-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-710		

TITLE:     Medicare Part D: Prescription Drug Plan Sponsor Call 
Center Responses Were Prompt, but Not Consistently Accurate and Complete

DATE:   06/30/2006 
				                                                                         
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GAO-06-710

     

     * Results in Brief
     * Background
          * Key Features of Medicare Part D
          * Characteristics of PDP Sponsors
     * CSRs Generally Provided Prompt, Courteous, and Helpful Servi
     * PDP Sponsor Call Centers Did Not Consistently Provide Caller
          * About One-Third of CSR Responses Were Accurate and Complete
          * CSRs Did Not Provide Answers to 15 Percent of Calls, Most Of
          * CSR Responses within Sponsor Call Centers Were Inconsistent
     * Concluding Observations
     * Agency Comments and Our Evaluation
     * GAO Contact
     * Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Report to Congressional Requesters

United States Government Accountability Office

GAO

June 2006

MEDICARE PART D

Prescription Drug Plan Sponsor Call Center Responses Were Prompt, but Not
Consistently Accurate and Complete

Medicare Prescription Drug Plan Sponsor Call Centers Medicare Prescription
Drug Plan Sponsor Call Centers Medicare Prescription Drug Plan Sponsor
Call Centers enters Medicare Prescription Drug Plan Sponsor Call Centers
Medicare Prescription Drug Plan Sponsor Call Centers Medicare Prescription
Drug Plan Sponsor Call Centers Medicare Prescription Drug Plan Sponsor
Call Centers Medicare Prescription Drug Plan Sponsor Call Centers Medicare
Prescription Drug Plan Sponsor Call Centers Medicare Prescription Drug
Plan Sponsor Call Centers Medicare Prescription Drug Plan Sponsor Call
Centers Medicare Prescription Drug Plan Sponsor Call Centers Medicare
Prescription Drug Plan Sponsor Call Centers Medicare Prescription Drug
Plan Sponsor Call Centers Medicare Prescription Drug Plan Sponsor Call
Centers Medicare Prescription Drug Plan Sponsor Call Centers Medicare
Prescription Drug Plan Sponsor Call Centers Medicare Prescription Drug
Plan Sponsor Call Centers Medicare Prescription Drug Plan Sponsor Call
Centers Medicare Prescription Drug Plan Sponsor Call Centers Medicare
Prescription Drug Plan Sponsor Call Centers Medicare Prescription Drug
Plan Sponsor Call Centers Medicare Prescription Drug Plan Sponsor Call
Centers Medicare Prescription Drug Plan Sponsor Call Centers Medicare
Prescription Drug Plan Sponsor Call Centers Medicare Prescription Drug
Plan Sponsor Call Centers Medicare Prescription Drug Plan Sponsor Call
Centers Medicare Prescription Drug Plan Sponsor Call Centers Medicare
Prescription Drug Plan Sponsor Call Centers Medicare Prescription Drug
Plan Sponsor Call Centers Medicare Prescription Drug Plan Sponsor Call
Centers Medicare Prescription Drug Plan Sponsor Call Centers

GAO-06-710

Contents

Letter 1

Results in Brief 6
Background 7
CSRs Generally Provided Prompt, Courteous, and Helpful Service 9
PDP Sponsor Call Centers Did Not Consistently Provide Callers with
Accurate and Complete Information 12
Concluding Observations 20
Agency Comments and Our Evaluation 20
Appendix I Comments from the Centers for Medicare & Medicaid Services 26
Appendix II GAO Contact and Staff Acknowledgments 30

Table

Table 1: Questions, Scenarios, and Criteria Used to Assess Response
Accuracy and Completeness 5

Figures

Figure 1: Percentage of Calls by Wait Time to Reach a CSR, and Percentage
of Calls Where We Did Not Reach a CSR, March 2006 11
Figure 2: Percentage of Calls with Accurate and Complete, Incomplete, or
Inaccurate Responses, and Those Where No Answer Was Provided, March 2006
13
Figure 3: Lowest, Highest, and Average Sponsor Call Center Accuracy and
Completeness Rate, by Question, March 2006 14
Figure 4: Percentage of Calls with Accurate and Complete, Incomplete, or
Inaccurate Responses, and Those Where No Answer Was Provided, by Question,
March 2006 16

Abbreviations

CMS Centers for Medicare & Medicaid Services CSR customer service
representative MMA Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 PDP prescription drug plan

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United States Government Accountability Office

Washington, DC 20548

June 30, 2006 June 30, 2006

Congressional Requesters Congressional Requesters

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(MMA) established a voluntary outpatient prescription drug benefit, known
as Medicare Part D, beginning January 1, 2006.1 Seventy-nine sponsors,
largely commercial insurers, have contracted with the Centers for Medicare
& Medicaid Services (CMS)-the agency that administers Medicare-to provide
this benefit in 2006. These sponsors offer over 1,400 stand-alone Medicare
prescription drug plans (PDPs) in one or more of 34 CMS-designated PDP
regions.2 Depending on where they live, Medicare beneficiaries typically
have a choice of 40 to 50 PDPs, which vary in cost and coverage.
Generally, beneficiaries had until May 15, 2006, to enroll in Part D
without the risk of a penalty in the form of higher premiums; as of June
11, 2006, about 16.4 million beneficiaries had enrolled in stand-alone
PDPs. The Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 (MMA) established a voluntary outpatient prescription drug
benefit, known as Medicare Part D, beginning January 1, 2006.1
Seventy-nine sponsors, largely commercial insurers, have contracted with
the Centers for Medicare & Medicaid Services (CMS)-the agency that
administers Medicare-to provide this benefit in 2006. These sponsors offer
over 1,400 stand-alone Medicare prescription drug plans (PDPs) in one or
more of 34 CMS-designated PDP regions.2 Depending on where they live,
Medicare beneficiaries typically have a choice of 40 to 50 PDPs, which
vary in cost and coverage. Generally, beneficiaries had until May 15,
2006, to enroll in Part D without the risk of a penalty in the form of
higher premiums; as of June 11, 2006, about 16.4 million beneficiaries had
enrolled in stand-alone PDPs.

