Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

SEPTEMBER 1998 

OEI-04-97-00033 

Beneficiary Awareness of HCFA Publications 

in 1997 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 

protect the integrity of the Department of Health and Human Services programs as well as the 

health and welfare of beneficiaries served by them. This statutory mission is carried out through a 

nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The 

Inspector General informs the Secretary of program and management problems and recommends 

legislative, regulatory, and operational approaches to correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 

Inspector General. It conducts short-term management and program evaluations (called 

inspections) that focus on issues of concern to the Department, the Congress, and the public. The 

inspection reports provide findings and recommendations on the efficiency, vulnerability, and 

effectiveness of departmental programs. 

OEI's 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: 

REGION 

Betty Apt, Project Leader

Jason Stanfield, Contractor

Joe Townsel, Program Analyst

Paula Bowker, Program Analyst

Greg Jones, Program Analyst

Janet Miller, Program Analyst

HEADQUARTERS 

Wynethea Walker, Program Specialist 

Linda Moscoe, Technical Support 

Barbara Tedesco, Statistician 

To obtain copies of this report, please call the Atlanta Regional Office at (404) 562-7743. 

Reports are also available on the World Wide Web at our home page address: 

http://www.dhhs.gov/progorg/oei 
EXECUTIVE SUMMARY

PURPOSE 

To determine Medicare beneficiary awareness of Health Care Financing Administration 

publications in 1997. 

BACKGROUND 

The Health Care Financing Administration (HCFA) publishes various booklets designed to help 

Medicare beneficiaries make informed health care decisions. The booklets are available from 

several sources, such as Social Security offices and senior citizen organizations. However, the 

Department has little information on the extent that beneficiaries know the booklets are available. 

As part of our 1997 survey to determine beneficiary satisfaction with Medicare, we asked 

beneficiaries about their awareness of the Medicare handbook and seven other HCFA 

publications. We reported on the handbook and six of the seven booklets in a 1995 report. 

FINDINGS 

Most beneficiaries were aware of the Medicare handbook 

Eighty-seven percent of beneficiaries surveyed in 1997 said they knew about the Medicare 

handbook. This was a statistically significant increase from 1995 when 75 percent said were 

familiar with the handbook. 

Beneficiary use of the Medicare handbook remains low, but users found it helpful 

In 1997, 38 percent of the beneficiaries who were aware of the handbook said they had used it in 

the past year. This is about the same as 1995. Of beneficiaries who had used the handbook, 95 

percent thought the handbook was helpful. 

Few beneficiaries were aware of HCFA's other publications 

! Twenty-four percent of the Medicare beneficiaries who responded to our survey were 

aware of HCFA's Guide to Health Insurance for People with Medicare Coverage. 

! Fifteen percent of the Medicare beneficiaries who responded to our survey were aware of 

HCFA's booklet on Medicare and Other Health Benefits. 

! Nine percent of the Medicare beneficiaries who responded to our survey were aware of 

HCFA's booklet on How to Help Medicare from Being Ripped Off. 

! Nine percent of the Medicare beneficiaries who responded to our survey were aware of 

HCFA's booklet on Medicare Hospice Benefits. 

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! Seven percent of the Medicare beneficiaries who responded to our survey were aware of 

HCFA's booklet Guide to Choosing a Nursing Home. 

! Six percent of the Medicare beneficiaries who responded to our survey were aware of 

HCFA's booklet on Medicare Managed Care Plans. 

! Six percent of the Medicare beneficiaries who responded to our survey were aware of 

HCFA's booklet on Medicare Coverage for Second Surgical Opinions. 

Most beneficiaries did not know how to obtain HCFA publications 

Seventy percent of the beneficiaries said they did not know how to obtain HCFA’s free 

publications. 

CONCLUSION 

HCFA publications provide important information that Medicare beneficiaries and their families 

may use to make informed health care decisions. However, beneficiaries can benefit from HCFA's 

guidance only if they know the information is available. Since awareness of publications other 

than the handbook have not increased, it is obvious that methods previously used are not working. 

We are aware that as a result of the Balanced Budget Act of 1997, HCFA will likely update 

several of their publications, such as the handbook and managed care booklet. This presents 

HCFA a good opportunity to intensify efforts to make beneficiaries aware of the availability of all 

its publications. 

