Medicare Advantage: CMS Assists Beneficiaries Affected by Inappropriate Marketing but Has Limited Data on Scope of Issue
Published: 2009-12-17T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Members of Congress and state agencies have raised questions about complaints that some Medicare Advantage (MA) organizations and their agents inappropriately marketed their health plans to Medicare beneficiaries. Inappropriate marketing may include activities such as providing inaccurate information about covered benefits and conducting prohibited marketing practices. The Centers for Medicare & Medicaid Services (CMS) is responsible for oversight of MA organizations and their plans. The Government Accountability Office (GAO) was asked to examine (1) the extent to which CMS has taken compliance and enforcement actions, (2) how CMS has helped beneficiaries affected by inappropriate marketing and the problems beneficiaries have encountered, and (3) information CMS has about the extent of inappropriate marketing. To do this work, GAO reviewed relevant laws and policies; analyzed Medicare data on beneficiary complaints, compliance actions and enforcement actions; and interviewed officials from CMS and selected state departments of insurance, state health insurance assistance programs, and MA organizations.
section_title: What GAO Found
paragraphs: CMS took compliance and enforcement actions for inappropriate marketing against at least 73 organizations that sponsored MA plans from January 2006 through February 2009. While the number of MA organizations varied during that time period, 192 MA organizations offered MA plans as of March 2009. Actions taken ranged from initial notices of noncompliance and warning letters to more punitive measures, such as civil money penalties and suspensions of marketing and enrollment. Nineteen of the 73 MA organizations had multiple types of actions taken against them. CMS helped beneficiaries who experienced inappropriate marketing by providing special election periods (SEP) through which beneficiaries could disenroll from their MA plan and enroll in new coverage without waiting for the twice yearly regular enrollment periods. However, some beneficiaries experienced financial or access-to-care problems as a result of inappropriate marketing that could not be addressed by a SEP. Financial hardships occurred, for example, when beneficiaries disenrolled from their MA plans and the withholding of premiums from Social Security for their former MA plan was not stopped promptly. In other cases, beneficiaries did not realize they had been enrolled in an MA plan until they tried to access services. Some of these beneficiaries experienced disruption of their access to providers and medications because their providers did not participate in the MA plan. CMS has limited information about the number of beneficiaries who experienced inappropriate marketing. Some beneficiaries who experienced inappropriate marketing may have exercised their option to disenroll from their MA plans during regular enrollment periods and might not have notified CMS of the marketing problems they encountered. For example, about 21 percent of beneficiaries disenrolled during the regular enrollment periods in 2007 from one type of MA plan that CMS officials acknowledged had a high incidence of inappropriate marketing. However, CMS discontinued a survey after 2005 that collected information on reasons for disenrollment and could have provided important information about the extent to which the disenrollments were the result of inappropriate marketing. CMS officials said that they plan to reinstitute a survey on disenrollment reasons in late summer 2010. CMS also has limited information about the number of beneficiaries who experienced inappropriate marketing because it did not directly track the number of SEP disenrollments. CMS did estimate the number of SEPs it provided for inappropriate marketing, but its estimates were based on data that were unreliable.

section_title: Letter
paragraphs: Members of Congress and state agencies have raised questions about  complaints that some Medicare Advantage (MA) organizations and their  agents inappropriately marketed their health plans to Medicare  beneficiaries. Inappropriate marketing activities may include, for  example, MA organizations and their agents misrepresenting plan benefits  and conducting prohibited marketing practices, such as door-to-door  marketing without appointments and providing potential beneficiaries  with meals or gifts of more than a nominal value at marketing events to  induce enrollment. In this report, the term inappropriate marketing also  includes organizations’ noncompliance with MA marketing requirements   pertaining to proper training, compensation, and licensure of agents and  registration of marketing events.
Congress held several hearings on inappropriate marketing during 2007  and 2008. In some of these hearings, officials of state departments of  insurance (DOI) and MA beneficiaries and their advocates testified that as  a result of inappropriate marketing, some beneficiaries were enrolled in  MA plans in which they had not intended to enroll or that did not address  their health care needs as well as their prior coverage. In June 2007, in  response to increasing concerns that MA organizations were not  adequately overseeing their marketing activities and that this could  negatively impact beneficiaries, the Centers for Medicare & Medicaid  Services (CMS), the agency responsible for administering Medicare and  contracting with MA organizations to provide Medicare-covered services,  took the unprecedented step of negotiating voluntary suspensions of  marketing and enrollment activities of seven MA organizations’ private fee- for-service (PFFS) plans. CMS officials and others have acknowledged  that inappropriate marketing has been particularly problematic in PFFS  plans, in part because the structure of PFFS plans differs from other types  of MA plans. For example, while other types of MA plans have provider  networks, most PFFS plans do not. Instead, providers can choose to  accept or not accept a PFFS beneficiary on a service-by-service basis,  which may be confusing to beneficiaries.
The federal government and states each have responsibilities regarding the  conduct of MA organizations and their agents. CMS is responsible for  enforcing MA organizations’ compliance with MA marketing requirements,  including the requirements concerning agents acting on behalf of MA  organizations. Subject to certain exceptions, these requirements  supersede state laws or regulations, and as a result, states generally do not  have the authority to regulate MA organizations’ marketing. MA  marketing requirements generally impose obligations upon MA  organizations and not directly upon their agents. States retain oversig authority over the marketing activities of agents. According to state  officials and the National Association of Insurance Commissio (NAIC), holding MA organizations accountable for the actions of agents  marketing their plans is an essential component of effective oversight of  agents.  NAIC officials told us that placing responsibility for agent activity  with MA organizations is important because organizations can implement  systemic requirements, such as rigorous training programs, and can act  faster than states to  discipline agents.
Marketing requirements for MA organizations are based, in part, on  provisions in the Balanced Budget Act of 1997 (BBA) and the Medicare  Improvements for Patients and Providers Act of 2008 (MIPPA). Under the  BBA, Congress required that private plans offered through Medicare  conform to fair marketing standards that, among other requirements,  prohibit organizations from providing monetary inducements to  beneficiaries for enrollment in a plan. In 1998, CMS published  implementing regulations that elaborated upon the BBA requirements,  including prohibiting MA organizations from engaging in door-to-door  solicitations and in activities that could mislead or confuse beneficiaries  or misrepresent the MA organization. CMS also provided guidelines to  MA organizations on appropriate marketing practices, which organizations  are required by regulation and under their contracts with CMS to follow.  The guidelines, among other things, require MA organizations to use state- licensed agents for marketing activities and set restrictions on these  activities, such as a maximum value for give-away promotional items.  MIPPA and its implementing regulations codified some of the  requirements already established under CMS’s marketing guidelines for  MA organizations. MIPPA and its implementing regulations also clarified  existing marketing-related requirements and created new requirements for  MA organizations such as limiting agent commissions and requiring MA  organizations to comply with any request by a state for information related  to agent performance when the state is investigating the conduct of an  agent.
