Medicare: Accuracy of Responses from the 1-800-MEDICARE Help Line Should Be Improved
Published: 2004-12-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In March 1999, the Centers for Medicare & Medicaid Services (CMS) implemented a telephone help line--1-800-MEDICARE--to provide information about program eligibility, enrollment, and benefits. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) directed GAO to examine several issues related to this 24-hour help line and the customer service representatives (CSRs) who staff it. In this report, GAO evaluated (1) the accuracy of the information the help line provides, (2) the training given to CSRs, and (3) CMS's efforts to monitor the accuracy of information provided through the help line.
section_title: What GAO Found
paragraphs: The 1-800-MEDICARE help line provided accurate answers to 61 percent of the 420 calls we made and inaccurate answers to 29 percent. We were not able to obtain any answers for the remaining 10 percent of our calls at the time we placed them. Most of these calls were not answered because they were transferred to other contractors responsible for processing Medicare claims that were not open for business at the time we called or these calls were inadvertently disconnected. To facilitate accurate responses, the 1-800-MEDICARE help line provides CSRs with written answers--called "scripts"--that CSRs use during a call. When CSRs provided inaccurate information, it was largely because they did not seem to access and effectively use a script that answered our questions. CMS and its contractor do not routinely pretest the scripts to ensure that they are understandable to CSRs or potential callers. The training for CSRs meets CMS's requirements, but it is not sufficient to ensure that CSRs are able to answer questions accurately on the help line. Before handling calls, CSRs must complete about 2 weeks of classroom training; accurately answer two simulated calls consecutively out of six; and score at least 90 percent on a written exam. In addition, all CSRs receive ongoing training. However, the results from our calls indicate that the testing and simulated call answering did not sufficiently measure whether CSRs were prepared to answer questions accurately. CMS delegates most accuracy monitoring to one of its contractors and reviews the results. The bulk of the monitoring focuses on how accurately individual CSRs answer questions. However, this monitoring does not systematically track questions answered inaccurately by CSRs as a group, which could help target training and script improvement. Through two smaller studies that measured how accurately specific questions were answered, CMS was able to identify areas to improve scripts and training.

section_title: Letter
paragraphs: Medicare is a federal program that helps pay for a variety of health care  services and items for approximately 41 million elderly and disabled  beneficiaries. One of the responsibilities of the Centers for Medicare &  Medicaid Services (CMS), the federal agency that administers Medicare, is  to provide beneficiaries and other members of the public with clear,  accurate, and timely information about the program. To help do so, in  March 1999, CMS implemented a nationwide toll-free telephone help  line—1-800-MEDICARE—which Medicare beneficiaries, their families, and  other members of the public can call to ask questions about program  eligibility, enrollment, and benefits. By 2001, the help line had customer  service representatives (CSR) answering calls 24 hours a day, 7 days a  week. For information about coverage and payment for medical services  and items, beneficiaries and others have also been able to call the  companies under contract with CMS to process and pay Medicare claims.
In 2004, the 1-800-MEDICARE help line significantly expanded its  operations in order to handle an increased number of calls. This increase  occurred after the enactment of the Medicare Prescription Drug,  Improvement, and Modernization Act of 2003 (MMA) in December 2003,  which established a prescription drug discount card program for Medicare  beneficiaries and required that information on this new program be made  available through the 1-800-MEDICARE help line. During the 6 months  following the enactment of MMA, the 1-800-MEDICARE help line handled  over 9 million calls, more than triple the number handled in the previous 6  months. Many of these callers asked about the prescription drug benefit  that will be available beginning in 2006, the prescription drug discount  cards available in the interim, and the $600 credit for prescription drugs  purchased by low-income beneficiaries with the cards. In response to the  increased call volume, in the first half of 2004, CMS added over 800  CSRs—more than doubling the number of staff who had previously been  available to respond to 1-800-MEDICARE help line inquiries. In June 2004,  CMS also increased the number of contractors managing the 1-800- MEDICARE help line from one to two.
MMA also required that GAO examine the accuracy and consistency of  answers provided through the 1-800-MEDICARE help line and the training  and education given to its CSRs. To address this requirement, as  discussed with the congressional committees with jurisdiction over  Medicare, we evaluated (1) the accuracy of information that 1-800- MEDICARE provides, (2) the training given to 1-800-MEDICARE CSRs,  and (3) CMS’s efforts to monitor the accuracy of information provided  through the 1-800-MEDICARE help line.
To evaluate the accuracy of information provided by 1-800-MEDICARE,  we made 420 calls to the 1-800-MEDICARE help line during July 2004 and  posed 1 of 6 questions about the Medicare program during each call. For  each question, we randomly placed calls at different times of the day and  days of the week to match the typical pattern of calls reported by the         1-800-MEDICARE help line in April 2004. To develop our 6 questions, we  initially formulated 20 questions from the 100 topics most frequently  addressed by the 1-800-MEDICARE help line’s CSRs in April 2004. For  each of our questions we developed criteria that we used to define an  accurate response, using information on the Medicare Web site’s  frequently asked questions section. CMS confirmed the responses we  provided, and provided us with the written answers that the CSRs would  be expected to use to respond to each question. From the list of 20  questions, we chose 6 questions, asked each one a total of 70 times, and  evaluated the accuracy of the responses using information provided by  CMS. If the CSR provided some information on the topic, but did not  provide sufficient and complete information to meet our criteria, we  considered the answer to be inaccurate. To evaluate the training provided  to CSRs, we interviewed officials at the primary contractor and CMS staff,  reviewed the instructional materials used in CSR training, and observed a  training session in June 2004. In addition, we reviewed previous GAO  reports on the training provided by help lines, including the training  provided to the CSRs answering calls on the Internal Revenue Service’s  (IRS) help line. To evaluate CMS’s efforts to monitor the accuracy of  information provided through the help line, we interviewed CMS officials  and officials from the primary 1-800-MEDICARE contractor. In addition,  we reviewed related documents and information about call centers in  other industries. We did not verify the reliability of CMS’s monitoring data.  Appendix I includes a more detailed discussion of our scope and  methodology. Our work was conducted from May 2004 through December  2004 in accordance with generally accepted government auditing  standards.
subsections: section_title: Background
paragraphs: CMS administers the 1-800-MEDICARE help line to answer beneficiaries’  questions about Medicare eligibility, enrollment, and benefits. The help  line currently operates 24 hours a day, 7 days a week, and has eight call  center locations that are run by two contractors. As of October 2004, the  primary contractor managed 1,332 of the 2,137 CSRs and operated seven  of the eight 1-800-MEDICARE call centers. In addition, the primary  contractor is responsible for other activities, such as distributing program  material requested by callers, training all new CSRs before they handle  calls on the 1-800-MEDICARE help line, and researching answers to more  complex questions some callers may have. Prior to 2004, one contractor  managed the 1-800-MEDICARE help line. In June 2004, in response to  increasing call volume, CMS hired a second contractor, which in October  2004 managed 805 CSRs and operated one of the eight 1-800-MEDICARE  call centers.
