Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
USE  OF  NURSING  HOME  AND  MEDIGAP

GUIDES

+  % 
~w  JUNE  GIBBS  BROWN 
2  Inspector  General 
2 
%  # 
%>.+   MAY  1994
%>d ya  OEI-04-92-00481 OFFICE  OF  INSPECTOR  GENERAL 
The  mission  of the  Office of Inspector  General  (OIG),  as mandated  by Public  Law 95-452, as 
amended,  is to protect  the  integrity  of the  Department  of Health  and Human  Services (HHS) 
programs  as well as the  health  and welfare  of beneficiaries  served  by those  programs.  This 
statutory  mission  is carried  out  through  a nationwide  network  of audits,  investigations,  and 
inspections  conducted  by three  OIG  operating  components:  the  Office of Audit  Services,  the 
Office of Investigations,  and the  Office of Evaluation  and Inspections.  The  OIG  also informs 
the  Secretary  of HHS  of program  and management  problems  and recommends  courses  to 
correct  them. 
OFFICE  OF  AUDIT  SERVICES 
The  OIGS  Office of Audit  Services  (OAS)  provides  all auditing  services for HHS,  either  by 
conducting  audits with its own audit resources  or by overseeing  audit work  done  by others. 
Audits  examine  the performance  of HHS  programs  and/or  its grantees  and contractors  in 
carrying out  their  respective  responsibilities  and are intended  to provide  independent 
assessments  of HHS  programs  and operations  in order  to reduce  waste,  abuse,  and 
mismanagement  and to promote  economy  and efficiency throughout  the Department. 
OFFICE  OF  INVESTIGATIONS 
The  OIGS  Office of Investigations  (01)  conducts  criminal, civil, and administrative

investigations  of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of

unjust  enrichment  by providers.  The  investigative  efforts  of 01  lead to criminal  convictions,

administrative  sanctions,  or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud

control  units which investigate  and prosecute  fraud  and patient  abuse  in the Medicaid  program.

OFFICE  OF  EVALUATION  AND  INSPECTIONS 
The  OIGS Office of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and

program  evaluations  (called inspections)  that  focus on issues of concern  to the  Department,

the  Congress,  and the  public.  The  findings and recommendations  contained  in these  inspection

reports  generate  rapid,  accurate,  and up-to-date  information  on the  efficiency, vulnerability,

and effectiveness  of departmental  programs.

OEIS Atlanta  Regional  Office prepared  this report  under  the  direction  of Jesse  J. Flowers,

Regional  Inspector  General,  and Christopher  Koehler,  Deputy  Regional  Inspector  General.

Principal  OEI  staff included:

AtlantaRegion  Headquarters

Betty  Apt,  Temn Leader  Tom Noplock

Kimberly  Graves,  Contractor  Barbara  Tedesco

Peggy Daniel

Jacqueline  Andrews

Josiah  Townsel

For  additional  copies  of this report,  please  contact  the Atlanta  Regional  Office at 404-331 -

5022.
 Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
USE  OF  NURSING  HOME  AND  MEDIGAP 
GUIDES  EXECUTIVE  SUMMARY 
PURPOSE 
To  determine  Medicare  beneficiaries  awareness  and  use  of  the  Health  Care  Financing 
Administrations  Guide  to Choosing a Nursing Home  and  Guide  to Health  Insurance for 
People with Medicare. 
BACKGROUND 
The  Office  of the  Assistant  Secretary  for  Public  Affairs,  Department  of Health  and 
Human  Services,  asked  us  to  examine  departmental  strategies  for  distributing  various 
reports  and  publications  to  ensure  they  are  received  by intended  users.  As part  of a 
1993  Medicare  beneficiary  satisfaction  survey,  we  asked  1257  randomly  selected 
beneficiaries  about  their  awareness  and  use  of two  Health  Care  Financing 
Administration  (HCFA)  booklets  that  provide  guidance  to  Medicare  beneficiaries  and 
their  families. 
These  two  booklets  guide  Medicare  beneficiaries  on  factors  to  consider  when  selecting 
(1)  a nursing  home,  and  (2) health  insurance  to supplement  Medicare  coverage  (often 
referred  to as Medigap  insurance).  According  to HCFA,  both  booklets  are  available 
from  local  Social  Security  offices  and  senior  citizen  organizations. 
FINDINGS 
Few beneficiaries were aware of or used the HCFA  guides 
Nine  percent  of the  beneficiaries  surveyed  were  aware  of the  Guide  ro Choosing 
	