CMS uses compliance and enforcement actions to bring noncompliant MA  organizations into conformity with MA marketing requirements.  Compliance actions include requiring MA organizations to develop  corrective action plans (CAP) that specify actions the organization will  take to address its noncompliance. Enforcement actions are more punitive  than compliance actions and include imposition of civil money penalties,  suspension of enrollment of Medicare beneficiaries, suspension of  payment to an MA organization, suspension of marketing activities for an  MA plan, and termination or non-renewal of the MA organizations’  contract. CMS has the authority to impose these sanctions for certain  types of violations of marketing requirements by MA organizations, though  the agency is not required to take such actions.
Given concerns about inappropriate marketing and its effects on  beneficiaries, you asked us to examine how CMS assists beneficiaries  affected by inappropriate marketing, the extent of the noncompliance, and  how CMS holds MA organizations accountable. Our report addresses the  following questions: (1) To what extent has CMS taken compliance and  enforcement actions against MA organizations for inappropriate  marketing? (2) How has CMS helped MA beneficiaries affected by  inappropriate marketing and what types of problems have they  encountered? (3) What information does CMS have on the number of  beneficiaries affected by inappropriate marketing?
To determine the extent to which CMS has taken compliance and  enforcement actions against MA organizations for inappropriate  marketing, we analyzed CMS data on compliance and enforcement actions  CMS took against MA organizations for inappropriate marketing for the  period January 2006 through February 2009.
To determine how CMS helped beneficiaries affected by inappropriate  marketing and the types of problems beneficiaries encountered, we  interviewed officials from CMS’s central office and all 10 regional offices,   6 state DOIs, and 6 state health insurance assistance programs (SHIP) and  reviewed relevant documentation. We also visited three CMS regional  offices to conduct more detailed interviews. We chose one of the regional  offices because it had conducted detailed compilations of complaint data;  another regional office because it housed the division that coordinated  regional office oversight and monitoring activities; and a third regional  office because it had responsibilities for MA organizations with a high  concentration of PFFS plans. We interviewed DOI officials and SHIP  officials in the three states where we conducted site visits. In addition, we  interviewed DOI and SHIP officials from another three states because in  one of the states, the DOI took an enforcement action against an MA  organization for inappropriate marketing and in the other two states, DOI  officials testified before NAIC on inappropriate MA marketing and sales  practices.
To obtain information about the number of beneficiaries affected by  inappropriate marketing, we used June 2007 through October 2008 data  from CMS’s complaint tracking module on the number of beneficiaries  who claimed they were affected by inappropriate marketing and requested  CMS assistance to disenroll from their MA plan. We interviewed officials  in CMS’s central office and all regional offices about their use of the  complaint tracking module data. We also reviewed a February 2008 study  conducted by one CMS regional office that analyzed CMS and MA  organizations’ resolution of cases entered into the complaint tracking  module. In addition, we interviewed officials from CMS’s central office  about plans to collect information on beneficiaries’ reasons for  disenrollment from their MA plan.
To determine the reliability of the data we used, we reviewed  documentation, examined the internal consistency and other aspects of  the data, interviewed CMS officials about reliability issues, or some  combination of the three. Based on our review, we determined that the  CMS regional office study of complaint tracking and the compliance and  enforcement data were sufficiently reliable for our purposes. We  determined that the complaint tracking module data had significant  limitations. As a result, we reported total complaints from the  inappropriate marketing categories because this is an indicator that CMS  uses, but did not include any additional analyses of the complaint tracking  module data. Appendix I provides more detailed information on our  methodology. We conducted this work from March 2008 through  December 2009 in accordance with generally accepted government  auditing standards. These standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: CMS monitoring and oversight activities of MA organizations’ compliance  with marketing requirements, include maintaining regular communication  with and providing technical assistance to MA organizations. In addition,  CMS conducts surveillance activities and audits of MA organizations to  collect information about potential problems and compliance with  marketing requirements.
CMS’s surveillance activities include tracking and analyzing complaint  rates by MA organization and category of complaint. In 2007, CMS initiated  a variety of new surveillance activities focused on monitoring MA  organizations’ marketing of PFFS plans. Among other activities, CMS  implemented a secret shopper program that had CMS representatives, with  their identity concealed, attend PFFS marketing events and report on the  accuracy of marketing presentations and agents’ compliance with  marketing requirements. Other surveillance activities included monthly  review of PFFS enrollment packages and review of agent training test  results. CMS also tracks other indicators under certain circumstances,  such as verifying that beneficiaries willingly and knowingly chose certain  plans. For example, for 2008, CMS required MA organizations to call  beneficiaries newly enrolled in PFFS plans to verify that beneficiaries  wanted to enroll in the plan and understood plan features. CMS  subsequently tracked the proportion of verified calls as one of its  marketing performance indicators.
In conducting audits of MA organizations, CMS assesses whether  organizations’ operations are consistent with federal laws, regulations, and  CMS policies and procedures in some or all of seven major categories,  including marketing. Audits typically involve a combination of desk  reviews of documents submitted by MA organizations, and, at CMS’s  discretion, site visits. CMS uses a risk-based approach to identify MA  organizations for audit. While CMS may choose to audit only certain  categories in any given year, since at least 2006, CMS has included  marketing operations, and specifically those related to misleading  marketing, in its audits. CMS also conducts focused, or out-of-cycle, audits  of MA organizations to ensure that MA organizations implemented new  processes for previously identified areas of noncompliance and to  investigate potential noncompliance issues that CMS identified outside of  the audit cycle.
In June 2008, CMS reorganized its internal structure for overseeing MA  plans and established standard operating procedures (SOP) for the  oversight of MA organizations. The 2008 SOPs outlined the agency’s  oversight approach and clarified, among other things, what actions CMS  may take when MA organizations were found to be out of compliance with  marketing and other requirements. According to CMS officials, the SOPs  formalized many procedures that CMS was already using to oversee MA  organizations and were intended to ensure that these procedures were  being applied in a uniform manner nationwide.
CMS’s SOPs state that CMS is to consider the nature of each violation in  determining the appropriate compliance or enforcement action. The 2008  SOPs include the following actions from least to most severe:    Informal contact: phone call, e-mail, or meetings with MA organization  officials to provide technical assistance.
