CMS-10028A. Client Contact Form - Crosswalk

Attachment A

Changes to SHIP National Performance Reporting (NPR) System Forms

Client Contact Form (CMS-10028A)

Current Form	Changes to Form	Reason for Change
TOP OF FORM
Counselor Name:	Dropped	Improved data quality if capture Counselor ID instead and link to counselor name via internal table
	Counselor User ID	Alternative to counselor name
	Agency Code	For administrative and jurisdictional accountability, since agency authority is not always bound to discrete county and zips
Counseling Location Zip Code:	ZIP Code of Counselor Location	Renamed for clarity
	County Code of Counselor Location	Has always been required, just left off the previous form, requiring staff to hand enter
	Client Identifier Used by Your Agency or State	Added so as to be able to assess the total unique clients receiving services, the total number of contacts per client, and the total time spent per client across contacts – using any agency-or-state-specific client identifier preferred by the particular state or agency
	Client Identifier Auto-Assigned by NPR - Optional	Added so as to be able to assess the total unique clients receiving services, the total number of contacts per client, and the total time spent per client across contacts – auto-generated by the NPR database, but also knowable by the end user in the event that the particular agency or state prefers to use this client ID
Type of Client/Assistance Requested by: (check all that apply) Beneficiary (self) Couple Caregiver (family member, conservator) Agency	Dropped	Insufficient value Almost all records coded as beneficiary (self) Reduce user burden
How Did Client Learn About the SHIP: (check one) CMS (1-800-Medicare, www.Medicare.gov , Medicare & You, CMS mailing) Presentations/Fairs State-specific mailings/brochures/ posters Agency (senior org, disability org, Social Security) Friend/Relative Media (PSA, ad, newspaper, radio, etc.) Other: ______________________ Not Collected	How Did Client Learn About SHIP Previous Contact CMS / Medicare Presentations Mailings Another Agency Friend or Relative Media State Website Other Not Collected	Added response options per requests from state SHIPs State Website Previous Contact Renamed Agency option Simplified and generalized other responses
Date of Initial Contact: __ __ / __ __ / __ __ __ __ month / day / year	Date of Contact __ __ / __ __ / __ __ __ __	Each contact is its own record. Removed the two contact restriction so as to allow as many contacts as needed to be recorded for a given client
Type of Contact: Quick call (<10 min) Telephone In- Person (site) In- Person (home visit) E- mail/fax/postal mail	Method of Contact Phone Call Face to Face at Counseling Location or Event Site Face to Face at Client's Home or Facility E-Mail Postal Mail or Fax	Drop quick call since length and nature of call can be deduced form Time Spent and other items. Spilt out email per SHIP requests Other items re-worded for clarity
Time Spent: _________ hours _________ minutes	Total Time Spent on This Contact Date Hours Minutes	Reworded for clarity and precision
Date if Multiple Contact: __ __ / __ __ / __ __ __ __ month / day / year	Dropped	Each contact is its own record.
Type of Contact: [Multiple] Quick call (<10 min) Telephone In- Person (site) In- Person (home visit) E- mail/fax/postal mail	Dropped	Each contact is its own record.
Time Spent: _________ hours _________ minutes	Dropped	Each contact is its own record.
SECTION 1 – BENEFICIARY INFORMATION	Client Name and Contact Information - Optional	Client used instead of beneficiary since some clients are pre-beneficiaries etc.
Beneficiary Name: ________________________________ First Last	Client First Name Client Last Name	Optional for state use. Reworded for clarity.
Beneficiary Telephone #: ( __ __ __ ) __ __ __ - __ __ __ __	Client Phone Number	Optional for state use. Reworded for clarity.
Beneficiary Zip Code:	ZIP Code of Client Residence	Reworded for clarity.
	County Code of Client Residence - Optional	Optional. Useful for county-based analyses since ZIP codes can cross county lines, also useful for referral of client to appropriate county-based services as needed.
