CMS-10836 Poor Plan Performance - Intemediaries

Medicare Plan Performance Warning Information: Guide 3 (i)
Poor Plan Performance
IDI Discussion Guide (90-minute online interviews)

Interviewer: _________________________
Participant:

_________________________

Date/Time:

_________________________

Objectives
●
●
●

Gauge reactions to and interest in information on poor plan performance.
Understand how intermediaries may use plan performance information when
discussing plan decisions with beneficiaries.
Gain insights on best ways to share poor plan performance information with
intermediaries.

Introduction (3 min)
Thank you for agreeing to speak with me today. My name is ______ and I’ll be leading our
conversation. This is opinion research, which means there are no wrong answers. I am
interested in everything you have to say. Since we are talking about your opinions, you are
the expert.
Before we get started, there are a few things I want to mention. First, I am an independent
researcher. You will not offend me or get me in any trouble. My only goal is to hear your
honest opinions. So please be as open and candid as possible.
We have a number of questions to get through and a few things to look at and read. So, if
at some point I ask that we move on, it’s because I want to make sure that we finish on
time. It’s not because I am not interested in what you have to say.
I am recording our conversation so I don’t miss anything. The recording is confidential and
is not shared outside the research team. There are also other people watching this
interview to help me take notes and to understand what was said. Ultimately, the findings
from this interview will be combined with other interviews we’re conducting, and we’ll write a
report with some recommendations. Your name won’t be used in the report.
The sponsor of this study is the Centers for Medicare and Medicaid Services, specifically,
the Medicare program, or CMS. I do not work for the Medicare program.

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Do you have any questions before we get started?
Warm-up (7 min)
I like to start by getting to know more about you.
1. How long have you been working as/with a [SHIP counselor / broker / advocacy
group]?
a. [IF A YEAR OR LESS]: Previous to this role, have ever you done similar work
in some other capacity?
b. What does that work look like on a day-to-day basis [PROBE TO
UNDERSTAND THEIR ENGAGEMENT WITH BENEFICIARIES]?
2. What do you find most challenging about this work? [KEEP BRIEF]
3. What are some of the most common things you get asked about by
beneficiaries/beneficiaries care about? [LISTEN FOR QUALITY OR
PERFORMANCE ISSUES]
a. What are some of the most common concerns that beneficiaries have about
Medicare plans? [PROBE TO UNDERSTAND ISSUES RELATED TO
QUALITY OR PERFORMANCE]
4. In general, how could you determine if a Medicare Advantage or prescription drug
plan is “good” or not? By “good,” I don’t mean affordable or if a beneficiary’s doctor
participates, I mean if the quality of the plan itself is good, or how well it operates or
serves beneficiaries? I’ll refer to this as “plan quality.” [IF RESPONDENT REFERS
TO HEALTHCARE QUALITY, CLARIFY THIS IS REFERRING TO PLAN
OPERATIONS AND HOW WELL THE PLAN CONDUCTS THOSE.]
Plan Performance Indicators: Introduction (10 min)
Today we are going to talk about how Medicare monitors plans, and collects information on
the performance of plans.
5. To begin, what do you know about how Medicare monitors plan performance? What
kind of activities would you expect it to conduct?
a. What would you expect or hope Medicare would share with intermediaries
who help beneficiaries, like yourself?
b. What would you expect or hope Medicare would share with beneficiaries?
c. Do you think sharing information on this topic would help beneficiaries to
have more trust in Medicare? IF YES: What would be most helpful to share?
6. I want to share some information with you about how Medicare monitors plan
performance. [SHARE OVERVIEW TO INCLUDE AUDITS, ENFORCEMENT
ACTIONS, AND OTHER PLAN PERFORMANCE INDICATORS]
a. What is your reaction to this information? How much of it was familiar to you
already?

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b. How have you learned about this in the past?
7. Now I want to share some information with you specifically about various possible
indicators of poor plan performance. [SHARE HIGH LEVEL OVERVIEW OF PLAN
PERFORMANCE INDICATORS. SHOW MODEL THAT VISUALLY DEPICTS
VARIOUS WAYS/TIMES THAT CMS GATHERS DATA ON PLAN
PERFORMANCE, INCLUDING POSSIBLE INDICATORS OF POOR PLAN
PERFORMANCE.]
a. What is your reaction to this information? How much of it was familiar to you
already?
b. How have you learned about this in the past?
8. In general, how interested are you in plan performance information about Medicare
plans? Please rate your interest on a scale from 1, not at all interested, to 10, very
interested. Please explain your answer.
a. What most interests you about plan performance information? Why?
b. How, if at all, would you use this information (e.g., general interest, informing
discussions with beneficiaries, etc.)?
c. When might you use it?
Plan Performance Indicators: Examples and Details (45 min)
Now we are going to talk in more detail about some of the information Medicare currently
collects related to poor plan performance.
9. I’m going to describe each of these for you, and ask you some questions about it.
[GO THRU EACH INDIVIDUALLY, ASKING ALL QUESTIONS BELOW.]
a. In your own words, what is it telling you?
b. Would you see this as an indicator of poor plan performance?
c. What questions do you have about this information?
d. Overall, how helpful is this kind of information as you think about your work
and/or educating and assisting beneficiaries? Please rate how helpful it is on
a scale from 1, not at all helpful, to 10, very helpful. Please explain your
answer. [MAKE NOTE OF ANYTHING RATED 7 OR HIGHER]
ITEMS TO BE REVIEWED; ORDER SHOWN WILL VARY ACROSS INTERVIEWS.
ALONG WITH DESCRIPTIONS FOR EACH, CREATE A 1-PG VERSION THAT CAN BE
USED AS A “CHEAT SHEET” TO REMIND PARTICIPANTS OF ALL THESE
INDICATORS:
o Complaints
o Grievances
o Financial solvency
o Denials:
▪ Initial denials
▪ Initial denial overturn rate
▪ Coverage denial overturn rate
▪ Pharmacy rejections/drug coverage denials
o Initial appeals (and appeals measures in general)

