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Accessibility Overview


The Centers for Medicare and Medicaid Services (CMS) is committed to ensuring that the Provider Enrollment, Chain, and Ownership System (PECOS) application is accessible to the widest possible audience, regardless of technology or ability.

PECOS strives to comply with technical standards §1194.21, §1194.22, §1194.31 and §1194.41 of the United States' Federal Section 508 accessibility legislation. These standards are intended to make web content and applications more accessible for people with disabilities. Moreover, conformance with these standards helps make the web more user friendly for all people.

If you should have any accessibility questions, suggestions or experience difficulty using PECOS, please contact the PECOS team via email at PECOS@cgifederal.com.

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Browser Settings and Features


The PECOS application was developed and tested to work with Internet Explorer (IE) Version 8 and 9. In addition, the PECOS application also supports the latest stable versions of Google Chrome and Mozilla Firefox browsers. Users must have JavaScript enabled in their browser in order for the PECOS application to work properly. Refer to the following directions to enable JavaScript if it has been disabled on your IE browser:

  1. Open Internet Explorer.
  2. Click the Tools menu and select Internet Options.
  3. Click the Security tab and select Internet.
  4. Click Custom Level.
  5. Scroll down to Active scripting.
  6. Click Enable.
  7. Click OK.
  8. Click Yes.
  9. Click OK.
  10. Refresh your browser window.

An Internet Explorer/Chrome/Firefox user can easily change the accessibility options in their browser. Use the following links to learn more about the options Internet Explorer/Chrome/Firefox includes to make things easier to see on the computer screen, or to adjust to your visual preferences:

For example, changing the way a web page looks can help users with vision impairments. All visual browsers should offer a means to increase or decrease the size of text on a web page. The PECOS application uses mostly relative font sizes, compatible with the user-specified "text size" option in visual browsers. The following table provides the IE keyboard keystrokes, menu commands, and shortcuts available to adjust text size.

Table 1: Methods to Resize Text in Internet Explorer

IE Access Method Increase Text Size Decrease Text Size Default Text Size
Keyboard Alt + V + X + L (Larger) or Alt + V + X + G (Largest) Alt + V + X + S (Smaller) or Alt + V + X + A (Smallest) Alt + V + X + M (Medium)
Menu View > Text Size > Larger (Largest) View > Text Size > Smaller (Smallest) View > Text Size > Medium
Shortcut Ctrl + Mouse Scroll Wheel Up Ctrl + Mouse Scroll Wheel Down None
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PECOS Interface Overview


The PECOS application's interface is designed to promote usability and support compliance with assistive technology. The following sections outline some specific design elements used throughout the PECOS application.


PECOS Page Structure


All primary pages in the PECOS application have a consistent structure as follows (reading from top to bottom):

  • Skip to main content link
  • Global navigation area
  • Heading at start of main content
  • Main content area
  • Global footer area

"Skip to Main Content" Link

The "skip to main content" link provides a convenient shortcut to the main content of the page. This shortcut saves a keyboard user from having to tab through the global navigation links before they get to the core information (content) on the page. It also enables screen reader users to jump their screen reader to the start of the content and saves them from having to listen to the global navigation area on each page. The "skip to main content" link is hidden as the first link on the top of every PECOS page. When focus is concentrated on the link, the "skip to main content" link text is visible above the PECOS logo. Once the user navigates away from the link, the link text once again becomes hidden. Clicking on the "skip to main content" link brings the user to the beginning of the PECOS breadcrumbs on the page.

Global Navigation Area

The global navigation area provides access to the PECOS Home page, Help interface and Logoff page from any page within the PECOS application. The global navigation area also includes a breadcrumb trail, which is a list of horizontal hyperlinks at the top of most pages (i.e. Home > My Enrollments > Application Questionnaire). These breadcrumbs provide the user with a quick location reference and illustrate the path they have taken through the system. Each segment of the breadcrumb is added or updated as the user continues on a navigation path. Clicking on the hyperlinked breadcrumbs navigates the user back to that PECOS application page.

Heading at the start of main content

Every PECOS page has a heading at the start of the main content of the page. This heading is always the first heading on the page.

Main Content Area

The main content area is included within a blue-bordered frame on every PECOS page. The heading for the main content area is included as white text with a blue background within the frame.

Global Footer Area

Like the global navigation area, the global footer area provides access to the PECOS Home page, Help interface, and Logoff page from any page within the PECOS application. The global footer area also includes links to other Department of Health and Human Services (HHS) and CMS websites.


