CMS administers 1-800-MEDICARE through a single contractor that operates the telephone help line 24 hours a day, 7 days a week. CMS initially designed 1-800-MEDICARE to assist beneficiaries in obtaining information about Medicare programs, including Medicare’s managed care program, and has since expanded the telephone line to handle increased call volume and additional inquiries, including inquiries about Medicare’s prescription drug benefit. Calls are answered by an automated system and, if requested, callers may be routed to a CSR for additional assistance. The contractor trains CSRs to respond to two types of inquiries—(1) general inquiries about the Medicare program (such as general inquiries about prescription drug coverage or beneficiary address changes) and (2) specific inquiries about some Medicare Part A and Part B claims—for both English- and Spanish-speaking callers. CMS uses performance metrics and indicators to oversee and measure the 1-800-MEDICARE contractor’s performance. To meet the needs of people with LEP, HHS developed an LEP Plan that identifies steps for its agencies, including CMS, to take to improve access for people with LEP to agency programs and activities, including 1-800-MEDICARE. CMS administers 1-800-MEDICARE to answer callers’ inquiries 24 hours a day, 7 days a week about Medicare eligibility, enrollment, and benefits. CMS initially developed 1-800-MEDICARE to assist beneficiaries and other members of the public in obtaining information about Medicare programs, including Medicare’s managed care program, as required by the Balanced Budget Act of 1997 (BBA). In 2003, the MMA required CMS to make information about the Medicare prescription drug benefit available through 1-800-MEDICARE and gave CMS increased flexibility in the administration of Medicare. CMS officials reported that they used this flexibility to transfer responsibility for information about Medicare-related Part A and Part B (including DME) claims calls, which previously had been handled by separate Part A and Part B contractors with their own help line numbers, to 1-800-MEDICARE. CMS completed the transition of Part A and Part B claims calls to 1-800-MEDICARE in September 2007. Each of these initiatives contributed to an increase in the overall volume of calls received by 1-800-MEDICARE. During the period encompassed in our review, overall call volume for 1-800-MEDICARE increased approximately 22 percent, from about 1.6 million calls in July 2005 to more than 2.0 million calls in July 2008. (See fig. 1.) A large increase in volume occurred close to the beginning of the Medicare prescription drug benefit in late 2005 and early 2006. Since that time, monthly call volume has ranged from about 2 million inquiries to slightly more than 3 million. Callers to 1-800-MEDICARE receive information from an automated interactive voice response (IVR) system, a CSR, or a combination of both. Calls to the line are initially answered by the IVR, which responds to voice and electronic prompts by the caller. Callers also may use the IVR to obtain assistance in either English or Spanish. Those who do not indicate a language preference in the IVR and wish to speak to a CSR are automatically routed to a CSR for assistance in English. If the IVR cannot address the needs of the caller or if the caller requests to speak to a person, the call is routed to a CSR for assistance. (See fig. 2.) 1-800-MEDICARE classifies incoming calls to CSRs into two types of requests: Inquiries about general Medicare issues, such as general inquiries about prescription drug coverage or beneficiary address changes. Specific inquiries about claims for Medicare Parts A and B. To provide assistance with these claims inquiries, 1-800-MEDICARE CSRs are able to access certain Part A and Part B claims data. Newly hired CSRs initially receive training to provide services related to general Medicare inquiries and, as they become more proficient, receive additional training to respond to claims inquiries. The 1-800-MEDICARE contractor hires additional, temporary CSRs to handle anticipated increases during 1-800-MEDICARE’s annual peak period from October through mid-January; these CSRs are trained to handle general Medicare inquiries. The IVR routes callers with general Medicare or specific claims inquiries to CSRs according to complexity. The approximately 2,600 CSRs responding to these calls are grouped into two skill levels, or “tiers,” based on their training and experience. (See fig. 3.) Tier 1 CSRs, who made up the majority of CSRs as of January 1, 2008, receive training to respond to simple inquiries about Medicare and claims. Tier 1 CSRs handle the majority of 1-800-MEDICARE inquiries. Between September 2007 and July 2008, Tier 1 CSRs handled over 15.1 million calls—95 percent of the approximately 15.9 million calls handled by CSRs. Approximately 11.8 million of these Tier 1-handled calls were general Medicare inquiries while approximately 3.3 million were claims inquiries. Tier 2 CSRs receive training to assist callers with more complex general Medicare and claims inquiries. For example, callers wishing to enroll in a Medicare Advantage plan would speak to a Tier 2 CSR. These CSRs also can respond to calls at the Tier 1 level if needed. Between September 2007 and July 2008, Tier 2 CSRs handled about 800,000 calls—5 percent of all calls handled by CSRs. Approximately 523,000 of these calls were general Medicare inquiries, while approximately 273,000 were claims inquiries. Particularly complex inquiries, about 1 percent of all calls received, may be referred by Tier 1 or Tier 2 CSRs to a reference center staffed by CSRs with additional training above the level of the Tier 2 CSRs. To provide responses to callers, CSRs in Tier 1 and Tier 2 use defined “scripts”—standard language explaining elements of the Medicare program—that they access using desktop computer software. CSRs listen to a caller’s inquiry and then enter related keywords into this system to generate a list of suggested scripts that could be used to answer the inquiry. The CSRs then select the script they consider best suited to answer the inquiry and read either excerpts or the entire script to the caller. CSRs may also consult other information sources if appropriate. For example, CSRs sometimes use tools available on the Medicare Web site to help beneficiaries select a prescription drug plan. CMS requires CSRs to read scripts in an effort to ensure that all callers receive consistent information from 1-800-MEDICARE—regardless of the expertise of the CSR—and that information being shared is easily understood by the caller. In October 2006, CMS awarded a single performance-based contract for the operation of its 1-800-MEDICARE contact centers valued at approximately $496 million over the life of the contract. This contract consisted of an initial 7-month transition period, during which the current 1-800-MEDICARE contractor assumed full responsibility for 1-800- MEDICARE help line operations, and 2 additional years, referred to as “option years.” The contractor is reimbursed for its costs and receives