1. Between 1978 and 1990, several state governments began programs to provide free information about health insurance options to their older citizens. These pioneer health insurance counseling programs have assisted thousands of senior citizens in making better informed decisions about their health insurance coverage. Modeled after these successful programs, HICAP began in early 1993 to provide these services to all senior citizens. HICAP is one of the many acronyms you will encounter in this manual. The resource section of this chapter identifies many of the acronyms you will utilize daily.

2. HICAP stands for Health Information, Counseling, and Advocacy Program. Its mission is to provide accurate and objective counseling, assistance, and advocacy in relation to public benefits such as Medicare, Medicaid, and private health insurance. The program targets seniors aged 60 and older. In Texas, the HICAP program is sustained in the Benefits Counseling program of the twenty-eight Area Agencies on Aging (AAA) across the state.

3. The Benefits Counseling program is addressed in the Older Americans Act (OAA), in the 42 United States Code (U.S.C.) §3058k. Insurance benefits and public benefits are the primary areas of involvement, with the requirement to give priority to older individuals with greatest economical need. In addition to providing counseling services, outreach activities are conducted to inform older individuals of available benefits. The law requires benefits counseling services to assist older individuals in understanding their rights, exercising choice, benefiting from services and opportunities authorized by law and maintaining the rights of older persons, especially those with reduced capacity, and solving disputes (42 U.S.C.§3058k(b). Assistance in applying for benefits and appropriate referrals are also a part of counseling process. The Older Americans Act defines legal services to include the work of non-lawyers, which means people who are trained to help the elderly with basic legal problems, but who are not under the direction of lawyers. The services Counselors provide, are of immense benefit to the elderly and are services that lawyers generally do not offer. In 1978, the section of the Older Americans Act relating to legal services, was amended by Congress to encourage the use of non-lawyers for delivery of legal help to older people. This section of the Act defines "legal assistance" as:

". . .legal assistance and representation by an attorney

(including, to the extent feasible, counseling or appropriate assistance by a paralegal or law student under the supervision of an attorney)and includes counseling or representation by a non-lawyer where permitted by law, to older individuals with economic or social needs."

4. These 1978 amendments indicated congressional approval of the OAA’s support of the use of non-lawyers as a component of legal services. Non-lawyers or Benefits Counselors are persons who are knowledgeable and experienced in handling specific legal problems on behalf of an elderly individual. Federal and state laws authorize non-lawyers or Benefits Counselors to counsel and represent people in dealing with eligibility for, or termination, of an array of public benefit programs. These include assistance with government benefits such as Social Security, Supplemental Security Income, Medicaid, Medicare, patient’s rights, Food Stamps, and Veterans benefits. These happen to be programs where there is a vast unmet need for assistance.

5. The OAA of 1965 established a division now known as the Health and Human Services (HHS) to provide a variety of services to older people. The division is the Administration on Aging (AoA). The Act created a system whereby every state would have a central statewide agency for elderly services, and would create sub-state agencies to distribute and monitor funding to service agencies at the community level. The services to be provided include health, transportation, counseling, in-home services, recreation, and nutrition. Services under the OAA are to be provided without demand for payment.

The Benefits Counseling Program consists of two components. In accordance with the Texas Department on Aging rules relating to Benefits Counseling, Texas Administrative Code 40(TAC)§ 260.1, (b) (41) and (42), defines the concepts of legal assistance and legal awareness. Legal Assistance is defined as:

"(A) Advice/Counseling—a recommendation made to a client regarding a course of conduct, or how to proceed in a matter, given either on a brief or one-time basis, or on an ongoing basis, and given either in person or by telephone.

(B) Documentation preparation—personal assistance given to a client which helps him in the preparation of necessary documents relating to public entitlements, health care/long-term care, individual rights, planning/protection options, and housing and consumer issues.

(C) Representation—advocacy on behalf of a client in protesting or complaining against a procedure, or seeking special considerations, appealing an administrative decision, or representation by an attorney of a client or class of clients in either the state or federal court systems."

7. Legal Awareness is defined as:

"The dissemination of accurate, timely and relevant information, eligibility criteria, requirements and procedures, to older Texans about public entitlements, health/long-term care, individual rights, planning/protection options and housing and consumer issues."

8. The Texas regulations at 40 TAC §260.1(a)(8) defines Benefits Counseling as:

"(8) Benefits Counseling – Legal awareness or legal assistance services that assist seniors in claiming the various kinds of benefits to which they may be entitled. Activities may include legal or other assistance in completion of insurance or application documents, and assistance with problems with Social Security, Medicaid, pensions or other benefits."

9. The AAAs recognize HICAP as an important enhancement to their client services. Many of these AAAs are under the umbrella of Councils of Government (COGs). Some exist in the framework of the United Way program.

