MEDICARE BENEFITS

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Baselines for FY 2000 Goal

Managed care without disenrollees - (a) Getting needed care for illness or injury: In 1998, in 74 percent of plans, at least 90 percent of beneficiaries reported that they could usually or always get care for illness or injury as soon as they wanted. (b) Ease of getting referral to a specialist: In 1998, in 70 percent of plans, at least 80 percent of beneficiaries reported that it was not a problem to get a referral to a specialist that they needed to sec.

Fee-for-service (FFS) - Developmental. Baseline data will become available in FY 2001. The CAHPS FFS survey was fielded in Fall 2000.)

FY 2000 Targets: Managed care - Continue efforts to achieve by CY 2003, (a) in 79 percent of plans, at least 90 percent of beneficiaries report that they could usually or always get care for illness or injury as soon as they wanted, and (b) in 75 percent of plans, at least 80 percent of beneficiaries report that it was not a problem to get a referral to a specialist that they needed to

see.

FFS - Targets will be established after baseline data become available in FY 2001. Performance: Managed care - Our interventions to improve beneficiary satisfaction have continued with regard to encouraging health plans and the PROS to use CAHPS measures in their quality improvement efforts. In an effort to capture more complete data for this goal, input from disenrolled beneficiaries will be included in the CAHPS survey. Therefore, baselines and future targets will be recomputed.

FFS - We began collecting CAHPS FFS data in Fall 2000.

FY 1999 Targets: Managed care - Develop target.

FFS Continue to develop measurement and reporting methodology.

Performance: Managed care - Goal met. Baseline and target developed.

FFS - Goal met. Development continuing with survey to be fielded in FY 2001.

Discussion: A fundamental goal is that beneficiaries are our primary customers and one of CMS's main reasons for being is to assure satisfaction in the experiences beneficiaries have in accessing care for illnesses and injuries when needed, including their access to care of specialists. In response to the need to standardize the measurement of and monitor beneficiaries' experience and satisfaction with the care they receive through Medicare, CMS developed a series of data collection activities under the Consumer Assessment Health Plans Surveys (CAHPS). The CMS fields these surveys annually to representative samples of beneficiaries enrolled in each Medicare managed care plan as well as those enrolled in the original Medicare fee-for-service plan and provides comparable sets of specific performance measures collected in CAHPS to Quality Improvement Organizations (QIOs), health plans, and beneficiaries through various means, including the National Medicare & You Education Program (NMEP).

Provision of CAHPS performance information assists beneficiaries in their health plan choices under Medicare. Annual development of specific performance measures also permits use of CAHPS as a tool for monitoring beneficiary experiences in and satisfaction with differing care delivery modes and in different regions of the country. Plan-specific measures provide direct incentives for managed care plans to improve performance and health services quality. FFS measures, reported by geographic arca, assist in development of strategies to improve care quality through targeted interventions implemented either directly by CMS or through State Medicare QIOs and other partners.

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The performance indicators and satisfaction measures disseminated through the NMEP also are part of a long-term strategy to monitor and evaluate the use of specific services provided through Medicare, and improve consumer satisfaction regarding the services received. The CMS conducts research on the use and understanding of these measures by beneficiaries as well as in the effectiveness of specific initiatives monitored by these measures in improving service quality. Our baselines for both managed care and FFS satisfaction are already fairly high. Given this type of survey for a large group of people and considering the unrelated factors that could influence responses, we know that a target of 100 percent satisfaction is unrealistic. Nonetheless, our targets are challenging and are set for a 5-year period in order for the percentage increases to be large enough to be statistically detected.

Coordination: The development and implementation of Medicare consumer assessment measures are coordinated by CMS's central and regional offices. Dissemination of information sets based on these measures is also coordinated through an array of Federal, State, and local agencies, and advocacy groups, including the Social Security Administration, the Administration on Aging, American Association of Retired Persons, National Association of Area Agencies on Aging, National Caucus and Center on Black Aged, National Asian Pacific Center on Aging, and other groups. The CMS also coordinates specific quality improvement activities and information dissemination through the QIOS and other partners.

Data Source(s): The Medicare CAHPS are a set of annual surveys of beneficiaries enrolled in all Medicare managed care plans and in the original Medicare fee-for-service plan. The CAHPS for managed care was fielded with a sample of 600 beneficiaries in each of over 250 managed care plans in Fall 2000, i.e. FY 2001. Data collection for managed care disenrollees (beneficiaries who voluntarily left their plans) began in Fall 2000 within the same managed care plans. This survey obtains information about the experience of beneficiaries in their former health plan. Data from this survey are combined with the information collected from current enrollees to obtain a more complete picture of plan performance.

Data collection in CAHPS-FFS began in Fall 2000 (FY 2001) with samples of 600 beneficiaries in 275 geographic areas nationally. Information comparable to that obtained from the MMC-CAHPS were available from the MFFS-CAHPS in FY 2001 and are available to beneficiaries and others on the Medicare Health Plan Compare web site. The Medicare managed care and the Medicare FFS CAHPS surveys consist of between 90-95 questions and have undergone extensive cognitive testing with Medicare beneficiaries. The information collected in the Medicare CAHPS is comparable to other CAHPS information collected in surveys of persons enrolled in commercial, i.e. nonMedicare health plans.

