2008 HICAP INTAKECOUNSELING FORM Model CDA 264 by a2302339

VIEWS: 13 PAGES: 63

									INTRODUCTIONS
 YOUR NAME

 HICAP COUNSELING SITE

 VOLUNTEER or PAID STAFF

 YEARS WITH THE PROGRAM


                           2
Agenda
  History Behind the New Form
  Data Reporting = Advocacy
  Overview of New Form Changes
  How to fill out New Intake Form (page 1 & 2)
  Break
  Practice Scenario – Activity Matrix
  Lunch
  How to fill out New Intake Form (page 3 & 4)
  Performance Measures
  Evaluations


                                                 3
INSIDE YOUR FOLDERS ~

   LEFT SIDE          RIGHT SIDE

 Agenda              Intake Form
 Acronyms            Intake Instructions
 Practice Scenario   Definitions
 Notepaper
 Evaluation


                                           4
   HOW AND WHY
WE HAVE A NEW FORM


                     5
History Behind the New Form
 The new Intake/Counseling Form was developed
 over a one year span of time by the MIS Task Group

 The Form was tested in the field by currently
 registered Counselors

 Anecdotes tell us the time spent per client in
 California is higher than the national average

 New fields to encourage documentation of all
 the actions required to assist a client

                                                      6
DATA REPORTING
  = ADVOCACY



                 7
HOW
will more data help my clients?
   Identifies specific client needs

  Documents the number of people who
  have the same issues –
     Systemic vs. Individual

  Empowers advocates who represent
  Medicare consumers
                                       8
WHY should I take the time away from
counseling to fill out more paperwork?
 Hard data documents the issues Medicare
 enrollees are facing daily.
  Reliable numbers augment and support the
 anecdotal information we have provided to CMS,
 Health Plans, and Rx Plans in the past.

 Data provides another format to present the
 problems being faced by the seniors and disabled
 clients you serve.
                                                    9
   OVERVIEW OF
NEW FORM CHANGES


                   10
What’s Different?
INTAKE & THE ADDENDUM - Merged!
DISCLOSURE STATEMENT …can’t miss it

NEW FIELDS
  Previous HICAP client
  Limited English Proficiency
  Dual Eligible check box
  150% Federal Poverty Rate included

CHANGES
 Removed Couples
  Medicare Number & Enrollment/Eligibility Dates
  Single Check Boxes for Veteran
  Medicare Due to Disability
                                                   11
Other Changes
Activity Matrix
    Category of Time Spent
Part D Problems
  3 Sections
       Comparisons – Education -Counseling
       Plan Problems – Non Compliance/Unmet Services
       Complaints - Filed taking action

 CDA Urgent Action Fax – Health and Safety Issues
 Program Manager Notification Required
 Formatting

                                                       12
MODEL FORM
What does this really mean?
The Intake/Counseling Form
    CDA 264 (REV 1/08)
 May be reformatted locally
 May have additional information or fields added
 May not remove any fields
 that also appear on the Aggregate Form
 All Changes Must have CDA approval prior to
 use locally
                                                   13
HOW TO FILL OUT THE
    NEW FORM


                      14
CLIENT ID NUMBER

 Client I.D. Number: Fill in the number that
 is used by your program site to identify
 each client.
 All programs should maintain a client
 tracking system.
   Frequently this is done by staff and not volunteers


                                                         15
 PROVIDER INFORMATION

1. HICAP   PROVIDER NAME
2. PSA   NUMBER
3.   OPEN DATE                4.   CLOSE DATE

            This section can be pre-printed locally


             OTHER INFORMATION AND INSTRUCTIONS REMAIN THE
               SAME AS THE CURRENT INTAKE / COUNSELING FORM

                                                          16
   DISCLOSURE STATEMENT
Moved to the top of the page
Located first – when it is to be read
Increased font size
Easier to read
Protection for registered HICAP Counselors
under W&I Code, Section 9541 (f)


                                             17
SECTION I – CLIENT PROFILE
6.   CLIENT NAME (FIRST, MI, LAST)        7.   DATE OF BIRTH:


8.   ADDRESS:                             9.   TELEPHONE NUMBER:


8a.   CITY:               8b.   COUNTY:   8c.   STATE     8d. ZIP   CODE:



          Moved up on form
          Larger space to write

              OTHER INFORMATION AND INSTRUCTIONS REMAIN THE
                SAME AS THE CURRENT INTAKE / COUNSELING FORM

                                                                            18
10.   ASSISTANCE REQUESTED BY: (check only one)


       Beneficiary (Self )
       Representative
       Agency Representative
11. NAME OF REPRESENTATIVE     12. TELEPHONE NUMBER of REPRESENTATIVE




       COUPLE – Deleted no longer collected
         OTHER INFORMATION AND INSTRUCTIONS REMAIN THE
          SAME AS THE CURRENT INTAKE / COUNSELING FORM


                                                                        19
 NEW ADDITION
13.                     14.

      PREVIOUS CLIENT   PREVIOUS CONTACT DATE
                        (optional)



 13. Check if client has been seen previously at your
       HICAP office…reported to CDA

 14. If applicable, enter date (mo/year) of previous
       contact with client.


                                                        20
Questions to Assist You in
Counseling
   15.   MEDICARE          MEDICARE ENROLLMENT                        16.   Dual Eligible
         NUMBER            (Check all that apply)
         _______           17.   Part A:______      Part B:_____            Part D:_____
                                  Effective Date     Effective Date          Effective Date
         (if applicable)


15. Write N/A if Medicare number is not needed for resolution of the case
16. Check if client is eligible for both Medicare and Medi-Cal.
      New for tracking Dual Eligibles
    17. No longer has a combined check box for “Both A & B”
17. Check a box for every part of Medicare coverage the client has.
    List the date of enrollment in the space provided.
Write N/A if the date of enrollment is not needed for resolution of the case.

                                                                                              21
 Less Boxes to Check!
18.   MEDICARE STATUS DUE TO DISABILITY     19.   VETERAN


 18. Check this box if the client’s Medicare status is due
   to disability.
    No longer Yes or No – must check box for Yes

 19. Check this box if the client is a veteran of the U.S.
     military.
    No longer Yes or No – must check box for Yes

                                                             22
Self Identified Demographics
20. GENDER

                   Female     Male      Not Collected


20. Check appropriate Female or Male box.
  Missing has been changed to Not Collected
     Note: Not collected can be used for phone calls
   where gender is not identified.

         ALL OTHER INFORMATION AND INSTRUCTIONS REMAIN
        THE SAME AS THE CURRENT INTAKE / COUNSELING FORM


                                                           23
NEW Box to Check…
21.   Non-English Speaker /         22.   Primary Language (If Applicable)
      Limited English Proficiency


21. Check this box if client has no or limited
    English speaking ability.
22. List client’s primary language.
    (if applicable)



                                                                             24
Same Question as Before
23. AGE

          Under 60   60-64   65-74   75-84   85+   Not Collected



 23. Client’s age group
    Missing has been changed to Not Collected

             ALL OTHER INFORMATION AND INSTRUCTIONS REMAIN
            THE SAME AS THE CURRENT INTAKE/ COUNSELING FORM



                                                                   25
MARITAL STATUS at Time of Visit
24. MARITAL STATUS

                     Married   Never Married      Separated     Divorced
                     Widowed   Domestic Partner     Not Collected


 24. Client’s Marital Status
       Missing has been changed to Not Collected


           ALL OTHER INFORMATION AND INSTRUCTIONS REMAIN
          THE SAME AS THE CURRENT INTAKE/ COUNSELING FORM




                                                                           26
FPL RATES Provided on Form
25. INCOME                                    2008 150% Monthly FPL Rate
  Less Than 150% of FPL Rate                          Single = $1,300
  Equal to or Greater than 150% of FPL Rate          Married = $1,750
  Not Collected                                (Subject to Change Annually)



25. Client’s Income: above or below 150% of FPL
     Missing has been changed to Not Collected
     Poverty Rate is listed    www.aging.ca.gov
     Be Aware - subject to change annually


                    ALL OTHER INFORMATION AND INSTRUCTIONS REMAIN
                    THE SAME AS THE CURRENT INTAKE/COUNSELING FORM
                                                                              27
ETHNICITY is not RACE
26.   ETHNICITY    (Not Race)
      HISPANIC / LATINO