Compliance: initial notice of noncompliance—e-mail to the MA  organization, usually through the MA organization’s compliance officer. An  initial notice of noncompliance is generally issued at the first finding of  relatively minor noncompliance with federal laws, regulations, or CMS  guidance, such as a single instance of inappropriate marketing activities.  The notice informs an MA organization that it is out of compliance and  directs MA organizations to reply to the email to indicate how it will  address the noncompliance.
Compliance: warning letter—formal letter to the MA organization’s  compliance officer stating the concern or area of noncompliance that  requires immediate remedy for a limited and quickly fixable situation. CMS  also notifies MA organizations that continued noncompliance will lead to  stricter actions by CMS, such as requiring the MA organization to develop  a CAP.
Compliance: CAP request letter—formal letter to the MA organization’s  chief executive officer stating the concern(s) and requiring the  organization to develop and implement a CAP for the specific violation(s).  CMS can require CAPs from MA organizations when the agency identifies  noncompliance that generally affects multiple beneficiaries and represents  an ongoing or systemic inability to adhere to Medicare requirements.  CMS’s SOPs provide time frames for CMS and MA organizations to  respond, accept, and implement CAPs. CAPs are reported publicly on the  CMS Web site.
Enforcement: sanctions provided for under federal law that CMS may  impose on MA organizations for what CMS considers egregious or  sustained noncompliance and for specific violations, including  misrepresenting or falsifying information to CMS, beneficiaries, or  potential beneficiaries, or substantially failing to carry out the terms of  their contracts with CMS. Sanctions may include civil money penalties;  the suspension of plans’ marketing activities, enrollment, or Medicare  payment; or termination or nonrenewal of organizations’ contracts with  CMS. Suspensions of plans’ marketing activities, enrollment, or Medicare  payment are to remain in place until CMS is satisfied that the  noncompliance that served as the basis for the suspension has been  corrected and is not likely to recur.
For more serious violations, CMS may choose to forgo initial, less formal  actions against an MA organization in favor of stricter actions, including  later-stage compliance or enforcement actions. However, the SOPs  indicate that compliance matters will generally escalate through the  compliance process in a step-by-step manner, starting with the initial  notice of noncompliance up through the CAP stage. CMS has also chosen  to negotiate voluntary suspensions with MA organizations rather than go  through formal processes to impose involuntary sanctions. According to  CMS officials, voluntary suspensions can result in a faster intervention. If  CMS makes the determination that the MA organization has engaged in  certain fraudulent activity, the agency is to refer the violation to the  Department of Health and Human Services Office of Inspector General  (HHS OIG) for review.
section_title: CMS Took Compliance and Enforcement Actions against at Least 73 MA Organizations for Inappropriate Marketing
paragraphs: From January 2006 through February 2009 CMS took a range of  compliance and enforcement actions against at least 73 MA organizations  for inappropriate marketing. While the number of MA organizations varied  during the approximately 3-year period, 192 MA organizations offered MA  plans as of March 2009. The exact number of MA organizations that were  subject to an action could be higher. According to CMS, the agency did not  begin tracking two types of action—initial notices of noncompliance and  warning letters—until June 2008. From June 2008 through February 2009,  CMS sent one initial notice of noncompliance and 76 warning letters to MA  organizations. (See app. II for more information about the types of  inappropriate marketing that resulted in initial notices of noncompliance  and warning letters.) From January 2006 through February 2009, CMS  required 37 CAPs from MA organizations and also took 5 enforcement  actions for inappropriate marketing—3 marketing and enrollment  suspensions and 2 civil money penalties. The 73 MA organizations against  which CMS took compliance or enforcement actions enrolled  approximately 7.4 million beneficiaries through February 2009. (See table  1.) These beneficiaries represented about 71 percent of all MA  beneficiaries. CMS also negotiated voluntary suspensions of marketing  and enrollment activities for PFFS plans with seven of these MA  organizations effective June 2007.
In some cases, during the period from January 2006 through February  2009, CMS took multiple types of actions against the same MA  organizations because it determined that these organizations had more  than one inappropriate marketing violation. (See app. III for information  about the criteria CMS uses to make compliance and enforcement  decisions.) Nineteen of the 73 MA organizations subject to compliance or  enforcement actions had multiple types of actions taken against them.  Fifteen of the 19 organizations received at least one warning letter or  notice of noncompliance and a CAP. Two MA organizations received at  least one warning letter or notice of noncompliance, were required to  submit at least one CAP, and were subject to an enforcement action. One  organization received at least one warning letter or notice of  noncompliance and was subject to an enforcement action and another was  required to submit at least one CAP and was subject to an enforcement  action.
The time it took for MA plans to implement CAPs varied widely and  changed over time. In May 2008, CMS revised its audit SOPs to generally  require MA organizations to fully implement CAPs within 90 days from  CMS’s acceptance. Consequently, the average time from when CAPs  were requested to when corrective actions were fully implemented  decreased for CAPs accepted after May 2008. Specifically, corrective  actions for inappropriate marketing deficiencies were fully implemented  an average of 218 days after CAPs were requested for the 22 CAPs  accepted from January 2006 through April 2008 and an average of 174 d for the 13 CAPs accepted from May 2008 through February 2009. The  period of time from when CMS requested the CAP to when CMS accepted  the CAP increased, on average, from 90 days for CAPs accepted prior to  May 2008 to 145 days for CAPs accepted May 2008 through February 2009.  However, the average time from CMS acceptance of the CAP to when  corrective actions were fully implemented decreased from 128 days for  CAPs accepted from January 2006 through April 2008 to 29 days for CAPs  ays  accepted from May 2008 through February 2009. (See fig. 1.) Overall, the  period of time from when CMS requested CAPs to when MA organizations  fully implemented them varied widely for CAPs accepted both for the  period from January 2006 through April 2008 (from 61 to 410 days) and  from May 2008 through February 2009 (from 68 to 345 days).
