Medicare is complicated.

There are pages and pages of rules about how coverage works, and a dizzying number of options to choose from if you want drug coverage or health coverage through a private plan. Not surprisingly, people are confused, and have questions—and they’re entitled to receive timely, accurate answers that are easy to understand. Their health, or the health of their loved ones, depends on it.

Unfortunately, many people who call 1-800-Medicare don’t get the service they’re entitled to. They’re put on hold for a long time, and when they finally speak to a live person, they don’t always get correct, let alone clear, answers.

65-year-old Mr. M wanted to find the right Medicare plan for his needs at the lowest cost. When he went to Medicare’s web site (www.medicare.gov), he discovered that there were 65 Medicare private health plans from which to choose. “Understanding them in order to determine which would be best . . . is a frustrating exercise that has taken several weeks,” he says.

Mr. M finally enrolled in an HMO plan without Part D. And because he knew that he would be penalized for not enrolling in Part D when he first became eligible, he chose a stand-alone Part D plan. “What I didn’t know was that I am not allowed to get a separate Part D plan if I am enrolled in an HMO plan,” said Mr. M. “And because I subscribed to the [Part D] plan, I was automatically disenrolled from the [HMO] plan.”

After spending yet another week looking for a suitable Medicare private health plan, Mr. M chose one and called an agent to enroll. The agent explained that Mr. M may have exhausted his one opportunity to make a selection and that he should call Medicare to verify that he was still eligible for getting another plan.

When Mr. M called 1-800-Medicare, “I was told that I had blown my one chance and that I could no longer get coverage from another plan. The person I spoke to was totally unsympathetic and was telling me it was all my own fault for not reading the manual that Medicare had sent me (and which I don’t recall receiving). When I asked to speak to a supervisor, she hung up on me. I called back and asked to speak to a supervisor who turned out to be just as unsympathetic and a bit nasty. She told me that I had no rights to appeal—that if I didn’t like it, I had to contact my congressional delegation because they made the rules and she was just following them. I asked her for a copy of the rules and she said she was unable to provide them, that they were on the computer and not available to me.”

At the government agency that runs Medicare, the Centers for Medicare & Medicaid Services (CMS), there is no central office that is dedicated to the day-to-day concerns of people with Medicare, no one person or department that is held accountable for meeting the information and counseling needs of consumers.

It doesn’t have to be this way.

CMS needs to make sure that consumers have the information they need to make the right decisions. By standardizing benefit packages, CMS can allow consumers to make apples-to-apples comparisons among a limited number of high-quality Medicare health and drug plans. By improving the information available online and making it easier to use, CMS can give people with Medicare, as well as counselors and caregivers, the tools they need to navigate the Medicare maze.

CMS could draw on the resources and expertise that already exist to improve its services and reach more people. There are State Health Insurance Assistance Programs (SHIPs) in every state (some go by different names) and Area Agencies on Aging with staff trained to help people with Medicare. And there are armies of workers and volunteers from community groups and advocacy organizations who also counsel consumers so they can get the health care and medicines they need. Community-based organizations are particularly adept at reaching people who are hard to reach—people whose primary language is not English, people with dementia or other cognitive impairments, people who have little or no reading skills. But these organizations need better funding so that they can reach the people who need their services.

We need a better system for educating people with Medicare about their coverage options and counseling them when they run into trouble.

In March 2009, the Medicare Rights Center submitted a proposal for how CMS might improve its counseling and education programs for people with Medicare. The proposal includes four key recommendations, which are:

  1. Congress and the Administration must standardize Medicare private health plans (also known as “Medicare Advantage” plans) and drug plan choices to allow people with Medicare to make informed choices and eliminate wasteful spending;
  2. CMS must revise its organizational structure and create a new office that is attuned to and accountable for meeting the educational and counseling needs of people with Medicare;
  3. CMS must harness the experience and resources of community and advocacy organizations, including State Health Insurance Assistance Programs (SHIPs), and better equip them to serve people with Medicare; and
  4. CMS must move toward greater use of dynamic, interactive web-based education and counseling resources, and reduce dependence on the 1-800-Medicare telephone hotline.

Have you ever contacted CMS, your state SHIP office or other group for help with a Medicare-related issue? If you would like to tell us about your experience, please click here.

Read about the most recent developments on this topic in Medicare Watch and recently archived issues of Asclepios. You can also learn more in the report below.

Proposal to Restructure and Improve Counseling and Education for Medicare Consumers