Reporting Forms and Instructions

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CALIFORNIA DEPARTMENT OF AGING

HEALTH INSURANCE COUNSELING & ADVOCACY PROGRAM
(HICAP)

INTAKE INSTRUCTIONS
MODEL CDA 264 (01/2008)

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
OVERVIEW OF THE INTAKE/COUNSELING FORM

The Intake/Counseling Form records each encounter with, or on behalf of a client. The data
gathered on each case is reported to CMS. It asks for information that profiles the client in the
case and his/her needs. The Intake/Counseling Form also records information necessary to
manage each case. It is the primary case management tool as well as a mechanism for
recording and reporting.

INSTRUCTIONS FOR THE INTAKE/COUNSELING FORM

The Intake/Counseling Form is organized into four sections.
Each section collects specific information describing the client or issue(s) of the case.

The questions at the top of Page 1 are for administrative tracking data.

* 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.

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

1. HICAP Provider Name: Identify the name of the agency that provides HICAP
services. The name of the provider may be pre-printed at the local level.
2. PSA Number: The Planning and Service Area (PSA) that provides services where
the client lives.
3. Open Date: Enter the month, day, and year when the counseling session started, in
this format (mm/dd/yyyy).
4. Close Date: Counseling clients may involve one or more visits. Enter the date when
counseling terminates and the case is closed, in this format (mm/dd/yyyy).
5.
Disclosure Statement Provided
HICAP counseling services are provided by Counselors registered by the California Department of
Aging who are acting in good faith to provide information about health insurance polices and
benefits to you, the client. This information shall not be construed to be legal advice, and the
volunteer HICAP Counselor is generally not liable for acts and omissions in providing counseling to
recipients of this service. If you choose a plan and have difficulty in completing the necessary forms
or process for enrollment, the HICAP Counselor will assist you. However, you will be responsible for
the actual plan contract. The HICAP Counselor will NOT choose your plan for you.

5. Disclosure Statement: Check the box to indicate that disclosure statement has been
read, given, and/or mailed to the client. Always provide disclosure statement in
advance of any counseling services. This provides protection for you under W&I
Code, Section 9541(f).

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
SECTION I – CLIENT PROFILE
The client profile collects client characteristics data. This is the individual listed under “client
name” in the form, the primary beneficiary of the counseling sessions.
6. 7.
CLIENT NAME (FIRST, MI, LAST): DATE OF BIRTH:
8. 9.
ADDRESS: TELEPHONE NUMBER:
8a. 8b. 8c. 8d.
CITY: COUNTY: STATE: ZIP CODE:

6. Client name: Name of the person who will benefit most directly from HICAP services.
7. Date-of-Birth: Client’s date of birth, using this format (mm/dd/yyyy).
8. Address: Identify the client’s home address.
a. City: City of the client’s home address or place of residence.
b. County: County where the client lives.
c. State: State where the client lives.
d. Zip Code: Five- or nine-digit zip code that corresponds to client's address. Use the
nine-digit zip code if known.
9. Telephone Number: The contact telephone number for the client (including the area
code) to be used for follow up.
10.
ASSISTANCE REQUESTED BY: (Check only one)
Beneficiary (Self)
Caregiver Representative (CR) (e.g., family member, conservator)
Agency Representative (AR)
11. 12.
NAME OF CR/ AR: TELEPHONE NUMBER of CR/AR

10. Assistance Requested by: Check the box that best describes the person requesting
assistance, either for them or on behalf of another. Note: Check only one box. This
information is aggregated and reported to CDA.
11. Name of CR/AR: The person acting on behalf of the client identified above.
12. Telephone Number of CR/AR: The contact telephone number of the client’s
representative (including the area code) to be used for follow up.
13. 14.
PREVIOUS CLIENT PREVIOUS CONTACT DATE (if known):

13. Previous Client: Check if client has been seen previously at your HICAP office.
14. Previous Contact Date: If applicable, enter date (mo/year) of previous contact with client.
15.
MEDICARE NUMBER:

(if applicable)

15. Medicare Number: Client’s Medicare number. Write “N/A” if the Medicare number is not
needed for resolution of the case.
HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
16.
MEDICARE ENROLLMENT Dual Eligible
(Check all that apply):
17.
Part A: ________ Part B:_______ Part D: _______
Effective Date Effective Date Effective Date