For enforcement actions, the implementation time periods varied widely  as well—from approximately 2 weeks to 2 years before CMS took an  enforcement action after first identifying what it considered to be  inappropriate marketing. For example, CMS suspended the marketing and  enrollment activities of one MA organization based on results of CMS’s  secret shopper activities that showed what CMS considered egregious  inappropriate marketing approximately 2 weeks after the MA organization  began marketing its MA plans. In contrast, in February 2009, CMS  suspended the marketing and enrollment activities for another MA  organization after 2 years of sustained noncompliance with marketing  requirements. During the 2-year period, CMS determined that this MA  organization employed agents who had engaged in activities that misled,  confused, or misrepresented the organization or its MA plans to  beneficiaries during three audits conducted between March 2007 and July  2008, for which CMS required CAPs. In addition, in July 2008, CMS sent the  MA organization a notice of noncompliance based on beneficiary  allegations of inappropriate marketing by agents selling its MA plans. (See  table 2 for a summary of the five cases for which CMS took enforcement  actions.)
section_title: CMS Helped Beneficiaries Who Experienced Inappropriate Marketing to Disenroll from Their MA Plans, but Some Faced Adverse Consequences
paragraphs: CMS assisted beneficiaries who experienced inappropriate marketing by  helping them restore their previous health insurance coverage or enrolling  them in another option. Some beneficiaries experienced financial liability  or access-to-care problems as a result of being enrolled in an MA plan or  stemming from their disenrollment and enrollment in prior or different  coverage.
subsections: section_title: CMS Uses Special Election Periods to Help Beneficiaries Who Experienced Inappropriate Marketing
paragraphs: CMS assisted MA beneficiaries who experienced inappropriate marketing  by MA organizations by providing special election periods (SEP), which  enable beneficiaries to disenroll from their MA plan outside of the regular  enrollment periods and to enroll in prior coverage or another option, such  as another MA plan, Medicare FFS, or a stand-alone Medicare prescription  drug plan. CMS announced that it had established a special SEP for  inappropriate marketing in a July 2007 memo to MA organizations. CMS  officials described these SEPs as their primary attempt to make  beneficiaries who experienced inappropriate marketing “whole.”
According to CMS’s SOPs, MA beneficiaries qualify for the SEP if they call  1-800-Medicare or contact a CMS regional office and give reasonable  assurance that they were subject to inappropriate marketing; CMS does  not require the beneficiaries to provide evidence. According to CMS  officials, they decide whether to provide SEPs before investigations into  inappropriate marketing allegations are complete to ensure that  beneficiaries who did experience misleading marketing can disenroll from  the MA plan and enroll in other health coverage as quickly as possible.  Consequently, some of the beneficiaries who were provided a SEP might  not have been subject to inappropriate marketing.
CMS offered MA beneficiaries either a prospective or retroactive SEP.  Under a prospective SEP, beneficiaries could disenroll from the MA plan  and return to their previous coverage or enroll in another option effective  the first day of the next month. CMS officials told us that the customer  service representatives at 1-800-Medicare generally processed prospective  disenrollments and enrollment in other MA plans or Medicare FFS. Under  the retroactive SEP, beneficiaries could disenroll from the MA plan and  return to their previous coverage or enroll in other coverage effective as  early as the date of their enrollment in the MA plan. Retroactive SEPs are  more complicated because they require payment adjustments for any  premiums paid and medical services received while the beneficiary was  enrolled in the plan. Retroactive SEPs are processed by regional office  staff.
According to CMS’s SEP SOPs, 1-800-Medicare customer service  representatives should ask beneficiaries who provide reasonable  assurance that they were subject to inappropriate marketing whether they  would like to prospectively disenroll from their plan and enroll in new  coverage. If the beneficiary agrees, the disenrollment from the MA plan  and enrollment in new coverage is handled by the customer service  representative. If the beneficiary requests a retroactive SEP, the case is  forwarded to a regional office. CMS’s SEP SOPs state that regional office  officials are required to explain the consequences of a retroactive  disenrollment or enrollment to the beneficiary before such a disenrollment  is processed. If a beneficiary directly contacts a regional office with a  complaint of inappropriate marketing, officials should offer beneficiaries a  prospective SEP, although they may offer a retroactive SEP if the  beneficiary insists. While CMS’s SOPs indicate a preference for offering  beneficiaries a prospective SEP, CMS officials we interviewed said that  whether CMS offers a prospective or retroactive SEP to a beneficiary  depends on what would be in the beneficiary’s best interest.
The most suitable SEP for a MA beneficiary depended on the beneficiary’s  circumstances. For example, if beneficiaries used services while enrolled  in an MA plan, they could benefit from a prospective SEP if their cost  sharing—the amount they paid out-of-pocket for a covered service—under  the MA plan was lower than it would be under their restored or other  coverage. If these beneficiaries chose a retroactive SEP, they would have  to make up the difference between the lower cost sharing amount under  the MA plan and the higher amount under their restored or other coverage.  Conversely, beneficiaries who chose restored or other coverage with cost  sharing that was lower than the MA plan could benefit from disenrolling  retroactively because they would be reimbursed for the difference  between the out-of-pocket costs they incurred for services received under  the MA plan and the lower costs under the restored or other coverage.
section_title: Some Beneficiaries Experienced Problems Associated with Retroactive Disenrollments, While Others Experienced Problems That Could Not be Fixed by a SEP
paragraphs: Some DOI and SHIP officials we interviewed told us that MA  disenrollments and enrollments resulting from inappropriate marketing  generally appeared to go smoothly, but that some beneficiaries  experienced problems. Officials from some DOIs and a SHIP we  interviewed said some beneficiaries’ retroactive disenrollments took  several months to process. Officials from one DOI said that some  beneficiaries received bills from collection agencies because provider  reimbursements associated with retroactive disenrollments were not  timely. An official from another DOI said that it could take from 10 to   30 days to receive enrollment material, including a plan identification card,  and this could cause access-to-care problems if beneficiaries needed  health care services before the material arrived. To help mitigate any  access-to-care problems, CMS officials said that they instructed 1-800- Medicare customer service representatives to give beneficiaries their MA  plans’ contact information when they enrolled so that beneficiaries could  contact the plans directly for information about accessing services.  Additionally, CMS officials stated that CMS regional office employees  routinely worked with MA organizations to ensure that beneficiaries who  received a retroactive SEP could access services prior to receiving plan  identification cards.
CMS officials told us that some of the problems encountered by MA  beneficiaries receiving a retroactive inappropriate marketing SEP were  unavoidable and inherent to the processing of a retroactive disenrollment.  They noted that under a retroactive SEP, different premium amounts  needed to be collected, provider bills and payments might need to be  retracted and reprocessed by the new insurer, and different cost-sharing  amounts applied. Therefore, a SEP could take time to be fully processed.  These officials stated that the administrative actions and associated  problems that beneficiaries may experience are preferable to keeping  beneficiaries in an MA plan after they have stated that they experienced  inappropriate marketing.
Beneficiaries who stated they experienced inappropriate marketing may  also have experienced problems that the SEP could not address. For  example, these beneficiaries could have experienced financial or access- to-care issues prior to receiving the SEP. CMS, DOI, and SHIP officials  described cases in which beneficiaries did not realize they had been  switched to an MA plan until they tried to access services. These officials  said some of the beneficiaries experienced disruption of their access to  providers and medications because their providers did not participate in  the MA plan. DOIs and SHIPs also cited several other problems the  inappropriate marketing SEP could not resolve because the problems  were associated with private or state employee insurance plan provisions  or involved other government agencies, and hence were outside CMS’s  jurisdiction. DOIs and SHIPs provided information about specific types of  cases that a SEP could not resolve:    A beneficiary had to pay higher premiums to obtain the same Medigap  polices that she had dropped when she was enrolled in a MA plan.