MMA requires each PDP sponsor to staff a toll-free call center. These call
centers serve as key sources of the information that beneficiaries need to
make informed choices among competing drug plans. Beneficiaries and others
assisting them may contact call centers to obtain general information on
Part D, ask detailed questions or verify information from other sources
about a sponsor's PDPs, or enroll in a PDP.3 Because beneficiaries have an
opportunity to switch to another PDP during an MMA requires each PDP
sponsor to staff a toll-free call center. These call centers serve as key
sources of the information that beneficiaries need to make informed
choices among competing drug plans. Beneficiaries and others assisting
them may contact call centers to obtain general information on Part D, ask
detailed questions or verify information from other sources about a
sponsor's PDPs, or enroll in a PDP.3 Because beneficiaries have an
opportunity to switch to another PDP during an annual open-enrollment
period, sponsor call centers will continue to play a significant role in
informing current and prospective enrollees.4

1Pub. L. No. 108-173, S: 101, 117 Stat. 2066, 2071-2152 (to be codified at
42 U.S.C. S:S: 1395w-101-1395w-152).

2Although beneficiaries may obtain drug coverage through either
stand-alone PDPs or Medicare Advantage (Medicare's private health plan
option) drug plans, this report addresses only stand-alone PDP sponsor
call centers. About 90 percent of Medicare beneficiaries are enrolled in
traditional Medicare, rather than Medicare Advantage. Therefore, most
beneficiaries will be making choices among stand-alone PDPs.

3Other sources of information about Part D and specific PDPs include
sponsors' Web sites, and CMS's Medicare.gov Web site and 1-800-MEDICARE
toll-free help line.

You were interested in the quality of the service and information provided
to beneficiaries by PDP sponsor call centers, as inaccurate or misleading
benefit information could lead beneficiaries to choose a PDP that does not
meet their needs. In this report, we examined (1) whether PDP sponsors
provide prompt, courteous, and helpful service to Medicare beneficiaries
and others accessing their toll-free call centers, and (2) the extent to
which PDP sponsors provide accurate and complete information to Medicare
beneficiaries and other callers.

To address these objectives, we made 900 calls to 10 of the largest PDP
sponsor call centers, all of which operate in 30 or more PDP regions and
offer two or three PDPs per region.5 As of April 27, 2006, each of these
sponsors served at least 100,000 beneficiaries. Each of our 10 sponsors
has one toll-free call center, which we contacted from March 2 through
March 31, 2006. We posed one of five questions about their Part D plans
during each call, asking each question a total of 180 times-18 times to
each of the 10 PDP sponsors.6 We developed scenarios with zip codes and
fictional relatives for each of the questions. To make them sound
realistic and provide needed information, we specified additional details,
such as drug dosage and frequency information, lack of current drug
coverage, low-income subsidy eligibility, and preference for retail
purchasing, if asked.7

In developing our five questions, we examined those addressed by the
Frequently Asked Questions section of CMS's Medicare.gov Web site. We also
reviewed materials from policy analysts that identified information
critical to making a choice among competing plans.8 In addition, we spoke
with representatives of beneficiary advocacy groups about the types of
information beneficiaries need to consider when selecting a PDP plan.
Finally, we asked CMS officials what types of information they required or
expected call center customer service representatives (CSR) to be able to
provide the public and developed our questions from this information.
Although CMS does not have requirements regarding the specific types of
information CSRs must be able to provide, agency officials told us that
CSRs should be able to accurately answer questions about the relative
costs of a sponsor's PDPs, the availability of a plan for beneficiaries
eligible for Medicare's low-income subsidy, actions that beneficiaries
could take if their drugs are not covered by the plan, and types of
restrictions plans use to manage their formularies.

4The 2006 open enrollment period is November 15, 2006, through December
31, 2006. Beneficiaries enrolling during this period will have coverage
effective January 1, 2007. Certain beneficiaries (such as certain
low-income beneficiaries) may switch PDPs at any time.

5We placed calls at different times of the day and days of the week to
match the typical pattern of calls reported by the 1-800-MEDICARE help
line for January 2006. (CMS requires that each PDP sponsor operate its
toll-free call center 7 days a week from at least 8:00 am to 8:00 pm in
the time zones in which it offers PDPs.) The population contacting
1-800-MEDICARE is likely to be very similar to the population contacting
PDP sponsor call centers.

6During our actual calls, CSRs were not aware that their responses would
be included in a research study.

7We used drug dosages and frequency information based on actual
prescriptions.

To evaluate the extent to which sponsor call centers provided prompt,
courteous, and helpful service during our calls, we analyzed information
on the amount of time it took to reach a CSR and the number of calls for
which we could not reach a CSR. In addition, our callers noted if they had
concerns about the appropriateness and clarity of CSRs' language. In such
cases, we evaluated whether the CSR was difficult to understand, impolite,
or unprofessional. We also noted any helpful suggestions or information
provided to the caller.

We developed criteria for accurate and complete responses for each
question from information provided on CMS's Web-based PDP finder tool on
Medicare.gov9 and information that CMS has approved for use by its
1-800-MEDICARE CSRs (see table 1). Excluding calls for which we did not
reach a CSR, we report results on the accuracy and completeness of
information obtained during the remaining calls.10 We considered an answer
accurate and complete if the CSR's response met all of our criteria and we
considered an answer incomplete if the CSR's response met one, but not
both of our criteria. We considered an answer inaccurate if the CSR's
response did not meet any of our criteria. If the CSR stated that they did
not know or could not provide an answer, we classified the call as "no
answer provided."

8See J. Antos, "Cutting through Confusion in Part D," American Enterprise
Institute for Public Policy Research: Health Policy Outlook, no. 2 (2006):
1-7, and J. Hoadley, statement before the Government Reform Committee
Briefing on the Medicare Drug Benefit, January 20, 2006.

9For the three questions about PDP costs, the source of our answer was
Medicare.gov. We periodically checked that Web site and updated our
answers, as needed. We also confirmed the accuracy of these data by
checking PDP sponsor Web sites, where possible.

10CMS does not have performance standards governing the accuracy rate of
PDP call centers. However, the agency does have such a standard for
1-800-MEDICARE CSRs, striving for a 90 percent accuracy rate. In 2004 and
2006, we reported on the accuracy of information provided by
1-800-MEDICARE CSRs. See GAO, Medicare: Accuracy of Responses from the
1-800-MEDICARE Help Line Should Be Improved, GAO-05-130 (Washington, D.C.:
Dec. 8, 2004) and GAO, Medicare: Communications to Beneficiaries on the
Prescription Drug Benefit Could Be Improved, GAO-06-654 (Washington, D.C.:
May 3, 2006).