a fixed base fee. In addition, the contractor can earn an “award fee”—a percent of the total contract amount—based on its performance in meeting specific metric standards and indicator targets that CMS identified as being particularly important to providing services to callers and controlling contract costs. The current metrics and their standards were put in place as of July 2007. Using the standards and targets, CMS evaluates the contractor’s performance three times a year. For each evaluation period, CMS can decide to award all, part, or none of the available award fee amount depending on the contractor’s performance. The current performance metrics quantify and measure the caller experience with 1-800-MEDICARE. Several metrics are specifically related to telephone access, such as the average amount of time callers wait after indicating that they want to speak to a CSR until their calls are answered by the CSR. The 1-800-MEDICARE contractor must meet the specific standards for these performance metrics in order to be awarded up to 15 percent of the award fee. Each evaluation period is 4 months long. If the contractor does not meet a performance metric standard during any month in an evaluation period, that month’s portion of the award fee is withheld at the end of that evaluation period. CMS also has designed several performance indicators that it considers when measuring the performance of the 1-800-MEDICARE contractor. Several of these indicators are specifically related to telephone access, such as the average amount of time a CSR talks to a caller. These performance indicators do not have fixed standards against which the contractor’s performance is measured; rather, CMS has established performance targets and compares the contractor’s actual performance against these targets, using a scale ranging from substandard to superior, to determine the contractor’s award fee. According to CMS officials, the purpose of the targets is to provide a baseline for planning and management of contact center activities. The performance indicators, when combined with other contract elements, account for up to 45 percent of the award fee. CMS also considers the contractor’s performance related to program management and communication, contract compliance, and fiscal responsibility when determining the award fee. These elements, when combined, account for up to 40 percent of the award fee. In addition to the main 1-800-MEDICARE contract, CMS has awarded four additional contracts to individual companies for other activities directly related to the support of 1-800-MEDICARE: A contract with a telephone company to manage the phone lines used by 1-800-MEDICARE. This company also ensures that calls to CSRs are routed to the next available CSR with the skill set to assist the caller. A contract to support and maintain the desktop application used by CSRs, including software CSRs use to access scripts. A contract to manage the NDW, a central data repository that captures, aggregates, and integrates data on 1-800-MEDICARE from multiple sources. A contract—referred to as the TQC contract—to conduct activities that include training, development of the scripts used by CSRs, and quality assurance, such as evaluation of CSR calls. As required by Executive Order 13166, HHS has developed a plan that identifies the necessary steps for the department and its agencies intended to ensure access to timely, quality language assistance services by eligible LEP persons to its programs and activities, such as 1-800-MEDICARE. The HHS LEP Plan, issued in December 2000, identifies seven elements designed to help each HHS agency, program, and activity to meet the department’s goal of providing “access to timely, quality language assistance services to persons.” For example, the Plan includes elements related to oral language assistance services and efforts to assess accessibility and the quality of language assistance activities. (See app. I for a list of the seven LEP Plan elements.) The Plan reflects HHS’s overall goals for improving language access for individuals and includes strategies for improving technical assistance for language access services. HHS officials said that the Plan provides a “road map” for addressing HHS’s goals, while allowing individual operating divisions and agencies, including CMS, some flexibility in implementing the Plan’s elements. The current 1-800-MEDICARE contractor met most standards and some targets for telephone access-related performance metrics and indicators— measures designed to ensure all callers’ access to services—from July 2007 through July 2008. In 10 of 13 months we analyzed, the current 1-800- MEDICARE contractor’s performance met the standards for each of the required access-related performance metrics. Because of waivers granted by CMS, the agency considered the contractor to have met the relevant standards in 12 of the 13 months. While generally meeting the required standards for the three access-related performance metrics, the 1-800- MEDICARE contractor consistently met the target for only one of the three access-related performance indicators we analyzed. However, the amount of time callers waited to access services has varied depending on the type and complexity of callers’ inquiries. The amount of time callers waited to speak with a CSR has increased since December 2005, but the performance standards related to caller wait time also have varied over time. In 10 of 13 months we analyzed (July 2007 through July 2008), the current 1-800-MEDICARE contractor’s performance met the standards for all three telephone access-related performance metrics required under its contract with CMS. Because of waivers granted by CMS, the contractor was considered by the agency to have met the relevant standards in 12 of the 13 months. Implemented in July 2007, the performance metrics and their associated standards were designed to measure, on a monthly basis, the 1-800-MEDICARE contractor’s ability to ensure callers can access services and to determine the contractor’s award fee during each evaluation period, which occur three times a year. The metrics, described below in table 1, are: (1) the average wait time (also referred to by CMS as the average speed of answer), (2) the percentage of unhandled CSR calls, and (3) the percentage of transfers. Average wait time. The 1-800-MEDICARE contractor met the overall monthly average wait time performance standard—between 5 minutes and 8 minutes, 30 seconds each month—in 12 of the 13 months (from July 2007 through July 2008) we analyzed and, because of a waiver granted by CMS, was considered by the agency to have met the relevant standard in all 13 months. (See fig. 4.) CMS granted the waiver for one month’s wait time standard for multiple reasons, including to account for the interruption of normal 1-800-MEDICARE contact center operations because of flooding in the Midwest. During the 13-month period we studied, the average wait time ranged from a low of less than 6 minutes in July 2008 to a high of more than 8 minutes in September 2007. For the 5 months (October 2007 