16. Dual Eligible: Check if client is eligible for both Medicare and Medi-Cal.
17. Medicare Enrollment: 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.
18. 19.
MEDICARE STATUS DUE TO DISABILITY VETERAN

18. Medicare Status Due to Disability: Check this box if the client’s Medicare status is
due to disability. This information is aggregated and reported to CDA.
19. Veteran: Check this box if the client is a veteran of the U.S. military. This information
is aggregated and reported to CDA.
20.
GENDER Female Male Not Collected
20. Gender: Check appropriate Female or Male box. Note: Not collected can be used for
phone calls where gender is not identified. This information is aggregated and reported
to CDA.

21. 22.
Non-English Speaker / Limited English Proficiency Primary Language: (If Applicable)

21. Non-English Speaker/Limited English Proficiency: Check this box if client has no/limited
English speaking ability. This information is aggregated and reported to CDA.
22. Primary Language: List client’s primary language (if applicable).
23.
AGE Under 60 60-64 65-74 75-84 85+ Not Collected
23. Age: Check the box for client’s age group at the time that counseling begins.
Note: Not Collected may be checked for clients who do not wish to provide his/her age
group or you cannot obtain it. This information is aggregated and reported to CDA.
24.
Marital Status Married Never Married Separated Divorced Widowed
Domestic Partner Not Collected
24. Marital Status: Check the box that indicates the client’s current marital status. This
information is aggregated and reported to CDA.
25.
INCOME 2007 150% Monthly FPL Rate
Less Than 150% of FPL Rate Single = $1,276
Equal to or Greater than 150% of FPL Rate Married = $1,711
Not Collected (Subject to Change Annually)

25. Income: Check the box that indicates whether the client’s income is above or below
150 % of the FPL rate. The income is self declared by the client. Be aware the FPL
rate changes annually. *Remember: Income level is not an eligibility requirement for
HICAP services. This information is aggregated and reported to CDA.

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
SECTION I - CLIENT PROFILE (Continued)
26
ETHNICITY (Not Race):
HISPANIC / LATINO

26. Hispanic/Latino Origin (Ethnicity): Hispanic is a separate category from race.
Check this box if the client identifies as Hispanic or Latino. (See definitions) This
information is aggregated and reported to CDA.

27.
RACE (Check One):
Two or More Races Asian Native Hawaiian / Pacific
Asian Indian Islander
Caucasian / White Cambodian Guamanian
African American / Black Filipino Hawaiian
Laotian Samoan
American Indian / Alaskan Native Korean Other Pacific Islander
Japanese
Some Other Race Vietnamese
Chinese
Not Collected Other Asian
27. Race: The information collected here follows the same standards used by the U.S.
Census. (See definitions.) Check the box that the client identifies as his/her racial
background. Check only one. If client identifies as two or more races, check only
that one box, you do not need to identify which races. Not Collected may be
checked for clients who do not wish to provide his/her race or you cannot obtain it.
This information is aggregated and reported to CDA.
Note: Asian and Pacific Islander breakouts (or subsets) are required by state law
(citation: Government Code, Section 8310.5).
28.
HOW DID CLIENT LEARN ABOUT HICAP? (Check One)
Centers for Medicare and Medicaid Services Community Forum
(e.g., 1-800-Medicare, www.medicare.gov, Medicare & You, CMS mailing) (e.g., Presentation / Fair)

Agency (e.g., Senior / Disability Organizations, Social Security, Medi-Cal) Friend / Relative
CDA HICAP State-Specific InfoVan
(e.g., Mailings, brochures, posters, 800-434-0222)

California Health Advocates (CHA) www.calmedicare.org Other:

Media (e.g., PSA, ad, newspaper, radio) Internet Not Collected

28. How Did Client Hear About HICAP: Check the box that best describes how the client
heard about HICAP. (Other: List any other method client learned about program)
Check only one box. This information is aggregated and reported to CDA.