Table 1: Questions, Scenarios, and Criteria Used to Assess Response
Accuracy and Completeness

                                                  Criteria for an accurate    
Question                 Scenario              and complete response       
      1. PDP comparison for My mother takes the   The name and annual cost    
      a low-utilization     following drugs:      (within 5 percent) of the   
      beneficiarya          Norvasc, Fosamax, and sponsor's PDP that would    
                            warfarin sodium.      cost the beneficiary the    
                            Which of the          least annually for the      
                            sponsor's plans would three drugs she uses.       
                            cost her the least    
                            amount annually and   
                            what is its annual    
                            cost?                 
      2. PDP comparison for My mother-in-law      The name and annual cost    
      a high-utilization    takes the following   (within 5 percent) of the   
      beneficiarya          drugs: Aciphex,       sponsor's PDP that would    
                            Benicar, Evista,      cost the beneficiary the    
                            Levoxyl, Pravachol,   least annually for the      
                            Synthroid, Zetia, and eight drugs she uses.       
                            Zoloft.b Which of the 
                            sponsor's plans would 
                            cost her the least    
                            amount annually and   
                            what is its annual    
                            cost?                 
      3. Low-income subsidy My mother             The name of the sponsor's   
                            automatically         PDP, if any, for which the  
                            qualifies for extra   beneficiary would not pay a 
                            help because          premium.                    
                            Medicaidc pays part   
                            of her Medicare       
                            premiums. Does the    
                            sponsor offer a plan  
                            that she can join     
                            without having to pay 
                            a premium?            
      4. Nonformulary drugs If some of my         A beneficiary may (1)       
                            grandfather's drugs   switch to a covered drug,   
                            are not covered, will and (2) ask for an          
                            he have to pay full   exception to the formulary. 
                            price for them, or    
                            are there other       
                            things he can do?     
      5. Utilization        If some of my         Descriptions of at least    
      management tools      grandfather's drugs   two of the following: for   
                            are covered, but      some covered drugs (1)      
                            subject to            beneficiaries need approval 
                            restrictions, what    from their PDP before they  
                            does that mean?       can fill their              
                                                  prescription; (2) the PDP   
                                                  limits the amount of the    
                                                  drug that it covers over a  
                                                  certain period of time; (3) 
                                                  the PDP requires that the   
                                                  beneficiary first try a     
                                                  less expensive drug for     
                                                  their condition before it   
                                                  will cover the              
                                                  beneficiary's prescribed    
                                                  drug; or (4) when there is  
                                                  a generic substitute        
                                                  available, the PDP will     
                                                  automatically provide the   
                                                  generic, unless the         
                                                  beneficiary's doctor        
                                                  specifically orders the     
                                                  brand-name drug.            

Source: GAO.

Note: We considered an answer accurate and complete if the CSR's response
met all of our criteria. We considered an answer incomplete if the CSR's
response met one, but not both, of our criteria. Specifically, for
questions 1 and 2, a response was incomplete if the CSR accurately named
the lowest annual cost plan, but either inaccurately calculated or could
not provide the annual cost. An incomplete answer was not possible for
question 3, as it had only one criterion for accuracy and completeness. A
question 4 response was incomplete if the CSR either stated that the
beneficiary could switch to a covered drug or that they could ask for an
exception, but did not state both these possibilities. Finally, a question
5 response was incomplete if the CSR accurately described only one
utilization management tool. We considered an answer inaccurate if the
CSR's response did not meet any of our criteria. If the CSR stated that
they did not know or could not provide an answer, we classified the call
as "no answer provided."

aIn 2003, 46 percent of all seniors reported taking five or more
prescription drugs. Based on this survey finding, we specified three drugs
for the low-utilization beneficiary and eight drugs for the
high-utilization beneficiary. See Health Affairs-Web Exclusive:
Prescription Drug Coverage And Seniors: Findings From A 2003 National
Survey, April 19, 2005.

bThis scenario is based on a list of medications provided to us by a
Medicare beneficiary. We recognize that Levoxyl and Synthroid are the same
chemically, but retained both drugs in this scenario to make the calls as
realistic as possible. Specifying that a beneficiary is taking both of
these drugs did not preclude the ability of CSRs to determine the least
costly plan and its annual cost.

cMedicaid provides health care coverage to eligible low-income people and
is jointly financed by the federal government and the states.

The results from our 900 calls are limited only to those calls and are not
generalizable to the population of calls routinely made to sponsor call
centers by beneficiaries and other callers. Although the five questions we
posed are among the most critical questions regarding PDP comparison, they
do not encompass all of the questions callers might ask. We did not
contact PDP sponsors other than posing questions to the call centers. In
addition, we did not examine other issues related to the performance of
call centers, such as CSR qualifications and training, nor did we evaluate
CMS oversight of sponsor call centers. We conducted our work from February
2006 through June 2006 in accordance with generally accepted government
auditing standards.

                                Results in Brief

Call center service was generally prompt and courteous, and many CSRs
offered helpful suggestions and information. We reached a representative
in less than 1 minute for 46 percent of the calls CSRs fielded, and in
less than 5 minutes for 96 percent of the calls fielded. While we did not
reach CSRs for 36 calls-4 percent of the 900 calls we placed-mainly due to
disconnections, we found that 98 percent of the CSRs with whom we spoke
were easy to understand, polite, and professional. Many CSRs also provided
helpful suggestions related to our questions. For example, for our
question on the PDP comparison for a high-utilization beneficiary, CSRs
provided the caller with information about lower-cost drugs in 41 percent
of the calls.

CSRs at 10 of the largest PDP sponsor call centers did not consistently
provide accurate and complete responses to our five questions. Excluding
the calls for which GAO did not reach a CSR, GAO obtained accurate and
complete responses to about one-third of our 864 calls. The overall
accuracy and completeness rates for the 10 PDP sponsor call centers varied
widely, ranging from 20 to 60 percent. Only 1 sponsor call center had an
overall accuracy and completeness rate of greater than 50 percent and 2
sponsor call centers had rates of 25 percent or less. CSRs were unable to
provide an answer for 15 percent of our questions, primarily those related
to plan costs. Furthermore, CSRs within the same call center sometimes
provided inconsistent answers. For example, in response to questions
regarding PDP comparisons, CSRs at 3 call centers told us that it was
against the sponsor's policies to identify any of their plans as having
the lowest annual cost. However, other CSRs at each of these call centers
did not cite this policy and did identify a plan as having the lowest
annual cost.

In written comments on a draft of this report, CMS stated that our
analysis was based on inaccurate, incomplete, and subjective methods that
limited our report's relevance and validity. We maintain that our methods
are sound and that our findings are accurate. In conducting this review,
we identified topics that CMS, policy analysts, and beneficiary advocacy
groups indicated were key to making an informed plan choice, posed
questions as we expected beneficiaries' family members to do, and relied
on information from CMS to develop criteria to assess the accuracy and
completeness of the responses we received. Further, CMS officials told us
at a May 2006 meeting that CSRs should have been able to accurately answer
the questions we posed. Our findings indicate that beneficiaries may have
difficulty getting appropriate information from PDP sponsors' call
centers. CMS also stated in its written comments that we were right to be
concerned about whether beneficiaries are getting effective services from
plan call centers.