A call placed to 1-800-MEDICARE is answered initially by an interactive  voice response system. This is an automated system that, depending on  the caller’s responses to the system’s automated prompts, routes a call to a  CSR or to other information sources. These other information sources can  include the other help lines maintained by Medicare’s claims  administration contractors or recorded information.
All CSRs must have a high school diploma or its equivalent, but they are  not required to be knowledgeable about the Medicare program at the time  they are hired. To help provide clear, accurate, and timely answers to  callers’ questions, CMS expects the CSRs to use written scripts, which  contain information about the program. CSRs listen to a caller’s question  and then type in related keywords to generate a list of suggested scripts  that could be used to answer the question. The CSRs select the script they  consider best suited to answer the question and read either excerpts or the  entire script. CSRs can also consult other information sources. For  example, CSRs can use Web-based tools available on the Medicare Web  site to help beneficiaries select a prescription drug discount plan, nursing  home, or home health agency.
Because the types of questions frequently posed to 1-800-MEDICARE  change in response to program or other policy changes, new scripts may  need to be created or existing ones updated. Either CMS or the primary  contractor may decide to develop a new script or update an existing one  for clarification or in response to program changes. CMS officials approve  scripts that are developed by the primary contractor, and check them for  accuracy and completeness.
section_title: 1-800-MEDICARE Provided Accurate Information for Less Than Two-thirds of the Calls We Placed
paragraphs: The 1-800-MEDICARE help line provided accurate answers to 61 percent  of the 420 calls we made. The accuracy rate varied significantly among the  six questions we posed. Overall, 29 percent of our calls were answered  inaccurately. In general, CSRs erred because they did not understand  enough about the Medicare program to access the script with information  to answer the question or clearly explain the material in it. In addition, for  10 percent of the calls we placed, we were unable to get a response to our  question at the time we contacted the 1-800-MEDICARE help line, mainly  due to problems when CSRs transferred calls.
subsections: section_title: Accuracy Rate Varied Significantly by Question
paragraphs: In response to our calls to the 1-800-MEDICARE help line, CSRs answered  our questions accurately for 256 out of 420 calls, a rate of 61 percent. The  criteria we developed to determine the information that constituted an  accurate answer for each question are shown in table 1. (A more detailed  version of the questions and information to answer them are in apps. II  through VII.) The criteria were based on answers we developed from  information on the Medicare Web site and were confirmed by CMS, which  provided us with the scripts that contained information to answer the  questions. We considered all calls we placed to the 1-800-MEDICARE  help line to be part of our test of its accuracy, even if the call was  transferred to a claims administration contractor to provide the answer.
The percentage of calls CSRs answered accurately varied by question, as  shown in figure 1. For example, CSRs accurately answered 81 percent of  the calls asking whether a beneficiary could receive a prescription drug  discount card if they had a Medigap policy. The answer to the Medigap  question was clearly described in a script, which allowed CSRs to respond  with the highest accuracy rate for all of our questions. Similarly, for  question 1—choosing a prescription drug discount card—CSRs answered  accurately 76 percent of the time. By July 2004, when we placed our calls,  a large number of CSRs had been recently hired and trained specifically to  answer this question, using a script and a Web-based tool. In contrast, for  question 2 calls about the $600 prescription drug credit, CSRs answered  inaccurately 79 percent of the time. CSRs scored poorly on this question  primarily because they based their answers on the beneficiary’s total  income without considering that some specific types of income should not  be included in the calculation of eligibility for the credit. CSRs would have  had to access two scripts to correctly answer the question, because the  more general script on the topic did not contain all of the needed  information. Question 5, which addressed Medicare part B enrollment,  also had a relatively high inaccuracy rate—41 percent. We were not able to  obtain an answer to some of our questions at the time that we called, most  commonly when CSRs or the interactive voice response system  transferred calls concerning questions 4 and 6 to other help lines.
section_title: Inaccurate Responses Were Largely Due to Ineffective Use of Scripts
paragraphs: CSRs responded inaccurately to our questions largely because they did not  seem to know enough to effectively use the scripts. According to a CMS  official and the primary contractor’s staff, CSRs are expected to use  scripts to guide their discussion with callers; they are not supposed to rely  solely on acquired knowledge of Medicare to answer questions. We found,  however, that in responding to our questions CSRs usually had one of four  problems using scripts. The CSRs (1) did not seem to access a script, even  when one was available; (2) did not seem to access a script with the right  information to answer the question; (3) did not obtain enough information  from the script; or (4) misunderstood some of the words in the scripts.
We found instances when CSRs did not seem to access scripts when  responding to calls. For example, when responding to our calls concerning  the prescription drug discount card question, 2 CSRs indicated that they  were not able to inform the caller about which card had the lowest drug  prices—even though 53 other CSRs successfully used a script and a Web- based tool to answer this question. One other CSR referred our caller to  AARP for an answer, rather than respond with the appropriate script and  Web-based tool. These 3 CSRs did not seem to know how to correctly  answer this question, which was addressed by one of the most commonly  accessed script for the first half of the year. During 20 of the calls to  answer our question on whether a spouse should enroll in Medicare part B  if he had current employment-based health insurance, CSRs told our  callers that enrolling in Medicare was a personal decision and they could  not answer the question, which we classified as an inaccurate answer.  They did not seem to recognize that they could access a script that  contained information designed to answer that question.
CSRs sometimes seemed to be accessing the wrong script to answer our  question. For example, in answering the question on whether a beneficiary  could receive a prescription drug discount card if she had a Medigap  policy, one CSR incorrectly stated that the caller needed to complete a  survey before receiving an answer. There is a script available that provides  the answer to the Medigap question, but the script does not mention a  survey. This CSR seemed to be using a different script about the  prescription drug discount card, which has the right information to answer  our question on the best prescription drug discount card to choose.
In some cases, CSRs did not obtain enough information from the scripts  they were using to accurately answer the question we asked. For example,  to answer our question concerning whether a beneficiary could qualify for  the $600 credit toward prescription drug purchases, the CSR should  consider the source, as well as the amount of the beneficiary’s income.  Some sources of income are not counted in determining a beneficiary’s  eligibility for the $600 credit. According to CMS, to answer this question  accurately the CSR would have to access two different scripts. The first  script provides general information about the $600 credit and refers CSRs  to the second script, which lists the sources of income that are not  included in the eligibility calculation. However, the CSRs who answered  this question incorrectly in 55 calls—or 79 percent of the time—focused  on the total amount of income and did not seem to seem to consider the  sources of the income or to access and use information from the second  script. In 14 of the calls—or 20 percent of the time—CSRs were able to  answer this question correctly, because they did consider the sources and  amounts of income that we indicated the beneficiary had.