to February 2008) encompassing the most recent annual coordinated election period and a portion of the open enrollment period—when call volume to 1-800-MEDICARE typically increases—the contractor’s monthly average wait time for all calls was between 6 minutes, 30 seconds and 7 minutes. CMS’s monthly average wait time standard during the time period we analyzed allowed longer wait times than were typical at two of the four federal agencies we interviewed that use this metric for their contact centers. These two agencies used average wait time as a performance metric, with performance standards ranging from 4 minutes, 30 seconds to 5 minutes, 30 seconds. CMS officials said they recognized that the 1-800- MEDICARE average wait time performance standard was long, but said that they selected it based on what could be reasonably achieved within the current budgeted amount available for the 1-800-MEDICARE contract. CMS officials also said that they believed that the budget would not allow for a standard that was more comparable to standards used in the contact center industry. However, CMS officials reported that in August 2008, they began requiring the contractor to meet an average wait time standard of between 1 minute and 5 minutes. CMS officials said that in order to better serve callers, they and the 1-800-MEDICARE contractor implemented processes and improved technologies that have increased the efficiency of the help line. For example, CMS and the contractor implemented new staffing initiatives to ensure that 1-800-MEDICARE has the necessary CSRs available to answer calls. Unhandled CSR call rate. The 1-800-MEDICARE contractor met its unhandled CSR call rate standard, keeping the number of unhandled calls within the required standards, in 11 of the 13 months we analyzed and, because of a waiver granted by CMS, was considered by the agency to have met the standard in 12 of 13 months. (See table 2 below.) The unhandled CSR call metric provides CMS with data on the extent to which callers abandon their calls while waiting for a CSR to answer the call, and CMS officials said that they expect the number of abandoned calls to decrease with shorter average wait times. CMS granted the waiver for one month’s unhandled CSR call rate standard because of changes during that month in its expectations of the contractor’s performance. Though the performance metric standard was not changed, CMS encouraged the contractor to keep its average wait time below 8 minutes. To do this, the contractor increased the number of callbacks—instances in which callers are called back within 48 hours rather than remaining on hold. Because CMS includes callbacks in the unhandled CSR call metric, in this month the contractor exceeded the unhandled CSR call standard. An expert in federal call centers indicated that the unhandled call rate standard used by CMS was high compared to some other federal agencies, but that these performance standards are usually based on what level of service an agency can afford to purchase with its contact center budget. Transfer rate. Transfers from one CSR to another occurred for no more than 20 percent of calls in each of the 13 months of data we analyzed, meeting the contractually required performance standard. While CMS officials said that they expect some transfers to occur normally, they also said a monthly transfer rate that exceeds 20 percent may imply that CSRs are inappropriately transferring callers. CSRs transferred nearly 13 percent of calls in July 2007, but the transfer rate increased to just under 20 percent by October 2007. Since October 2007, the transfer rate has generally decreased, with the lowest percentage of transferred calls of the 10 months we studied occurring in June 2008. (See fig. 5.) CSRs can transfer calls to other CSRs for various reasons, including transferring a call from a Tier 1 CSR to a Tier 2 CSR if the complexity of a caller’s inquiry requires a greater degree of training. According to CMS officials, most transfers occur between Tier 1 and Tier 2 CSRs, although transfers can also occur between two Tier 1 CSRs. For example, a caller may have a general Medicare inquiry answered initially by a Tier 1 CSR, but then raise a claims-related inquiry that may be better answered by another Tier 1 CSR with additional training. In addition to the three required performance metrics, CMS also established several performance indicators and associated targets for the 1-800-MEDICARE contractor to meet in order to receive a portion of its award fee. Three of the indicators are particularly related to callers’ telephone access: (1) the average amount of time CSRs spend assisting callers, referred to as average handle time; (2) agent occupancy—the percentage of CSRs answering calls; and (3) forecasting of call volume going to CSRs. (See table 3 for more information on these selected performance indicators.) The 1-800-MEDICARE contractor met its performance target in each of the 13 months between July 2007 through July 2008 for one performance indicator—agent occupancy—but had varying experience in meeting its targets for the average handle time and CSR call volume forecasting. For agent occupancy, the 1-800-MEDICARE contractor met its performance target—to have 80 percent or more of its CSRs answering calls—in each of the 13 months of data we analyzed. During these 13 months, the 1-800-MEDICARE contractor’s agent occupancy ranged from 83 percent to 89 percent. For average handle time, the 1-800-MEDICARE contractor did not meet its performance target—most recently set at 8 minutes—in any of the 13 months analyzed. Average handle time peaked in December 2007 at 11 minutes, 18 seconds and then decreased each month, reaching an average handle time of 8 minutes, 59 seconds in July 2008. CMS officials said that, because there are many factors that could affect call length, they consider average handle time in conjunction with other metrics and indicators to determine if the contractor is managing CSRs’ time effectively. The 1-800-MEDICARE contractor met its CSR call volume forecasting target—having a variance of less than 10 percent between its forecasted CSR call volume and actual CSR call volume—in 4 of the 13 months of data we analyzed. During the current contract period, callers with claims inquiries or complex inquiries who needed assistance from a Tier 2 CSR generally experienced longer wait times than other callers. Although the current 1-800-MEDICARE contract does not have an average wait time metric or indicator specifically related to the type of call, CMS’s evaluation reports have noted that the agency expected the contractor to manage wait times by type of call to ensure that a caller with a claims inquiry does not wait longer than a caller with a general Medicare inquiry. Wait times varied by type of call. Callers waited, on average, less time to have general Medicare inquiries answered than to have calls about claims inquiries answered in all but 1 of the 11 months we analyzed under the current contract. During that month—December 2007—the difference between wait times for these two