                                   Background

Medicare Part D coverage is provided through private sponsors that offer a
choice of PDPs with different costs and coverage. The largest sponsors
offer PDPs to beneficiaries throughout the United States and generally
have experience in providing Medicare coverage and with call center
operations.

Key Features of Medicare Part D

Under Part D, each PDP may offer the standard prescription drug benefit or
coverage that is different, but at least actuarially equivalent, to the
standard benefit.11 According to the Medicare Payment Advisory Commission,
for 2006, 9 percent of PDPs offer the standard benefit, 48 percent offer a
basic plan that has the same actuarial value as the standard benefit but
with a different design, and 43 percent offer enhanced coverage that
exceeds the standard benefit.12 Therefore, the specific premium,
deductible, and copayment or coinsurance amounts, as well as the coverage
gap-the period during which beneficiaries must pay 100 percent of their
drug costs-of each PDP may vary.

11As defined in MMA, for 2006, the standard benefit includes a $250
deductible, and 25 percent coinsurance for costs after the deductible has
been met, but before the initial limit of $2,250 in total drug spending is
reached. Once this initial limit is reached, beneficiaries must pay 100
percent of their drug costs until total drug spending reaches the
catastrophic limit of $5,100 ($3,600 in out-of-pocket spending). The
amount between $2,250 and $5,100 is referred to as the "coverage gap."
Once beneficiaries reach the catastrophic limit, they pay only 5 percent
of their drug costs for the rest of the calendar year, with Part D paying
95 percent.

12Medicare Payment Advisory Commission, Report to the Congress: Increasing
the Value of Medicare (Washington, D.C. June 2006), 145.

In addition, MMA and CMS regulations require plan formularies-the list of
drugs a PDP covers-to meet certain standards, but within these standards,
the drugs that are covered and the utilization management tools that are
used to control costs may vary.13 If beneficiaries' drugs are not on their
PDP's formulary, rather than paying full (retail) price for them,
beneficiaries may switch to a similar drug that is on the formulary.
Beneficiaries may also request that the plan make an exception to the
formulary and cover their drugs.14 If the PDP denies that request, CMS
regulations require that beneficiaries generally be able to appeal the
decision to the sponsor.15

Although certain drugs may be on a PDP's formulary, they may be subject to
one or more of several utilization management tools-the most common of
which are prior authorization, quantity limits, step therapy, and generic
substitution. For drugs subject to prior authorization, beneficiaries need
approval from their PDP before they can fill their prescription and for
drugs subject to quantity limits, the plan limits the amount of the drug
it covers over a certain period of time. For drugs subject to step
therapy, the PDP requires that the beneficiary first try a less expensive
drug for their condition before it will cover the beneficiary's prescribed
drug. Finally, generic substitution means that when there is a generic
substitute available, the PDP will automatically provide the generic,
unless the beneficiary's doctor specifically orders the brand-name drug.

13MMA requires that formularies include at least two drugs in each
approved category and class (unless only one drug is available for a
particular category or class). MMA 117 Stat. 2085 and 69 Fed. Reg. 46,632,
46,660 (Aug. 3, 2004). Formularies often consist of different "tiers,"
which are categories of drugs grouped according to their cost.

1442 C.F.R. S: 423.578(b) (2005).

1542 C.F.R. S: 423.580 (2005).

To help cover costs under Part D, Medicare provides subsidies to certain
low-income beneficiaries. For example, Medicare beneficiaries for whom
Medicaid16 pays their Medicare Part B17 premium automatically receive the
full low-income subsidy. This subsidy provides the beneficiary with
reduced copayment amounts, covers any deductible, provides drug coverage
during the coverage gap, and helps pay their PDP premium, up to a certain
amount.18 Other Medicare beneficiaries, however, must apply for the
low-income subsidy through the Social Security Administration, and may
receive only a partial subsidy.

Characteristics of PDP Sponsors

For 2006, 79 sponsors are offering over 1,400 PDPs, each of which has been
approved by CMS to ensure that it meets established standards. Ten of
these sponsors are offering PDPs in all 34 PDP regions, and they account
for nearly 62 percent of PDPs nationwide.19 The largest PDP sponsors are
either in the commercial insurance or pharmacy benefit management and
services sectors and generally have prior experience with call center
operations.20 In addition, the largest PDP sponsors all have some prior
experience with Medicare. Most offered a Medicare prescription drug
discount card or partnered with a company and most offer Medicare
Advantage plans.21

         CSRs Generally Provided Prompt, Courteous, and Helpful Service

Almost all of the calls we placed were answered by a CSR with minimal
delay. A limited number of calls were not answered by CSRs, mainly due to
disconnections. Further, we found that most CSRs with whom we spoke were
easy to understand, polite, and professional, and many provided helpful
suggestions and information.

16Medicaid provides health care coverage to eligible low-income people and
is jointly financed by the federal government and the states.

17Medicare Part B provides coverage for certain physician, outpatient
hospital, and other services to beneficiaries who pay monthly premiums.

18The amount of the subsidy varies by PDP region and does not cover the
entire premium of all PDPs. Accordingly, not all PDP sponsors have a plan
for which the subsidy covers the plan's entire premium.

19The Henry J. Kaiser Family Foundation, The Landscape of Private Firms
Offering Medicare Prescription Drug Coverage in 2006 (Washington D.C.:
March 2006).

20Many employer-sponsored health plans and insurers contract with pharmacy
benefit managers for services such as negotiating price discounts with
retail pharmacies, operating mail-order prescription services, and
formulary development and management.

21The prescription drug discount card was a program authorized by MMA to
give beneficiaries access to lower-priced drugs from 2004 through 2005.

Call centers generally provided prompt service in answering our calls. The
wait time to reach a CSR was generally short-46 percent of the 864 calls
CSRs fielded were answered in less than 1 minute and 96 percent of the
calls were answered in less than 5 minutes (see fig. 1). Only 9 calls (1
percent) were answered in 10 minutes or more, with the longest wait time
being 25 minutes (1 call). For a small number of calls-36 of the 900 calls
we placed (4 percent)-we did not receive an answer to our questions
because we did not reach a CSR. For almost all of these calls (33), this
occurred because we were disconnected.22

22We did not reach a CSR for the remaining three calls due to system
errors or because the calls were misdirected, such as if the interactive
voice response stated that the sponsor's call center was closed and that
the caller should call back during certain specified hours. However, the
call had been placed during those hours.