Finally, CSRs sometimes misinterpreted or did not understand the words  they were reading from the scripts or other written materials. For  example, to answer our Medigap question, a CSR incorrectly told the caller  that the beneficiary would automatically receive a prescription drug  discount card if enrolled in a Medigap plan. The CSR may have been  confusing Medigap policies with Medicare managed care plans, because  both are discussed in the script that answered this question. In another  example, for our question related to power wheelchair coverage, a CSR  misread the requirement that a beneficiary must have adequate trunk—or  upper body—strength. The CSR mistakenly informed us that a Medicare  beneficiary needs to have adequate “trunk space” in order to qualify for a  power wheelchair. When we asked for clarification, the CSR stated that  Medicare requires a qualifying beneficiary to have adequate trunk space in  his or her car to hold a power wheelchair. Similarly, during one of our  calls about eye exam and glasses payment, the CSR informed us that an  eye exam would be covered and then stated, “the only part of the exam  that is not covered is ‘refraction,’ but I don’t know exactly what that is.”  Because the CSR did not understand that a typical eye exam would be  considered a refraction, she gave the caller the incorrect impression that  Medicare would pay for a routine eye exam.
CMS and contractor staff acknowledged that scripts for the 1-800- MEDICARE help line are not routinely pretested to ensure that both the  CSR and the caller can understand the script before it is used to answer  callers’ questions. On occasion, the 1-800-MEDICARE contractor has  obtained CSRs’ feedback on draft scripts before they are used on the         1-800-MEDICARE help line to ensure that scripts can be easily read and  understood. But this is not done as a routine step before new and revised  scripts are used in handling calls. In addition, even if the CSRs consider  the script understandable, it may still be confusing to Medicare  beneficiaries. We found that pretesting to ensure that written material is  understandable to its intended audience is a standard practice used to  develop effective communications materials. For example, prior to issuing  the first Medicare & You handbook nationwide to beneficiaries, CMS  conducted consumer testing of its publication to evaluate its effectiveness  as a communication tool. CMS has revised subsequent editions of the  handbook to make it easier to read and use, based on feedback from  beneficiaries. Moreover, other HHS agencies, such as the Centers for  Disease Control and Prevention and the Substance Abuse and Mental  Health Services Administration, have developed guidance on steps for  ensuring that written material is understandable for intended readers and  pretesting the materials before use.
section_title: Ten Percent of Calls Were Not Answered, Often When Calls Were Transferred to Other Contractors’ Help Lines
paragraphs: We did not receive answers to our questions for 10 percent (42) of the 420  calls we placed at the time we originally called. Several reasons accounted  for this, as table 2 shows. For half (21) of the unanswered calls, the CSRs  or the interactive voice response system transferred the calls placed  during morning, evening, and weekend hours to claims administration  contractors that were not open for business at the time of our call.  Although the 1-800-MEDICARE help line is open 24 hours a day, 7 days a  week, these other help lines are not. The transferred calls pertained to our  questions concerning Medicare coverage about power wheelchairs and  eye exams and glasses. The 1-800-MEDICARE CSRs or the interactive  voice response system transfer such questions to the claims  administration contractors’ help lines because these contractors generally  have greater knowledge about Medicare coverage issues. Once our calls  were transferred to closed help lines, we generally heard recordings that  stated the contractors’ regular business hours and suggested calling back  at that time. However, for 7 of those 21 calls, the contractors’ recorded  messages did not provide a telephone number to use to call back during  the stated business hours.
The second most common reason we did not receive answers to our calls  was that our calls were disconnected. Sixteen of the 42 unanswered calls  were disconnected. For example, calls were disconnected before we were  able to obtain a response to our questions. In one instance, the call was  placed on hold for 30 minutes and then was disconnected. Four calls made  on the same day did not receive a response because computer  maintenance prevented the CSRs from accessing the Web-based tool they  needed to use to answer our question about the prescription drug discount  card. Finally, one other call was unanswered because the call was routed  to a wrong telephone number.
section_title: CSR Training Met CMS’s Requirements, But Was Not Sufficient to Ensure Accurate Responses
paragraphs: As required by CMS, both newly hired and experienced CSRs receive  training to help them answer questions posed on the 1-800-MEDICARE  help line. The training for newly hired CSRs includes instruction on  accessing and using scripts, customer service etiquette, and information  about the Medicare program. As part of the training, CMS requires newly  hired CSRs to score 90 percent or higher on a written exam before they  handle calls on the help line. All CSRs also receive continuing training, and  take written quizzes on the new material. Although the 1-800-MEDICARE  contractors met CMS’s training requirements by providing instruction and  testing, the testing does not fully measure CSRs’ ability to accurately  answer real questions from callers.
The primary contractor develops and conducts the training new CSRs  receive. Most of the training consists of 2 weeks of classroom instruction.  In general, the instruction introduces CSRs to scripts and provides general  information about the Medicare program. For example, in a training  session we observed for newly hired CSRs in June 2004, the instructors  helped the CSRs prepare for the types of inquiries that might be expected  from callers on the 1-800-MEDICARE help line. The instructors posed  different questions to the class, and each CSR attempted to identify and  access a script with the right information to answer the instructor’s  question. One CSR would be selected to read the script that they chose,  and participants discussed whether they thought this was the script with  the best information to answer the question. After completing their initial  instruction, CMS requires the new CSRs to score at least 90 percent on a  written exam and successfully complete a call handling simulation  exercise before they answer calls on the help line without supervision. To  successfully complete the call handling simulation exercise, CSRs must  accurately answer two consecutive simulated help line calls out of six  possible attempts. In addition, new CSRs generally spend about 4 hours  listening to calls answered by an experienced CSR.
In addition to the initial training for newly hired CSRs, CMS requires all  CSRs to receive continuing training. Continuing training is delivered  through three methods: refresher classes, online broadcast  announcements, and small group meetings. Weekly refresher classes  provide a means of instructing CSRs about Medicare program changes.  Following each refresher training class, CSRs complete a short quiz to  show that they understand the new information. While there is no  minimum score that CSRs must achieve on the short quiz, CMS staff  informed us that help line supervisors review each quiz to ensure that any  questions that posed problems for CSRs would be addressed with further  training. To provide CSRs with information quickly, the primary contractor  sends online broadcast announcements to each CSR’s computer  workstation. These online announcements usually contain information  that may affect CSRs’ responses to help line questions, such as news about  a change in a specific script. Lastly, small group meetings of about 12  CSRs and their supervisor are held for 30 minutes each week so that CSRs  can discuss topics that can help them improve their call handling skills.
After gaining experience in answering calls, some CSRs receive 4  additional days of special training and are promoted to a senior position.  These CSRs receive classroom training on using Web-based computer  programs that can assist Medicare beneficiaries in selecting a managed  care plan, a nursing home, or other Medicare-related services. Like other  CSRs, they must score 90 percent or higher on a written exam, and  successfully complete a simulated call handling exercise before they can  handle calls using the Web-based computer programs. Currently, about  200 senior CSRs answer calls on the 1-800-MEDICARE help line.