a Nursing Home,  and  one  percent  had  used  it. 
Fourteen  percent  of the  beneficiaries  surveyed  were  aware  of the  Guide  to 
	
Health  Insurance for People  with Medicare,  and  two percent  had  used  it. 
Benq%iaries  who used the booklets found  them usefi.d 
Most beneficiarim stated they would use the booklets  if thq  needed ru.minghome  care or 
Medigap insurance 
Eighty-four  percent  of the  beneficiaries  surveyed  said they would  use  the  Guide 
	
to Choosing  a Nursing Home  should  they need  to select  a nursing  home. 
.	 Sixty-five percent  of the beneficiaries  surveyed  said they would  use  the  Guide  to 
Health  Insurance for  People with Medicare  should  they  need  to obtain  or change 
supplemental  health  insurance. 
i  RECOMMENDATION 
We  recommend  that  HCFA  work with the  Social  Security  Administration  (SSA)  and 
the  Assistant  Secretary  for Public  Affairs  to develop  a more  effective  strategy  to make 
the  guides  available  to beneficiaries. 
AGENCY  COMMENTS 
The  Assistant  Secretary  for Public  Affairs  (ASPA),  Commissioner  of Social  Security, 
and  HCFA  Administrator  commented  on our  draft  report.  Appendix  B shows the  full 
text  of their  comments. 
All agreed  with  our  recommendation  and  have  already  begun  exploring  strategies  to 
make  HCFA  guides  more  accessible  to beneficiaries.  For  example,  HCFA  and  SSA 
staff  are  working  together  to determine  ways to improve  access  to Medicare 
information.  HCFA  staff have  also been  considering  the  feasibility  of making  the 
guides  available  through  hospitals  and  physicians.  ASPA  suggests  that  the  Department 
advertise  the  guides  through  senior  citizen  groups  and  public  service  announcements. 
ii  TABLE  OF  CONTENTS

PAGE 
EXECUTIVE  S~y 
lNTRODU~ON  . . . . . . . . . . . . . . . . . . ...............................1 
FINDINGS 
Few Beneficiaries  Were  Aware  of or Used  Guides  . . . . . . . . . . . . . . . . . . . . . .  5 
Users  Found  Guides  Helpful..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3 
Beneficiaries  Are  LikelytoUse  GuidesWhenNeeded  . . . . . . . . . . . . . . . . . . . 4 
RECOMMENDATION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 
APPENDICES 
A-1 
Responses  toSu~ey  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
B-1 
Agency  Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  INTRODUCTION

PURPOSE 
To  determine  Medicare  beneficiaries  awareness  and  use of the  Health  Care  Financing 
Administrations  Guide  to Choosing  a Nursing Home  and  Guide  to Health  Insurance for 
People with Medicare. 
BACKGROUND 
The  Office  of the  Assistant  Secretary  for Public  Affairs,  Department  of Health  and 
Human  Services,  asked  us to examine  strategies  used  by agencies  in the  Department 
to ensure  that  reports  and  publications  are  received  by intended  users.  As part  of a 
1993 Medicare  beneficiary  satisfaction  survey, we asked  1257 randomlyselected 
beneficiaries  about  their  awareness  and  use  of two  Health  Care  Financing 
Administration  (HCFA)  booklets  that  provide  guidance  to  Medicare  beneficiaries  and 
their  families. 
Medicare Guides 
HCFA  publishes  two booklets  to guide  Medicare  beneficiaries  in selecting  (1) a 
nursing  home,  and  (2) health  insurance  to supplement  Medicare  coverage  (often 
referred  to  as Medigap  insurance). 
The  Guide  to Choosing  a Nursing Home  was  first  published  in  1991.  The  booklet 
contains  information  on  (1)  factors  to  consider  in  selecting  a nursing  home,  and  (2) 
Medicare  and  Medicaid  coverage  of nursing  home  care. 
The  Guide  to Health  Insurance for People  with Medicare  was first published  in 1979

and  most  recently  revised  in 1992.  The  booklet  provides  information  on (1) Medicare

coverage,  (2) types  of Medigap  policies,  and  (3) tips for purchasing  Medigap  coverage.