Beneficiaries could not have coverage restored by their prior employer’s  retiree health plan. DOI and SHIP officials said that employer retiree  health plans are generally not required to restore coverage to MA  beneficiaries who stated they experienced inappropriate marketing. CMS  officials said that they were able to get retiree health coverage restored for  some beneficiaries, but not for others.
Beneficiaries who had premiums withheld from their Social Security  checks experienced delays in ending the withholding after they were  disenrolled from their MA plan, which could have caused financial  hardships.
section_title: CMS Has Limited Information on the Number of Beneficiaries Affected by Inappropriate Marketing
paragraphs: The information CMS has on the number of beneficiaries affected by  inappropriate marketing is limited for two reasons. First, some  beneficiaries who experienced inappropriate marketing may have  exercised their option—available during certain times of the year—to  disenroll from their MA plan and might not have notified CMS of the  marketing problems they encountered. Second, CMS did not directly track  the number of beneficiaries who contacted the agency and were provided  a SEP. CMS did estimate the number of SEPs it provided for inappropriate  marketing, but its estimates were based on data that were unreliable.
All MA beneficiaries, including those who had been affected by  inappropriate marketing, may have elected to change their health plans  during the annual coordinated election period or the annual open  enrollment period. CMS had the information to determine the number of  beneficiaries who disenrolled during these regular enrollment periods, but  during the time of our study, the agency did not collect information that  would have allowed it to determine the extent to which beneficiaries  disenrolled from health plans as a result of inappropriate marketing.
Disenrollment rates varied considerably among plans and types of plans.  For example, we previously reported on disenrollment rates in PFFS plans  occurring during the regular enrollment periods for 2007. PFFS plans  were considered by CMS and others to have high rates of inappropriate  marketing. From January through April 2007, when the disenrollments  took effect, about 169,000 beneficiaries in PFFS plans, or 21 percent of the  total number of PFFS beneficiaries, disenrolled from the plan that they  were enrolled in. This 4-month total was more than double the  disenrollments from other plan types during that same time period.  However, the number of these beneficiaries who changed plans because  they were affected by inappropriate marketing was unknown because  CMS did not have data on why these beneficiaries disenrolled.
After 2005, CMS discontinued a survey on disenrollment reasons that  provided information on the frequency of certain problems leading to  disenrollment. From 2000 to 2005, CMS conducted an annual survey  asking MA beneficiaries who disenrolled why they left their plan. Among  the disenrollment reasons that beneficiaries could have chosen was:  “Given incorrect or incomplete information at the time you joined the  plan.” A 2005 analysis prepared by CMS contractors of survey results from  2000 through 2003 found that over this time period, the percent of  beneficiaries who said they disenrolled because they were given incorrect  or incomplete information at the time they joined their plan ranged from  about 9 to about 11 percent. However, in each of the 3 years, less than one  percent of beneficiaries who responded to the survey stated that this was  the most important reason for their disenrollment. The survey did not  collect information on the problems beneficiaries experienced as a result  of the reasons that led to their disenrollment or the disenrollment itself.  The analysis prepared by CMS contractors noted that the survey’s primary  goals were to enhance CMS’s ability to monitor MA plan performance and  assist plans in identifying areas where they might focus their quality  improvement efforts.
CMS officials said that they plan to reinstitute a survey on disenrollment  reasons in late summer 2010. CMS officials plan to collect data over a 9- to  12-month period, so final results should be available sometime in 2011.  After the survey ends and results are analyzed, CMS will determine  whether to conduct additional surveys on disenrollment reasons.
CMS did not directly track the number of SEPs it provided, but instead  estimated the number based on information collected in its complaint  tracking module. Complaints from beneficiaries who stated they  experienced inappropriate marketing and wanted to disenroll from their  MA plans were classified into one of two categories in CMS’s complaint  tracking module. One category was for inappropriate marketing cases  that required regional office action to complete beneficiaries’  disenrollment and enrollment in another plan. According to complaint  tracking module data provided by CMS, during the 17-month period from  June 2007 through October 2008, CMS received 18,331 such complaints.  CMS officials said that most of these cases were retroactive SEP  requests. The second category was for inappropriate marketing cases  that did not require regional office action to complete beneficiaries’  disenrollment and enrollment in another plan. During the 7-month period  from April 2008 through October 2008, CMS received 1,689 inappropriate  marketing complaints that the agency determined did not need regional  office action. According to CMS officials, cases included in the second  category were primarily prospective SEP requests. CMS officials told us  that most of the complaints in these two categories resulted in an  inappropriate marketing SEP but that the total included some  beneficiaries who made such statements but did not disenroll.
However, the complaint data were not a reliable source of information on  the number of beneficiaries who received the SEP. A study conducted by a  CMS regional office of a sample of about 170 complaints lodged between  August 2007 and January 2008 highlighted inaccurate and incomplete  documentation as well as a portion of inappropriate marketing complaints  that had been miscategorized:    About 33 percent of cases were resolved or closed inappropriately or  involved duplicate cases. For example, some cases were closed prior to  final resolution. In one of these cases, the MA organization indicated in  case notes that a beneficiary was experiencing a problem with  reimbursement and that it was doing additional research on the issue.  However, the MA organization closed the case prior to completing its  research on whether the beneficiary was due reimbursement and, if so,  whether the beneficiary received it. Four of the 54 cases in this category  were for instances in which multiple cases were open for the same  member and issue.
About 28 percent of case resolutions were poorly documented. Most  frequently these cases contained notes in the complaint tracking module  that did not indicate when disenrollments took effect or addressed part of  the complaint but notes did not reflect that all aspects of the complaint  had been resolved.
About 20 percent of cases were incorrectly categorized. The majority of  miscategorized cases were inappropriate marketing complaints that were  coded in categories other than inappropriate marketing.
About 12 percent of cases lacked specific information about at least one  issue involved in the complaint, such as details about refunds or payments  owed to the beneficiary.
Officials from another CMS regional office conducted a more informal  examination of complaint tracking module cases in 2008 and found similar  problems. The officials told us that the regional office did a spot check of  50 inappropriate MA marketing complaints by calling the beneficiaries and  determined that the notes in the complaint tracking module often did not  match the description of the complaint that the beneficiary provided  during the follow-up call. The officials also said that CMS staff examined  complaints against one MA organization and found cases of alleged  inappropriate marketing that were not categorized as such. The officials  from this regional office estimated that they had recategorized 60 percent  of all complaint tracking module cases within this region. However, other  CMS regional offices said the percentage of cases that needed to be  recategorized was small. The reason for this disparity is unclear, but it may  be due to how regional offices determined whether cases needed to be  recategorized.