Verification and Validation: The Medicare CAHPS are administered according to the standardized protocols as delineated in the CAHPS 2.0 Survey and Reporting Kit developed by the Agency for Healthcare Research and Quality (AHRQ). This protocol includes two mailings of the survey instruments to randomized samples of Medicare

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beneficiaries in health plans and geographic areas, with telephone follow-up of nonrespondents with valid telephone numbers. CAHPS data are carefully edited and cleaned prior to the creation of composite measures using techniques employed comparably in all surveys. Both non-respondent sample weights and managed care-FFS comparability weights are employed to adjust collected data for differential probabilities of sample selection, under-coverage, and item response. More detailed plan-level and geographicarea CAHPS results are also checked for consistency with the experience and satisfaction data collected both on a national and regional basis annually in the Medicare Current Beneficiary Survey (MCBS). Although MCBS satisfaction questions do not match those in CAHPS on an item-by-item basis, several measures are similar enough to be used for consistency checking especially with regards to national trending of beneficiary experience.

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Performance Goal MB3-02

Process Medicare+Choice Organization Elections in Compliance with the BBA Beneficiary Election Provisions (Discontinued after FY 2002)

Baseline: Prior to CY 2002, there was no ability to track elections at the plan benefit package (PBP) level or to apply the lock-in provisions affecting enrollments/disenrollments.

FY 2002 Target: Developmental. Develop a target that measures performance in processing enrollments/disenrollments in compliance with the beneficiary election provisions of the BBA Performance: Goal not met and discontinued due to legislation.

Baseline: In FY 1998, for clean* managed care plan enrollment transactions received in compliance with the monthly processing schedule (generally the first Tuesday or Wednesday of each month), the system updates beneficiary records with requested enrollment effective dates by the first of the following month.

FY 1999-2001: For 98 percent of clean* Medicare+ Choice organization (M+CO) enrollment transactions received in compliance with the monthly processing schedule (generally the first Tuesday or Wednesday of each month), the system will update beneficiary records with enrollment effective dates equal to the effective dates on the transactions. (See chart below)

Discussion: For FY 1999 through FY 2001, this performance goal measured the timeliness of CMS systems' processing of Medicare beneficiary enrollment transactions received from Medicare+Choice organizations (M+COs) as specified by the Balanced Budget Act of 1997 (BBA).

The performance goal for FY 2002 measured the processing of enrollment and disenrollment transactions received from M+COs in compliance with the beneficiary election provisions of the BBA effective in 2002. M+COs contracted with CMS to provide medical services to Medicare beneficiaries. In providing such services, M+COs

MEDICARE BENEFITS

could offer multiple plan benefit packages (PBPs) for members to elcct. The BBA requires that beneficiary elections be tracked at the PBP level and also specifies time periods when beneficiaries may elect to enroll or disenroll from M+COS or to change PBPS. The CMS is maintaining PBP information for all members of M+COs for the first time in 2002.

The BBA requires that if a beneficiary wishes to make an election during an open enrollment period (OEP), he/she must do so in the first 6 months of CY 2002 or the first 6 months of Medicare eligibility (for new Medicare beneficiaries). In addition, only one election may be made during this timeframe. This election period is reduced in calendar year 2003 to 3 months. Elections are defined as enrollments and disenrollments into and out of a M+CO as well as PBP changes within an M÷CO. These requirements are known as the lock-in provisions. There are some exceptions to these provisions related to special election periods (e.g., the beneficiary moves out of the M+CO's service area; the M+CO terminates).

To support these requirements, M+COS were to submit new data. In addition, since the lock-in provisions severely limited when such data could be submitted, it could only be accepted during certain times of the year. Currently, M+COS can submit enrollment/ disenrollment data at any time. The CMS receives and edits M+CO transaction data for validity. The system ensures that each enrollee is a Medicare beneficiary and entitled to make an election.

The passage of the Bioterrorism Preparedness Act of 2001 (enacted June 2002) has statutorily delayed the implementation of lock-in provisions until FY 2005. As a result of this Act, beneficiaries are allowed to continue to enroll and disenroll on a monthly basis. However, CMS will require the reporting of the PBP Identifier and the Application Signature Date on enrollments, and on the new PBP election transaction code 71 to process PBP elections. M+COs will not report the type of election (i.e. Annual Election Period, Open Enrollment Period). Also, CMS will not implement the lock-in provisions, so election limits will not be counted or applied to any transaction. Given the impact of the Act on this activity, this goal is discontinued at this time.

Coordination: The CMS will coordinate its efforts with M+COS and beneficiaries. The improvements stated above are directly related to accurate submittals by M+COs. The CMS will reject noncompliant transactions and notify M+COs of errors. Beneficiaries will be informed about the election provisions so they are aware of the revised timeframes. In addition, as changes are made to the current system and/or as the new system modules become active, user-impacted changes will be communicated to the M+COS and training provided as necessary.

Data Source(s): The source of the data will be the Group Health Plan (GHP) system, which maintains enrollment and disenrollment information.