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TABLE OF CONTENTS

PAGE 

EXECUTIVE SUMMARY 

INTRODUCTION .......................................................... 1

FINDINGS 

Most Beneficiaries Aware of Handbook ..................................... 4

Use of Handbook Remains Low, But Users Found It Useful ..................... 4

Few Aware of Other Publications .......................................... 5

Most Did Not Know How to Obtain Publications .............................. 6

CONCLUSION ............................................................. 7

APPENDICES

Responses to 1997 Medicare Beneficiary Survey ............................ A-1

Confidence Intervals ................................................. B-1
INTRODUCTION

PURPOSE 

To determine Medicare beneficiary awareness of Health Care Financing Administration 

publications in 1997. 

BACKGROUND 

Medicare Program 

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 benefits in 1997 totaling over $211 billion to approximately 38 million 

beneficiaries.1 The Health Care Financing Administration (HCFA) within the Department of 

Health and Human Services has responsibility for the Medicare program. 

HCFA Publications 

HCFA publishes a Medicare handbook for beneficiaries that explains how the Medicare program 

works and what the benefits are. HCFA publishes a new handbook every year, but generally only 

mails it to new enrollees. In 1996, the year preceding our survey, HCFA mailed a new handbook 

to all beneficiaries. HCFA officials now are considering the feasibility of mailing another new 

handbook to all beneficiaries. 

HCFA also publishes various booklets designed to help beneficiaries make informed health care 

decisions. The booklets provide (1) guidance on Medicare coverage for specific services, such as 

hospice and second surgical opinions, (2) advice on criteria beneficiaries should consider in 

selecting services, such as nursing home care and supplemental health insurance, and (3) tips that 

should alert beneficiaries to fraudulent activities. 

The handbook and other booklets are available upon request from several sources, such as Social 

Security offices, insurance offices that process Medicare claims (called carriers), and senior citizen 

organizations. However, the Department has little information on the extent that beneficiaries 

know the handbook and booklets are available. 

__________________ 1

Health Care Financing Administration, United States Department of Health and Human Services, HCFA Statistics, 

October 1997. 

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1 
Previous Surveys 

In 1993, the Office of Inspector General conducted a survey of Medicare beneficiaries to 

determine their awareness of the Medicare handbook and two booklets published by HCFA.2 In 

1994 and 1995, we conducted a similar survey of Medicare beneficiaries, and asked about their 

awareness of the handbook and seven booklets.3 

In all three surveys, we found that while most beneficiaries were aware of the handbook, few 

knew about the booklets. 

METHODS 

In July 1997, we mailed a questionnaire to 1269 randomly selected Medicare beneficiaries for 

whom Part B claims had been filed in Calendar Year 1996. We used standard equations for 

estimating sample size with a binary response variable. 

Beneficiary participation in the survey was voluntary. A total of 977 beneficiaries returned 

completed questionnaires, for a response rate of 77 percent. Percentages in the report are based 

on the number of people answering each question. Based on our response rate, estimates are 

within 3.5 percent of the true value at the 95 percent confidence level. Some individual findings 

may be less precise, depending on the number of beneficiaries who responded to specific 

questions. Appendix A shows beneficiary responses to the questionnaire. Appendix B shows 

confidence intervals for the findings. 

As part of our 1997 survey to determine beneficiary satisfaction with Medicare,4 we asked 

beneficiaries about their awareness of eight HCFA publications. The eight publications included 

the Medicare Handbook, and seven other HCFA publications. The eight publications are 

described below. 

! HCFA's Medicare Handbook explains the Medicare program and benefits. 

! HCFA's Guide to Health Insurance for People with Medicare Coverage booklet provides 

information on (1) Medicare coverage, (2) types of Medigap policies, and (3) tips for 

purchasing Medigap insurance. 

__________________ 2

Office of Inspector General, United States Department of Health and Human Services. Use of Nursing Home and 

Medigap Guides. OEI-04-92-00481, May 1994. 

3

Office of Inspector General, United States Department of Health and Human Services. Beneficiary Awareness of 

HCFA Publications. OEI-04-94-00141, June 1995. 

4

Office of Inspector General, United States Department of Health and Human Services. Medicare Beneficiary 

Satisfaction: 1997. OEI-04-97-00030. 

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2 
---------------

! HCFA's Medicare and Other Health Benefits booklet explains how Medicare coordinates 

with other insurance that beneficiaries may have, such as Medigap, employer health plans, 

and Workman's Compensation. 

! HCFA's How to Help Stop Medicare from Being Ripped Off booklet describes what 

beneficiaries can do to prevent Medicare fraud. 

! HCFA's Medicare Hospice Benefits booklet explains (1) hospice services, (2) eligibility 

requirements, and (3) Medicare payments for hospice services. 