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
29.
ACTIVITY MATRIX
29a. 29b.
Mode of Client Contact Time Spent
Date T IPH IPS M C R O T
8/26 1 1:00 :45
8/27 2 1:30
8/29 1
9/2 1

30.
SUB TOTAL 1:00 2:15
29. The Activity Matrix is where contacts with the client, including all counseling
activities on behalf of the client are recorded and time spent providing counseling
services, including services on behalf of the client.
29a. Mode of Client Contact: Record the dates of contact with the client, or his/her
representative. Document any additional dates that don't fit into matrix in
Section III (Notes). Record the number of contact modes for each date
under the corresponding column T, IPH, IPS, and M. (See above.)
Example:
o You met with the client on August 26th in-person at HICAP site (IPS) 1
hour and researched plan for 45 minutes.
o August 27th you made 2 telephone calls (T) on behalf of client lasting a
total of 1 ½ hours.
o August 29th and September 2nd you e-mailed the client (M)
Enter the dates 08/26, 08/27, 8/29, and 9/02 in the date spaces and the
number of contacts under the corresponding category and the time spent in
the corresponding categories.
29b. Time Spent: Enter the time (hour: min) spent for each encounter/contact in the
corresponding category (C, R, O, T). Include direct client counseling, time spent on
behalf of the client researching or other work related to the client’s case. Enter time
as hour: minutes (4:45). (See above)
 Counseling: Enter the time spent providing direct counseling services with client

or client's representative
 Research: Enter the time spent on behalf of client doing research, contacting

other agencies, or other activities related to the case.
 Other: Enter the time spent providing counseling services on behalf of the client.

Other time spent counseling includes, but not limited to, referring, advocating
trying to reach the client, preparing materials to send to the client, completing
paperwork/forms to document the client contacts. Refer to date of counseling, if
applicable. See Definition List for all activities under this category.
 Travel: Enter time spent traveling from the normal place of work to the field

location where other work is to be done that is directly related to the client’s case.
(Time to get there and back to the home office is the travel time). Travel hours do
not include normal commuting time from home to the HICAP office or counseling
locations.
30. Sub-Total Time Spent: Enter total time spent for each category (C,R,O,T).

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
31.
TOTAL REPORTED CLIENT CONTACTS AND TIME SPENT
31a. 31b.
T IPH IPS M
3:15
CONTACTS 2 1 0 2 TIME SPENT

31. Total Reported Client Contacts & Time Spent: These categories are aggregated
and reported to CDA.

31a. Add all client contacts and enter in Total Client Contacts boxes T, IPH, IPS, M.
(See Above)
31b. Add all time sub-totals for Time Spent and enter in Total Time Spent box.
DO NOT ROUND NUMBERS. This category is aggregated and reported to
CDA. (See Above)

32.
Category of Time Spent:
Less than 30 minutes 30-59 minutes 60+ minutes

32. Category of Time Spent: Check the category that identifies the total amount of
time spent providing services to/or on behalf of the client. For example, for 1.5
hours counseling time, the box of 60+ minutes will be checked. (See above)
These categories are aggregated and reported to CDA.

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
SECTION II – CLIENT NEEDS AND COUNSELING TOPICS
This section contains eight categories that identify the type of insurance being discussed.
These categories are aggregated and reported to CDA (except where indicted).
The categories are: Medicare Parts A&B, LTC/LTCI, Medigap/Supplement/SELECT
Medicare Health Plans, Medi-Cal, Other Issues, Part D-Medicare Prescription Drug Coverage,
and Other Prescription Coverage Plans. (See definitions for explanation of topics in each
category.)
33.
SECTION II CLIENT NEEDS / TOPICS (Check All That Apply)
Medicare Parts A/B
LTC/LTCI Medigap/Supplement/SELECT
(Original Medicare)
Enrollment/Eligibility Enrollment/Eligibility Enrollment/Eligibility
Benefit Comparison Benefit Comparison Benefit Comparison
Appeal/Grievances Appeal/Grievances Appeal/Grievances
Billings/Claims Billings/Claims Billings/Claims
Fraud/Abuse Fraud/Abuse Fraud/Abuse
Coverage Changes Coverage Changes Coverage Changes
Medicare Health Plans
(MA, specialty plans, Medi-Cal Other Health Coverage/Issues
managed care)
Enrollment/Eligibility Enrollment/Eligibility Employee Health (Including FEHB)
Benefit Comparison Fraud/Abuse TRI-Care / VA
Appeal/Grievances Share of Cost: $ * COBRA
Billings/Claims QMB Mental Health
Fraud/Abuse SLMB Fraud/Abuse
Coverage Changes Q-1 Other: *
Denial of Service SSI
Re-enrollment Part D
Retro. Dis-enrollment Other: *

33. Check all topics in each category that were discussed with the client.
For example, you may discuss various topics with a client in a single session.