types of calls was 1 second. (See fig. 6.) During the time period we reviewed—ending July 2008—callers with general Medicare inquiries waited between 5 minutes and 8 minutes, 30 seconds on average—a time that matches the performance standard for all calls during that period—in 10 of the 11 months we analyzed. In contrast, claims callers were within that range in only 5 of the 11 months with the longest waits in the first two months of this period—almost 18 minutes in September 2007 and just over 11 minutes in October 2007. In September 2007, about 48 percent of callers disconnected before a CSR could answer their calls. Beginning in November 2007 and continuing through July 2008, average wait times for callers with claims inquiries were more closely aligned with that of callers with general Medicare inquiries. (For more information on differences in average wait times by type of claims call, see app. II.) Wait times varied by complexity of calls. Between September 2007 and July 2008, callers generally waited longer, on average, to speak with a Tier 2 CSR—a CSR with additional training to respond to more complex calls— than to speak with a Tier 1 CSR. (See fig. 7.) The average wait time for a Tier 1 CSR was between 5 minutes and 8 minutes, 30 seconds—a time that matched the performance standard for all calls during that period—in 10 of 11 months we reviewed. In contrast, callers waited more than 8 minutes, 30 seconds to speak with a Tier 2 CSR in 5 of 11 months we reviewed. During the first two months of this period, the average wait time for callers needing to speak with a Tier 2 CSR was much longer—more than 12 minutes in September 2007 and 9 minutes in October 2007. Beginning in November 2007 through July 2008, average wait times for callers needing to speak to a Tier 2 CSR were more closely aligned with that of callers needing to speak to a Tier 1 CSR. (For more information on differences in average wait times by complexity of inquiry, see app. II.) CMS’s performance standards for caller wait times have varied since December 2005, and, since that time, callers have waited longer, on average, to have their calls answered by a CSR. (See fig. 8.) The varying performance standards have allowed for a very short caller wait time, such as requiring 80 percent of calls to be answered in 30 seconds, while at other times allowing for a longer wait time, such as requiring that 80 percent of calls be answered in 10 minutes. During the current contract period, CMS’s performance standards have consistently allowed for a longer average caller wait time. From December 2005 to October 2006, when two contractors operated 1-800-MEDICARE, the average wait time in 8 of 11 months was below 5 minutes—the minimum average wait time standard under the current contract period through July 2008. During the transition period of the current 1-800-MEDICARE contract, October 30, 2006 through May 31, 2007, the average wait time ranged from a low of 2 minutes, 6 seconds to a high of 10 minutes, 22 seconds. From the end of the transition period through July 2008, the monthly average wait times have been at or above 6 minutes, 30 seconds in all but one month, though they have not varied as widely as in prior periods we reviewed. CMS has made efforts to provide LEP callers with access to services through 1-800-MEDICARE by requiring the contractor to provide services in either English or Spanish and to provide interpretation services for callers speaking other languages. To meet these requirements, the contractor uses CSRs who are bilingual in English and Spanish and a telephone interpretation service to assist callers who speak other languages. Spanish-speaking callers waited less time on average to reach a CSR than their English-speaking counterparts in almost two-thirds of the months we reviewed—from December 2005 through July 2008. Officials from the Office of Beneficiary Services (OBIS)—the CMS office with primary responsibility for 1-800-MEDICARE—said they were not aware of the HHS LEP Plan when awarding and assigning the current 1-800- MEDICARE contract and CMS has not identified an office responsible for acting as a point of contact for its management of the LEP Plan. Nonetheless, steps CMS has taken to provide services to LEP callers are consistent with some elements of the HHS LEP Plan adopted by the agency without modification, such as the element related to oral language assistance, but not others, such as the Plan’s element for assessing quality and accessibility, which identifies the need for complaint mechanisms for language issues. As required by CMS, the 1-800-MEDICARE contractor provides callers with service in either English or Spanish and provides interpretation services for callers speaking other languages. The 1-800-MEDICARE contractor uses CSRs who are bilingual in English and Spanish to provide services to Spanish-speaking callers. As of January 1, 2008, slightly more than 7 percent of all CSRs at 1-800-MEDICARE were bilingual. Bilingual CSRs complete the same training required of CSRs who are not bilingual and must successfully handle test calls in both English and Spanish prior to answering 1-800-MEDICARE calls. Like CSRs who speak only English, bilingual CSRs use scripts, translated into Spanish, to provide assistance to callers. To meet CMS’s requirement that the contractor ensure “real-time phone translations” for callers who speak neither English nor Spanish, the 1-800 contractor subcontracts with a “language line”—a telephone interpretation service. Through this language line, English-speaking CSRs have access to interpretation services in more than 150 languages. According to the 1-800- MEDICARE contractor, the language line provider uses internal certification and assessment to assure the quality of its interpreters. The number of languages for which CSRs have requested assistance has increased over time, from 40 languages in 2005 to 73 as of March 2008. The language line also is used to provide interpretation services for Spanish- speaking callers if the wait for a bilingual CSR exceeds 20 minutes. In these cases, Spanish-speaking callers are transferred to non-Spanish- speaking CSRs who then use the language line to assist these callers. According to CMS officials, the cost of language line interpreters and the additional length of time required to connect and handle the call using the language line increases the costs of these calls. Calls needing Spanish interpretation accounted for the majority of calls to the language line during the time period we reviewed, growing from 60 percent of all calls to the line in 2005 to 80 percent of all calls in 2007. However, while the use of the language line for Spanish interpretation has increased, in most months we reviewed more than 90 percent of all Spanish-speaking callers to 1-800- MEDICARE were assisted by bilingual 1-800-MEDICARE CSRs. Spanish-speaking callers who speak with bilingual CSRs frequently experienced shorter average monthly wait times to reach a CSR than their English-speaking counterparts. (See fig. 9.) Spanish-speaking callers waited less time, on