Although all CSRs receive training and are tested as required, the  responses we received indicate that not all CSRs had the necessary  knowledge and skills to answer our questions accurately. In our opinion,  testing how effectively CSRs use scripts to answer frequently asked  questions provides the best measure of their preparation to do so. While 24  of the exam’s 52 questions ask CSRs to identify scripts that could be used  to answer specific inquiries, the remaining 28 questions target other  skills. In addition to the written test, new CSRs must appropriately  answer questions posed in two consecutive simulated calls before they  staff the help line. This simulated call handling and some of the written  exam questions are the only measures of the CSRs’ ability to accurately  answer calls using scripts. In combination, the test and the two simulated  calls do not appear to be a sufficient measure of new CSRs’ ability to  accurately answer the most frequently asked questions, given our findings  on the accuracy of their responses. Further, while all CSRs receive  continuing training, they are not required to demonstrate that they have  effectively mastered the new material in handling calls.
Developing a more targeted assessment of where CSRs need to augment  their skills helped focus another help line’s training efforts and allowed it  to meet its accuracy goals. In 2001, we assessed the telephone help line  maintained by the IRS to answer taxpayers’ questions and found that it  had not met the agency’s goals for accurately answering general questions  about tax law and specific questions about individuals’ tax returns in  2001. In response, the IRS analyzed the specific types of inquiries within  the area of tax law and individual returns that were answered inaccurately  and identified the knowledge and skills its CSRs needed to answer  questions more accurately. The IRS also identified the CSRs most in need  of training to improve accuracy in those knowledge and skill areas and  provided additional training to them before call volume increased for the  2002 tax season. By the end of the training period, these CSRs were  required to be certified by their managers as capable of providing correct  responses to taxpayer questions. The IRS also assigned responsibility for  selected tax law topics to individual call center managers, making them  accountable for ensuring that CSRs were trained and could accurately  address inquiries on these topics. After these initiatives were complete, we  found that the help line had improved its accuracy enough to meet its 2001  goals. In the span of 1 year, the accuracy rate on answering tax law  questions increased from 79 to 85 percent and the accuracy rate for  answering questions about individuals’ tax returns increased from 88 to 91  percent.
section_title: Monitoring Generally Focused on Performance of Individual CSRs, Rather than Accuracy Rates for Specific Questions
paragraphs: CMS monitors the 1-800-MEDICARE help line mostly by requiring its  primary contractor to evaluate four individual conversations that each  CSR has with callers each month. Based on these conversations, the  primary contractor evaluates the performance of individual CSRs in  several categories, including accuracy, and reports the overall results to  CMS. CMS also occasionally directly monitors a small number of  individual CSRs’ calls. However, the contractor’s and CMS’s monitoring  does not systematically track the accuracy rates for commonly asked  questions. As a result, the monitoring does not assess how accurately  CSRs as a group answer particular questions, which could help CMS target  additional training efforts. Two smaller evaluation efforts did focus on  specific questions answered inaccurately, and these targeted monitoring  efforts provided information that CMS used to improve CSR training and  the scripts used on the help line.
subsections: section_title: CMS’s Primary Contractor Monitors Performance of Individual CSRs
paragraphs: At the time of our review, CMS had delegated most of the responsibility for  monitoring the accuracy of the 1-800-MEDICARE help line to the primary  contractor, while maintaining oversight by reviewing the primary  contractor’s results. To monitor 1-800-MEDICARE, the primary contractor  focuses on the performance of individual CSRs, evaluating four calls per  month for each person. The primary contractor evaluates either live  conversations—known as blind monitoring—or recorded conversations  on the help line, while viewing displays of the CSRs’ computer activity  during calls. Viewing the CSRs’ computer activity allows the primary  contractor’s staff to observe the scripts or other materials that CSRs  access to answer callers’ questions. After monitoring a call, the primary  contractor’s supervisory staff uses a checklist to evaluate the CSR’s  response to the caller. Help line supervisors share the results with each  CSR to help improve performance. The primary contractor provides  monthly reports to CMS on the results of its monitoring. The primary  contractor has a subcontractor, which is responsible for conducting some  independent call monitoring, as well as reviewing the results of some of  the primary contractor’s call monitoring. In addition to the four calls per  CSR per month that CMS requires the primary contractor to monitor, the  subcontractor monitors up to one additional call per month per CSR. The  subcontractor reports its monitoring results monthly to CMS and the  primary contractor.
In addition to meeting CMS requirements, the amount of call monitoring  per CSR approximates industry standards. A survey of 735 North American  call centers that represent help lines in various industries, including  telecommunications, financial services, and health care, found a wide  variance in the number of calls monitored per month. The most commonly  reported monthly monitoring frequencies were 4 to 5 calls per CSR or 10  or more calls per CSR.
The evaluation checklist used by CMS’s contractor for monitoring calls  indicates that a CSR’s performance should include certain components— such as using an appropriate greeting, showing respect to the caller,  actively listening to the caller, responding accurately to the question,  providing a complete response, using appropriate tone and speed, offering  to provide additional information if necessary, and ending the call politely.  The primary contractor’s staff uses the checklist to evaluate both the  customer service skills and knowledge skills demonstrated during a call  and classify these into one of four categories—“unacceptable,” “needs  improvement,” “achieves expectations,” and “exceeds expectations.”
CMS requires the primary contractor to reach a quality rating of “achieves  expectations” or higher for at least 90 percent of the total number of CSR  calls evaluated each month. The primary contractor evaluates a call as  either “accurate” or “inaccurate,” and because accuracy is weighted more  heavily than other components, a CSR cannot provide inaccurate  information on a call and still have the call scored as “achieves  expectations.” However, in contrast to our methodology for this report, a  CSR can provide incomplete information—information that is correct but  does not fully answer the question—and still have the call scored as  “achieves expectations.” In addition, the evaluation checklist does not  indicate the specific criteria used to determine a call’s accuracy.
Although CMS’s main role in monitoring the help line is to review the  efforts of the primary contractor, the agency also conducts some  monitoring of CSRs on its own. Like the primary contractor, CMS  occasionally uses blind monitoring to evaluate the performance of  individual CSRs—listening to real-time calls and watching the scripts and  other materials the CSRs use. CMS does not conduct blind monitoring  routinely and document the results, and therefore, CMS staff could not  provide us any information on the extent of this monitoring. According to  a CMS official, the agency conducts blind monitoring on a “limited and as- needed” basis.
section_title: CMS Has Tracked Accuracy Rates by Question on Occasion
paragraphs: Although CMS’s primary 1-800-MEDICARE contractor monitors the  accuracy of individual CSRs, CMS does not use the regular monthly  monitoring to identify trends in inaccurate responses by question.  Specifically, the primary contractor does not routinely classify or  categorize CSRs’ answers by specific question to identify the questions  that collectively were answered less accurately. While routine information  about a question’s accuracy rate could be used to target improvement  efforts, CMS has only taken this approach twice in recent years. Both of  these efforts were small compared to the primary contractor’s monitoring.  The larger effort to monitor accuracy by question lasted 29 months and  involved 300 calls a month, whereas the primary contractor evaluated  about 7,350 calls in July 2004.