PECOS I&A Page Structure


The PECOS Identity and Access Management (I&A) interface provides user authentication services for the PECOS application. The page structure in PECOS I&A differs from the page structure in the rest of the PECOS application.

All PECOS I&A pages have a consistent structure as follows (reading from top to bottom):

  • Skip to main content link
  • Global navigation area
  • Heading at start of main content
  • Main content area

"Skip to Main Content" Link

The "skip to main content" link in PECOS I&A is hidden as the first link on the top of every page. The link text remains hidden when focus is concentrated on the link (either via keyboard or mouse). Clicking on the "skip to main content" link brings the user to the heading at the start of the main content on the page.

Global Navigation Area

The global navigation area provides access to the PECOS I&A Help interface and Logoff function from any page within PECOS I&A. The global navigation area also includes an Application Sections menu, which displays each of the PECOS I&A pages that the user must complete to create a PECOS login application. The current page in the path is highlighted in yellow text and the Previous Page and Next Page buttons are used to navigate between the application sections. The Application Sections menu contains the following sections: User Profile, Employer Information, and Provider/Supplier Organization.

Heading at the start of main content

Every primary PECOS I&A page has a heading at the start of the main content of the page. This heading is always the first heading on the page.

Main Content Area

The main content area is identified by the headings defined on each PECOS I&A page.


Use of Cascading Style Sheets (CSS)


CSS is used to control some visual formatting and presentation in both PECOS I&A and the PECOS application. PECOS pages are not designed to interfere with user-defined style sheets. Moreover, if your browser or browsing device does not support style sheets at all, the content of most pages is still readable and understandable. Note: There are certain pages in PECOS that do not display content correctly when CSS is disabled. Please refer to the Accessibility Exceptions section for more information.


Links that Open a New Browser Window


On some pages, text links will trigger a new browser window to open. Text links that open a new browser window are denoted as follows:

  • A small icon (opens new browser window) is displayed to indicate that the link will open in a new browser window.
  • The icon's alternative text is defined as the phrase "Opens new browser window."

Use of Tables


The PECOS application uses "layout tables" to control the visual layout of the pages. As a result of the table-based layouts, screen reader users have to listen to the screen reader detect this information. However, screen reader users can distinguish between the presence of actual data tables used for presenting and tabulating data versus layout tables.

For actual data tables, table headers are used to help screen readers make sense of table structures. For layout tables, neither a summary description nor table headers are provided.


Downloading Reports Data


Users may download populated CMS 855 Medicare forms, supporting documentation, and other PECOS documents as an Adobe Acrobat PDF. PECOS includes the following note on each page that a PDF can be generated:

Session Timeout


For security purposes, the PECOS application times out after thirty minutes of inactivity. Once the session has been inactive for twenty-five minutes, a dialog box displays to notify the user that they are about to be timed out. The dialog box explains that the user will lose any unsaved data if they do not continue working in the PECOS application before their session expires. Once the session inactivity has reached the thirty-minute mark, then the user is logged out of PECOS and any unsaved data is lost.


Access Keys


The PECOS application does not use access keys.

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Accessibility Guidance for Keyboard Users


Every PECOS page should be fully accessible with a keyboard; a mouse should not be required. In other words, a user can use the keyboard to navigate through pages in the PECOS application by selecting links, completing form controls, and using form buttons.


Useful IE Keystrokes


The following table provides a summary of useful IE keystrokes used to navigate pages and complete forms in the PECOS application.

Table 2: Useful IE Keystrokes

Action Key
Move forward and backward through links and form controls on a page Tab (to move forward), Shift + Tab (to move backward)
Activate a link Enter

NOTE: Visual browsers highlight the current link with a "focus". In IE it appears as a dotted border around the link. It is the link with the focus that will be acted upon when you press Enter.
Select and deselect checkboxes Spacebar
Select from a group of radio buttons Up Arrow, Down Arrow
Select a choice from a selection box Up Arrow, Down Arrow or the First Letter

Alternatively, the Alt + Down Arrow key combination can also be used to first open the list of choices.
Top of page Ctrl + Home
Bottom of page Ctrl + End
Scroll page down Page Down
Scroll page up Page Up

Microsoft Windows Keyboard Accessibility Options


Microsoft Windows provides a range of accessibility options that can be turned on from the keyboard. The following table provides a summary of some common Windows XP accessibility options a user can choose to make their keyboard easier to use.