average, in slightly more than 60 percent of the months we reviewed (20 of 32), which encompassed parts of both the prior and current contract. While the current 1-800-MEDICARE contract does not have metrics specifically focused on call language, the average wait time experienced by Spanish-speaking callers under the current contract, beginning at the end of October 2006, was consistent with CMS’s performance standard for overall average caller wait times as of July 2008 in almost two-thirds of the months we reviewed. However, Spanish-speaking callers have recently waited slightly longer, on average, than their English-speaking counterparts. In addition, while Spanish-speaking callers with simple claims inquiries have experienced shorter average wait times than English- speaking callers, they have waited, on average, longer for all general Medicare inquiries and more complex claims inquiries. (For more information on differences in average wait times by caller language, see app. II.) Officials from OBIS—the CMS office with primary responsibility for 1-800- MEDICARE—said they were not aware of the LEP Plan when awarding and assigning the current contract for operation of the help line. Rather, they relied primarily on industry best practices when determining how to require the 1-800-MEDICARE contractor to provide LEP services. In addition, while officials from HHS’s OCR and CMS’s OEOCR said CMS chose to adopt the HHS LEP Plan as issued—although HHS allowed its agencies flexibility to modify it—officials from multiple CMS offices were unable to identify an office or official responsible for acting as the central point of contact responsible for the agency’s management of the Plan. A key factor in meeting standards for internal control in federal agencies is defining and assigning key areas of authority and responsibility—such as a point of contact for an agency-wide plan—and communicating that information throughout the organization. Without an office or official responsible for management of the Plan, staff lack a source of guidance that could assist them in taking steps consistent with the Plan to provide services to people with LEP. Although CMS officials did not consider the LEP Plan when determining how services for LEP callers to 1-800-MEDICARE would be provided, steps they have taken to implement language services are consistent with some—but not all—elements of the Plan. In particular, by requiring its contractor to provide services to all LEP callers, CMS has taken a step consistent with the LEP Plan element stating that “each agency, program, and activity… will arrange for the provision of oral language assistance in response to the needs of LEP customers, both in face-to-face and telephone encounters.” In addition, the LEP Plan states that agencies, activities, and programs will implement mechanisms to assess the LEP status and needs of current and potential customers. To do this, CMS officials said they and the contractor regularly review the frequency with which LEP callers contact the 1-800 line to determine appropriate bilingual CSR staffing levels. In addition, CMS officials noted that this information could be used to determine whether CSRs who speak languages other than English and Spanish should be made available to callers. However, CMS has not taken steps consistent with other Plan elements related to 1-800-MEDICARE. For example, CMS officials did not identify, and did not require the contractor to identify, a specific official or office to allow LEP callers to register concerns or complaints regarding language assistance services provided by 1-800-MEDICARE, as indicated by the LEP Plan element for assessing accessibility and quality. In addition, while CMS considers the number and languages of LEP callers currently using 1-800-MEDICARE, consistent with the LEP Plan’s element related to the assessment of needs and capacity, neither the number nor proportion of Medicare-eligible or Medicare-enrolled LEP beneficiaries is specifically considered when planning how 1-800-MEDICARE language services will be provided. The LEP Plan also directs agencies to develop policies and procedures for each Plan element, to designate staff responsible for implementing these policies and procedures, and to provide staff with training on them. However, given that CMS staff within OBIS were not aware of the existence of the LEP Plan until our review, no uniform CMS policies and procedures had been used to implement any elements of the LEP Plan for 1-800-MEDICARE, nor had training specific to the LEP Plan occurred. CMS uses all six of the management practices we identified as commonly used by contact centers to oversee 1-800-MEDICARE callers’ access to services and to accurate information. (See table 4 for a description of these six common oversight practices.) These practices are addressed in the current 1-800-MEDICARE contract and reflected in CMS’s ongoing oversight of the help line. For example, CMS awarded some of the available award fee to the 1-800-MEDICARE contractor for meeting certain performance metrics and used CSR feedback to improve the oversight of information CSRs provide to beneficiaries. In addition, CMS used customer satisfaction surveys to identify areas for improvement, including the IVR, and worked with the contractor to improve call volume forecasting in an effort to ensure appropriate staffing levels to meet callers’ needs. Clearly defining performance metrics and indicators. The performance metrics and indicators that CMS officials said they designed to encourage improved performance and correct identified problems are clearly defined in the 1-800-MEDICARE contract. The current 1-800- MEDICARE contract identifies each metric and indicator, provides a definition for these measures, and sets a standard or target for each measure. CMS uses these measures to evaluate contractor performance three times a year and to provide an award fee if the contractor performs at or above set levels. Because the contractor did not meet all standards and targets for any evaluation period as of May 2008, CMS has awarded only part of the possible award fee to date, in accordance with the award guidance in the 1-800-MEDICARE contract. Award fees are based on a scoring system, in which a percentage of the award fee is distributed depending on CMS’s rating of the contractor’s performance, ranging from the lowest rating, substandard, to the highest rating, superior. CMS rated the contractor as good or very good from the start of the current contract through May 2008. CMS also uses the performance metrics and indicators on a continuous basis to monitor and evaluate callers’ ability to access information from 1-800-MEDICARE. For example, CMS officials said they receive updates from the contractor on the average wait times—a measure of caller access—through daily e-mails. If callers’ average wait time exceeds 5 minutes, CMS officials receive e-mail notification every half hour. During that time, CMS officials said the contractor also notifies them of actions it is taking to improve caller wait times. Customer