If beneficiaries are not satisfied with certain aspects of the   Part D program, they may file a complaint with CMS, a grievance with  their respective plan sponsors, or they can file with both. 2). Complaints Data Highlight Beneficiaries’ Enrollment Problems, Decline in Complaint Rates, and Ongoing Challenges

Most complaints related to enrollment issues and while both the number  of complaints and the time needed to resolve them decreased as the Part D  program matured, ongoing challenges continued to pose problems for  some beneficiaries. In addition, a small proportion of complaints involved  cases where beneficiaries were at risk of depleting their medication  supplies. Most Complaints Were Related to Enrollment Issues and Were Resolved

During the 18-month period from May 1, 2006, through October 31, 2007,  629,792 complaints were filed with CMS—an average monthly complaint  rate of 1.5 complaints per 1,000 beneficiaries. In addition, the average time needed to resolve beneficiaries’ complaints  declined by 73 percent, from a peak of 33 days in July 2006 to 9 days in  October 2007 (see fig. Specifically, the data confirmed  information-processing issues related to beneficiaries’ requests for  enrollment changes and automatic premium withholds from their Social  Security payments remained. Limitations in Grievances Data Reported by Plan Sponsors for Their Contracts Prevent Reliable Assessment of Beneficiaries’ Experiences with Part D

Grievances data reported by plan sponsors for their contracts contained  limitations and anomalies and did not yield sufficient insight into  beneficiaries’ experiences with Part D. In contrast to the data CMS collects  on complaints, CMS only requires plan sponsors to submit quarterly  reports on the total number of grievances they received in 11 CMS-defined  categories for each of their Part D contracts. In addition to their limited nature, we identified a number of anomalies in  the grievances data that raise questions about their accuracy and  usefulness in drawing conclusions about beneficiaries’ experiences with  Part D. Among these anomalies, we found that grievances were  concentrated in a small number of contracts, and at a rate that was  significantly disproportionate to their respective enrollments, raising  questions about whether plan sponsors were reporting grievances data for  their contracts in a comprehensive and consistent manner. To oversee the complaints process, CMS has established a  framework consisting of several key elements, which include standard  operating policies and procedures and a centralized repository of  complaints data, and staff that routinely review and assess the complaints  data and take actions against plan sponsors it determines have  noncompliant processes. In contrast to complaints, CMS’s oversight of  plan sponsors’ grievances processes has been more limited. medication. In contrast to complaints, CMS’s oversight of plan sponsor grievances  processes has been more limited. CMS provided plan sponsors with  general guidance for determining whether beneficiaries’ problems were  grievances or coverage determinations, which are addressed through a  separate process. CMS also provided plan sponsors with time frames for  resolving grievances, periodically reviewed plan sponsor grievances data,  and began auditing plan sponsors’ grievances processes in 2007. Such  confusion about how to classify grievances increases the likelihood that  plan sponsors report erroneous or inconsistent information to CMS and  that they rely on the wrong processes to address beneficiaries’ concerns. CMS officials also could not explain many of the  anomalies we identified in the grievances data, such as substantial  variation in the enrollment category from 2006 to 2007 and considerable  variation in the grievance rates between contracts with similar levels of  enrollment. CMS took issue with the report’s conclusion that its oversight activities  were focused almost exclusively on resolving complaints with little  attention devoted to plan sponsors’ grievances processes. Appendix II: Comments from the Centers for Medicare & Medicaid Services
Why GAO Did This Study

Medicare Part D coverage is provided through plan sponsors that contract with the Centers for Medicare & Medicaid Services (CMS). As of April 2008, about 26 million beneficiaries were enrolled in Part D. When beneficiaries encounter problems with Part D, they can either file a complaint with CMS or a grievance with their plan sponsors. CMS centrally tracks complaints data and plan sponsors must report summary data on grievances for each of their contracts. GAO provided information on (1) complaints and what they indicate about beneficiaries' experiences with Part D, (2) whether grievances data provide additional insight about beneficiaries' experiences, and (3) CMS's oversight of the complaints and grievances processes. To conduct its work, GAO reviewed CMS's complaints and grievances data and interviewed the plan sponsors of eight, judgmentally selected contracts, which accounted for 40 percent of 2006 enrollment.

What GAO Found

While the number of complaints filed with CMS and the time needed to resolve them has diminished as the Part D program has matured, complaints data indicate that ongoing challenges pose problems for some beneficiaries. From May 1, 2006, through October 31, 2007, about 630,000 complaints were filed; most complaints were related to problems in processing beneficiaries' enrollment and disenrollment requests. The monthly complaint rate declined by 74 percent over the period, and the average time needed to resolve complaints decreased from a peak of 33 days to 9 days. However, trends in the complaints data also indicate ongoing implementation issues, such as information-processing issues related to beneficiaries' requests for enrollment changes and automatic premium withholds from Social Security payments. In addition, CMS and plan sponsors did not resolve a significant proportion of complaints related to beneficiaries at risk of depleting their medications in accordance with applicable time frames. Due to limitations and anomalies, the grievances data that plan sponsors reported for their contracts did not provide sufficient insight into beneficiaries' experiences with Part D. Specifically, these data did not include information about whether beneficiaries who filed grievances were at risk of depleting their medications or whether plan sponsors were resolving grievances in a timely manner. In addition, GAO identified a number of anomalies in the grievances data, raising questions about whether plan sponsors were reporting these data consistently and accurately. For example, reported grievances were concentrated in a small number of plan sponsors' contracts and at a rate that was significantly disproportionate to their respective enrollment levels; varied considerably among contracts with similar levels of enrollment; and increased from 2006 to 2007, in contrast to patterns in complaints data. CMS's oversight efforts thus far have focused almost exclusively on resolving complaints with little attention devoted to plan sponsors' grievances processes. CMS routinely monitors the status of complaints and has taken actions against plan sponsors who failed to comply with requirements for the complaints process. In contrast, CMS oversight of plan sponsor grievances processes has been more limited. CMS provided plan sponsors with general guidance for classifying grievances and periodically reviewed these data. However, several plan sponsors indicated that the guidance was insufficient, increasing the likelihood that plan sponsors report erroneous and inconsistent information to CMS and that they rely on the wrong processes to address beneficiaries' concerns. Further, CMS could not explain many of the anomalies in the grievances data that GAO identified.