CMS contracted for a study to evaluate the 1-800-MEDICARE help line’s  accuracy in answering specific questions, but did not receive results  quickly enough to immediately address problems. Beginning in January  2002 and until May 2004, the CMS contractor hired to assess the “Medicare  & You” program placed about 300 calls per month to the 1-800- MEDICARE help line. These callers used a set of hypothetical scenarios to  assess how specific questions were answered. This study also established  criteria specifying the information an accurate answer should provide  and made a distinction between fully responsive answers—in other words,  complete and accurate answers—or partially responsive answers—not  complete but providing some accurate information. For the first 19  months studied, the average percentage of calls that received fully  responsive answers ranged from under 40 percent to over 90 percent,  depending on the question and the period of time studied.
The study helped CMS identify questions that the CSRs were answering  less accurately. However, CMS staff told us that the agency received the  reports 4 to 5 months after monitoring occurred, which did not allow CMS  to immediately address any identified problems. Nevertheless, CMS staff  indicated to us that the results of these evaluations were used to identify  areas where CSR refresher training was needed. Due to funding  constraints, this project was terminated in May 2004. CMS told us it  planned to resume a similar project in November 2004 around the time  when the next cycle for the “Medicare & You” program contract begins.
In another study, CMS measured 1-800-MEDICARE’s accuracy by question  rather than individual CSR and found that certain questions were  answered more accurately than others. In April 2004, a private consultant  group that was under contract with CMS placed 49 calls to 1-800- MEDICARE to determine whether CSRs were relaying accurate  information about Medicare’s new prescription drug discount card and  benefit. The study established specific criteria on the information that  CSRs should include for an answer to be accurate. Evaluating accuracy  by question, the study found that CSRs accurately answered between   39 percent and 69 percent of the questions asked about the new Medicare  prescription drug discount card and benefit. In contrast, in that same  month the subcontractor—using its evaluation checklist—determined that  the overall accuracy rate for the calls it measured on all topics to be about  94 percent.
As a result of this study, CMS improved its scripts and related training. The  private consultant’s report indicated that CSRs were having difficulty  distinguishing between the Medicare prescription drug coverage benefit  that will be in effect in 2006 with the Medicare prescription drug discount  card that is currently available. CMS responded by clarifying the scripts  used to answer these questions and improving the related materials used  to train CSRs. For example, CMS worked with the contractor to rename  the titles of the different scripts to include the term “benefit” or “card” as a  method of differentiating between them. When the subcontractor noted  about 3 months later that a few CSRs were continuing to confuse the  prescription drug discount card and prescription drug benefit, CMS further  clarified the scripts and its primary contractor conducted additional  refresher training to attempt to correct the problem.
section_title: Conclusions
paragraphs: Each year, millions of Medicare beneficiaries, their family members, and  other callers rely on the 1-800-MEDICARE help line for information.  Providing them with accurate answers is critical to keeping them informed  about Medicare’s benefits. However, we found that 6 out of 10 calls were  answered accurately, 3 out of 10 calls were answered inaccurately, and we  were not able to get a response for 1 out of 10 calls.
To answer inquiries accurately, CSRs have to be able to effectively access  and use scripts. Given the lack of prior Medicare knowledge among CSRs,  the 1-800-MEDICARE help line’s script-based approach is a reasonable  means to facilitate accurate and consistent responses to caller’s questions.  However, this approach makes CSRs—and thus the help line they  support—dependent on the clarity and accuracy of the scripts available.  Pretesting scripts might have identified ones that were difficult to  understand by either the CSR or by potential callers, but this is not  routinely done. Further, the training that CSRs receive on using scripts is  also essential to their ability to answer questions accurately. However, the  written exam that newly hired CSRs must pass and the continuing training  quizzes do not measure the ability to use information in scripts to provide  accurate and complete answers on the help line.
Monitoring the help line could identify areas where CSRs’ knowledge and  skills are lacking. Although CMS ensures that the amount of the  contractor’s monitoring per CSR falls within industry standards, the bulk  of the monitoring methods are not designed to systematically assess how  accurately CSRs as a group answer particular questions. Evaluating how  accurately particular questions are addressed is an important step to  improving scripts and CSR training for those topics.
Finally, 1-800-MEDICARE is advertised as providing information 24 hours  a day, 7 days a week, but we could not always obtain answers to our  questions when we called. When we called with questions about Medicare  payment for power wheelchairs and coverage of eye exams and glasses,  the help line frequently transferred our calls to claims administration  contractors that were closed at the time. For a third of these transferred  calls, we were not given a call-back number. This practice of transferring  calls to claims administration contractors that are closed, in effect,  reduces the benefit of a 24-hour help line to a business-hour help line for  many beneficiaries.
section_title: Recommendations
paragraphs: In order to improve the accuracy of responses made on the 1-800- MEDICARE help line and callers’ ability to have their questions answered,  we recommend that the CMS Administrator take four actions:    Assess the current scripts for the most commonly asked questions to  ensure that they are understandable to CSRs and potential callers and if  not, revise them as needed and pretest new and revised scripts to ensure  that CSRs can effectively use them to accurately answer callers’ questions.
Enhance testing of CSRs’ skills in accurately answering the most  commonly asked questions using scripts and, if needed, provide additional  training to improve the accuracy and completeness of their responses.
Supplement current monitoring efforts to include a systematic review of  the accuracy of information provided by the CSRs as a group for the most  frequently asked questions and use the results to modify scripts or provide  more training, as needed.
Revise routing procedures and technology to ensure that calls are not  transferred or referred to claims administration contractors during  nonbusiness hours.
section_title: Agency Comments and Our Evaluation
paragraphs: In its written comments on a draft of this report, which are reprinted in  appendix VIII, CMS agreed with our recommendations and stated that it  had begun several efforts to address them. CMS also provided more detail  on the challenges it faced in administering 1-800-MEDICARE due to the  massive increase in call volume that occurred after the passage of the  MMA.
CMS agreed with our recommendation to assess current scripts and  pretest new and revised scripts to ensure that they are understandable. In  its comments, CMS stated that the written information used to develop      1-800-MEDICARE scripts often comes from Medicare publications that  have been consumer tested as part of the publication preparation process.  Language that has undergone some consumer testing is often incorporated  into the scripts to improve clarity. While this step may be helpful, we  believe that pretesting scripts verbally is also important, as consumer  testing of material intended for written publication may not be adequate to  determine whether the scripts are understandable to CSRs and the public.  CMS also stated that it is considering implementing an editorial board to  review scripts, which we believe would be another positive step to help  assure the scripts’ clarity.