CMS officials told us that they used the results of internal studies of the  complaint tracking module to improve their ability to categorize  complaints. However, it was beyond the scope of our study to determine  the effectiveness of these changes.
section_title: Conclusions
paragraphs: Inappropriate marketing can adversely affect MA beneficiaries, causing  financial hardship and difficulty in accessing needed care. While CMS has  used SEPs to assist beneficiaries, the agency was unable to prevent some  of them from experiencing negative consequences. Currently, CMS has  limited information on the extent of inappropriate marketing and the  number of beneficiaries affected. The agency intends to conduct a survey  of beneficiaries who disenrolled from MA plans and ask about their  reasons for disenrollment. Depending on the specific questions included,  such a survey could provide information about the number of beneficiaries  who experience inappropriate marketing and identify plans, plan types,  and geographic locations where inappropriate marketing problems are  most prevalent. CMS’s information about the extent of inappropriate  marketing is also limited because the agency has not gathered reliable  information about the number of prospective and retroactive SEPs  provided for this reason. Without an investigation into individual cases,  CMS cannot determine whether all of the problems reported by  beneficiaries represent inappropriate marketing. Nonetheless, gathering  information on the reasons beneficiaries disenroll from their MA plans and  tracking the number of the SEPs that the agency provides would enable  the construction of useful indicators of the potential scope and location of  the marketing problems. Because of the potentially serious implications  for beneficiaries as a result of inappropriate marketing, it is important for  CMS to have information that can inform the agency’s oversight efforts  and help it to appropriately target interventions when necessary.
section_title: Recommendation for Executive Action
paragraphs: To improve CMS’s oversight of MA organizations and its ability to  appropriately target interventions, we recommend that the Administrator  of CMS gather more information on the extent of inappropriate marketing  and the types of problems beneficiaries experienced as a result of  inappropriate marketing. As part of this effort, CMS should directly track  retroactive and prospective SEPs provided for inappropriate marketing.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report for comment to HHS, the department  under which CMS resides. Responding for HHS, CMS stated that it  concurred with our recommendation and that it would assess the costs  and benefits of alternative systems that could be used to collect  information on the extent of inappropriate marketing and the types of  problems beneficiaries experience as a result. CMS also stated that while it  did not directly track the number of retroactive and prospective SEPs  provided for inappropriate marketing, it used data from its complaint  tracking module and considered that data a reasonable proxy of the total  number of SEPs requested for inappropriate marketing. As our report  notes, findings from a formal and informal study conducted by two CMS  regional offices demonstrated that data from the complaint tracking  module were not a reliable source of information on the number of  beneficiaries who received a SEP. However, CMS officials told us in an  interview that they used the results of these studies to improve their ability  to categorize complaints. It was beyond the scope of our study to  determine the effectiveness of these changes. CMS also stated in its  comments that it had taken additional steps in 2009 to protect  beneficiaries from deceptive marketing practices conducted by agents,  including establishing stronger rules for governing the commissions that  can be paid to independent sales agents, disseminating new marketing  guidelines about how MA plans identify themselves to beneficiaries, and  expanding its secret shopper program. (CMS’s comments are reprinted in  app. IV.) CMS provided technical comments, which we incorporated as  appropriate.
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If you or your staff have any questions about this report, please contact me  at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. Key contributors to this report are listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: This appendix describes in detail the scope and methodology we used   to address the report objectives. We briefly summarize the methodologies  by objective and then discuss for all objectives (1) our review of   relevant federal laws, regulations, and guidance from the Centers for  Medicare & Medicaid Services (CMS), including policies and procedures;  (2) interviews with CMS officials and other stakeholders; and (3) CMS  data.
subsections: section_title: Methodology by Objective
paragraphs: To determine the extent to which CMS has taken compliance and  enforcement actions against Medicare Advantage (MA) organizations for  inappropriate marketing, we analyzed CMS data on the number and types  of corrective and enforcement actions taken against MA organizations for  inappropriate marketing. We conducted an analysis of noncompliance and  warning letters from CMS notifying MA organizations about marketing  violations, such as providing inappropriate information to beneficiaries at  marketing events, or agent-related operational violations, such as those  related to agent compensation. We excluded from our analysis letters for  non-agent-related violations such as incorrect information on an MA  organization’s Web site. We analyzed corrective action plans (CAP) that  CMS required if the agency determined that the MA organization had  engaged in activities that materially misled, confused, or misrepresented  the MA organization to beneficiaries.
To determine how CMS helped MA beneficiaries affected by inappropriate  marketing and the types of problems beneficiaries encountered, we  reviewed relevant agency documentation for the period January 2006  through February 2009 and interviewed officials at CMS’s central office  and all 10 regional offices, 6 state departments of insurance (DOI), and 6  state health insurance assistance programs (SHIP). We also conducted  site visits at the Dallas, Kansas City, and New York City CMS regional  offices to interview officials from these regions more extensively.
To determine what information CMS had on the number of beneficiaries  affected by inappropriate marketing, we analyzed CMS’s complaint data to  quantify the number of beneficiaries who complained about inappropriate  marketing and requested to disenroll from their plan outside of the annual  coordinated election and open enrollment periods, when beneficiaries can  join, switch, or drop MA plans. We reviewed one CMS regional office’s  study of CMS’s complaint tracking module conducted in February 2008.  We also interviewed CMS officials about the agency’s plan to obtain  information about reasons for disenrollment during the annual  coordinated election and open enrollment periods. Unless otherwise  noted, we limited our analysis of inappropriate marketing in this report to  instances of agent-related noncompliance with marketing requirements.
section_title: Review of Relevant Federal Laws, Regulations, and CMS Guidance
paragraphs: We reviewed relevant federal laws, regulations, and CMS guidance for the  provisions related to inappropriate marketing, compliance and  enforcement actions, and the time frames for which the provisions were in  effect. We interviewed CMS officials about agency guidance related to  oversight of the MA program, including policies and procedures, for the  period of January 2006 through February 2009.
section_title: Interviews with CMS Officials and Other Stakeholders
paragraphs: We interviewed officials from CMS, state DOIs, SHIPs, and MA  organizations and reviewed any documentation referenced during our  interviews. In our interviews with state DOIs and SHIPs, we asked both  specific and open-ended questions about the problems beneficiaries  encountered and, on some occasions, interviewed officials from a state’s  DOI and SHIP concurrently. Because of this, the frequency of our  interviewees’ responses is not comparable. Therefore, we report these  responses without reporting the total number of state DOIs or SHIPs  associated with each response. In addition, state DOIs, SHIPs, and MA  organizations we interviewed may not be representative of all state DOIs,  SHIPs, and MA organizations, and thus the information is not generalizable  to these entities.