See Definitions for information on each topic.
* Indicates not aggregated. CDA collects the total number of categories checked,
not the list of names for “Other” or dollar amounts listed.

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
34 35.
. Part D – Medicare Prescription Part D Plan Problems
Drug Coverage (Non-Compliance/Services Unmet)
Plan Eligibility Eligibility
Benefit Comparisons Lag-time
Enrollment Assistance Multiple Enrollment
Enrolled in Part D Poor training of agents
Appeals/Grievances Poor training CSR
Billings/Claims Fraud/Abuse
Coverage Changes Marketing fraud/abuse
Re-enrollment Agent fraud/abuse
Retro. Dis-enrollment Formulary problem
TRooP Formulary changes
Low Income Subsidy Dosage problem
LIS Application Delay in medications
Other Data problems
Other Prescription Drug Coverage Incorrect co-pay
Plans Can’t afford co-pay
Union/Employer Client reached donut hole
PPARx SSA Premium withheld
Drug Discounts Other
Other

34. Part D Medicare Prescription Drug Coverage: This category is specific to Part D –
Medicare prescription Drug Coverage. Check all that apply, including Low Income
Subsidy (LIS) application assistance.

35. Part D Plan Problems (Non-Compliance/Services Unmet): This category is specific to
problems a client has with PART D ONLY. Check all that apply. See Definitions for
further information on Part D Problems.

o Multiple Enrollments: Client is mistakenly enrolled in more than one Part D
plan at the same time.
o Formulary Changes: Any changes to the plan’s formulary that remove,
change tiers, or cost changes that negatively affect the client.
o Can’t Afford Co-pay: Client can not afford the co-pay amount to obtain
medications.
o SSA Premium Withheld: Incorrect automatic withholding of Part D premium
payments by Social Security.

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
36.
Part D Complaint Filed
36a.
Filed Complaint with Plan
Name of Plan:
Contract ID:
36b.
Follow-Up Needed with:
Plan Client
36c.
800 MEDICARE Complaint
Quality Report Casework
37.
Notify Program Manager to Continue
Filed Complaint with CMS-RO9
Filed Urgent Action Fax
37a.
Filed Complaint with SMP
37b.
Filed Complaint with CDI
Agent Name:
Agent License #:
36. Part D Complaints Filed: This category is specific to Part D complaints filed.
Check all that apply.

36a. If applicable, list the name of the plan in question and the plan code. Always
start with the Plan then proceed in the order listed.
36b. Follow-Up Needed: Check Plan if you gave the plan HICAP’s number for further
action, check Client if you gave the client’s number to the plan for further action.
Use this reminder to call back either the plan or the client to determine if the
case has been resolved prior to taking further action.
36c. 800 - MEDICARE: Check the appropriate box; Quality Report indicates the plan
has resolved the problem but you are reporting for quality control data purposes.
(CMS Report Card) Casework indicates you are requesting the problem be put in
the tracking system for a CMS caseworker to assist with resolution.
37. Notify Program Manager to Continue: Direct consultation with the Program Manager is
required prior to filing Part D complaints with CMS Region IX (CMS-RO9), CDA Urgent
Action Fax, and/or CDI, which is done simultaneously.
37a. Filed Complaint with SMP: All fraud and abuse complaints should be reported to
SMP. All Part D fraud and abuse cases are automatically reported to the
MEDIC by SMP.
37b. Filed Complaint with CDI: List the agent’s name and the agent’s license number
(if known) for all complaints being referred to CDI.

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
SECTION III – NOTES ON PROBLEMS, ACTIONS, AND RESOLUTIONS
This section is for information you deem important to the client’s case. Attach extra pages if
necessary. Clear documentation is very important for follow-up, Program Manager’s oversight
and the evaluation of counseling and casework. The Program Manager will select one case
summary per reporting period and submit to CDA on the Quarterly Aggregate Report.

38.
SECTION III – NOTES ON PROBLEMS, ACTION AND OUTCOME
(Add additional pages to record if needed.)

Client: Annie Anonymous; a 71-year old woman.

