Twenty-six interviews were conducted with organizations that provided services for older adults; three participants were insurance brokers, and one interview was conducted with an advocacy organization. The majority of the participants were located in urban areas, and six participants were from rural areas. Eleven participants were located in the Southwest, nine participants were located in the Northeast, six participants were located in the West, and four participants were located in the Midwest.
Every stakeholder mentioned that some older adults have difficulty making Medicare decisions, and 16 stakeholders mentioned that their system is complex and/or overwhelming for older adults. Twenty-three stakeholders mentioned that Medicare beneficiaries are often confused about Medicare, and this is more noticeable among new enrollees. “Choosing coverage can be stressful and nerve-racking, and Medicare gets more complicated every year!” Thus, pre-pandemic, these community organizations and insurance brokers often met with people in-person to go over questions and details. With the onset of the pandemic, 22 of these organizations and insurance assistance programs mentioned that they had to move to a virtual model in order to assist beneficiaries, especially at the beginning of the pandemic. However, older adults seeking advice/meetings have a strong preference for in-person meetings most of the time. Given that the majority of the beneficiaries that these stakeholders serve may not have access to technology, it was difficult for some of them to smoothly transition to a virtual environment. With Medicare counseling moving to virtual or telephone methods, stakeholders discussed that many beneficiaries had difficulty utilizing these options in a variety of ways.
Theme 1: Choosing a Medicare plan was already a complex task for Medicare beneficiaries pre-COVID-19
Finding the optimal Medicare insurance plan can be confusing. When prompted, one participant said “it's confusing. It's problematic because we're throwing so many choices at individuals from the very beginning. It's not easily understood.” Another stakeholder highlighted that sometimes beneficiaries do not know the difference between traditional Medicare and Medicare Advantage. For instance, one participant mentioned,
“It can take two to three years for seniors to understand what Medicare advantage is. So, they spend the first year to three years kind of floundering around the system, trying to understand how Medicare works and, in the process, they could be missing out on care that they need, they could be paying more, they could be experiencing a lot of frustrations with that interaction between their care and Medicare.”
Another participant from a different organization described something similar:
“I would say all seniors struggle, especially in the beginning when they are getting onto Medicare. They struggle because there are so many choices and so many details within those choices. Even supplements, do you just go with the most coverage, or do you go with something that's a more cost-effective with a little less coverage, but still great coverage? Does it work for you?”
When asked whether participants understood these differences, one stakeholder mentioned that:
“When folks are comparing Medicare Advantage, there are a lot of different supplemental benefits that go with those plans that we do get that information every year,” she went on to say that “we can't just put on a chart and say, ‘Well, here's a comparison of what you'll get with this and this and this.’ Because you really have to delve into the plan documents to get the details, ‘Oh, this has dental. This also has dental." But what are those dental benefits, right? What are those supplemental benefits?’”
One stakeholder mentioned that they have worked with people from all income brackets. She said:
“We've had judges, attorneys, etc. be totally confused about Medicare. We've had people that are working class, lower income, totally confused. So, we need to look at each individual's needs to help them understand what it is they're looking at, what the foundation is, and going from there as to what to do.”
However, participants mentioned that Medicare may be more complex among people with cognitive disabilities:
“It's like you might have a conversation with someone and say like, ‘Okay, here's what we're going to do. Let's do this.’ and then that person may not remember the conversation the next day and so that can be very, very difficult for everyone involved but it's not something that there's always supports in place for and that's something I used to find in my role a lot, is that sometimes people don't have those formal supports in place because they may not want them or for a variety of reasons. So, there are a lot of barriers to making those decisions for folks who may have some cognitive issues or disabilities.”
Theme 2: Before the pandemic, older adults had a strong preference for in-person meetings, which changed during the pandemic as services were more likely to be offered virtually
Ten of these stakeholders described that most beneficiaries and/or family members have a strong preference for meeting with them in-person despite COVID-19 restrictions. One stakeholder said that:
“The biggest [barrier] would be that we were not able to make in-person appointments, obviously, so this was a major barrier, especially for older adults who do not have access to technology, do not have a computer, things like that so it's possible to do these enrollments and these conversations over the phone, but it's not easy, and it's not something that's preferable to most beneficiaries, and so that was probably the biggest and most obvious barrier.”
Similarly, another stakeholder described that before the pandemic it was not necessary to make appointments. Older adults were able to go to the offices and asked for help. She stated that:
“Oftentimes, our seniors prefer to talk to someone face to face. Our office specifically, and most of our satellite offices, they're [a] walk-in business. People don't necessarily make an appointment; they just show up, kind of like for the Social Security office or something. And so, for some of those people, that was a challenge because they like to know who they're talking to; they like to see that person. So, that's been one challenge for them.”
Some stakeholders described the challenges of helping people who may have had a hearing or cognitive difficulty/impairment, which was even more complex earlier in the pandemic. “It was more challenging for people with disabilities, especially cognitive disabilities. That was more challenging because we couldn't see them face-to-face.” Another stakeholder said:
“Medicare is hard in itself, and having to go through an interpreter and/or one of these services makes our job a little bit more difficult as well. We get through it, but it is very taxing.” In addition, other stakeholders mentioned that for some beneficiaries with cognitive disabilities, this may have been hard because “especially during COVID… if they didn't know how to click a link to get on Zoom where we can screen share, it was all through the phone and all verbal and sometimes words can mesh together.”