We interviewed officials from CMS’s central office and its 10 regional  offices. For three regional offices (Dallas, Kansas City, New York City), we  conducted our interviews during site visits. We chose the Dallas regional  office because it has a high concentration of enrollment in private fee-for- service plans, a type of MA plan for which there has been a high  percentage of allegations of inappropriate marketing. We chose the Kansas  City regional office because it conducts detailed analyses of complaint  data for the other regional offices. We chose the New York City regional  office because it houses the division that coordinates CMS’s regional office  MA monitoring and oversight activities.
subsections: section_title: State DOIs
paragraphs: We interviewed officials from six state DOIs. We chose the Texas,  Missouri, and New York DOIs because they were located in the states  where we conducted site visits to CMS regional offices. We chose the  Oklahoma DOI because it took enforcement action against at least one MA  organization that was related to inappropriate marketing by agents. In  addition, we interviewed officials from the Florida and Ohio DOIs because  officials from these DOIs have testified before the National Association of  Insurance Commissioners (NAIC) on inappropriate MA marketing and  sales practices.
We interviewed officials from 6 SHIPs, which we chose because they were  located in the same states as the DOIs whose officials we interviewed.
section_title: MA Organizations
paragraphs: We interviewed officials from five MA organizations that CMS regional  officials we spoke with identified as having had major performance  problems and that had been subject to one or more CMS compliance and  enforcement actions, or that had voluntarily suspended marketing and  enrollment for inappropriate marketing and noncompliance with agent- related marketing requirements. The five MA organizations varied in  enrollment size, ranging from fewer than 230,000 beneficiaries to more  than 1 million beneficiaries. As of March 1, 2009, these MA organizations  provided Medicare coverage for approximately 26 percent of all MA  beneficiaries.
section_title: CMS Data
paragraphs: We reported on results from a February 2008 study performed by one CMS  regional office and analyzed data from CMS’s complaint tracking module  and on the compliance and enforcement actions taken by the agency.
subsections: section_title: CMS Regional Office Study of Complaint Tracking
paragraphs: We reviewed a study conducted in February 2008 by one CMS regional  office that examined how complaint cases entered into the complaint  tracking module were resolved by current staff in the regional office and  MA organizations, and whether staff followed agency guidelines when  resolving cases. The study findings were based on a content analysis  performed by CMS officials of about 170 randomly selected cases that  were closed in the region between August 2007 and January 2008. Because  the study only reviewed complaints received by the one regional office,  the results of this study are not generalizable to other CMS regional  offices. In addition, we did not independently assess the accuracy of study  results. Based on our review of the study’s methodology, we concluded  that the study results were sufficiently reliable for our purposes.
section_title: Complaint Data
paragraphs: We reviewed data from the complaint tracking module that serves as  CMS’s best estimate of the number of beneficiaries who received a SEP.  The SEP estimates come from two categories in the complaint tracking  module: inappropriate marketing complaints that required regional office  action and inappropriate marketing complaints that did not require  regional office action. We analyzed data on complaints that required  regional office action from June 2007 through October 2008 and  complaints that did not require regional office action from April 2008  through October 2008. During our interviews with CMS officials, we  identified several limitations associated with the complaint tracking  module data. While CMS officials told us that the agency had made  improvements to its complaint tracking module, it was beyond the scope  of our report to evaluate the effectiveness of these changes. On the basis  of our review of the data and interviews with CMS officials, we determined  that the complaint tracking module data had significant limitations. As a  result, we include totals for the two complaint categories in our finding,  but do not provide any additional analyses of the data. We also include a  discussion of the data limitations in our finding.
section_title: Compliance and Enforcement Action Data
paragraphs: We analyzed data for the number and type of compliance and enforcement  actions that CMS took against MA organizations from January 2006  through February 2009 for violations related to inappropriate marketing.  CMS provided us with marketing-related notices of noncompliance and  warning letters issued during the agency’s review of compliance letters  issued from June 2008 through February 2009. We conducted a content  analysis of CMS’s marketing-related compliance letters to identify those  related to inappropriate marketing and noncompliance with agent-related  marketing requirements. We included in our count letters that CMS sent to  MA organizations for agents providing inappropriate information to  beneficiaries at marketing events, engaging in prohibited activities such as  providing meals to beneficiaries, and for high rates of beneficiary  complaints of inappropriate marketing for which CMS considered the  organizations to be outliers. We also included compliance letters for  operational violations that are related to agent oversight. We excluded  compliance letters for operational violations that were not agent-related  such as incorrect information on MA organizations’ web sites, security  breaches, and failure to issue beneficiary notices about plan changes in  a timely manner.
For our CAP analysis, we included those CAPs that CMS required if the  agency determined that the MA organization engaged in activities that  materially misled, confused, or misrepresented the MA organization to  beneficiaries. We confirmed with CMS officials that violations in this  category were related to inappropriate marketing by agents and that most  deficiencies associated with inappropriate marketing that CMS identified  fell under this audit category. This category can include deficiencies  related to MA organizations’ internal operations related to agent oversight,  such as agent training programs and processes for monitoring agent  behavior, and deficiencies related to agent-related noncompliance with  marketing requirements. However, it is possible that some instances of  inappropriate marketing may have been included in violations identified in  other categories. We note this limitation in the report. When MA  organizations requested CAPs from multiple contracts under the same  audit ID, we counted these as one CAP. Similarly, when there were  multiple audits for the same parent organization that had the same date for  the CAP request, we counted these as one CAP. In calculating the length of  time CAPs remained open, we used the dates for when CMS accepted and  closed the corrective action element for the specific inappropriate  marketing deficiency, rather than the dates for which the entire CAP was  accepted and closed. CMS requests CAPs to address multiple violations of  agency requirements in addition to marketing; CMS may accept and close  individual corrective actions for specific deficiencies under a CAP at  different times.