Table 3: Common Windows Keyboard Accessibility Options

Accessibility Option Keystroke to Activate/Deactivate Option
FilterKeys - used to ignore brief or repeated keystrokes and slow down the repeat rate. Hold down the Right Shift key for eight seconds to activate/deactivate FilterKeys.
MouseKeys - allow a user to use the numeric keypad to control the mouse; use 5 to "click". Use the Left Alt + Left Shift + Num Lock key combination to activate/deactivate MouseKeys.
StickyKeys - allow a user to use the Shift, Ctrl, Alt and Windows-Logo keys by pressing them one at a time. Press the Shift key five times to activate/deactivate StickyKeys.
ToggleKeys - allow a user to hear a tone when they press the Caps Lock key, Num Lock key or Scroll Lock key. Hold down the Num Lock key for five seconds to activate/deactivate ToggleKeys.
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Accessibility Guidance for Screen Reader Users


This section provides some basic guidance for screen reader users based on our testing with JAWS 9.0. We recognize that not all screen reader users use JAWS and not all JAWS users are using the same version, but the advice and principles should be applicable to other screen readers and most versions of JAWS.


Recommended JAWS Configuration Options


In order to benefit from all the accessibility features available in the PECOS application, it is recommended that JAWS screen reader users use the following HTML configuration options while working in the PECOS application. To set these options:


  1. Access the Utilities menu in JAWS 9.0 and select the Configuration Manager menu item (Alt + U + C).
  2. When the JAWS Configuration Manager window opens, access the Set Options menu and select the HTML Options menu item (Alt + S + H). When the HTML Options window opens, set the following options:

    1. On the Text tab: Expand abbreviations. Expand acronyms.
    2. On the Graphics tab: All Graphics, Use Alt attribute.
    3. On the Links tab: Text Link Options: Use Longest or Custom Search title|text.

      NOTE: Many links have TITLE attributes which describe the link in greater detail. Enabling this option in JAWS allows the screen reader to read either the "title" description for the link or the on-screen text for the link.
    4. On the Misc tab: Form Fields Prompt Options: Use Both Label and Title If Different

      NOTE: Some fields have TITLE attributes which describe the name of the field as well as any completion instructions or formatting guidance for fields where there is no visual form field prompt (i.e., on-screen label text) for the field. Enabling this option in JAWS allows the screen reader to read the "title" description for the form field and/or the on-screen label text.
  3. Select the OK button on the HTML Options window.
  4. Access the File menu in the JAWS Configuration Manager window and select the Save menu option to save these configuration options (Alt + F + S).

Useful JAWS Keystrokes


The following keystrokes all find the next occurrence of a particular element on a page. Using the Shift key at the same time will find the previous occurrence.

Table 4: Useful JAWS Keystrokes

Key What it finds Why this is useful
F Form field The majority of the application is made up of forms. The F key can be a quick way to find out what fields are on these form pages. Also see Forms and Useful Dialogs sections below.
H Heading On some pages, headings assist to define the structure of the page which means you can use headings as a "table of contents" for the page and as a quick way of moving between sections of a page. Also see Headings and Useful Dialogs section below.
G Image Alternative (alt) text has been provided for all content images and link images.
L List Lists are being used throughout the application to structure listed information, and this includes the navigation links. Pressing L is therefore a quick way of getting to navigation links on any page - the global navigation area is the first list on every page.
T Table If JAWS finds a table on a page it will either be to control the visual layout of the page or will contain useful data/information. Also see the 'Accessing Tables with JAWS' section below.

Accessing Forms with JAWS


To use the forms in the PECOS application:

  1. Use the F key to cycle through the fields and hear the prompts
  2. Press Enter to put JAWS in Forms Mode. Until you do this you will not be able to enter values into the fields.
  3. When in Forms Mode you can use the Tab key to cycle through the fields.
  4. Press Space to activate the submit button when you are done. By default JAWS will automatically exit Forms Mode when you submit the form. You can exit Forms Mode manually before this by pressing Num Pad Plus.
  5. If errors are found when you submit the form, you will be taken back to the same page. A new message section will appear at the start of the main content area. The section will be marked with the text "You must resolve the following error(s) to continue" and a list of error messages applicable to the page will follow.

In general, mandatory fields are indicated by an asterisk (*) at the end of the field label. Each PECOS page containing mandatory fields has an indicator in the main content area stating that "(*) Red asterisk indicates a required field."