CMS agreed with our recommendation to enhance testing of CSRs’ ability  to accurately answer questions and provide additional training, as needed.  CMS indicated that it was reassessing its testing requirements to  determine better ways to ensure that CSRs are prepared to handle calls,  once they are certified. The agency stated that it planned to benchmark its  efforts against industry standards to determine more effective approaches.  In its comments, CMS expressed concern that we had characterized  customer service skills as less meaningful than knowledge skills. While we  believe both are important, in keeping with our congressional mandate,  this report focused on the accuracy of information provided by 1-800- MEDICARE and did not address the quality of its CSRs’ customer service  skills.
CMS agreed with our recommendation to supplement its current  monitoring efforts by including a systematic review of the accuracy of  information provided by CSRs as a group for the most frequently asked  questions and using the results to modify scripts and provide more  training, as needed. CMS indicated that it believed it had done a good job  developing a quality assurance program that focuses on the most  important requirements for both accuracy and customer service skills  needed to answer calls from the elderly population. We agree that CMS  has focused on quality assurance for 1-800-MEDICARE. Our  recommendation did not deal with changing, but with enhancing, its  quality assurance efforts. To address our recommendation, CMS indicated  that it would implement a plan to develop trend information on the results  of its quality assurance activities and would focus on improving the  accuracy of responses to frequently asked questions.
CMS agreed with our recommendation to revise procedures so that calls  are not transferred to claims administration contractors during their  nonbusiness hours. The agency indicated that although the 1-800- MEDICARE CSRs are available 24 hours a day, 7 days a week, they do not  have access to claim-specific information. Therefore, the 1-800- MEDICARE CSRs would have to direct callers asking questions about  specific claims to contact the claims administration contractors during  their normal business hours. Our report focused on questions for which  the CSRs had scripted responses and did not need to access claim-specific  information. Nevertheless, for 7 of the 21 calls that were routed to claims  administration contractors that were closed at the time we called, the  contractors’ recorded messages did not provide a telephone number to  call back during stated business hours. In its comments, CMS indicated  that it had implemented additional routing plans to address this problem  and is expanding access to claims data that will help reduce this problem  in the future. CMS also raised concerns that we did not release the  detailed audit documentation on our test calls while our work was still in  progress. GAO’s policy does not allow us to provide audit documentation  to an agency while work is ongoing. At the time of CMS’s request, we  described our policy and offered to verbally provide more detail on  telephone disconnections, but CMS did not follow up with us to obtain this  information. After our report is published, we will address this request.
Finally, CMS expressed concern that we did not describe the criteria we  used to evaluate the accuracy of responses to our six questions and stated  that incomplete answers should not be considered inaccurate responses.  As noted in the draft report, table 1 lists the criteria that we established for  each of our six questions. We developed these criteria so that we could  objectively evaluate responses received from CSRs. For four of these  questions (numbers 1, 2, 3, and 6), there was only one element in the  correct response, so an incomplete response was not possible. For the  remaining two questions, we considered the answer accurate if it included  two elements. We believe that by not including both elements for each of  these questions, callers would be left with a false impression, rather than  with an accurate answer. For example, in evaluating the response to the  question of whether Medicare would pay for a power wheelchair, we  thought it was important for the caller to know that (1) the wheelchair  needed to be prescribed by a physician and (2) the beneficiary would be  responsible for a copayment. Because the copayment for a power  wheelchair is at least $1,000, we believe that it would be misleading not to  mention either a copayment or cost sharing when a caller asks whether  Medicare pays for this item. Likewise, needing to have a physician  prescribe the power wheelchair is a Medicare requirement, and we did not  think a response could be accurate without mentioning it. For the question  on Medicare part B enrollment, we thought that it was important to know  that a beneficiary could wait to enroll but, once other health insurance  coverage ended, had a limited time period to enroll in part B without  incurring higher premiums. Without knowing both elements of this  answer, beneficiaries would not have enough information to guide their  decision on part B enrollment and, therefore, the answer provided would  be misleading.
We are sending copies of this report 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 staff have any questions about this report, please call me on  (312) 220-7600. An additional GAO contact and other staff who made  contributions to this report are listed in appendix IX.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine the accuracy of information provided, we placed a total of  420 calls to the 1-800-MEDICARE help line. We made 420 calls in order to  have a sample that was large enough to determine if differences in  accuracy were significant. We selected six questions about Medicare— three related to the Medicare prescription drug discount card and three  related to Medicare coverage or eligibility for benefits. We asked each of  the selected questions a total of 70 times. We randomly placed calls at  different times of the day and different days of the week between July 8  and July 30, 2004, to match the daily and hourly pattern of calls reported  by 1-800-MEDICARE in April 2004.
To select the 6 questions, we initially chose 20 questions that related to the  100 topics most frequently addressed by the 1-800-MEDICARE help line’s  CSRs in May 2004 and developed criteria for an accurate response from  information on the Medicare Web site’s frequently asked questions  section. We then presented the 20 questions and answers to Centers for  Medicare & Medicaid Services (CMS) officials, who provided us with a  script number and text for each question. CMS officials did not object to  using any of the 6 questions that we ultimately chose, or suggest that the  answers that we had provided for these questions were incorrect. We  informed both CMS and one of the 1-800-MEDICARE contractors that we  would be placing these calls. However, we did not tell them which 6 of the  20 questions we selected, or the specific dates and times when we would  be placing our calls.
Before placing our calls, we created a scenario with fictional names and  zip codes for each of the six questions to make them sound more realistic.  (Appendices II to VII contain the scenarios that we used.) We made pretest  calls for each question before we finalized its wording. During our actual  calls, the CSRs were not aware that their responses would be included in a  research study. We recorded the length of, and routing process for, each  call. We evaluated the accuracy of the responses by CSRs to the 420 calls  we placed by whether key information was provided.
The results from our 420 calls are limited only to those calls and are not  generalizable to the population of calls routinely made to call centers by  beneficiaries or other callers. Although the six questions we posed were  among topics most often accessed by CSRs, they do not encompass all of  the questions callers might ask. In addition, we did not verify the reliability  of CMS’s monitoring data.
To examine the training provided to 1-800-MEDICARE CSRs, we  interviewed officials representing CMS and the 1-800-MEDICARE  contractor responsible for training CSRs. We reviewed the primary  contractor’s training requirements and the instructional materials that are  used to educate new CSRs. We also observed a training session for new  CSRs at a 1-800-MEDICARE call center. In addition, we reviewed previous  GAO reports on the operations of other help lines, including the training  provided to the CSRs answering calls on the Internal Revenue Service’s  help line.