Figure 1: Percentage of Calls by Wait Time to Reach a CSR, and Percentage
of Calls Where We Did Not Reach a CSR, March 2006

Note: Percentages of calls by wait time to reach a CSR are based on the
864 calls for which we reached a CSR. Percentage of calls where we did not
reach a CSR is based on the total number of calls (900) we placed.

CSRs generally provided courteous service. Our callers noted that many
were helpful and friendly, and we found that CSRs were easy to understand,
polite, and professional in 98 percent of the calls. In addition, if a CSR
did not know or could not answer a question, many provided additional
resources for obtaining the answer, most commonly during calls on the
low-income subsidy (question 3). While CSRs did not provide an answer for
over one-third of the calls for this question, in over 80 percent of these
cases, CSRs suggested another source the caller could contact to obtain
the answer-most commonly Medicare or the Social Security Administration.

Many CSRs also provided callers with helpful suggestions that related to
our questions. For example, during question 1 calls on the PDP comparison
for a low-utilization beneficiary, CSRs provided information about a
mail-order option to obtain drugs in 22 percent of the calls. For question
2 on the PDP comparison for a high-utilization beneficiary, CSRs provided
the caller with information about lower-cost drugs in 41 percent of the
calls and inquired as to whether the beneficiary was eligible for the
low-income subsidy in 24 percent of the calls.

PDP Sponsor Call Centers Did Not Consistently Provide Callers with Accurate and
                              Complete Information

CSRs at the 10 PDP sponsor call centers we contacted provided accurate and
complete responses to about one-third of the calls they fielded, although
the accuracy and completeness rates for each of the 10 sponsor call
centers and for each of the five questions varied. CSRs were unable to
provide an answer for 15 percent of the questions posed, primarily those
related to plan costs. In addition, we found that CSRs within the same
call centers sometimes provided inconsistent responses to our questions.

About One-Third of CSR Responses Were Accurate and Complete

Excluding the 4 percent of calls for which we did not reach a CSR, we
obtained accurate and complete responses to 34 percent of the calls-294 of
864-and obtained incomplete responses to another 29 percent of the calls
(see fig. 2).

Figure 2: Percentage of Calls with Accurate and Complete, Incomplete, or
Inaccurate Responses, and Those Where No Answer Was Provided, March 2006

Note: Percentages are based on the 864 calls for which we reached a CSR
and exclude the 36 calls for which we did not reach a CSR. An incomplete
answer was not possible for question 3. Calls were categorized as "no
answer provided" if the CSR stated that they did not know or could not
provide an answer.

The overall accuracy and completeness rates for each of the 10 PDP sponsor
call centers varied widely, ranging from 20 to 60 percent (see fig. 3).
Only 1 sponsor call center had an overall accuracy and completeness rate
of greater than 50 percent and 2 sponsor call centers had rates of 25
percent or less. No sponsor's call center consistently had the highest or
lowest accuracy and completeness rate for all questions. For example,
although 1 call center had the highest accuracy and completeness rate for
both question 1 (the PDP comparison for a low-utilization beneficiary) and
question 2 (the PDP comparison for a high-utilization beneficiary), it had
the second-lowest accuracy and completeness rate for question 4
(nonformulary drugs).

Figure 3: Lowest, Highest, and Average Sponsor Call Center Accuracy and
Completeness Rate, by Question, March 2006

Note: Percentages are based on the calls for which we reached a CSR and
exclude the calls for which we did not reach a CSR. We placed 180 calls
for each question; we reached a CSR 170 times for question 1, 169 times
for question 2, 174 times for question 3, 176 times for question 4, and
175 times for question 5.

Variation across call centers was due, in part, to differences in the
resources that CSRs said were available to them. For example:

           o  In response to questions 1 and 2, CSRs at two call centers
           indicated that they were able to compute the annual cost of the
           least expensive plan because they had access to a computerized
           "cost calculator." However, CSRs at other call centers stated that
           they could not compute an annual cost because they did not have
           access to such a resource. We located cost calculators on the Web
           sites of seven sponsors, each of which had call center CSRs who
           stated that they did not know or could not calculate an annual
           cost.

           o  CSRs at six different sponsor call centers stated that they
           could not calculate the annual cost of the least expensive plan
           because they did not have access to the retail prices of the
           beneficiary's drugs.23 In contrast, CSRs at two other call centers
           stated that they did have access to these prices, and were able to
           use them in calculations.

           For each of the five questions, accuracy and completeness rates
           varied, but were generally low. They ranged from 14 to 60 percent
           (see fig. 4).

           Figure 4: Percentage of Calls with Accurate and Complete,
           Incomplete, or Inaccurate Responses, and Those Where No Answer Was
           Provided, by Question, March 2006

           Note: Percentages are based on the calls for which we reached a
           CSR and exclude the calls for which we did not reach a CSR. We
           placed 180 calls for each question; we reached a CSR 170 times for
           question 1, 169 times for question 2, 174 times for question 3,
           176 times for question 4, and 175 times for question 5. An
           incomplete answer was not possible for question 3. Calls were
           categorized as "no answer provided" if the CSR stated that they
           did not know or could not provide an answer. Total may not add to
           100 due to rounding.

           Relatively few CSRs were able to accurately identify the least
           costly plan and calculate its annual cost.24 In addition, the
           annual cost estimates that CSRs provided were often substantially
           different from the plans' actual costs. For example:

           o  For the low-utilization beneficiary (question 1), about 1 in 3
           responses were incomplete; that is, CSRs identified the least
           costly plan, but either inaccurately calculated its annual cost or
           stated that they could not provide any annual cost. Over half of
           the CSRs that provided an inaccurate response quoted a cost that
           was greater than the actual cost.
           o  For the high-utilization beneficiary (question 2), about 3 in
           10 responses were incomplete. Among the 23 CSRs that correctly
           identified the least costly plan, but gave an inaccurate annual
           cost, almost all provided a quote that was less than the actual
           cost, and in 11 cases over $1,000 less.25

           About two-thirds of the CSRs were unable to accurately report
           whether the sponsor offered a PDP for which a Medicare beneficiary
           that received help from Medicaid would not have to pay a premium
           (question 3). Specifically, CSRs fielding this call answered
           inaccurately 31 percent of the time and did not provide an answer
           35 percent of the time. For most of the inaccurate answers, CSRs
           stated that a certain PDP would not require a premium from the
           beneficiary, but, in fact, it would. Other inaccurate responses
           showed a poor understanding of the low-income subsidy benefit; for
           example, two CSRs incorrectly stated that the low-income subsidy
           did not help offset the premium at all.