According  to HCFA,  both  booklets  are  available  from  HCFA,  local  Social  Security

offices,  and  senior  citizen  organizations.  The  Guide  to Health  Insurance for People  with

Medicare  is also  available  from  State  insurance  departments,  and  through  the

Medicare  Handbook.  The  Medicare  Handbook  instructs  beneficiaries  on how to

order  the  health  insurance  guide,  The  Medicare  Handbook  is issued  to all

beneficiaries  when  they  enroll  in Medicare.

Medicare l?ogram 
Medicare  is a Federal  health  insurance  program  for individuals  age  65 and  older  and 
for certain  categories  of disabled  people.  Authorized  in  1965 by title  XVIII  of the  Social  Security  Act, Medicare  paid  benefitsin  1992 totalling  $129 billionth 
approximately  35.5 million  beneficiaries.1 
Within  the  Department  of Health  and  Human  Services,  HCFA  has responsibility  for 
administering  the  Medicare  program. 
METHODS 
As part  of a  1993 survey  to determine  beneficiary  satisfaction  with Medicare;  we 
asked  beneficiaries  about  their  awareness  and  use  of HCFAS  Guide  to Choosing  a 
Nursing Home  and  Guide  to Health  Insurance for People  with Medicare.  Appendix  A 
shows responses  to these  questions. 
In February  1993, we mailed  a questionnaire  to  1257 randomly  selected  beneficiaries 
for whom  Medicare  Part  B claims had  been  filed in Calendar  Year  1991.  Based  upon 
previous  experience  with  similar  client  and beneficiary  surveys, the  sample  size was 
calculated  to produce  an estimate  within  3.5 percent  of the  true  value  at the  95 
percent  confidence  level.  We  used  standard  equations  for  estimating  sample  size with 
a binary  response  variable. 
Beneficiaries  participation  in the  survey was voluntary.  A total  of 1053 beneficiaries 
returned  completed  questionnaires,  for a response  rate  of 84 percent.  Given  the  size 
of our  sample  and  response  rate,  results  of the  survey are  protectable  to the  universe 
of 35 million  Medicare  beneficiaries.  Percentages  in the  report  are  based  on the 
number  of respondents  answering  each  question. 
We  conducted  this  inspection  in  accordance  with  the  Quality Standards for Inspections 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
lHealth  Care  Financing  Administration,  HCFA Statistics,September  1992 
20ffice  of Inspector  General,  United  States  Department  of Health  and Human  Services.  Medicare 
Beneficiary  Satisfaction:  1993.  0EI-04-92-O0480. 
2  FINDINGS 
FEW BENEFICIARIES WERE AWARE  OF OR USED THE HCFA GUIDES 
Table  1 shows that  less than  15 percent  of the  beneficiaries  surveyed  knew  about  the 
booklets  HCFA  publishes  to guide  them  in selecting  nursing  homes  and  Medigap 
insurance.  Only two percent  or fewer  of the  beneficiaries  surveyed  had  ever  used 
either  of the  guides. 
TABLE 1

KNOWLEDGE  AND USE OF HCFA GUIDES

Guide  to Choosing  a Nursing Home  9%  170 
Guide  to Health  Insurance for People  1470  2% 
withMedicare 
BENEFICIARIES WHO USED THE GUIDES FOUND THEM USEFUL 
All  seven  of the  beneficiaries  who had  used  the  Guide  to Choosing  a Nursing Home

said they  found  the  booklet  helpful.  Twenty-two  of 24 beneficiaries  who had  used  the

Guide  to Health  Insurance for People  with Medicare  said they  found  the  booklet

helpful.  Two users  of the  health  insurance  guide  did not  answer  the  question  about

usefulness.  No beneficiary  said either  booklet  was not  useful.