10. HICAP is made successful through volunteer counselors who use specific information or assistance to counsel individuals. Volunteers are an essential component of HICAP. Only through a statewide network of hundreds of dedicated and trained volunteers will HICAP be able to provide the services seniors require. The training sessions for staff and volunteers provide an objective approach to specific problems with claims and insurance policy review. The program combines federal, state and local resources to serve seniors.

11.  HICAP receives grant dollars from HCFA. At the Federal level the Health Care Financing Administration (HCFA), provides federal grants for HICAP and similar state programs. HCFA is the agency that administers Medicare. At the state level, the Texas Department on Aging (TDOA) is the designated State Health Information Assistance Program (SHIP). The program was created under Section 4360 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 (Public Law 101-508). This section of law authorized HCFA to use funds drawn from the Medicare trust fund to make grants to States to establish service programs for Medicare beneficiaries. Legislation authorized appropriations for three fiscal years and the first grants were issued on September 28, 1992. This authorization was extended through FY 1996. Authorization was not extended after this period, but HCFA continued to fund the programs annually in its own budget.

12. Grant funds were made available to support information, counseling and assistance activities relating to Medicare, Medicaid, and related insurance options. The primary emphasis is customer service on a one-to-one counseling level, to help beneficiaries navigate the new era of health care delivery. SHIPs are viewed as primary HCFA partners in HCFA’s National Medicare Education Program (NMEP).

13. This education program is a multi-faceted campaign that ensures Medicare beneficiaries receive accurate, unbiased information about benefits, rights and options. The campaign includes:

a.  The Medicare and You handbook

b.  The Medicare web site "www.medicare.gov", which includes plan comparison information

c.  The toll-free, consumer friendly "1-800-MEDICAR(E)" call center.

14. This national campaign features a different issue each month. It also sponsors the "Train The Trainer" national workshops. The HICAP and HCFA commitment continues to provide services that provide personal assistance, are responsive, community-based, user-friendly, objective, and complements other channels of information.

15. TDOA and the Texas Department of Insurance (TDI), in conjunction with the Texas Legal Services Center (TLSC) are the support agencies for HICAP.

16. Recognizing the need for a support system to educate beneficiaries and assist them in understanding their available options, and to help them recognize fraudulent practices and react accordingly, Congress authorized the grant program. These programs are designed to offer free and objective information that maintain and operate on the strength of its volunteer base.

17. The training is a 25-hour course to help staff and volunteers hone their counseling skills and outreach techniques. These skills address specific problem solving, support of individual decision-making and referrals to appropriate agencies including legal services for seniors. Proficiency will include Medicare, insurance in the areas of supplemental policies, HMOs, Medicare + Choice, long-term-care policies, Medicaid, Social Security and other related issues. Staff counselors and volunteers will be familiar with the various applications needed to access benefits for qualified seniors.

18. Each Benefits Counselor is responsible for maintaining training files for staff and volunteers and filing certification and re-certification documents. This is a requirement of the Texas Department on Aging. This subject is covered in more detail in the certification program requirements in chapter two of this textbook.

19. The volunteer base is essential to secure Medicare beneficiaries’ appropriate free services. Counselors are responsible for recruiting, screening, training, and placing volunteers throughout their assigned service area. Certified staff counselors and volunteers complete the same training course. Counselor training and oversight of volunteers can be completed in-house, at the sponsoring agency. Volunteers may take calls and practice resolving problems with the guidance of staff counselor oversight. Counselors can supervise the volunteer’s quality of work, record-keeping practices, ability to identify specific "profiles of need" issues and observe communication skills and interaction with clients.

20. The task of recruiting, screening, training and placement of volunteers is a major component of HICAP for staff counselors. As mentioned in the first part of this chapter, the HICAP program is designed to function through volunteers to provide elders with cost-free, competent and confidential counseling. Staff and trained volunteers generate units of Legal Awareness and Legal Assistance and file the same reports each month to TDOA. Again, these numbers become part of the national summary of how this state serves its seniors.

21.  Counselors need to plan a training strategy that:

• Includes a schedule reflecting the dates, time and material covered in each training session;

• Establishes a timeframe for completion of the volunteer course;

• Includes a schedule for volunteer oversight and documentation to support oversight; and

• Provides a filing method which tracks potential volunteers from the initial interest query, actual screening, and the filing of an application and support documentation essential for certification and proof of training.

22. The counselor then determines potential locations for placement. This may be a nutrition site; a church, civic group or any appropriate location that provides confidentiality and privacy. Generally, it should be a location that is frequented by seniors, such as a nutrition site.