Theme 3: Zoom and/or virtual consultations work for some but not for everyone due to issues of internet literacy, technological adaptability, and access to stable internet or broadband
Two stakeholders discussed that some older adults were comfortable doing virtual meetings (WebEx teams, Zoom) to receive assistance but highlighted the challenges that other older adult faced:
“All of our area agencies on aging, which provides the Medicare service at the local and regional level, were required to use a web platform to do outreach and to provide assistance to Medicare beneficiaries. And so, they use things like WebEx teams, Zoom to provide this assistance… we found that that worked very well again for people that have internet access” then she went on to explain that there were challenges during open enrollment and being unable to assist people in-person “they expected the same level of help this last year… And we couldn't provide it and they didn't have internet access. So, we had to provide it over the phone, which for some people was not a good replacement. They did get somewhat upset.”
Thus, one of the major challenges reported by stakeholders was the lack of access to technology. For instance, one participant mentioned, “there's wide areas…without any broadband. And several places that you can't get a cell signal. So that's something that they'd work hard on.” Nine stakeholders talked about having some form of Zoom meetings/appointments. However, some of them indicated that using a virtual platform was not easy for everyone. One of them mentioned, “I mean, we offered Zoom calls and over the phone, but some, of course, if you have a disability, like hearing disability, sometimes [that] can be difficult if you're not tech-savvy. So, a lot of barriers were involved with that.” Six stakeholders described that some of the older adults they served had issues with internet literacy or access to the internet. For instance, one of the stakeholders talked about this and stated that “some people have less access to that technology. There’re wide areas of [this rural city] without any broadband. And several places that you can't get a cell signal. So that's something that they'd work hard on.”
One stakeholder mentioned that “because it's complex and it is difficult for some people to hear the information over the phone and be able to put it together into a picture that makes sense. Even when we are doing Zoom or WebEx consultations, it's still not quite the same as being able to sit down and have a conversation.” Another stakeholder also described similar issues. For instance, he said that “just [the other day] I did have a lady that is new to Medicare, and so I tried helping her as much as I could over the phone and I'll go over that in the other questions. Unfortunately, I was limited to what she was able to comprehend over the phone.”
Similarly, another stakeholder also mentioned that:
“It's real hard to explain Medicare without having somebody that can look at paperwork, because if they have a question, I can't explain the paperwork over the telephone. You don't have it in front of you, so we can't even look at the same line together. Because by the time I call you, I don't know what your question's going to be.”
In fact, the stakeholders mentioned that sometimes older adults did not know that they have to complete paperwork. One of the stakeholders noted the following: “and if you don't see them person to person, how do you even show them the paperwork that you get from the federal government? Otherwise, they have to find the paperwork… So, if [they] can't find it, how do I help them find it?”.
In addition to the confusion that some older adults were experiencing when trying to understand the intricacies of Medicare, some stakeholders also talked about how some beneficiaries did not want to provide information over the phone. One of these stakeholders described that “[some people] sounded really confused or they were very guarded as far as giving us information, but they really wanted to review their plans or they were new to Medicare or wanted to make changes.” So, they had to figure it ways to convey the information in an easier way and/or bring people in-person, “when we mention, ‘Okay, we can schedule you for an in-office appointment,’ and they're like, ‘Yes, please. I would really appreciate that.’"
When asked how virtual appointments have worked for everyone, one stakeholder responded, “I wouldn't say it's been a complete success, I think there were some people who really needed that in-person appointment but we did what we could to try and stay connected with people and help them enroll during the pandemic and continue to do so.”
Theme 4: Older adults are overwhelmed with information overload and have received conflicting advice/misinformation, especially during the pandemic
Overall, stakeholders mentioned that they received a lot of phone calls during the pandemic asking questions related to COVID and insurance plan coverage and benefits. One stakeholder described that “we have kept track of the numbers of callers that have called us specifically with COVID questions. And we have over 700 followers that have called us specifically about COVID.”
According to stakeholders, it was not uncommon to hear from beneficiaries that "someone called me and they told me to enroll in this plan and I don't know what I did, and I don't know what I'm enrolled in now…".
Another stakeholder stated that this was often related to the fact that:
“People got phone calls stating that ‘because of COVID, Medicare has to give you new Medicare cards.’ So, then [beneficiaries] give them the Medicare number[s].” Stakeholders mentioned that these companies often sound like they are representing Medicare. Thus, community organizations and other agencies are working on educating people. “Medicare doesn't call you, but I'm able to still talk to them. And we do have people who get changed that did not have a valid, special enrollment period. So, people are not supposed to be able to change just Willy-nilly throughout the year.”
According to some stakeholders, while socially distancing, beneficiaries were spending time at home watching television or other media and may have been vulnerable to false marketing messages. “This past year and a half, with people being home, with COVID, and seeing a lot of the commercials… that Joe Namath commercial that's out right now, so that has sparked people to maybe make changes to their coverage that maybe did not turn out to be as prudent for them.” Another stakeholder mentioned similarly:
“My staff person said, "I grew up loving Joe Namath, and now I can't stand him." Because he does those commercials. And most of what he's talking about isn't available here. So, we get all these questions of are they going to pay for my meals? No, we don't have plans that do that. They're going to do this? No, we don't have plans to do that. And then it also kind of misleading talking about, oh, you can get an extra $140. No, it's not an extra $140. It's only if you're low income and you're getting your 140 back. It's those little things. There's so much on commercials that they are supposed to be helpful and they're just making it more confusing than it has to be.”
Another participant also agreed that these commercials are misleading beneficiaries:
“Making it sound like every older adult in Medicare is entitled to all those benefits. And what I can tell you in [this state], none of our plans, and I mean, none of the Medicare advantage plans provide all those options he talks about or other people that are trying to market and sell Medicare advantage plans. They don't provide that coverage. So, people are being misled.”
Another participant mentioned the rise of third-party companies through Medicare Direct Contracting and/or other managed care entities, “third party companies have definitely increased because I feel like they know people are at home. So, like those phone calls that people are getting is definitely more than what even two or three years ago people were getting, but so are the television commercials and advertisements, so all of that's increased.”