To evaluate CMS’s role in overseeing the accuracy of information provided  through the 1-800-MEDICARE help line, we interviewed officials from  CMS and one of the two 1-800-MEDICARE contractors about their  monitoring and oversight activities. For our first objective, we focused on  the accuracy of information provided by the CSR regardless of the  contractor who managed their work. For our other two objectives, we  relied on information provided by one of the two contractors—which we  refer to as the primary contractor. We also identified CMS requirements  for call center operations and reviewed contractor reports to identify the  types of problems encountered through the help line. We performed our  work from May 2004 through December 2004 in accordance with generally  accepted government auditing standards.
section_title: Appendix II: Prescription Drug Discount Card Questions and Information Used to Develop Accuracy Criteria
paragraphs: For question 1, which is about choosing a prescription drug discount card,  we used scenarios with different combinations of prescription drugs and  one of four different locations, in order to ensure our anonymity. If a CSR  named one of the two prescription drug discount cards with the lowest  cost for the combination of prescription drugs in the scenario posed, we  considered it to be a correct response to our question. To ensure that we  obtained the correct answer for each question, we periodically checked  the prescription drug prices using the prescription drug tool on the  Medicare.gov site. This is the same tool CSRs used to answer our  questions. The answers shown in this appendix were accurate as of July  15, 2004.
Question 1a posed to CSRs:  My father-in-law lives in Wayne, Pennsylvania, and wants to continue to  shop at Yorke Apothecary (located at 110 S. Wayne Ave., Wayne,  Pennsylvania, 19087). What drug card can he get that will cover all of  his drugs at Yorke Apothecary, and cost the least amount?
He takes the following drugs:  Other information to provide to the CSR if asked:    He is single.    He lives in Wayne, Pennsylvania, in Delaware County. His zip code is  19087.
He currently has fee-for-service Medicare with no other drug benefits.    He does not use an American Indian Health pharmacy.    He does not live in a long-term care facility.    He has $20,000 in annual income and is not interested in any drug  assistance programs, including the $600 credit.
His sources of income are a pension and Social Security, but the amount  from each is unknown.
He has some bank accounts, but their value is unknown.    The amount he currently pays for drugs is unknown.    Default answer for other questions: “I don’t know.”
Two prescription drug discount cards listed on Medicare.gov with  the lowest prices for the combination of drugs in our scenario:  myPharmaCare Prescription Drug Discount Card  1-800-601-3002  Monthly drug costs: $116.69  Annual enrollment fee: $25.00  U Share Prescription Drug Discount Card  1-800-707-3914  Monthly drug costs: $115.59  Annual enrollment fee: $19.95  Question 1b posed to CSRs:  My father lives in Homewood, Illinois, and wants to continue to shop at  the K-Mart Pharmacy in Homewood, Illinois (located at 17550 Halsted Rd.,  Homewood, Illinois, 60430). What drug card can he get that will cover  all of his drugs at the K-Mart Pharmacy, and cost the least amount?
He takes the following drugs:  Other information to provide to the CSR if asked:    He is single.    He lives in Homewood, Illinois, in Cook County. His zip code is 60430.    He currently has fee-for-service Medicare with no other drug benefits.    He does not use an American Indian Health pharmacy.    He does not live in a long-term care facility.    He has $20,000 in annual income and is not interested in any drug  assistance programs, including the $600 credit.
His sources of income are a pension and Social Security, but the amount  from each is unknown.
He has some bank accounts, but their value is unknown.    The amount he currently pays for drugs is unknown.    Default answer for other questions: “I don’t know.”
Two prescription drug discount cards listed on Medicare.gov with  the lowest prices for the combination of drugs in our scenario:  U Share Prescription Drug Discount Card  1-800-707-3914  Monthly drug costs: $174.91  Annual enrollment fee: $19.95  Any of several prescription drug discount cards available with this  combination of drugs priced at $182.80.
Question 1c posed to CSRs:  My father lives in Cincinnati, Ohio, and wants to continue to shop at the  CVS Pharmacy (located at 3195 Linwood Ave., Cincinnati, Ohio). What  drug card can he get that will cover all of his drugs at the CVS  Pharmacy, and cost the least amount?
He takes the following drugs:  Other information to provide to the CSR if asked:    He is single.    He lives in Cincinnati, Ohio, in Hamilton County. His zip code is 45226.    He currently has fee-for-service Medicare with no other drug benefits.    He does not use an American Indian Health pharmacy.    He does not live in a long-term care facility.    He has $20,000 in annual income and is not interested in any drug  assistance programs, including the $600 credit.
His sources of income are a pension and Social Security, but the amount  from each is unknown.
He has some bank accounts, but their value is unknown.    The amount he currently pays for drugs is unknown.    Default answer for other questions: “I don’t know.”
Two prescription drug discount cards listed on Medicare.gov with  the lowest prices for the combination of drugs in our scenario:  myPharmaCare Prescription Drug Discount Card  1-800-601-3002  Monthly drug costs: $202.79  Annual enrollment fee: $25.00  Anthem Prescription Drug Discount Card  1-800-730-2804  Monthly drug costs: $209.87  Annual enrollment fee: $14.95  Question 1d posed to CSRs:  My father lives in Brooklyn, New York, and wants to continue to shop at  the Neergaard Pharmacy (located at 454 Fifth Avenue, in Brooklyn, New  York). What drug card can he get that will cover all of his drugs at  the Neergaard Pharmacy, and cost the least amount?
He takes the following drugs:  Other information to provide to the CSR if asked:    He is single.    He lives in Brooklyn, New York, in Kings County. His zip code is 11215.    He currently has fee-for-service Medicare with no other drug benefits.    He does not use an American Indian Health pharmacy.    He does not live in a long-term care facility.    He has $20,000 in annual income and is not interested in any drug  assistance programs, including the $600 credit.
His sources of income are a pension and Social Security, but the amount  from each is unknown.
He has some bank accounts, but their value is unknown.    The amount he currently pays for drugs is unknown.    Default answer for other questions: “I don’t know.”
Two prescription drug discount cards listed on Medicare.gov with  the lowest prices for the combination of drugs in our scenario:  EnvisionRx Plus Prescription Drug Discount Card  1-866-250-2005  Monthly drug costs: $46.33  Annual enrollment fee: $30.00  Any of several prescription drug discount cards available with this  combination of drugs priced at $50.45.
section_title: Appendix III: $600 Credit Question and Information Used to Develop Accuracy Criteria
paragraphs: Question 2 posed to CSRs:  I’ve heard about the $600 credit that can help pay for prescriptions and  wanted to know if my mother was eligible for it. Could she qualify for  the credit? I know she has three sources of income.
She has about $765 per month from Social Security.    She also gets $250 each month in rental income from the apartment in the  downstairs part of her house. She has a tenant that pays rent to her.
She’s also getting a payout from my father’s life insurance policy of $70  each month.
Other information to provide to the CSR if asked:    She is single and lives alone.    She only has fee-for-service Medicare as health insurance.    She owns her house.    She lives in Miami, Florida, 33129.    Default answer for other questions: “I don’t know.”