! HCFA's Medicare Coverage for Second Surgical Opinions booklet provides information 

on (1) when beneficiaries should get second surgical opinions, (2) how to find physicians 

to give second surgical opinions, and (3) Medicare payments for second surgical opinions. 

! HCFA's Guide to Choosing a Nursing Home booklet contains information on (1) factors 

to consider in selecting a nursing home, and (2) Medicare and Medicaid coverage of 

nursing home care. 

! HCFA's Medicare Managed Care Plans booklet contains information on managed health 

care plans (health maintenance organizations and competitive medical plans) that contract 

with HCFA to provide health care for Medicare beneficiaries. 

Comparison to Previous Surveys 

During our 1993, 1994, 1995, and 1997 surveys, we asked Medicare beneficiaries similar 

questions about the Medicare Handbook. We compare their responses in this report. 

We asked Medicare beneficiaries similar questions about two of HCFA's publications in our 1993, 

1994, 1995, and 1997 surveys. In 1994, 1995, and 1997 we asked similar questions about six 

publications. For those publications on which we asked similar questions in more than one survey 

year, we calculated the percentage of responses so that they were comparable from year to year. 

We determined significant differences in responses to the two most recent surveys through use of 

a t-test. If there was a statistical difference between the responses to the surveys, we stated the 

percent increased or decreased in the report. If there was not a statistical difference, we stated 

that the percent stayed the same. 

We conducted this inspection in accordance with the Quality Standards for Inspections issued by 

the President's Council on Integrity and Efficiency. 

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3 
FINDINGS

MOST BENEFICIARIES WERE AWARE OF THE MEDICARE HANDBOOK 

Eight-seven percent of the beneficiaries surveyed said they knew about the Medicare Handbook. 

Figure 1 illustrates that the percent of beneficiaries who knew of the handbook increased 

significantly from 1995 to 1997. This increase may be due to HCFA having mailed a new 

handbook to each beneficiary in 1996. 

FIGURE 1

BENEFICIARY AWARENESS OF THE MEDICARE HANDBOOK

1997 

1995 

76 

76 

75 

87 

YEAR 

1994 

1993 

0 10 20 30 40 50 60 70 80 90 100 

PERCENT 

BENEFICIARY USE OF THE MEDICARE HANDBOOK REMAINS LOW, BUT USERS 

FOUND IT HELPFUL 

Figure 2 shows that slightly over a third of beneficiaries said they had used the handbook in the 

last year. This number is about the same as in 1995. 

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4 
FIGURE 2

BENEFICIARY USE OF THE MEDICARE HANDBOOK

1997 

1995 

1994 

1993 55 

58 

38 

37 

10 20 30 40 50 60 70 80 90 100 

PERCENT 

At the same time, in 1993, 1994, 1995, and 1997, over half of the beneficiaries surveyed said they 

would refer to the Medicare handbook to get information concerning what Medicare pays for. Of 

the beneficiaries who had used the handbook, 95 percent thought it was helpful. Figure 3 shows 

that beneficiaries responded virtually the same in our 1993, 1994, and 1995 surveys. 

FIGURE 3

BENEFICIARIES WHO, HAVING USED THE HANDBOOK, FOUND IT USEFUL

1997 

1995 

1994 

1993 93 

93 

94 

95 

0 10 20 30 40 50 60 70 80 90 100 

PERCENT 

YEAR YEAR 

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5 
FEW BENEFICIARIES WERE AWARE OF HCFA'S OTHER PUBLICATIONS 

Table 1 illustrates that only 6 to 24 percent of the 977 beneficiaries responding to our survey in 

1997 were aware of HCFA's other publications. 

TABLE 1

AWARENESS OF HCFA PUBLICATIONS

PUBLICATION 

BENEFICIARIES 

AWARE 

1993 1994 1995 1997 

Guide to Health Insurance for People with Medicare 

Coverage 

13% 24% 26% 24% 

Medicare and Other Health Benefits * 14% 18% 15% 

How to Help Medicare from Being Ripped Off * * 9% 9% 

Medicare Hospice Benefits * 9% 8% 9% 

Guide to Choosing a Nursing Home 9% 8% 7% 7% 

Medicare Managed Care Plans * * * 6% 

Medicare Coverage for Second Surgical Opinions * 9% 7% 6% 

* If no percentages are shown, we did not ask about that publication in that 

particular year. 

As in previous years, the most familiar publication to beneficiaries relates to insurance policies 

that supplement Medicare. It is important to realize that awareness of other publications may be 

dependent on a beneficiary’s need. For example, a beneficiary who has never had to choose a 

nursing home may not be aware of the publication concerning such a matter. 