3
 BENEFICIARIES STATED THEY WOULD  USE THE GUIDES IF THEY 
NEEDED NURSING HOME CARE AND MEDIGAP INSURANCE 
We  asked  all the  beneficiaries  surveyed  if they would  be  likely to use  the  booklets  if 
they  had  a need  to (1) obtain  nursing  home  care,  or (2) obtain  or change  Medigap 
insurance.  Table  2 shows that  more  beneficiaries  would  be  likely to use  the  nursing 
home  guide  than  the  guide  for selecting  Medigap  insurance. 
TABLE 2 
POTENTIAL  USE  OF  HCFA  GUIDES 
! Guide  to Choosing a Nursing Home  I  84%  II 
Guide  to Health  Insurance for People  65% 
wi~hMedicare 
4
 RECOMMENDATIONS

The  guides  are  available  from  several  sources,  including  Social  Security  offices, but  at 
least  85 percent  of Medicare  beneficiaries  do not  know  about  them.  Thus,  they 
cannot  benefit  from  the  guidance  on selecting  nursing  homes  and  Medigap  insurance 
when  needed.  If a larger  number  of beneficiaries  who needed  assistance  knew  of the 
guides,  use would  likely increase. 
We recommend thatHCFA work withthe Social SecurityAdministration(SSA) and 
the AssistantSecretaryfor PublicAffairs to develop a more effective strategyto make 
the booklets availableto all beneficiaries. 
The  availability  of these  guides  should  be  publicized  to both  beneficiaries  and  their 
families.  Some  potential  ways that  could  increase  awareness  of the  guides  are 
mentioned  below. 
Since  most  beneficiaries  see physicians,  and  family members  often  take  them, 
	
a list of HCFA  guides  could  be  distributed  through  physicians. 
Carriers  could  include  a listing of HCFA  guides  with  the  Explanation  of 
	
Medicare  Benefits  sent  to beneficiaries  after  claims  for Part  B services  have 
been  processed. 
.	 In locations  where  Peer  Review  Organizations  conduct  town  meetings,  they 
could  distribute  lists of HCFA  guides  to attendees. 
The  Medicare  Handbook  could  list all HCFA  guides,  not just  a selected  few. 
 
Post  offices  could  display  lists of HCFA  guides. 
 
5

  AGENCY  COMMENTS

The  Assistant  Secretary  for Public  Affairs  (ASPA),  Commissioner  of Social  Security, 
and  HCFA  Administrator  commented  on our  draft  report.  Appendix  B shows the  full 
text  of their  comments. 
All agreed  with  our  recommendation  and  have  already  begun  exploring  strategies  to 
make  HCFA  guides  more  accessible  to beneficiaries.  For  example,  HCFA and SSA 
staff  are  working  together  to determine  ways to improve  access  to Medicare 
information.  HCFA  staff have  also been  considering  the  feasibility  of making  the 
guides  available  through  hospitals  and  physicians.  ASPA  suggests  that  the  Department 
advertise  the  guides  through  senior  citizen  groups  and  public  service  announcements. 
6
 APPENDIX  A