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o
o
o
o
o
o
o

IRE overturn rate
Failure to effectuate
Revamped Beneficiary Access and Performance Problems (BAPP) measure
Call center hold times
Enrollment-related measures
Survey data (e.g., disenrollment reasons)
Marketing misrepresentation

10. Let’s look again at the things you said you were most interested in [RE-SHOW
EVERYTHING RANKED 7 OR HIGHER, SHOW 1-PG REMINDER AS-NEEDED].
a. What would be most helpful? Top 3-5?
b. Would having this kind of information be useful in any way to your work?
c. How, if at all, would you use this information (e.g., general interest, informing
discussions with beneficiaries, advocacy work, etc.)?
d. When would you use it?
e. Is this kind of information official/impartial enough such that you could/would
share this information with a beneficiary to advise them about a plan if you
had concerns?
11. Now I want to describe some other kinds of information that CMS collects about
plans. [GO THRU EACH INDIVIDUALLY, ASKING ALL QUESTIONS BELOW.]
a. What is your reaction to this information?
b. Overall, how helpful is this kind of information as you think about your work
and/or educating and assisting beneficiaries? Please rate how helpful it is on
a scale from 1, not at all helpful, to 10, very helpful. Please explain your
answer.
ITEMS TO BE REVIEWED; ORDER SHOWN WILL VARY ACROSS INTERVIEWS:
o Plan enrollment (# of beneficiaries)
o Length of time plan has been in existence
o Plan that is too new or too small to be rated in several areas
Ways to Share Information (20 min)
Thank you. Now I want to get your feedback on how to share this kind of information.
12. Where would you expect to learn about this kind of plan performance information?
Why?
a. IF NOT DISCUSSED: How might you expect to find it?
b. Where do you think beneficiaries would expect to learn about this kind of plan
performance information? Why?
13. Are you familiar with Medicare’s Plan Finder website? Have you used it before?
a. [IF NOT: SHOW SITE]
b. What’s your reaction to this site?
c. Who do you think is the audience for this site?

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14. Are you familiar with Medicare Star Ratings? Have you used them before [PROBE
TO UNDERSTAND DEPTH OF USE AND HOW THEY HAVE USED WITH
BENEFICIARY WORK (IF APPLICABLE)]
a. [FOR ALL: SHOW STAR RATINGS IN DETAIL]
b. What’s your reaction to this information?
c. How, if at all, would you use this information (e.g., general interest, informing
discussions with beneficiaries, advocacy work, etc.)?
d. Would it be helpful to have comparative information on Star Ratings, e.g.,
where a plan ranks relative to other plans? Why or why not?
i. IF YES: How might that be helpful? How would you use that
information?
15. Now I want to share some examples of how the type of information we’ve been
talking about might be shared. [SHOW EXAMPLES OF WAYS TO SHARE
INFORMATION; KEEP IN MIND PURPOSE OF PLAN FINDER VS. OTHER
SOURCES LIKE MEDICARE & YOU TO EXPLORE WHAT THE BEST PLACE IS
FOR THIS TYPE OF INFORMATION] What is your reaction to:
a. Adding some of this information to Star Ratings
b. Language on the Plan Finder website
c. Indicators or icons on the Plan Finder website
d. Links from Plan Finder to a separate website with more information (including
existing letters or reformatted information)
e. Information hosted on a separate website not directly linked from Plan Finder
f. Others?
16. Which of these options to share information is most helpful? Why? Who do you think
the target audience of this information should be?
a. Does it depend on the type of information being shared? How so?
b. Does it depend on the engagement level of the beneficiary? [PROBE TO
UNDERSTAND IF WHERE OR HOW INFORMATION IS DISPLAYED
WOULD DIFFER BASED ON WHETHER A BENEFICIARY IS MORE OR
LESS ENGAGED]
c. Is there some other way CMS could communicate information related to plan
performance that would be helpful to your work or for assisting beneficiaries?
d. Thinking of your own work and all the information you (or your organization)
share, when, if ever, would you share plan performance information with
beneficiaries? Why?
17. Let’s assume a plan a beneficiary was considering enrolling in had some indicators
of poor plan performance. Would you want them to know about that if the
information was from [ASK FOR EACH AND HAVE THEM EXPLAIN WHY]:
a. The last year?
b. The last two years?
i. Does your answer change if the plan has had multiple/repeated
issues with some of these indicators? IF YES: How so?
ii. Should Medicare highlight in some way if a plan has had
multiple/repeated issues with some of these indicators?

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Wrap-up (5 min)
TIME ALLOWING: Before we wrap up, I’m going to check to see if there are any additional
questions for you from anyone else on the team. [CHECK FOR QUESTIONS]
18. This has been really helpful. Thanks so much for participating in this project. Do you
have any other thoughts or comments you’d like to share?
We really appreciate your assistance. Have a great day.
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