           Half of the CSRs responding to question 4 incompletely described
           the options available to a beneficiary taking a nonformulary drug.
           Of the incomplete responses, about 4 in 5 CSRs mentioned that the
           beneficiary could request an exception to have the plan cover the
           nonformulary drug, but not that the beneficiary could switch to a
           drug that the plan covers.26 In addition, 15 percent of CSR
           responses included neither possibility, with many CSRs stating
           that the beneficiary's only option would be to pay full price for
           nonformulary drugs.

           Finally, CSRs accurately described at least two utilization
           management tools in 60 percent of our calls for question 5-the
           highest accuracy and completeness rate of our five questions.
           Other CSRs identified, but could not accurately describe, specific
           tools. For example, one CSR incorrectly stated that quantity
           limits-a limit on the amount of a drug that the plan will cover
           over a certain period of time-means that a pharmacy may not have
           enough of a drug to fill the beneficiary's prescription.

           Overall, CSRs stated that they did not know or could not answer
           our question for 15 percent of the calls. This was most common for
           the questions related to PDP costs (the PDP comparison for a
           low-utilization beneficiary, the PDP comparison for a
           high-utilization beneficiary, and the low-income subsidy).

           For question 2 calls regarding the PDP comparison for a
           high-utilization beneficiary, 30 percent of the CSRs stated that
           they were unable to tell the caller which PDP would cost the
           beneficiary the least annually. In contrast, only 8 percent of
           CSRs provided this response for question 1 on the low-utilization
           beneficiary. This difference in the percentage of calls for which
           an answer was provided is likely due to the added complexity of
           comparing PDPs and calculating the annual cost for a beneficiary
           using eight drugs versus a beneficiary using three drugs. However,
           reliance on at least five drugs is common in the Medicare
           population.27

           Question 3 regarding the low-income subsidy had the highest "no
           answer provided" rate-35 percent. Of the CSRs that did not provide
           an answer to this question, almost all stated that they did not
           know the subsidy amount the beneficiary would receive. Because
           they did not recognize that beneficiaries with both Medicare and
           Medicaid automatically receive the full low-income subsidy, they
           could not effectively determine whether that subsidy would cover
           the sponsor's PDP premiums.

           CSRs within the same call center sometimes provided inconsistent
           responses to our five questions. For example, within each of six
           different call centers, among CSRs who accurately identified the
           least costly plan for the low-utilization beneficiary (question
           1), some CSRs calculated an accurate annual cost, some calculated
           an inaccurate annual cost, and others stated that they could not
           calculate an annual cost. In response to question 2 regarding the
           high-utilization beneficiary, different CSRs within five call
           centers identified each of their sponsor's PDPs as the least
           costly. In addition, in response to questions 1 and 2, CSRs at
           three call centers told us that it was against the sponsor's
           policies to identify any of their plans as having the lowest
           annual cost.28 However, other CSRs at each of these call centers
           did not cite this policy and did identify a plan as having the
           lowest annual cost.

           In part, these inconsistencies were due to differences in CSRs'
           knowledge about their sponsor's plans. For example, CSRs' varying
           knowledge related to the low-income subsidy question (question 3)
           produced contradictory responses. Within each of the 10 sponsor
           call centers, different CSRs answered accurately, inaccurately,29
           or stated that they did not know or could not answer the question.
           When asked about the options for a beneficiary using nonformulary
           drugs (question 4), different CSRs within each of 6 sponsor call
           centers stated that a beneficiary could either switch to a covered
           drug or apply for an exception, stated only that the beneficiary
           could switch to a covered drug, stated only that the beneficiary
           could apply for an exception, or stated neither possibility. Among
           CSRs that stated neither possibility, the specific responses
           differed. For example, at 1 of the above call centers, although
           five CSRs answered the question accurately, one erroneously stated
           that the beneficiary's only option was to pay full price for
           nonformulary drugs, and another erroneously stated that any drugs
           not covered by the PDP would be covered under Medicare Part B.

           In answering question 5 on utilization management tools, different
           CSRs within the same call center provided varying descriptions of
           the utilization management tools PDPs use. For example, although
           four CSRs within one call center provided accurate descriptions of
           at least two tools, three other CSRs within this call center each
           provided a different, and inaccurate, description of utilization
           management tools.30 At another call center, two CSRs stated that
           they could not describe any tools without knowing the specific
           drugs the beneficiary was taking-even though eight other CSRs at
           that call center were able to accurately describe at least one
           tool without knowing the beneficiary's drugs.

           Our calls to 10 of the largest PDP sponsors' call centers show
           that Medicare beneficiaries face challenges in obtaining the
           information needed to make informed choices about the PDP that
           best meets their needs. Call center CSRs are expected to provide
           answers to drug benefit questions and comparative information
           about their sponsors' PDP offerings. Yet we received accurate and
           complete responses to only about one-third of our calls. In
           addition, responses to the same question varied widely, both
           across and within call centers. Sponsor call centers' poor
           performance on our five questions raises questions about whether
           the information they provide will lead beneficiaries to choose a
           PDP that costs them more than expected or has coverage that is
           different than expected. Rather than consider PDP options solely
           on the basis of the call centers' information, callers may benefit
           from consulting other information sources available on Medicare
           Part D when seeking to understand and compare PDP options.

           CMS reviewed a draft of this report and provided written comments,
           which appear in appendix I.

           In its comments, CMS characterized our analysis as based on
           inaccurate, incomplete, and subjective methods that limit the
           report's relevance and validity. However, CMS went on to say that
           despite its view on the study's limitations, GAO is right to be
           concerned about whether beneficiaries are getting effective
           service from plan call centers.

           CMS asserted that our questions did not reflect the usual
           questions received by PDP sponsor call centers. As noted in the
           draft report, we selected topics that were addressed in the
           Frequently Asked Questions section of the Medicare.gov Web site
           and regarded by policy experts and beneficiary advocates as
           important to making an informed plan choice. Furthermore, at a May
           2006 meeting with CMS officials, the agency's Deputy Administrator
           stated that CSRs should be able to accurately answer all of the
           specific questions we posed during the study.

           CMS also stated that we asked for information that CSRs are not
           required to provide. Specifically, for questions 1 and 2 on PDP
           comparisons for low and high-utilization beneficiaries, CMS stated
           that it does not require sponsor call centers to provide
           information on the annual costs of their PDPs. However, while not
           necessarily required, agency officials had indicated that the
           information we sought from CSRs was within the scope of plan
           sponsor customer service efforts. In a discussion held before we
           conducted our March calls, CMS officials told us that the agency
           had not established any requirements regarding the specific types
           of information plan CSRs must be able to provide, but that it was
           reasonable to expect CSRs to give callers accurate information on
           the topics we included in our review.