Information from Medicare.gov that GAO used to develop accuracy  criteria:  If your annual gross income is currently no more than $12,569 ($1,048 per  month) as a single person or no more than $16,862 ($1,406 per month) for  a married couple, you might qualify for a $600 credit to help pay for your  prescription drugs and Medicare may pay your annual enrollment fee. If  you and your spouse both qualify for the credit, the credit will be put on  each of your cards.
TRICARE for Life provides secondary military health coverage available for Medicare- eligible uniformed services beneficiaries, their eligible family members, and survivors  enrolled in Medicare part B.
The following sources of income should be included when calculating  your gross income for your $600 credit enrollment form:    Employee compensation (salary, wages, tips, bonuses, awards, etc.)    Unemployment compensation    Pensions and annuities    Social Security benefits (including Social Security Equivalent  portion of Railroad Retirement)
Railroad Retirement benefits    Veterans Affairs benefits    Military and government disability pensions – armed forces, Public Health  Service, National Oceanic and Atmospheric Administration, Foreign  Service (based on date pension began, combat-related pension, etc.)  Individual Retirement Account distributions  Interest (savings accounts, checking accounts, etc.)
Ordinary dividends (stocks, bonds, etc.)    Refunds, credits, or offsets of state and local income taxes    Alimony received    Business income    Capital gains    Farm income    Rental real estate, royalties, partnerships, trusts, etc.    Other gains (sale or exchange of business property)    Other income (lottery winnings, awards, prizes, raffles, etc.)
The following sources of income should not be included when calculating  your income for $600 credit enrollment form:  Inheritances and gifts (taxed to estate or giver if not under limits for  exemption)  Interest on state and local government obligations (e.g., bonds)
Workers compensation payments    Federal Employees Compensation Act payments    Supplemental Security Income benefits   Income from national senior service corps programs    Public welfare and other public assistance benefits    Proceeds from sale of a home    Lump sum life insurance benefits paid upon death of insured    Life insurance benefits paid in installments    Accelerated life insurance death benefit payments (e.g., viatical  settlements, terminal illness, chronic illness)
section_title: Appendix IV: Medigap Question and Information Used to Develop Accuracy Criteria
paragraphs: Question 3 posed to CSRs:  I’m calling with a question about my grandmother. She is 69 and she has  Medicare, and she also has a Medigap policy. Could you please tell me  if she can still get a Medicare-approved drug discount card?
Other information to provide to the CSR if asked:    She is single and lives alone.    She lives in Miami, Florida. I don’t know the zip code off-hand.    She is not in a long-term care facility.    She is enrolled only in Medicare fee-for-service. She doesn’t have a  Medicare managed care plan.
She is not enrolled in Medicaid.
I don’t think she’s interested in the $600 credit right now; I was just  wondering if she could get the prescription drug discount card.
Default answer for other questions: “I don’t know.”
Information from Medicare.gov that GAO used to develop accuracy  criteria:  Having a Medigap policy does not preclude a Medicare beneficiary from  being eligible for a Medicare prescription drug discount card.
section_title: Appendix V: Power Wheelchair Question and Information Used to Develop Accuracy Criteria
paragraphs: For question 4 about power wheelchairs, we provided the CSRs with one  of four different city and state combinations, as shown below. The four  city and state combinations were randomly assigned to different power  wheelchair calls. We did this to ensure that if our call was transferred to  one of the four claims administrator contractors that administer  Medicare’s durable medical equipment claims—including power  wheelchair claims—we were not biasing our results toward any particular  claims administrator.
Question 4 posed to CSRs:  My father is having trouble getting around. He has a hard time walking and  doesn’t have much upper body strength. Could you please tell me if  Medicare will pay for a power wheelchair for him?
Other information to provide to the CSR if asked:    He is enrolled in Medicare, both parts A and B.    He lives in :    Philadelphia, Pennsylvania. His zip code is 19105.    Detroit, Michigan. His zip code is 48209.    Pensacola, Florida. His zip code is 32516.    Scottsdale, Arizona. His zip code is 85262.
His doctor has suggested he get a power wheelchair to improve his  mobility.
He doesn’t have enough strength to use a manual wheelchair.    He lives alone and is not married.    Default answer for other questions: “I don’t know.”
Information from Medicare.gov that GAO used to develop accuracy  criteria:  Power wheelchairs and/or scooters are covered if they are medically  necessary based on Medicare’s criteria for coverage. In order for Medicare  to cover a power wheelchair/scooter, the beneficiary’s doctor must  provide a prescription or certificate of medical necessity that states that  he needs it because of his medical condition.
If your father qualifies for coverage, Medicare will pay 80 percent of the  Medicare-allowed amount.
section_title: Appendix VI: Medicare Part B Question and Information Used to Develop Accuracy Criteria
paragraphs: Question 5 posed to CSRs:  Should my husband sign up for part B if I am still working and we  have health insurance coverage from my employer?
Other information to provide to the CSR if asked:    My husband is about to turn 65 next January.
If asked whether working for a large or small employer: I work for the  federal government.  I have full medical coverage, including dental and vision.
My husband is fully covered under my insurance plan.    Neither of us is disabled.    The city/zip code information that corresponds with the location of the  caller.
Default answer for other questions: “I don’t know.”
Information from Medicare.gov that GAO used to develop accuracy  criteria:  Your husband might want to wait to sign up for part B, because he would  have to pay the monthly part B premium and the benefits may be of limited  value as long as the group health plan  is the primary  payer. You could save on monthly premiums by waiting to sign up.
If your husband doesn’t sign up for part B when first eligible because he  has group health coverage through an employer, he can sign up for  Medicare part B during a special enrollment period. This can be anytime  he is still covered by the employer’s group health plan or during the 8  months following the month when either the coverage or the employment  ends—whichever is first.
Most people who sign up for Medicare part B benefits during a special  enrollment period do not pay higher premiums.
section_title: Appendix VII: Eye Glasses/Exam Question and Information Used to Develop Accuracy Criteria
paragraphs: Question 6 posed to CSRs:  My mother is 66 and is enrolled in Medicare. She has been complaining  lately that she is having trouble reading the paper and thinks she may need  new eyeglasses. Will Medicare pay for an eye exam and a new pair of  eyeglasses if her prescription has changed?
Other information to provide to the CSR if asked:    The city/zip code information that corresponds with the location of the  caller.
She is not married.    She is enrolled in Medicare fee-for-service only.   I do not know the name of the county she lives in.    Default answer for other questions: “I don’t know.”
Information from Medicare.gov that GAO used to develop accuracy  criteria:  Medicare does not pay for routine eye exams, eyeglasses, or contact  lenses. The beneficiary must pay 100 percent of these services.
section_title: Appendix VIII: Agency Comments
section_title: Appendix IX: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: Shaunessye D. Curry, Joy L. Kraybill, Krister P. Friday, Sari B. Shuman,  Mary W. Reich, Ramsey L. Asaly, Alexis Chaudron, Perry G. Parsons, and  Leslie Spangler made key contributions to this report.