      No longer Yes or No – must check box for Yes

26. ETHNICITY
     Separate category from race




                                                     28
27.   RACE (Check One):
  Two or More Races           Asian           Native Hawaiian / Pacific
  African American/Black       Asian Indian   Islander
                               Cambodian        Guamanian
  Am. Indian/Alaskan Native    Chinese
                                                 Hawaiian
                               Filipino
  Caucasian/White              Japanese          Samoan
                               Korean            Other Pacific Islander
  Some Other Race              Laotian
                               Vietnamese
  Not Collected                Other Asian


27. Information collected here follows the
same standards used by the U.S. Census.
                                                                          29
      Previously on addendum
   28.HOW          DID CLIENT LEARN ABOUT
                   HICAP? (Check One)
Centers for Medicare and Medicaid Services              Community Forum
  (e.g. 1-800 Medicare, medicare.gov)                     (Presentation/Fair)
Agency (e.g. Senior/Disability Orgs)                    Friend/ Relative

CDA HICAP State-Specific (mailing, brochure,             InfoVan
1-800-434-0222 )
CA Health Advocates (CHA, www.calmedicare.org)          Other

Media (PSA, radio, newspaper)                Internet   Not Collected



          28. Reformatted
              Added California Health Advocates (CHA)

                                                                                30
EXAMPLE ~ From Instructions
                              29.   ACTIVITY MATRIX
           29a.   Mode of Client Contact                                   29b.Time   Spent
Date                   T    IPH      IPS          M      HOURS/MINUTES               ALLOWABLE ACTIVITIES

 8/26                                                           1:45                Counseling      Researching
                                         1          1
                                                                                    Referring       Advocating
  8/27                 2                                         1:30                             (calling agencies on
                                                                                     Trying to
                                                                                                  the client’s behalf )
                                                                                  reach the
  8/29                                             1              :15             client            Preparing material
                                                                                                  to send to the client
  9/2                                              1              :10                Waiting to
                                                                                  meet with a       Completing
                                                                                  client          paperwork/forms to
                                                                                                  report the client
                                                                                                  contact


30.   Legend – Contact Mode:
      T = telephone                          IPS = in person at program site
      IPH = in person at client’s home       M = miscellaneous = mail, fax, e-mail, internet




                                                                                                                          31
EXAMPLE ~ From Instructions

       31.   TOTAL REPORTED CLIENT CONTACTS AND TIME SPENT
                                     31b.
31a.               T   IPH IPS   M
                                     TOTAL COUNSELING   3:40
CONTACTS           2   0    1    3   TIME




                                                               32
EXAMPLE ~ From Instructions
           32.   Category of Time Spent

 Less than 30 minutes    30-59 minutes    60+ minutes




                                                        33
BREAK TIME


             34
PRACTICE CASE SCENARIO
                               29.   ACTIVITY MATRIX
            29a.   Mode of Client Contact                                   29b.Time    Spent
Date                    T    IPH         IPS        M      HOURS/MINUTES               ALLOWABLE ACTIVITIES

  1/23                                                               1:00             Counseling      Researching
                                         1
                                                                                      Referring       Advocating
 1/23                  2                                             :25               Trying to
                                                                                                    (calling agencies on
                                                                                                    the client’s behalf )
                                                                                    reach the
 1/24                                               1                :45            client            Preparing material
                                                                                                    to send to the client
                                                                                       Waiting to
 1/24                  1                                             :34            meet with a       Completing
                                                                                    client          paperwork/forms to
 1/25                                                                :50                            report the client
                                         1                                                          contact

 1/25                                               1                :18

30.   Legend – Contact Mode:
      T = telephone                            IPS = in person at program site
      IPH = in person at client’s home         M = miscellaneous = mail, fax, e-mail, internet


EXAMPLE #1
Multiple contacts on the same date are entered on separate lines.                                                           35
PRACTICE CASE SCENARIO
                               29.   ACTIVITY MATRIX
            29a.   Mode of Client Contact                                   29b.Time    Spent
Date                    T    IPH         IPS        M      HOURS/MINUTES               ALLOWABLE ACTIVITIES

  1/23                                                             1:25               Counseling          Researching
                       2                 1
                                                                                      Referring           Advocating
  1/24                 1                            1              1:19               Trying to reach
                                                                                                        (calling agencies
                                                                                                        on the client’s
                                                                                    the client
                                                                                                        behalf )
  1/25                                    1         1              1:08               Traveling see
                                                                                                          Preparing
                                                                                    definitions
                                                                                                        material to send
                                                                                       Waiting to       to the client
                                                                                    meet with a
                                                                                                           Completing
                                                                                    client
                                                                                                        paperwork/form
                                                                                                        s to report the
                                                                                                        client contact