           In addition, as noted in the draft report, some call centers were
           relatively successful in providing accurate and complete answers
           to questions 1 and 2, indicating that call center CSRs can handle
           such questions appropriately. One call center's CSRs answered the
           question accurately and completely in 88 percent of the calls for
           the low-utilization beneficiary, and one call center's CSRs
           responded correctly in 81 percent of the calls for the
           high-utilization beneficiary. In addition, we found that 7 of the
           10 PDP sponsors had cost calculators on their Web sites that could
           have been used to answer these questions.

           CMS commented that, to be counted as providing a complete response
           to questions 1 and 2 on PDP comparisons, we expected CSRs to
           recommend a specific plan to the caller, a practice that often
           constitutes "steering," which is prohibited under Medicare
           marketing guidance.31 As noted in the draft report, our callers
           identified themselves as family members wishing to assist
           beneficiaries in choosing a drug plan. Providing assistance to
           beneficiaries-which is encouraged by CMS-generally consists of
           learning the characteristics of various PDPs and assessing their
           relative merits given the potential enrollee's needs. This is
           clearly allowed in CMS's Marketing Guidelines, which distinguish
           between assistance based on objective information and steering to
           a drug plan for financial gain.

           CMS also took issue with how we counted a specific CSR response to
           questions 1 and 2. The agency incorrectly claimed that a CSR's
           referral to 1-800-MEDICARE was categorized as an incomplete
           response. As noted in the draft report, we categorized responses
           as incomplete if the CSR accurately named the lowest annual cost
           plan, but either inaccurately calculated or could not provide the
           annual cost. If the CSR did not answer the question and instead
           referred the caller to 1-800-MEDICARE for information on PDPs, we
           classified the response as "no answer provided."

           CMS stated that the wording of question 3 on the low-income
           subsidy was inaccurate and therefore misleading. This question
           specifies that the beneficiary automatically qualifies for extra
           help because Medicaid pays part of her Medicare premiums.
           According to CMS, the wording of question 3 is incorrect because
           only Medicare pays the drug premium for low-income beneficiaries
           and Medicaid would fully (not partly) pay the Part B premium.
           However, CMS's comment conflicts with the information we obtained
           from its Medicare.gov Web site in developing the wording and
           answer for this question. Using the Web-based PDP finder tool on
           this Web site, the user can select one of several options
           specifying why the beneficiary qualified for extra help. We
           selected the option specifying that the beneficiary automatically
           qualified for extra help because they receive "help from [the]
           State paying Medicare premiums." We agree that only Medicare, and
           not Medicaid, pays the Medicare Part D premium for low-income
           beneficiaries and Medicaid would fully (not partly) pay the Part B
           premium. Therefore, for such a beneficiary, Medicaid would pay
           part of the beneficiary's Medicare premiums.

           CMS also stated that, for certain questions, many reasonable
           answers were not counted as correct. The agency cited our question
           regarding a beneficiary's options should he or she be prescribed a
           nonformulary drug, and asserted that our criteria for a correct
           response-switching to a covered drug or asking for an
           exception-was too limited. The agency stated that other reasonable
           answers should have been counted as correct because we conducted
           our calls at a time when all plans covered all Part D drugs.32 We
           obtained the answer to this question from a script that CMS
           approved for use by CSRs operating its 1-800-MEDICARE help line.
           In addition to the two options we used as criteria for an accurate
           and complete answer, the script mentioned that PDPs are required
           to provide beneficiaries with temporary transitional coverage
           (generally for 30 days after enrollment) of drugs not on the PDP's
           formulary. However, according to CMS, the purpose of this
           temporary coverage is to provide beneficiaries with sufficient
           time to switch to another drug or to request an exception to the
           formulary. Therefore, in specifying our criteria for an accurate
           and complete answer, we chose to include only the two options that
           CMS sees as longer-term solutions for the beneficiary.

           CMS stated that we did not examine certain features of the support
           services that plan sponsors' call centers are required to provide,
           such as hours of operation, wait times, disconnection rates, and
           language services. It also noted requirements that plans report a
           range of performance measures, such as beneficiary complaint rates
           and timeliness of exceptions and appeals decisions. As noted in
           the draft report, the scope of our review was limited to the
           accuracy and completeness of information disseminated to the
           public by PDP sponsors' call centers-a feature of plan customer
           service for which CMS has established no performance requirements.

           Finally, CMS believes that, as written, our study provides little
           practical guidance of value in improving the drug benefit and that
           our conclusion-that callers may benefit from consulting other
           information sources available on Medicare Part D when seeking to
           understand and compare PDP options-is obvious. In quoting our
           conclusion, CMS omitted the key part of the paragraph preceding
           the quoted phrase where we state that "sponsor call centers' poor
           performance on our five questions raises questions about whether
           the information they provide will lead beneficiaries to choose a
           PDP that costs them more than expected or has coverage that is
           different than expected. . . ." We continue to believe that plan
           sponsors should be accountable for the accuracy of their
           information and make maintaining effective call centers a
           priority.

           CMS also provided us with detailed, technical comments, which we
           incorporated where appropriate.

           As agreed with your offices, unless you publicly announce the
           contents of this report earlier, we plan no further distribution
           of it until 30 days from the date of this letter. We will then
           send copies to the Administrator of CMS, appropriate congressional
           committees, and other interested parties. We will also make copies
           available to others upon request. This report is also available at
           no charge on GAO's Web site at http://www.gao.gov.

           If you or your staffs have any questions about this report, please
           contact me at (312) 220-7600 or [email protected]. Contact points
           for our Offices of Congressional Relations and Public Affairs may
           be found on the last page of this report. GAO staff who made
           contributions to this report are listed in appendix II.

           Leslie G. Aronovitz Director, Health Care

           List of Requesters

           The Honorable John D. Dingell Ranking Minority Member Committee on
           Energy and Commerce House of Representatives

           The Honorable Henry A. Waxman Ranking Minority Member Committee on
           Government Reform House of Representatives

           The Honorable Charles B. Rangel Ranking Minority Member Committee
           on Ways and Means House of Representatives

           The Honorable Sherrod Brown Ranking Minority Member Subcommittee
           on Health Committee on Energy and Commerce House of
           Representatives

           The Honorable Pete Stark Ranking Minority Member Subcommittee on
           Health Committee on Ways and Means House of Representatives

           Leslie G. Aronovitz, (312) 220-7600 or [email protected]

           In addition to the contact named above, Rosamond Katz, Assistant
           Director; Manuel Buentello; Jennifer DeYoung; and Joanna L. Hiatt
           made major contributions to this report. Other contributors
           include Lori D. Achman, Diana B. Blumenfeld, Gerardine Brennan,
           Laura Brogan, Lisa L. Fisher, M. Peter Juang, Martha R.W. Kelly,
           Ba Lin, and Michaela M. Monaghan.