RESPONSES TO 1993SURVEY  OF MEDICARE  BENEFICIARIES 
Not  every  respondent  answered  every  question.  Percentages  are  based  on actual 
responses.  The  number  of respondents  not  answering  an individual  question  is not 
included  in the  calculation  of percentages. 
Question  Responses  Percentage 
1.	 Medicare publishesa booklet entitled Guide to Choosing a Niusing Home.  It 
discussesthingsto look for in selectinga nursinghome, and is availablefrom 
several offices, includingyour Social Securityoffice. 
Before today, were you aware Medicare had information on choosing a nursing 
home? 
YES  93 9 
NO  917  91 
NO ANSWER:  43 
2.  Have you ever used the booklet to help you select a nursinghome? 
YEs  7  1 
NO  83  8 
I DID  NOT  KNOW  MEDICARE 
HAD  A BOOKLET  ABOUT 
CHOOSING  NURSING  HOMES  917  91 
NO  ANSWER:  46 
3.  Was the booklet helpful? 
YEs  7  1 
NO  o  0 
I HAVE  NOT  USED  THE  BOOKLET  1002  99 
NO  ANSWER:  44 
A-1
 Responses  Percentage 
Question 
4.	 Now thatyou know aboutthebookletj areyou likelyto use itif you shouldneed 
to select a nursinghome? 
YEs  805  84 
149  16 
NO 
NO  ANSWER:  99 
5.	 Medicare  also has  a booklet  entitled  Guide to Health Insurance for People  with 
Medicare.  It discussesthingsyou should look for in choosing Medigap insurmce 
ILtoo, is availableatyour Social Security 
to supplementyour Medicare coverage. 
office. 
~,  were you aware Medicare had a booklet to help you choose other 
healthinsurance? 
YEs  139  14 
875  86 
NO 
NO  ANSWER:  39 
6.  Have you ever usedthebooklet to helpyou selecthealthinsuranceto supplement 
your Medicare? 
YEs  24  2 
114  11 
NO 
I DID  NOT  KNOW  MEDICi%RE 
HAD  A BOOKLET  ABOUT 
CHOOSING  OTHER 
875  87 
HEALTH  INSURANCE 
NO  ANSWER:  40 
7.  Was the booklet helpful? 
2 
22 
YES

0 0 
NO

I HAVE  NOT  USED  THE

1008  98 
BOOKLET 
NO  ANSWER:  23 
A-2
 Question  Responses  Percentage 
8.	 Now that  you know Medicare  has  a booklet  to help  you choose  health  insurance, 
are  you likely to use it should  you wish to purchase  health  insurance  to 
supplement  your  Medicare  or to change  your  current  supplemental  policy? 
YEs  618  65

NO  338  35

NO  ANSWER:  97

A-3
 APPENDIX  B 
AGENCY  COMMENTS 
  Assistant  Secretary  for  Public  Affairs 
Commissioner  of  Social  Security 
 
Administrator,  Health  Care  Financing  Administration 
 
B-1  [~ 
*Y-~


4 
DEPARTMENT  OF HEALTH&  HUMAN  SERVICES  Officoefthe Aaaiatant Sacfataw
for Public Affaira 
L Washington, D.C. 20201 
November  12,  1993 
To:  Bryan  Mitchell,  principal  Deputy  InSpf=Ctor  General  . 
From:  Avis  LaVelle,  Assistant  Secretary  for  Public  Affairs  &  , 
Re:  OIG  Draft  Report:  Use  of  Nursing  Home  and  Medigap 
Guidest  @/- ~~~j.  1  ,Z,  ~ , 
After  learning  of  the  woeful  underutilization  of  HCFA4S  Medigap 
and  Nursing  Home  Guides,  I  offer  these  suggestions: 
1.	 Secretary  Shalala,  HCFA Director  Bruce  Vladeck  and  Fernando 
Torres-Gil,  Assistant  Secretary  for  Aging  should  send 
out  a  joint  communique  to  Senior  Citizen  Groups  and 
publications  urging  the  use  of  these  guides. 
2.	 Secretary  Shalala,  in  conjunction  with  some  commemorative 
occasion  (such  as  National  Senior  Citizens  month) 
should  do  public  service  announcements  for  radio  and 
television  for  di.stributi.on  to  commercial  and  cable 
stations  particularly  in  geographic  regions  heavily 
populated  by  seniors. 
3.	 We should  look  for  news  events  or  stories  that  provide  the 
opportunity  for  publicizing  the  use  of  both  of  these 
guides  (for  example,  a  report  on  a  study  that  indicates 
the  growing  number  of  nursing  home  residents  or  a 
report  of  the  soaring  cost  of  health  care  for  the 
elderly)  .  Stories  such  as  these  would  provide  a  news 
hook  for  Vladeck,  Torres-Gil  and/or  Shalala  to  do 
interviews  on  resource  material  that  is  available  to 
guide  the  decisions  being  made  with  respect  to  those 
topics. 
4.	 The  American  Association  of  Retired  Persons  (AARP)  has  a 
newsletter  that  serves  an  estimated  30  million  senior 
citizens  around  the  country  and  a  radio  network  that  is 
carried  in  dozens  of  markets  nationwide.  Both  would 
provide  opportunities  for  widespread  dissemination  of 
information  on  these  consumer  guides.  6LHUMAN  8oGld SecurityAdmhl*tr8Mn
DEPARTMENT  OF HEALTH  SERVICES 
Memorandum 
Refer  !0 
. m 
25  1994 
Shirley  S.  Chater  =ZZa$&ti 
Commissioner  of  Social  Secu  ty 
~ffice  of  Xnspector  General  Draft  Report,  We  of  N~siw  Home
Subjecl:  and  Medigap Guides,  (OEI-04-92-00481)--INFORMATION 
	 June Gibbs Brown

