other reasonable answers should have been counted as correct  because we conducted our calls at a time when all plans covered all Part D  drugs. We obtained the answer to this question from a script that CMS  approved for use by CSRs operating its 1-800-MEDICARE help line. In  addition to the two options we used as criteria for an accurate and  complete answer, the script mentioned that PDPs are required to provide  beneficiaries with temporary transitional coverage (generally for 30 days  after enrollment) of drugs not on the PDP’s formulary. However, according  to CMS, the purpose of this temporary coverage is to provide beneficiaries  with sufficient time to switch to another drug or to request an exception to  the formulary. Therefore, in specifying our criteria for an accurate and  complete answer, we chose to include only the two options that CMS sees  as longer-term solutions for the beneficiary.
CMS stated that we did not examine certain features of the support  services that plan sponsors’ call centers are required to provide, such as  hours of operation, wait times, disconnection rates, and language services.  It also noted requirements that plans report a range of performance  measures, such as beneficiary complaint rates and timeliness of  exceptions and appeals decisions. As noted in the draft report, the scope  of our review was limited to the accuracy and completeness of  information disseminated to the public by PDP sponsors’ call centers—a  feature of plan customer service for which CMS has established no  performance requirements.
Finally, CMS believes that, as written, our study provides little practical  guidance of value in improving the drug benefit and that our conclusion— that callers may benefit from consulting other information sources  available on Medicare Part D when seeking to understand and compare  PDP options—is obvious. In quoting our conclusion, CMS omitted the key  part of the paragraph preceding the quoted phrase where we state that  “sponsor call centers’ poor performance on our five questions raises  questions about whether the information they provide will lead  beneficiaries to choose a PDP that costs them more than expected or has  coverage that is different than expected. . . .” We continue to believe that  plan sponsors should be accountable for the accuracy of their information  and make maintaining effective call centers a priority.
CMS also provided us with detailed, technical comments, which we  incorporated where appropriate.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution of it until 30 days from  the date of this letter. We will then send copies to the Administrator of  CMS, appropriate congressional committees, and other interested parties.  We will also make copies available to others upon request. This report is  also available at no charge on GAO’s Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made contributions to this report are  listed in appendix II.
section_title: Appendix I: Comments from the Centers for Medicare & Medicaid Services
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Rosamond Katz, Assistant  Director; Manuel Buentello; Jennifer DeYoung; and Joanna L. Hiatt made  major contributions to this report. Other contributors include Lori D.  Achman, Diana B. Blumenfeld, Gerardine Brennan, Laura Brogan, Lisa L.  Fisher, M. Peter Juang, Martha R.W. Kelly, Ba Lin, and Michaela M.  Monaghan.