We identified enforcement actions related to inappropriate marketing and  noncompliance with agent-related marketing requirements by performing  a content analysis of the enforcement actions listed on CMS’s Web site. We  reviewed the sanction letters CMS sent to these organizations or  interviewed agency officials to determine that the enforcement actions we  had identified were related to inappropriate marketing. Based on our  review of the data and interviews with CMS officials, we concluded that  the compliance and enforcement action data were sufficiently reliable for  our purposes.
section_title: Appendix II: Inappropriate Marketing Violations for Which CMS Sent Compliance Letters to MA Organizations, June 2008
paragraphs: In June 2008 CMS began tracking the number of compliance letters— initial notices of noncompliance and warning letters sent to MA  organizations. For the period of study, CMS issued one initial notice of  noncompliance and 76 warning letters for various instances or areas of  noncompliance. (See table 3.) During the 2008 annual election period, CMS  conducted multiple surveillance activities: analyzing rates of beneficiary  allegations of agent-related noncompliance in the agency’s complaint  tracking module, and secret shopping of MA organizations marketing  events and customer call centers. CMS also reviewed MA organizations’  compliance with required agent commission limits. CMS then sent the  letters as a result of its findings from its surveillance activities and its  review of compliance with required agent commission limits.
section_title: Appendix III: CMS Criteria for Taking Compliance and Enforcement Actions
paragraphs: CMS’s MA organization account management SOPs provide general  guidelines for when a compliance action may be appropriate:  the MA organization has engaged in an activity that is egregious in nature, the MA organization has demonstrated sustained poor performance over a  period of time, the issue involves a large number of MA beneficiaries, or  the issue raises significant compliance concerns, such as the MA  organization not meeting certain contractual requirements.
CMS has implemented its general guidelines for compliance actions such  that the agency has taken such actions based on specific oversight  activities for which it has explicit criteria. Specifically, the agency issued  the majority of notices of noncompliance and warning letters based on MA  organizations’ noncompliance with required agent commission limits or  the results of surveillance activities (such as analysis of inappropriate  marketing complaints and secret shopper activities). CMS required the  majority of CAPs based on the results of audits of MA organizations.  Required agent commission limits, surveillance activities, and audits all  have explicit criteria for assessing compliance with agency requirements.  For example, of the 76 warning letters CMS sent to MA organizations for  inappropriate marketing practices, 44 were based on noncompliance with  required agent commission limits and 30 were based on the results of  surveillance activities. CMS regulations published in September 2008  require MA organizations to establish reasonable agent commission limits;  CMS sent warning letters to those MA organizations that had commission  limits that the agency determined were unreasonable. As part of the  surveillance activities, during the 2008 annual election period, CMS  analyzed the rates of inappropriate marketing complaints and sent  warning letters to those MA organizations that met the criteria of having  more than 15 complaints per 1,000 beneficiaries. During the same period,  CMS sent warning letters to those MA organizations that met the criteria of  committing one or more violations at secret shopper events, based on  specific marketing guidelines that the agency developed. Similarly, 36 of  37 CAPs for deficiencies associated with inappropriate marketing were  required by CMS based on audit findings. For its audit activities, CMS’s  audit SOPs contain specific criteria for assessing compliance with  requirements in defined areas that trigger the agency to require MA  organizations to develop and implement CAPs for identified deficiencies.
CMS’s MA organization account management SOPs and its audit SOPs  provide guidelines for when an enforcement action may be appropriate:    all compliance actions have been exhausted,  the MA organization has a repeat deficiency,   an area of noncompliance could result in harm to one or more Medicare    an area of noncompliance is deemed as a “substantial failure” of Medicare  requirements.
Unlike compliance actions, criteria for enforcement actions are derived  from federal statute and regulations. Enforcement actions are expressly  provided for in federal statute as a remedy for certain violations. CMS  officials told us that the agency initiates enforcement decisions when  particular instances of non-compliance or failures to correct deficiencies  warrant a higher level of intervention. According to CMS officials, they  review various sources of evidence in determining whether to initiate an  enforcement action, including: beneficiary complaints; results of  surveillance activities, such as secret shopper observations; problems self- reported by the MA organization; data from audits; reporting requirements;  and information from DOIs and SHIPs. In addition, when making  enforcement decisions, CMS officials said that they consider the nature,  scope, and severity of the particular non-compliance, how many  beneficiaries have been or potentially could be adversely affected by the  noncompliance, whether the MA organization has failed to address a  serious compliance deficiency for which it has received prior notice and  opportunity to correct, whether the compliance deficiency has been  previously corrected but recurred, and CMS precedent in taking  enforcement actions in similar circumstances. However, CMS officials said  they prefer to resolve cases through lower levels of intervention given the  resources required to investigate cases and the potential disruption to  beneficiaries.
section_title: Appendix IV: Agency Comments
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: Other contributors to this report include Christine Brudevold,   Assistant Director; Shana Deitch; Gregory Giusto; Kevin Milne;   Elizabeth T. Morrison; Michael Rose; and Hemi Tewarson.
section_title: Related GAO Products
paragraphs: Medicare: Callers Can Access 1-800-Medicare Services, but  Responsibility within CMS for Limited English Proficiency Plan  Unclear. GAO-09-104. Washington, D.C.: December 29, 2008.
Medicare: HCFA Needs to Take Stronger Actions Against HMOs  Violating Federal Standards. GAO/HRD-92-11. Washington, D.C.:  November 12, 1991.
Medicare: Increased HMO Oversight Could Improve Quality and Access  to Care. GAO/HEHS-95-155. Washington, D.C.: August 3, 1995.
Medicare: Experience Shows Ways to Improve Oversight of Health  Maintenance Organizations. GAO/HRD-88-73. Washington, D.C: August  17, 1988.
Medicare Advantage: Characteristics, Financial Risks, and  Disenrollment Rates of Beneficiaries in Private Fee-for-Service Plans.  GAO-09-25. Washington, D.C.: December 15, 2008.
Medicare Advantage: Increased Spending Relative to Medicare Fee-  for-Service May Not Always Reduce Beneficiary Out-of-Pocket Costs.  GAO-08-359. Washington, D.C.: February 22, 2008.
Medicare Advantage Organizations: Actual Expenses and Profits  Compared to Projections for 2006. GAO-09-132R. Washington, D.C.:  December 8, 2008.
Medicare Advantage Organizations: Actual Expenses and Profits  Compared to Projections for 2005. GAO-08-827R. Washington, D.C.:   June 24, 2008.
Medicare Part D: Complaint Rates Are Declining, but Operational and  Oversight Challenges Remain. GAO-08-719. Washington, D.C.: June 27,  2008.
Medicare Part D: Some Plan Sponsors Have Not Completely Implemented  Fraud and Abuse Programs, and CMS Oversight Has Been Limited.  GAO-08-760. Washington, D.C.: July 21, 2008.
Schedule and Timing Issues Complicate Withholding Premiums for  Medicare Parts C and D from Social Security Payments. GAO-08-816R.  Washington, D.C.: July 15, 2008.