trust and would use such organizations (Gibbs, 1995). Currently, all states have established ICA programs. Departments of Aging administer the grants in two thirds of the states, whereas Insurance Commissioners operate the remainder.

Through individual counseling, group presentations, and written materials, the programs provide information about Medicare, supplemental insurance products, long-term-care insurance, managed care plans, and eligibility for Medicaid and other public programs. They also can help Medicare beneficiaries complete claims forms and file appeals. Programs in half of the states have developed consumer guidebooks. An evaluation of the first year of ICA program experience reported that it provides a valued service and has attracted committed volunteers and in-kind support, although evaluators recommended increased publicity and outreach and more standardized data collection and sharing of materials. For many years, some states had developed a spectrum of senior information and counseling services financed with state funds (Davidson, 1988; U.S. General Accounting Office, 1991). California, for example, funds its counseling programs through an earmarked portion of insurance agent and broker licensure fees. Neither the ICA program evaluation nor the few assessments of earlier programs for providing health insurance information to Medicare beneficiaries has demonstrated a clear effect on knowledge, attitudes, or decision making (Davidson, 1988).

It is likely that most plans employ customer service representatives and other staff who can assist enrollees with access or other problems, but one plan providing information for this paper reported its intention to create a formal Medicare ombudsman position in 1996. An ombudsman can be either a neutral mediator or, as with long-term care ombudsmen, a patient advocate (Harris-Wehling et al., 1995). PROs in some states act as patient advocates. Wisconsin requires plans enrolling Medicaid beneficiaries to employ an independent enrollee ombudsman. ICA programs with sufficiently large paid or volunteer staffs function as mediators or patient advocates in some states.

Quality, Access, and Information Standards

In view of the types of problems reported by some Medicare



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