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23In estimating the amount a beneficiary pays annually, information on the
plan's negotiated retail price is required, for example, to account for
the purchase of any nonformulary drugs or the purchase of drugs during the
coverage gap. In both these instances, the beneficiary typically pays the
plan's negotiated retail price for the drug.

24Inaccurately identifying the sponsor's least costly plan and its annual
cost could have financial consequences for beneficiaries because the
actual cost differences among sponsors' PDPs were often substantial. In
the low-utilization beneficiary scenario, for 8 of the 10 sponsors, the
cost differences between the least costly and the next-to-least costly PDP
ranged from $106 to $388 per year. For the remaining 2 sponsors, the
differences were less than $25. In the high-utilization beneficiary
scenario, for 3 of the 10 sponsors, the cost differences between the least
costly and the next-to-least costly PDP ranged from $517 to $2,346 per
year. For the remaining 7 sponsors, the differences were less than $200.

25For question 2 regarding the high-utilization beneficiary, the annual
cost of the least expensive PDP for each sponsor ranged from $3,659 to
$7,122.

CSRs Did Not Provide Answers to 15 Percent of Calls, Most Often for Questions
regarding Plan Costs

26A few CSRs mentioned that certain drugs (such as barbiturates, which are
often used for seizure disorders or to relieve anxiety, and
benzodiazepines, which are often used to treat anxiety and insomnia), are
excluded from Part D completely and can never be covered.

27See Health Affairs-Web Exclusive: Prescription Drug Coverage And
Seniors: Findings From A 2003 National Survey, April 19, 2005.

CSR Responses within Sponsor Call Centers Were Inconsistent

28In three of these calls, the CSR further stated that it was the
individual's responsibility to determine the least costly plan.

29Inaccurate responses include CSRs that stated there was one plan without
a premium (when there was not), there was no plan without a premium (when
there was), and that none of the sponsor's plans had a premium.

                            Concluding Observations

                       Agency Comments and Our Evaluation

30Specifically, one CSR at the call center stated that, for drugs subject
to utilization management, the beneficiary may have to get a new
prescription each time they obtain their drugs, rather than obtaining
refills at the pharmacy. Another CSR at this call center stated that, for
drugs subject to utilization management, the beneficiary will need a
prescription for any "addictive" drugs. A third CSR said that utilization
management means that certain drugs may only be covered at select
pharmacies and specific strengths of certain drugs may not be covered.

31Steering constitutes an attempt to guide beneficiaries to a specific PDP
or group of PDPs to further financial or other interests.

32Because all PDPs do not routinely include all Part D drugs on their
formularies, we assume that CMS's comment refers to the requirement that
all beneficiaries enrolled in January or February 2006 receive temporary
drug coverage through March 2006, and that all beneficiaries enrolled
thereafter receive temporary drug coverage for at least 30 days.

Appendix I: Comments from the Centers for Medicare & Medicaid Services
Appendix I: Comments from the Centers for Medicare & Medicaid Services

Appendix II: Appendix II: GAO Contact and Staff Acknowledgments

                                  GAO Contact

                                Acknowledgments

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Highlights of GAO-06-710 , a report to congressional requesters

June 2006

MEDICARE PART D

Prescription Drug Plan Sponsor Call Center Responses Were Prompt, but Not
Consistently Accurate and Complete

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(MMA) established a voluntary outpatient prescription drug benefit, known
as Medicare Part D. Private sponsors have contracted with the Centers for
Medicare & Medicaid Services (CMS) to provide this benefit and are
offering over 1,400 stand-alone prescription drug plans (PDP). Depending
on where they live, beneficiaries typically have a choice of 40 to 50
PDPs, which vary in cost and coverage. MMA required each PDP sponsor to
staff a toll-free call center, which serves as a key source of the
information that beneficiaries need to make informed choices among PDPs.
GAO examined (1) whether PDP sponsors provide prompt, courteous, and
helpful service to Medicare beneficiaries and others and (2) the extent to
which PDP sponsor call centers provide accurate and complete information
to Medicare beneficiaries and other callers.

To address these objectives, we made 900 calls to 10 of the largest PDP
sponsor call centers during March 2006, posing one of five questions about
their Part D plans during each call. We tracked the amount of time it took
to reach a customer service representative (CSR), the number of calls that
did not reach a CSR, and the appropriateness and clarity of CSRs'
language. We developed criteria for determining accurate and complete
responses based on CMS information.

Call center service was generally prompt and courteous, and many CSRs
offered helpful suggestions and information. GAO reached a representative
in less than 1 minute for 46 percent of the calls CSRs fielded and in less
than 5 minutes for 96 percent of the calls fielded. While GAO did not
reach CSRs for 4 percent of the calls it placed, mainly because of
disconnections, GAO found that 98 percent of CSRs with whom GAO spoke were
easy to understand, polite, and professional. In addition, many CSRs
provided helpful suggestions related to GAO's questions, such as details
about a mail-order option to obtain drugs or lower-cost drugs.

However, CSRs at 10 of the largest PDP sponsor call centers did not
consistently provide accurate and complete responses to GAO's five
questions, which GAO developed using information from CMS and other
sources. GAO obtained accurate and complete responses to about one-third
of the 864 calls for which GAO reached a CSR. The overall accuracy and
completeness rate for each call center ranged from 20 to 60 percent. CSRs
were unable to answer 15 percent of the questions posed, primarily those
related to plan costs. Furthermore, CSRs within the same call center
sometimes provided inconsistent answers. For example, in response to
questions about PDP cost comparisons for specified sets of drugs, CSRs at
3 call centers told GAO that it was against the sponsors' policies to
identify any of their plans as lowest cost. However, other CSRs at each of
these call centers did not cite this policy and did identify a plan as
lowest cost.

Percentage of 864 Calls with Accurate and Complete, Incomplete, or
Inaccurate Responses, and Those Where No Answer Was Provided, March 2006

In commenting on a draft of this report, CMS criticized the analysis as
based on inaccurate, incomplete, and subjective methods that limit the
report's relevance and validity. GAO maintains that its methods are sound
and its findings are accurate. CMS officials told GAO at a May 2006
meeting that CSRs should have been able to accurately answer the questions
GAO posed.
*** End of document. ***