30.   Legend – Contact Mode:
      T = telephone                            IPS = in person at program site
      IPH = in person at client’s home         M = miscellaneous = mail, fax, e-mail, internet


EXAMPLE #2
All contacts and times combined by date on one line                                                                         36
PRACTICE CASE SCENARIO
       31.   TOTAL REPORTED CLIENT CONTACTS AND TIME SPENT

                   T   IPH IPS   M   31b.
31a.
                                     TOTAL COUNSELING   3:52
CONTACTS
                   3    0   2    2   TIME




                                                               37
PRACTICE CASE SCENARIO
           32.   Category of Time Spent

 Less than 30 minutes    30-59 minutes    60+ minutes




                                                        38
Lunch Break


              39
  CLIENT NEEDS
  EDUCATION &
ASSISTANCE = DATA

                    40
33.   SECTION II CLIENT NEEDS / TOPICS

      Medicare Parts A/B (Original Medicare)
      LTC/LTCI
      Medigap/Supplement / SELECT
      Medicare Health Plans
           All categories listed above have
               Common Sub-Categories



                                               41
33.   SECTION II CLIENT NEEDS / TOPICS
      (Check All That Apply)
                          CLIENT NEEDS
                      Enrollment/Eligibility
                      Benefit Comparison
                      Appeal/Grievances
                      Billings/Claims
                      Fraud/Abuse
                      Coverage Changes

33. Check all topics that were discussed in each category with the client.
        For example; you may discuss various topics with a client in a
        single session.
                  ALL OTHER INFORMATION AND INSTRUCTIONS REMAIN
                 THE SAME AS THE CURRENT INTAKE/COUNSELING FORM
                                                                         42
33. SECTION II CLIENT NEEDS / TOPICS
                    Medi-Cal
           Enrollment/Eligibility
           Fraud/Abuse
           Share of Cost: $    *
           QMB
           SLMB
           Q-1
           SSI
           Part D
           Other:    *

                              * Indicates not aggregated.
                                                            43
33.
      SECTION II CLIENT NEEDS / TOPICS
                     Other Health
                    Coverage/Issues
                Employee Health (Including FEHB)
                TRI-Care / VA
                COBRA
                 Mental Health
                 Fraud/Abuse
                 Other:   *



Renamed: Military Benefits
Removed: Consumer Services Benefits
                                      * Indicates not aggregated.   44
34.   Part D – Medicare Prescription   34. PartD Medicare Prescription
             Drug Coverage
                                         Drug Coverage:
      Plan Eligibility
                                       This category is specific to Part D
      Benefit Comparisons
                                       Medicare Prescription Drug Coverage
      Enrollment Assistance
         Enrolled in Part D
                                        These are topics DISCUSSED
      Appeals/Grievances
                                         Check all that apply
      Billings/Claims
      Coverage Changes                 Enrolled in Part D
      Re-enrollment                           Enrollment in Counselor’s presence OR
                                              knows client will enroll at later date
      Retro. Dis-enrollment
                                              (follow-up may be needed)
      TRooP
                                       LIS Application
      Low Income Subsidy                      Help filling out LIS form
          LIS Application
      Other                                       This was a section of the
                                                     Part D addendum
                                                                                 45
35. Other Prescription
    Drug Coverage Plans

           35. Other Prescription
            Drug Coverage Plans
            Union/Employer

            PPARx

           Drug Discounts

           Other



                                    46
NEW SECTION
36. Plan problems (Non-Compliance/Services Unmet)

        36. Part D Plan Problems
            (Non-Compliance/Services Unmet)
            Eligibility
            Lag-time
            Multiple Enrollment
            Poor training of agents
            Poor training CSR
            Fraud/Abuse
               Marketing fraud/abuse
               Agent fraud/abuse
           Formulary problem
                                                    47
36. Plan problems (Non-Compliance/Services Unmet)
       Continued

       36. Part D Plan Problems
           (Non-Compliance/Services Unmet)
            Formulary changes
            Dosage problem
            Delay in medications
            Data problems
            Incorrect co-pay
            Can’t afford co-pay
            Client reached donut hole
            SSA
           Premium withheld
           Other                                    48
                           NEW SECTION
37. Part D Only Complaint          37. Part D Only Complaint Filed:
               Filed               37a. List the name of the plan and the
                                        plan code, if needed.
37a.   Filed Complaint with Plan   37b. Follow-Up Needed:
                                     Check Plan if you gave the plan
Name of Plan:                        HICAP’s number for follow up,
                                     Check Client if you gave the plan
Contract ID:                         client’s number for follow up.