Presenting Problem: Annie needed assistance changing her
Medicare Advantage Plan. The client currently has Medicare and
Health Net as her HMO. She has been with Health Net for many years
and is satisfied with the health care that she receives. However, her eye
doctor wanted her to switch health plans. The client was very perplexed
on how to "switch" health plans so that she could keep her eye doctor.

Action: After some research, the HICAP counselor discovered that the
doctors' office was encouraging his clients to switch from Health Net
(HMO) to a Medigap policy because he was no longer contracting with
Health Net HMO.
However, if the client switched from an HMO to a Medigap policy, she
would have to pay a much higher premium.
With the assistance of the HICAP counselor, the client was able to
compare health coverage offered with the Medigap policies and the
current policy she had with the HMO. As a result, the client decided to
stay with the HMO because she could not afford the Medigap policy,
and simply changed her eye doctor to one that was within the network.

Outcome: With the help of HICAP, the client was able to clearly view
her options and make a sound decision about her healthcare. In
addition, without the counselor, it is quite possible that she may have
taken the advice of her doctor and not been able to afford her own
healthcare.

38. Presenting Problem: Identify the issue or problem that brought client to HICAP for
assistance.

Action: Document all action (see activity matrix) taken to address the issue or
information provided, include key information such as the name of the insurance
company, type of plan, and the policy number. Include anyone contacted and
how they can be reached.

Outcome: Document the outcome of the counseling session. Was the problem
resolved? Is the client now able to make an informed decision? Does the client
have a plan of action?

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
39. 42.
Estimated Financial Savings: $ Counselor Name:
40. 43.
Counselor Follow-up Needed Counselor is: Paid In-Kind Volunteer
41. 44.
Technical Assistance Needed Counseling Site:

39. Estimated Financial Savings: Enter the dollar amount of money saved due to your
assistance. Indicate whether the amount is actual or estimated and check the
corresponding box. (see definitions for estimated savings) This category is aggregated
and reported to CDA.

40. Counselor Follow Up Needed: Check this box if you (Counselor) want to follow up with
the client directly for any reason.

41. Technical Assistance Needed: Check this box if you need additional help to manage
the client’s case. The assistance could come from a more experienced counselor, the
program manager, a special consultant, or an analyst from CDA.

42. Counselor Name: Write the name of the HICAP Counselor with primary responsibility
for counseling and processing the case.

43. Counselor is: Paid, In-Kind, Volunteer (choose one). These categories are reported to
CDA.

44. Counseling Site: Write in the site name where the counseling took place. (e.g., Oak
Leaf Library) Note: For PSA’s where the HICAP program has multiple locations, write
in the name of the site where the counseling sessions took place. If counseling took
place in multiple locations, write the site name where the majority of counseling took
place.
45.
REFERRALS:
Other Legal LTC Ombudsman Medi-Cal SSA SMP
Other (Specify)

45. Referrals: This category lists referrals that can be made without prior Program Manager
Consultation. Check the boxes that apply to your client case. These categories are
aggregated and reported to CDA.

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008
SECTION IV – PROGRAM MANAGER CONSULTATION REQUIRED

SECTION IV – PROGRAM MANAGER CONSULTATION REQUIRED
46.
COMPLAINTS FILED: REFERRALS:
CDI CMS SMP APS Medigap Web Site HICAP Legal (if applicable)
QIO (Lumetra) Other (Specify):

46. Complaints Filed: Direct consultation with the Program Manager is required prior to
filing complaints with CDI, CMS, SMP, APS, QIO, or referring to HICAP Legal. Check
the boxes next to the organizations where complaints are being submitted. These
categories are aggregated and reported to CDA.

47. 48.
PROGRAM MANAGER INITIALS: DATE OF REVIEW:

47. Program Manager Initials: This box should be initialed by the program manager or
designated representative after he/she has reviewed and approved the information
contained in the form. This review must be done within 90 days of the termination or
disengagement of the client case. This is important in the monitoring of performance
and quality control.
48. Date of Review: Write in the month, day, and year (mm/dd/yyyy) of when the Program
Manager or designated representative reviewed and initialed the form. 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. All such records are subject to audit and monitoring.

HICAP Intake/Counseling Form MIS Instructions For Official Use: July 1, 2008

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