Get documents about "2008 HICAP INTAKECOUNSELING FORM Model CDA 264
Document Sample
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
Related docs