37b.                               37c. 800 – MEDICARE Complaint
       Follow-Up Needed with:
                                     Quality Report
                                     Problem is resolved, your report
        Plan      Client             is for quality control data
                                      purposes. (CMS Report Card)
37c.   800 MEDICARE Complaint        Casework
                                     You are requesting a CMS
                                     caseworker to assist with the
  Quality Report       Casework      problem’s resolution.

                                                                         49
38. Notify Program Manager to
    Continue – NEW SECTION
   Part D Complaint Filed (cont.)
   38. Notify    Program Manager to Continue
   38a        Filed Complaint with CMS

   38b.       Filed Urgent Action Fax

   38c.        Filed Complaint with SMP

   38d.        Filed Complaint with CDI

          Agent Name: John Doe

          Agent License #: 123ABC
                                               50
39. SECTION III – NOTES ON PROBLEMS,
ACTION AND OUTCOME
 39.   SECTION III–NOTES ON PROBLEMS,
        ACTION AND OUTCOME
 Client:
 Presenting Problem:
 Action:
 Outcome:

 Electronically
     Form grows to fit information
        Extra rows can be removed by deleting to prevent printing
         blank pages
 Manually
     Form may be printed with lines by program
        Written in blank space or on extra pages attached to
         Intake Form
                                                                     51
New CDA Counselor
   ID Numbers


                    52
41. CDA Counselor ID Number
Registration        Sequential number as             Counselor’s
   Year                  registered                    Initials
  ___ ___             __ __ __ - __ __ __ -              __ __


    07                 000     -    345                   JD

                 07– 000- 345– JD

    Everyone will receive a new Counselor registration card
                       Prior to July 1, 2008


                                                                   53
  COUNSELOR
INFORMATION
 Overview
40. Counselor Name _________                    41. CDA Counselor ID No._____

42. Counselor is             HICAP Paid            In-Kind Paid        Volunteer
43. Counseling Site
44.Estimated   Financial Savings                               46.
                                   45.   Counselor Follow-up         Technical Assistance
$_____________                                                       Needed
                                         Needed




                                                                                       55
REFERRALS
No Consultation Required

 47. REFERRALS:
     Other Legal    LTC Ombudsman    Medi-Cal        SSA
     I&A/R         Other (Specify)



 47. Referrals: This category lists referrals that can be
     made without prior Program Manager Consultation.

   Check the boxes that apply to your client case.



                                                            56
FINAL STEP
- Assuring Quality Control -

49.PROGRAM MANAGER SIGNATURE:   50. DATE OF REVIEW:


     After a case is closed, reviewed, and
  signed off by the Program Manager it must
  be kept in a locked file and maintained for
  a period of time specified in the agency
  contract per agreement with CDA.

                                                      58
PERFORMANCE
  MEASURES


              59
Performance Measures

  CMS has implemented nationally mandated
  performance measures
  Data is used to measure comparable State’s
  activities
  New form will help capture data to reflect
  program success in California
  You are the key


                                               60
CMS Performance Measures –
 What They’re Looking At:
 Total Clients Reached

 Medicare Status Due to Disability

 Under 150% of the FPL

 Total Contacts

 Enrollment / Assistance
   Part D Enrollment

 Total Active Counselors
CA Performance Measures OR
Ad Hoc Reports

 Dual Eligible
 Non-English Speaker / LEP
 Mental Health Topics Discussed
 Rural
 Part D Problems / Complaints
ANY QUESTIONS?
 CONTACT INFORMATION
XOCHI PROCK – (916) 928-2289
    xprock@aging.ca.gov
STEVE MIARS – (916) 928-2290
    smiars@aging.ca.gov

       CDA WEBSITE
      www.aging.ca.gov
                               64
     THANK – YOU
 Please take a moment to fill
out your Evaluation Form

 Your feedback is very
important to CDA and the
training process.
                                65

								
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