To:
Inspector General

Attached is our response to the subject report.  If we can be

of further assistance, please let Us knC3W.

Attachment:

SSA Response

L>  =& 
-. ,  c
k 
-,.- 
--
.-
4. 
-:  .

office 13fInsDeetar General -~  lumo~

We recmnmend that tha Health Cara Finance Adminiatratim  (HCFA) 
work  with  the  Social  Security  Administration  and  the  Assistant 
Secratary for  Public  Affairs  to  develop  a  strate  to  more 
affectively make  the  guides available to benefitFarhs. 
88A  cam elat 
We appreciate  the  opportunity  to  ccmment  on  the  draft  report. 
We will be happy to work with JiC!~A  in  any  strategy development  it 
undertakes  for  publicizing  the  availability  of the guides to 
beneficiaries  and  their family members.  
8--:

hedttl  am
4 
DEPARTMENT  OF HEALTH&  HUMAN  SERVICES  FinerIcing  AdministMtIon 
~ 
a 
Memorandum 
L
- offiw  of  ~ec~or  &ne~  (OIG)  D*  R~por&  ~se  of Nursing Home  and 
Medigap Guides (OEI-04-92-~81) 
To 
June Gibbs Brown 
Inspector General 
We reviewed the above-referenced  report in which OIG  found that a significant 
number of beneficiaries are not aware of nursing home and Medigap guides that the 
Health Care Financing Administration (HCFA)  publishes to help them make more 
informed decisions about their health care. 
We concurwiththerecommendatiotnhatHCFA  work with the Social Security 
Administration and the Assistant Secretary for Public Affairs to develop a more 
effective strategy to make the booklets  available to all beneficiaries.  We also concur 
with most of the suggestions for ways to increase awareness of Medicare publications. 
Thank you for the opportunity to review and comment on this draft report  Our 
detailed comments on the reports findings and recommendations are attached for 
your consideration.  Please advise us if you would like to discuss our mmments at 
yourearliecsotn
 venience.