Accessing Headings with JAWS


Users using recent versions of the JAWS screen reader can navigate using headings via the following keystrokes:

  • H key to cycle forwards through the headings
  • Shift + H key combination to cycle backwards through the headings
  • 1 key to navigate to the next level 1 heading (or a number between 1 and 6 to navigate to the next heading on this level)
  • Shift + 1 key combination to navigate to the previous level 1 heading (or a number between 1 and 6 to navigate to the previous heading on this level)
  • Insert + F6 key combination to provide a list of all headings

Accessing Tables with JAWS


Although a screen reader user can listen to the contents of tables cell by cell by pressing the down arrow, JAWS gives the user the ability to move their cursor around the table so they can read the data table in much the same way as a sighted person. The keystrokes for doing this are in the following table.

Table 5: JAWS Table Reading Keystrokes

Action Desktop Key
Down one cell Alt + Ctrl + Down Arrow
Up one cell Alt + Ctrl + Up Arrow
Right one cell Alt + Ctrl + Right Arrow
Left one cell Alt + Ctrl + Left Arrow
Read current cell Alt + Ctrl + Num Pad 5

Useful Dialogs in JAWS


JAWS provides the very useful "navigation lists" to list the page's form fields, headings and links in dialog boxes. Not only does this give you a convenient summary of these elements but you also have the option of acting on them. The keys used to display the dialogs and the actions you can perform are as follows:

Table 6: JAWS Navigation Lists

Dialog Key Action
Form fields Insert + F5 Select
Headings Insert + F6 Move to
Links Insert + F7 Move to or Activate

Alternatively, you can use Insert + F3 to open the JAWS Virtual HTML Features dialog and select from the full set of JAWS navigation lists.

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Accessibility Exceptions


While the PECOS application strives to adhere to the Federal Section 508 guidelines and standards for accessibility, it is not always possible to do so in all areas of the application. This section provides information on the aspects of the PECOS and PECOS I&A applications that are currently inaccessible.

If you should have any accessibility questions, suggestions or experience difficulty using PECOS, please contact the PECOS team via email at PECOS@cgifederal.com. In addition, if you find that PECOS is inaccessible to your needs, you may submit a paper CMS-855 Medicare Enrollment Application as an alternative.


Reading Order of PDFs


The PECOS application generates all documents as an Adobe Acrobat PDF. Currently there are known defects with the PDF reading order that make it difficult for the PDFs to be read by a screen reader. For example, a screen reader such as JAWS will read the page headers and footers on every page of a PECOS PDF before reading the main content of the page. This means that a screen reader user listening to a forty page PDF will hear the header and footer forty times before listening to the main content of the page. In addition, on some pages of the PECOS PDFs, the main content of the page is read out of order. For example, on some pages a screen reader will skip the section title for the page and instead read the first paragraph of the main content. Once the first paragraph is read, the screen reader will then read the section title that it previously skipped and continue reading the remainder of the main content of the page.


Use of CSS


CSS is used to control the content that is displayed on certain PECOS pages. When CSS is disabled on these pages, the presentation of the content may become confusing to users. For example, some PECOS pages feature a question with Yes/No options (e.g., "Does the applicant have any billing agencies for this application?"). The content that is displayed on the page is controlled by CSS and changes according to the response the user provides to the question. When CSS is disabled, all of the messages that could appear are displayed to the user and it is unclear which message actually applies.


Section Navigation in PECOS I&A


PECOS I&A uses yellow font color to convey meaning. The PECOS I&A section navigation sidebar highlights in yellow font the step the user is currently on in the application process. The yellow font on the white background provides poor color contrast and may be difficult for visually-impaired users to distinguish.


Skip Navigation in PECOS I&A


The skip navigation method ("Skip to Main Content" link) in PECOS I&A is affected by a known defect in the Microsoft IE version 6 browser. This defect occurs when a user utilizing the JAWS screen reader navigates to the PECOS I&A Login Form page (or any other page beyond the PECOS I&A login form). The input focus does not work correctly for in-page links using IE with the keyboard. In addition, when the user tabs to the "Skip to Main Content" link, presses the Enter key, and then tabs again, they are navigated back to the "Skip to Main Content" link instead of being navigated to the first active element in the "main content".


Session Timeout in PECOS I&A


For security purposes, PECOS I&A is required to time out after a predetermined period of inactivity. PECOS I&A does not currently alert users to give them an option to request more time to complete the operation. As a result, the user is not notified before the system times out and any information displayed on the screen (and not yet saved) is lost.


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