satisfaction surveys. CMS officials said they use the results of customer satisfaction surveys to gain insight into callers’ experiences with 1-800-MEDICARE services and to identify opportunities for improving services. In June 2008, the TQC contractor assumed responsibility for conducting a customer satisfaction survey of 20 percent of randomly selected 1-800-MEDICARE callers. The TQC contractor will provide CMS with the results from this survey on an ongoing basis; however, initial results were not available as of May 2008. Prior to June 2008, CMS required the 1-800-MEDICARE contractor to call back randomly selected beneficiaries who contacted 1-800-MEDICARE and administer a customer satisfaction survey developed by CMS. CMS officials said they used the information from the surveys to make changes to 1-800-MEDICARE. For example, based on survey participant concerns about the IVR, which is used by 18 to 20 percent of callers to resolve their inquiries, CMS officials indicated they made changes to the IVR prompts to make them easier to follow. CMS officials said that they anticipate future callers to 1-800-MEDICARE will be more willing to use technologies such as the IVR to obtain information. However, as of November 2008, only limited testing and focus groups had been conducted to confirm this anticipated trend. Ensuring accurate information. To ensure that beneficiaries receive consistent and accurate program information, CSRs are required to use scripts approved by the agency and CMS, and contractor officials reported taking steps designed to make correct scripts easier for CSRs to identify and to make scripts easier to understand. In April 2008, the TQC contractor began developing content for 1-800-MEDICARE scripts, which previously had been developed by the 1-800-MEDICARE contractor and reviewed by CMS. The TQC contractor employs staff with expertise in Medicare who develop and revise scripts as needed. CMS reviews and approves all scripts before making them available to CSRs. According to CMS officials, in August 2008 the TQC contractor began quarterly script reviews for accuracy as well as legislative, program, or policy changes. In addition to reviews conducted by the TQC contractor, CMS officials said that they have used the results of customer satisfaction surveys and call evaluations to assess how well scripts meet the needs of callers and how easy scripts are for CSRs to find. CMS can also access a computer application that captures CSR feedback on scripts, including how easy scripts are to understand, an issue identified in previous GAO work. Evaluating CSR interaction with callers. To assess whether callers receive consistent and accurate information from 1-800-MEDICARE, CMS requires both the 1-800-MEDICARE contractor and the TQC contractor to evaluate CSRs’ interactions with callers through call monitoring. The 1-800-MEDICARE contractor listens to four calls a month for each CSR, evaluating the CSRs’ performance on customer service skills identified by CMS, including tone, using scripts appropriately, and completeness of information provided. CMS officials said they designed the 1-800- MEDICARE contractor’s call evaluation process for contractor supervisors to coach CSRs on their performance and to help improve CSRs’ ability to use software to find appropriate scripts. The 1-800-MEDICARE contractor has reported on the required evaluations monthly. Using these evaluation reports, CMS officials said, they worked with the 1-800-MEDICARE contractor to identify and correct trends or issues with scripts, software, or CSR training. For example, CMS used the call evaluation process to determine the reasons why callers may need to be transferred to a more experienced CSR or place another call to 1-800-MEDICARE. This analysis was part of the “First Call Resolution Initiative,” an effort to increase the number of callers who have their inquiries resolved with one phone call rather than many. However, in its evaluation of the 1-800-MEDICARE contractor for the period ending May 2008, CMS reported that it observed callers receiving poor service from CSRs who received perfect call evaluation scores from the 1-800-MEDICARE contractor for those calls. CMS noted the 1-800-MEDICARE contractor needed to improve consistency between actual CSR call evaluation scores and the quality of service callers receive. In addition, since April 1, 2008, CMS has required the TQC contractor each month to monitor and evaluate 600 randomly selected calls in English and 225 randomly selected calls in Spanish. This call sample is designed to allow CMS to generalize trends that emerge from this sample to the call volume of 1-800-MEDICARE as a whole. CMS officials said they anticipate analyzing any trends identified from this call monitoring to note areas for improvement to the 1-800-MEDICARE help line. CMS officials also said that they will use the results of the TQC scores as part of the 1-800- MEDICARE contractor’s regular performance evaluation and resulting award payment beginning in October 2008. In addition, CMS officials reported monitoring calls themselves and meeting weekly with the 1-800- MEDICARE and TQC contractors to listen to and rate recorded calls as a group. CMS officials said that these meetings help to ensure that the contractors understand the standard of service CMS expects callers to receive. CMS officials also planned to perform similar evaluations on calls for which customer satisfaction survey information is available—a practice identified by an industry expert as a method to improve contact center service. Capacity planning. CMS officials said they work with the 1-800- MEDICARE contractor to create short- and long-term call volume forecasts and to determine whether systems and staffing can handle call volume, taking into account Medicare’s annual coordinated election and open enrollment periods when inquiries peak. CMS requires the 1-800- MEDICARE contractor to produce call volume forecasts that are accurate within 10 percent of actual call volumes for the forecasted period. CMS oversight of the contractor’s forecasting efforts has identified significant differences between the long-term forecasts and actual monthly volume of calls going to CSRs—forecasting up to 35 percent more calls than were actually received by CSRs for the performance period ending January 2008 and causing projected staffing costs for this period to be overstated. In its evaluation of the performance period ending January 2008, CMS notified the contractor that performance in this area needed to improve and stated that it wanted the contractor to identify methods of ensuring consistent and accurate forecasts. However, CMS noted that when the forecasted call volume was not realized, the 1-800-MEDICARE contractor adjusted its staffing so that only the number of CSRs needed to meet the performance standard related to average wait times were available. In its evaluation for the period ending May 2008, CMS noted a significant improvement in long- term forecasting and indicated that the 1-800-MEDICARE contractor had a better understanding of