Attachments  Recornmendation 
We recommend that HCFA work with the Social Security A~  tion (SSA) and 
the Office of the As&ant  Secretary for Public Affairs (OASPA)  to develop a 
strategy to more effectively make the booklets available to all beneficiaries. 
HCFA Remonse 
We concur with the recommendation to work with SSA and OASPA  to impruve our 
dissemination of information to beneficiaries  We believe  these recommendations 
complement  a ntimber of ongoing HCFA  initiatives. Some examples are: 
o	 HCFA and SSA have established a work group of Senior Staff members who 
meet quarterly to discuss ongoing issues in an effort to improve coordination 
and dissemination of information and other operational initiatives. 
0	 HCFA staff recently visited an SSA District Office  to get firsthand feedback 
from representatives on ways to improve expanded access to HCFA System$ 
andprovide needed information to SSA staff on Medicare programs so they 
can assistour beneficiaries more effectively. 
0	 HCFA and SSA staffs are currently exploring the feasibility of an inmmgenq 
agreement with the U.S. Postal Service, the Veterans Admin@a tion, and the 
Internal Revenue Service to develop a prototype kiosk which could potentially 
contain Medicare/Medicaid and Social Security information, including  -
information currently contained in our guides and publications. 
0	 We are also working with OASPA to learn more about the expertise they can 
provide to HCFA to enhance and improve our media  relations and capabilities 
to communicate with our beneficiaries.  In addition, we submit all proposed 
publications developed by HCFA to OASPA for review and clearance. 
We believe  that continuous improvement and feedback are necesswy  requirements to 
effectively meet our customers needs.  Therefore, HCFA  intends to seek direct input 
from beneficiary action groups, e.g., the American Association  of Retired Persons 
(-),  as we revise and improve our products and broaden the base of contacts 
who can disseminate our publications.  Page 2 
With respect to the suggestionsfor ways to increase public awareness of HCFAS 
guid~  we offer the following camments. 
OIG Sumzestion 
Since most beneficiaries see physici~  and family members often take them, a list of 
HCFA guides could be distributed through physicians. 
HCFA Resuonse 
The reporti ndicattehsa tthephysicianofsf icies aconvenienlto catiofno
r

disseminatitnogb eneficiaraielsi sotf availabHlCeF
 A  publications and guides.  We 
have recently completed  a series of focus groups which dealt in part with 
beneficiaries knowledge and understanding of HCFA  programs through use of our 
various publications.  Coincidently, one of the recomm endations of the focus groups 
is to distribute information through physicians offices. 
As a result of the findings from the focus groups and recommendations for 
improvernen~ we are developing a project to reevaluate our series of publications 
with respect to their usefulness, conten~  and design in an effort to maximize their 
potential in the most cost-effective  manner.  In addition, we are looking at a number 
of other ideas to improve the distribution and availability of our publications.  We 
believe  distribution of information through physicians offices to be a valid 
consideration. 
In addition to distribution to physician% HCFA will also consider the feasibilityof 
making guides available to beneficiaries through hospital personnel.  Because 
Medicare pays for nursing home care only when it follows a hospital stay,we believe 
most persons become  aware of their need for this information as they approach 
discharge from a hospital. 
OIG Sumzestion

Carriers could include a listing of HCFA  guides with the explanation of Medicare

benefits sent to beneficiaries after claims for Part B SeMCeShave been processed.

HCFA Remonse

Prior experiences have shown that adding information to the Explanation of

Medicare Benefits  confuses beneficiaries.  We believe mat utilizing the Medicare

Handbook as a vehicle to disseminate information regarding a list of HCFA

~ubiic3t53ns is a pmferabie abnative.  TM Medicare Flam%cok 5  se3t % newiy

entitled beneficiaries as weu as those who request the pub~~tion.  ~~A  believes it.