MOST BENEFICIARIES DID NOT KNOW HOW TO OBTAIN HCFA PUBLICATIONS 

Seventy percent of the beneficiaries surveyed said they did not know how to obtain HCFA's free 

publications. 

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6 
CONCLUSION

HCFA publications provide important information that Medicare beneficiaries and their families 

may use to make informed health care decisions. However, beneficiaries can benefit from HCFA's 

guidance only if they know the information is available. Since awareness of publications other 

than the handbook have not increased, it is obvious that methods previously used are not working. 

We are aware that as a result of the Balanced Budget Act of 1997, HCFA will likely update 

several of their publications, such as the handbook and managed care booklet. This presents 

HCFA a good opportunity to intensify efforts to make beneficiaries aware of the availability of all 

its publications. 

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7 
APPENDIX A

RESPONSES TO 1997 SURVEY OF MEDICARE BENEFICIARIES 

(977 Respondents) 

___________________________________________________________________________ 

Question Responses 

___________________________________________________________________________ 

1. Where would you go to get information about what Medicare pays for? 

The following are some places people might go to get answers if they have questions 

about what Medicare pays for. Check all the places you would go to find out what 

Medicare pays for. 

(N = 952 - Number Responding to Question) 

Your doctor's office 

Friend or relative 

AARP or other 

membership organization 

Insurance company that 

processes your Medicare claims 

Medigap insurance company 

Social Security office 

Local senior citizen's group 

The Health Care Financing 

Administration (HCFA) 

Insurance salesperson 

Medicare Handbook 

Medicare Peer Review 

Organization 

State's Information, Counseling, 

and Assistance office 

Other 

Not Answering: 25 

644 

95 

133 

364 

221 

268 

73 

22 

18 

523 

25 

30 

27 

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A - 1 
Question Responses 

___________________________________________________________________________ 

2. Listed below are Medicare booklets that you can obtain free of charge. Please 

check the booklets you were aware of before today. 

(N = 750 - Number Who Checked One or More Publications) 

Guide to Health Insurance 

for People with Medicare 

Guide to Choosing a 

Nursing Home 

Medicare Coverage for 

Second Surgical Opinion 

Medicare Hospice Benefits 

Medicare Managed Care 

Plans 

Medicare and Other Health 

Benefits 

How to Help Medicare from 

Being Ripped Off 

Medicare Handbook 

Not Checking Any of the Above: 227 

182 

54 

46 

68 

43 

114 

64 

650 

___________________________________________________________________________ 

3. Do you know how to obtain these free publications from Medicare? 

Yes 278 

No 660 

Not Answering: 39 

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A - 2 
Question Responses 

___________________________________________________________________________ 

4. How many times in the past year have you used your Medicare Handbook? 

(Check one answer.) 

1 to 3 times 

More than 3 times 

I have not used the 

Medicare Handbook in 

the past year 

I do not know what the 

Medicare Handbook is 

I do not recall receiving a 

Medicare Handbook 

Not Answering: 73 

281 

51 

403 

51 

118 

___________________________________________________________________________ 

5. Do you think the Medicare Handbook is: 

(Check one answer.) 

(N = 332 - Number Who Had Used Handbook) 

Very Helpful 137 

Generally Helpful 171 

Generally Not Helpful 13 

Not Helpful 3 

Not Answering: 8 

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A - 3 
APPENDIX B

CONFIDENCE INTERVALS 

Description Estimate Boundaries for the 95% 

Confidence Intervals 

Beneficiaries who knew about 

Medicare handbook 87% +/- 2.4% 

Beneficiaries who had used 

Medicare handbook 37% +/- 3.1% 

Beneficiaries who would refer to 

handbook for information 55% +/- 3.2 % 

Beneficiaries who had used Medicare 

handbook and found it useful 95% +/- 2.4% 

Beneficiaries who did not know how to 

obtain free publications 70% +/- 2.9% 

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B - 1
Description Estimate Boundaries for the 95% 

Confidence Intervals 

Beneficiaries aware of other publications: 

Guide to Health Insurance for 

People with Medicare 

Medicare and Other Health 

Benefits 

How to Help Medicare From 

Being Ripped Off 

Medicare Hospice Benefits 

Guide to Choosing a Nursing 

Home 

Medicare Managed Care Plans 

Medicare Coverage for Second 

Surgical Opinions 

24% 

15% 

9% 

9% 

7% 

6% 

6% 

+/- 3.1% 

+/- 2.6% 

+/- 2.0% 

+/- 2. 0% 

+/- 1.8% 

+/- 1.7% 

+/- 1.7% 

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B - 2