events that affected call volume throughout the year. To ensure that 1-800-MEDICARE systems, such as phone lines and desktop software, are available to handle forecasted call volumes, CMS requires the 1-800-MEDICARE contractor to notify the agency of systems outage incidents that affect callers’ access. In the evaluation period ending January 2008, CMS identified inconsistencies in the outage reporting process, which caused key information to be omitted from reports about systems outage incidents. In its evaluation for the period ending May 2008, CMS noted some improvement in reporting systems outage incidents, but indicated that the 1-800-MEDICARE contractor needed to improve the consistency of its reporting practices in the future. CMS officials said they are working with the contractor to address this issue and reported finalizing a process for reporting systems outages in early November 2008. Validation of contractor reports. CMS officials said they validate contractor reports—many of which are used to determine contract award fees—by analyzing data captured by 1-800-MEDICARE computer systems and having regular meetings with their contractors. To ensure the integrity of data collected by 1-800-MEDICARE systems, CMS collects and stores these data in the NDW, which is managed by a separate contractor. CMS officials compare data from the NDW on the actual call center performance to reports submitted by the 1-800-MEDICARE contractor, such as the long-term call volume forecasts. Using this method of validating reports, CMS determined that the 1-800-MEDICARE contractor’s forecasting reports were inaccurate and required the contractor to improve in this area, which the contractor did over the next evaluation period. In addition to validating contractor reports through the NDW, CMS officials said they used weekly and monthly status reports, meetings with contractors, and visits to 1-800-MEDICARE contractor sites to monitor contractor performance between periodic evaluations. To date, the current 1-800-MEDICARE contractor has met most of CMS’s performance standards and some of the performance targets designed to ensure callers’ access to services from the help line. In addition, by employing all six commonly used management practices to oversee 1-800- MEDICARE callers’ access to services and accurate information, CMS gains valuable data to assess the contractor’s performance and identify areas for improvement. In particular, the new TQC contract provides CMS with an opportunity to continue to improve both access to, and accuracy of, information. However, while callers with LEP can access services through 1-800- MEDICARE, CMS has not taken steps to ensure that officials throughout the agency, including within OBIS, are fully aware of the LEP Plan, which HHS designed to be a “road map” for providing appropriate services to this population. By not identifying an official point of contact responsible for management of the Plan, CMS is lacking a key internal control measure—a clearly defined area of responsibility that has been communicated agencywide. While CMS has taken steps to ensure access for LEP callers to 1-800-MEDICARE, a clearly identified office or official responsible for the Plan could provide guidance in areas where steps consistent with the LEP Plan have not been taken and could work to ensure consistent use of the Plan across the agency. To ensure CMS offices, including those that oversee the operation of the 1-800-MEDICARE help line are aware of, and take steps consistent with, the HHS LEP Plan when considering the needs of people with LEP, CMS should designate an official or office with responsibility for managing the LEP Plan. We provided CMS with a draft of this report for its review and comment. The agency provided written comments, which we addressed as appropriate and which have been reprinted in appendix III. The current 1-800-MEDICARE contractor stated that the report was factually accurate and provided oral technical comments, which we incorporated as appropriate. The Social Security Administration and the departments of Defense, Education, and Treasury told us they had no comments on the draft report. In responding to our draft, CMS stated that it has taken steps to implement our recommendation. More specifically, CMS has identified an official responsible for the development of an LEP Plan for the agency that, when finalized, is intended to define responsibility for ensuring consistent and reliable LEP tracking and reporting. CMS also noted that the report identified issues related to accurate forecasts and wait times experienced by callers for general Medicare and claims calls. The agency reiterated that these issues were affected by the transition, completed in 2007, of claims calls previously answered by FFS contractors to 1-800-MEDICARE. CMS also stated that its intent is to try to fully answer callers’ questions rather than focusing exclusively on reducing average handle time—the average amount of time CSRs take to respond to callers’ inquiries. Additionally, CMS stated that while it has not specifically evaluated the number or proportion of LEP beneficiaries who are Medicare eligible and enrolled, it continues to review demand and consider other opportunities to best serve LEP callers. Finally, CMS noted that some information regarding the 1-800-MEDICARE contractor’s operations and contract with the agency are considered proprietary. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the Secretary of Health and Human Services and others. The report also will be available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at kingk@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix IV. Appendix I: Elements of the Department of Health and Human Services’ Limited English Proficiency Plan “Each agency, program, and activity of the HHS [Department of Health and Human Services] will have in place mechanisms to assess, on a regular and consistent basis, the LEP status and language assistance needs of current and potential customers, as well as mechanisms to assess the agency’s capacity to meet these needs according to the elements of this plan.” “Each agency, program, and activity of HHS will arrange for the provision of oral language assistance in response to the needs of LEP customers, in both face-to-face and by telephone encounters.” “Each agency, program, and activity of HHS will provide vital documents in languages other than English where a significant number or percentage of the customers served or eligible to be served has . These written materials may include paper and electronic documents such as publications, notices, correspondence, web sites and signs.” “Each agency, program, and activity of HHS will have in place specific written policies and procedures related to each of the plan elements and designated staff who will be responsible for implementing activities related to these policies.” “Each agency, program, and activity of HHS will proactively inform LEP customers of the availability of free language assistance services through both oral and written notice, in his