can effectively reach its customeri using an existing mechanism.
 . 
. 
Page 3 
OIG Suzzestion 
In locations where Peer Review Organizations (PROS) conduct town meeting&they 
oould distribute lists of HCFA guides to attendees 
HCFA Rcxmonse 
HCFA currently distributes publications to PROS for use at town meetings.  We are 
in the process of disseminating up to 1,000 copies of the Medicare Handbook and 
Guide to Health Insurance to the PRO in North Carolina for an upcoming meeting. 
We will explore increasingthe utilization of this avenue for dissemination and 
communication. 
OIG Swwestion  , 
The Medicare Handbook could list all HCFA  guides  not  just  a select  few. 
HCFA Resoonse 
HCFA will evaluate adding a complete listing of all HCFA guides in the Medicare 
Handbook. 
OIG Suwzestion 
Post offices could display lists of HCFA guides. 
HCFA Remonse 
HCFA will be broadening the scope of organizations to consider post offices and 
other public places that can disseminate publications as we continue to improve our 
communications with beneficiaries. 
TECHNICAL COMMENTS 
The report does not recognize that every insurer selling health insuranoe or accident 
or sickness insurance that provides hospital or medical expense caverage to elderly 
Medicare beneficiaries is required to deliver to all prospective buyers a copy of the 
Medigap Buyers Guide (the Guide), which was jointly developed  by ~CFA  and the 
National Association of Insurance Commissioners (NAIC).  This quirement  is 
contained in section 16 of the lWLICmodel regulation for Medigap policies.  The 
hLUC model regulationis incorporated by reference into section  1882 of the Social 
Securiiy Act [the Act).  Therefore, it has the force of Federal law.  Section  1182 of 
the Act requires alI States to have in force Medigap standards that are at least as 
stringent as those contained in the NAIC model regulation.  , 
Page 4 
Given this requiremen~ and the fa~  that appr~ate~  75 percent of ben*&iaries 
have some type of insurance to supplement Me&~  it is puzzling to us that the 
Guide is so little known to benefitia,ri~  HCFA believes that bene&cia&s  may not 
-gnize  the Guide they receive horn the insurer as a HCFA  publicati~  because 
most insurers either obtain camera ready copies of the Guide  and reproduce their 
own copies or reprint the text in another format  wtich  is required to be cmsistent 
with the NAIC modek  Because insurers attach their own logo to the Guide, many 
purchasersmay be unaware that the Guide  in this fornq is a HCFA publication. 
Additionally, the insurers may not be compl@g  with tie  NAIC requirement which 
eve~  State should enforce as part of its Medigap regulatory program.  Although 
insurers are required to deliver the Guide to prospective buye~  HCFA has no way 
of knowing whether they actually comply with the law, since enforcement is a State 
responsibility. 
During the exit conference, it was mentioned  that the average age of the beneficiary 
surveyed was between 73 and 74.  We have found that benefitities  in the 65-68 age 
group are more likely to be faced with the decision about whether to purchase 
Medigap insurance (i.e., because they are ceasing work and m-g  decisions about 
Medicare Part B coverage at this time). 
Since the time thatthe beneficiaries were surveye~  there has been increased 
outreach by the AMRP and the Health Insuran~  In.formatio~ Counseling  and 
kistance  (ICA) programs.  ICA was created by the Omnibus Budget Reconciliation 
Act of 1990 and funded for Fiscal Years 1992 and 1993.  This grant programfunds 
all the States to provide information to Medicare beneficiaries.  The Guide to Health 
Insurance for People With Medicare is one of the required publications for this 
program. A Guide to Selecting a Nursing Home  is an optional publication for use by 
the States.  These State ICA programs provide one mech- for dissemination of 
these and other pamphlets as well as one-on-one  cxmnseli.ngfor questions. 
Beneficiaries who were in the 65-68 age group at the time the survey was conducted 
have received additional counseling and information.  Because  these improvements 
took effect after the studys cornpletio~  HCFA believes that if another sunwy was 
conducted the results would be more favorable.  These ICA programs are now part 
of HCFASstrategy for information dissemination. 
If such a survey is reconducte~  we would fid  it helpful if the stmey  asks the 
interviewees whether they had ever purchased or applied for any Medigap or health 
insurance policy to supplement their Medicare coverage and whether they had 
received a copy of the Guide from the insurer at the time of the purchase.  Page 5 
We believe a sample cmrfined to recent purchasers of Medigap insurance would alSO 
give us more reoent data on whether they used the Guide in their pumhase deoision. 
We believe the same is true with regard to the nursing home guide.  Xl&booklet is 
only relevant to the beneficiary when they need to make suoh a decision.  In any 
future restweying,  we suggest OIG ask providers and discharge planners if they are 
disseminating the Guide for Nursing Homes  at probable decision points 
EDITORXALCOMMENTS 
k  the recommendation sentence  on page ii and page 5 of tie  repo~  we suggest that 
the phrase to develop a strategy to more effectively make the guides available be 
changed to, to develop a more effective strategy to make the guides available. 
The word guideshould be inserted after HCFA on page 5, the third bullet item.