23. Contact the potential site manager to determine if the director or manager is agreeable to accepting a volunteer. Scheduling an appropriate time that does not conflict with site activities is very important. Try to give the manager a timeframe for placing a volunteer and explain in great detail what the volunteer will bring to the seniors that congregate at the site. Learn what the manager’s and potential volunteers’ expectations are to avoid confusion about their expectations of each other. Mention that a "get acquainted" introduction will be provided and understand that some time may be needed for the volunteer and seniors to get comfortable with one another before potential clients request one-to-one assistance. Some nutrition sites are interested in the number of seniors that see the volunteer counselor in a month and what subjects were of interest. As long as a breach of confidentiality does not occur, the request for numbers of attendees and subject material is a reasonable request.

24. How does one recruit volunteers? Publicity and announcements are a beginning. Post flyers and announce your recruitment needs at community meetings. Other target sites are housing sites, beauty parlors, churches and libraries. A local church may entertain posting an announcement in their weekly church bulletin. Another publicity tool is the use of "gatekeepers". Gatekeepers are organizations that help seniors by providing some type of social or medical service. Meals on Wheels, physician’s offices, and pharmacies are examples of gatekeepers. Always contact the location you target before you post your advertisement. Vista volunteers have been very effective in the recruitment of counseling volunteers for the AAAs.

25. Establishing a location and placement of your first trained volunteer is just the beginning of elevating the profile of your agency and promoting cost-free valuable senior services. Training will be a constant ongoing project that you will refine with your own creative techniques. What works for one service area may not work for another. You will have to discover the perfect mix of the volunteers’ abilities and the seniors needs. Over time, as a staff counselor, you will come to regard the volunteer as a valuable program tool and counseling partner.

26. Not every potential volunteer will want to do all aspects of the counseling program. Some volunteers may be very successful as outreach public speakers. Others may find the one-to-one counseling a desirable challenge. Sometimes the potential volunteer may find the job different from their expectations. Never send a volunteer away without other avenues to explore. Begin within the agency to determine if there is another position available.

27. For example, the AAA Information and Referral Specialist may need a volunteer to do call-backs to clients, the Ombudsman program may have a volunteer position available or administrative services may need someone to do filing or other office duties. In some areas, competition for volunteers can be very intense. Several competing groups that also recruit volunteers could meet with your agency to share volunteers, looking for the right volunteer activity.

28. Local community-based resources are accessed through county or city based programs and the Texas Department of Human Services (TDHS). For example, the City of Austin and Travis County maintain health clinics to eligible persons based on income and resources through the Medical Assistance Program (MAP). MAP offers limited prescription drug assistance to qualified residents and client cost sharing responsibilities are based on a sliding income scale.

29. Some Departments of Health provide drug assistance using the pharmaceutical indigent drug directory to access free medications. Some county Indigent Health Programs also use this free medication tool. This directory, once available on the Internet on the US Senate Special Committee on Aging WebPages, is no longer published for the public.

30. TDHS provides several in-home care programs that promote independence for the aged and disabled and also administers other Medicaid programs. Family Care, Primary Care and Community Based Alternatives (CBA) are Medicaid in-home care options that have income and asset guidelines, along with physical need criteria. Personal care, homemaker services and licensed nursing case management services are offered to maintain independent living for seniors in their homes. These are programs of the Community Care for the Aged and Disabled (CCAD) segment of TDHS. An assessment and a care plan are developed by the TDHS caseworker and the services are contracted through local home health agencies. A list of contract provider agencies allows the client to select an agency of their choice to provide the care plan services.

31. Benefits Counselors and volunteers will be responsible for screening clients for eligibility benefit requirements and explaining how these programs promote client independence and save money. When a client requests a counselor to act on the client’s behalf, there must be a written client agreement in the client’s file. An example is included in the resource section of this chapter.

32. The HICAP partners also provide valuable resources. The Texas Department of Insurance (TDI) is a support agency of HICAP. TDI is a valuable resource for counselors in their task of counseling and educating seniors about supplemental insurance, HMOs, Medicare + Choice and of long-term-care policies. This agency also generates rate guides for shoppers and complaint and financial information about insurance agencies that sell these types of products. The TDI web site, www.tdi.state.tx.us, showcases its many publications and includes Spanish versions as well. TDI is responsible for generating HICAP videos and other valuable training tools. It is also the repository of counselors and volunteers certification records. All certification applications and support documents of training are submitted to this agency. Certificates and badges are dispensed to qualified applicants after appropriate review.

33. The Texas Legal Services Center (TLSC) is also a support agency of HICAP. The Legal Hotline for Older Texans (LHOT) is a component of the legal assistance advocacy process for clients and counselors. Information about powers of attorney for health care, advance directives, and guardianship are legal issues addressed by this resource.