or her primary language.” “Each agency, program, and activity of HHS will train front-line and managerial staff on the policies and procedures of its language assistance activities.” “Each agency, program, and activity of HHS will institute procedures to assess the accessibility and quality of language assistance activities for LEP customers.” This appendix provides more detailed information on the average wait times experienced by callers depending on the type of inquiry—general Medicare and claims—and complexity of their call or the language in which they need assistance for the period September 2007 through July 2008 of the current contract. Figures 10 and 11 provide information on differences in average wait times experienced by callers depending on their type of inquiry—general Medicare and claims—and the complexity of their inquiry. While simple inquiries may be resolved by Tier 1 CSRs, inquiries of greater complexity may require the assistance of a Tier 2 CSR. Figures 12 through 14 compare the wait times for callers with simple inquiries to callers with complex inquiries by type of claims inquiry—Medicare Part A, Part B, and, within Part B, durable medical equipment (DME). Figures 15 through 18 provide information on differences in average wait times experienced by callers depending on the language in which they are assisted. The information provided compares the wait times of English- and Spanish-speaking callers for each type of inquiry, by complexity level. In addition to the person named above, Karen Doran, Assistant Director; Jennie F. Apter; Hernan Bozzolo; Eleanor M. Cambridge; Emily R. Gamble Gardiner; Barbara A. Hills; Martha R.W. Kelly; Ba Lin; Lisa S. Rogers; and Hemi Tewarson made key contributions to this report. Tax Administration: 2007 Filing Season Continues Trend of Improvement, but Opportunities to Reduce Costs and Increase Tax Compliance Should be Evaluated. GAO 08 38. Washington, D.C.: -- November 15, 2007. Tax Administration: Most Filing Season Services Continue to Improve, but Opportunities Exist for Additional Savings. GAO 07 27. Washington, -- D.C.: November 15, 2006. Federal Contact Centers: Mechanisms for Sharing Metrics and Oversight Practices along with Improved Data Needed. GAO 06 270. Washington, -- D.C.: February 8, 2006. Tax Administration: IRS Improved Some Filing Season Services, but Long-term Goals Would Help Manage Strategic Trade-offs. GAO 06 51-- Washington, D.C.: November 14, 2005. . Social Security Administration: Additional Actions Needed in Ongoing Efforts to Improve 800-Number Service. GAO 05 735. Washington, D.C.: -- August 8, 2005. Immigration Services: Better Contracting Practices Needed at Call Centers. GAO 05 526. Washington, D.C.: June 30, 2005. -- Tax Administration: IRS Improved Performance in the 2004 Filing Season, But Better Data on the Quality of Some Services Are Needed. GAO 05 67. Washington, D.C.: November 15, 2004. -- Tax Administration: IRS Needs to Further Refine Its Tax Filing Season Performance Measures. GAO 03 143. Washington, D.C.: November 22, -- 2002. IRS Telephone Assistance: Limited Progress and Missed Opportunities to Analyze Performance in the 2001 Filing Season. GAO 02 212. -- Washington, D.C.: December 7, 2001.

Summary: The Centers for Medicare & Medicaid Services (CMS) is responsible for providing beneficiaries timely and accurate information about Medicare. Receiving nearly 30 million calls in 2007, 1-800-MEDICARE, operated by a contractor, is the most common way members of the public get program information. The help line provides services both to English-speaking and limited English proficiency (LEP) callers. In this report, GAO describes (1) the extent to which access performance standards and targets have been met by the current contractor, (2) the efforts by CMS to provide LEP callers access to help line services and wait times experienced by these callers, and (3) CMS's oversight of callers' access to 1-800-MEDICARE and the information's accuracy. To conduct this work, GAO reviewed documents and analyzed help line data through July 2008. In addition, GAO interviewed agency staff, industry experts, and officials at four federal agencies with high call volume contact centers. The 1-800-MEDICARE contractor met most standards and some targets for the required telephone performance metrics and indicators CMS designed to ensure callers' access--from July 2007 through July 2008. The 1-800-MEDICARE contractor's performance met the standard for each of the three access-related metrics--the average amount of time callers wait to reach customer service representatives (CSR), the percent of unhandled calls, such as abandoned calls, and the percent of calls transferred among CSRs--in 10 of 13 months analyzed. Because of waivers granted by CMS, the contractor was considered by the agency to have met the standards in 12 of 13 months. During that time, the contractor met the target for only one of three access-related indicators--the percent of CSRs answering calls. Other indicators were the average amount of time needed to respond to callers' inquiries and the accuracy of CSR call volume forecasting. CMS's efforts to provide LEP callers with access have led to shorter average wait times for Spanish-speaking callers, but are not consistent with all elements of the HHS LEP Plan. CMS requires its help line contractor to provide services to Spanish-speaking callers by employing bilingual CSRs and to provide interpretation services for other LEP callers, which the contractor does by using telephone interpreters. In 20 of the 32 months reviewed, Spanish-speaking callers waited less time, on average, to reach a CSR than English-speaking callers. CMS officials with primary responsibility for 1-800-MEDICARE said they were not aware of the LEP Plan when awarding the current contract, and CMS has not identified an office responsible for acting as a point of contact for management of the LEP Plan. Without a responsible office or official, an internal control for federal agencies, CMS staff lack a source of guidance to assist them in taking steps consistent with the LEP Plan when considering the needs of people with LEP. However, CMS has taken steps consistent with some elements of the agency's adopted LEP Plan, such as the element related to oral language assistance, but not others, such as the element identifying the need for complaint mechanisms for language issues. To oversee 1-800-MEDICARE callers' access to services and accurate information, CMS uses all six commonly used contact center management practices. Based on GAO's review of the literature and interviews with federal agencies and industry experts, these management practices are: (1) clearly defining performance metrics, (2) performing accurate capacity planning, (3) conducting customer satisfaction surveys, (4) ensuring information for CSRs to reference is accurate, (5) evaluating CSRs' interaction with callers, and (6) validating contact center performance reports. These practices are addressed in the current 1-800-MEDICARE contract and reflected in CMS's ongoing contract oversight.