34. The LHOT provides all technical assistance to clients regarding any type of legal document. These two agencies help counselors navigate the appeals and hearing processes on behalf of clients. For matters which a counselor cannot handle, low-income clients can seek the services of the legal service office that serves the area. The eligibility criteria may vary. Legal service offices cannot accept criminal cases, or fee-generating cases. Most legal service offices do accept cases in the core areas of domestic violence, landlord-tenant, mortgage foreclosure, and public benefit cases. If a legal service office is not the answer for the client, the Legal Hotline for Older Texans may be able to offer a referral to a reduced-fee attorney.

35. The Hotline also provides cost-free legal advice and consultation. In larger cities of Texas, the local bar association often operates a lawyer referral program. The Hotline and TLSC have an Internet web page, www.tlsc.org. The TLSC site showcases several resources that include the links to the basic tools of the Texas Administrative Code (TAC) and the Code of Federal Regulations.

36. Reporting is a significant program requirement for counselors. Interest has grown relative to how all parts of the information infrastructure perform in the effort to serve the sixty plus population. As a result, there is new government-wide emphasis on results and outcomes in all areas. This has brought about increased focus on accountability, including reporting of activity and performance assessments to determine the impact of these service programs. HCFA has begun using its National Performance Report (NPR) as a tool to measure outcomes of the grant partnerships with all states. TDOA is implementing the Advanced Information System (AIM) to satisfy HCFA and the Legislative Budget Board (LBB) in this accountability effort.

37. It is the intent of TDOA to collect the state outcomes generated by the AAAs in the AIM program. Staff Benefit Counselors, their volunteers, and their contractors generate reports in the AIM system. Reports are an essential component in the national summary of how this nation serves its elderly population. The NPR and AIM make accountability possible in Texas.

38. Training or continued professional education is essential to stay abreast of the ever-changing public benefit programs. Always maintain a file to track all training for staff and volunteers. Training is not limited to the manual or TDOA training activities. The AAA may sponsor monthly in-service programs that are relevant to the "profile of needs" list used in legal assistance reporting. This list is part of the "Reports" chapter of the manual. You may also acquire credits through the Ombudsman program’s quarterly training. The Attorney General’s office and AARP generate many fraud-related videos and public educational programs. The Texas Young Lawyers Association is another resource that may provide free clinics for estate planning issues and advanced directives and these activities would be counted toward training and certification requirements for staff and volunteers. Attendance of programs that feature information about Medicaid, insurance or other relevant topics would also be documented and counted as training. Regional counselors can jointly provide training for staff and volunteers with the assistance of HICAP partners. There are limitless opportunities to augment training needs and training opportunities are abundant. The Information and Referral Specialist program is an extension of the program with significant resources for clients. The I & R specialist is also the first source of contact in the AAA for all clients.

39. The HICAP position for AAA staff counselor has three functional layers. The first layer is that of a Staff Benefits Counselor. The second layer is a volunteer coordinator and trainer. The third layer is that of a public relations representative for your respective AAA.

40. The counselor layer provides Legal Assistance and Legal Awareness and generates reports that reflect these tasks. Legal Assistance is one-to-one counseling and advocacy services provided to persons sixty (60) plus and the disabled with Medicare. A need issue is identified, an intake and narrative are generated and reporting is in terms of hourly units spent on the case. When a monetary impact is a result of the case resolution, that is also reported. Most counselors have a set goal of units to be met each month within each AAA. Volunteers and contractors perform this same assignment from an assigned station within the community. More detail about these tasks is in the reporting chapter of the training manual.

41. Legal Awareness includes aspects of outreach and public relations tasks. Legal Awareness is community education and puts into practice communication or Public Relations skills. Legal Awareness involves detailed information about public and private benefits, legal rights, and other elder related issues. A topic is identified, such as "Medicaid programs for Eligible Medicare Beneficiaries", and details of these programs are shared with an audience of one or many. This report counts the number of such events, forums or presentations and includes a sign-in sheet of the attendees. Other outreach activities include public service announcements (PSA’s) to newspapers, radio and television broadcasts. These examples are not limited to specific topics and can include efforts to recruit volunteers. Again, volunteers perform these same tasks and report them in a timely manner to the supervising Staff Benefits Counselor. Successful outreach initiatives will help staff and volunteers identify candidates in need of Legal Assistance. These successful initiatives serve to have a positive influence on the local communities and enhance the awareness of the aging network and its system of service access and delivery.

42. In the resources for this chapter you will find examples for a volunteer job description, a volunteer job application and a complaint resolution tool for volunteers. Included is a list of acronyms, an acronym puzzle to help you become familiar with them and ways to acknowledge and reward your volunteers. An example of a "client release of information" form has been added. There is a survey for volunteers that reflect staff support and training. A Texas map of the 28 Area Agencies on Aging and the regional divisions for these agencies is provided. Appendix A addresses the OAA Benefits Counseling Section.

43. There is a chapter test that can be used to document the HICAP portion of training. The completion of this chapter and test equates to one hour of training credit.

Benefits Counseling Certification Program Chapter One--6/2000

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