Representative Name (if applicable): ____________ ___________________ First Last	Representative First Name Representative Last Name	Reworded
SECTION 2 – BENEFICIARY DEMOGRAPHICS
Is this his/her first contact with a SHIP since April 1? (If Yes, Complete this section. If No, Skip to Section 3)	First Service vs Continuing Service First Contact for Issue Continuing Contacts for Issue	First service vs continuing service replaces the first contact since April 01 item. More precise. Allows grouping of all of a client's contacts into episodes of service to sum total time spent, history of topics, outcomes
Age: Date of Birth: __ __ / __ __ / __ __ __ __ OR month / day / year Under 65 years 75 – 84 Not Collected 65 – 74 85 or older	Client Age Group 64 or Younger 65-74 75-84 85 or Older Not Collected	Reworded. Dropped DOB option
Monthly Income: Below 150% of FPL At or greater than 150% of FPL Not Collected $_____________	Client Monthly Income Below 150% FPL At or Above 150% FPL Not Collected	Reworded title Dropped $ dollar amount
	Client Assets Below LIS Asset Limits Above LIS Asset Limits Not Collected	Added asset item per SHIP request so as to more precisely identify true potential LIS clients
Race/Ethnicity: American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White, Not of Hispanic origin Other Not Collected	Client Race-Ethnicity - Check all that Apply Hispanic, Latino, or Spanish Origin White, Non-Hispanic Black, African American American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan Other Asian Other Pacific Islander Some Other Race-Ethnicity Not Collected	Expand race-ethnicity categories to approximately match 2010 Census. Changed to All the Apply
Gender: Female Male Not Collected	Client Gender Female Male Transgender Not Collected	Reworded title Added Transgender per requests from SHIPs Removed Transgender per OMB comment received
	Primary Language Other Than English Primary Language Other Than English English is Client's Primary Language Not Collected	Added per SHIP request and to document diversity and complexity of cases
Disabled: Yes No Not Collected	Receiving or Applying for Social Security Disability or Medicare Disability Yes No Not Collected	Reworded title for clarity.
	Dual Eligible with Mental Illness Mental Disability Yes No Not Collected	Added a formal item to replace the current ad-hoc method of data collection on this data element (currently “DMD” is entered as a special Other topic via other topic text box).
SECTION 3 – TOPICS DISCUSSED (check all that apply)
Prescription Assistance: Medicare Prescription Drug Coverage (PDP/MA-PD):	Medicare Prescription Drug Coverage (Part D)	Reworded
Plan eligibility, benefit comparisons	Eligibility/Screening	Additional detail and differentiation requested by state SHIPs
	Benefit Explanation	Additional detail and differentiation requested by state SHIPs
	Plans Comparison	Additional detail and differentiation requested by state SHIPs
Enrollment / application assistance	Plan Enrollment/Disenrollment	Additional detail and differentiation requested by state SHIPs
	Plan Non-Renewal	Additional detail and differentiation requested by state SHIPs
Claims / billing	Claims/Billing	Additional detail and differentiation requested by state SHIPs
Appeals/quality of care/complaints	Appeals/Grievance	Additional detail and differentiation requested by state SHIPs
	Fraud and Abuse	Additional detail and differentiation requested by state SHIPs
	Marketing/Sales Complaints or Issues	Additional detail and differentiation requested by state SHIPs
	Quality of Care	Additional detail and differentiation requested by state SHIPs
Low-income assistance - eligibility, benefit comparisons	Part D Low Income Subsidy (LIS/Extra Help) Eligibility/Screening	Additional detail and differentiation requested by state SHIPs
	Part D Low Income Subsidy (LIS/Extra Help) Benefit Explanation	Additional detail and differentiation requested by state SHIPs
	Part D Low Income Subsidy (LIS/Extra Help) Application Assistance	Additional detail and differentiation requested by state SHIPs
	Part D Low Income Subsidy (LIS/Extra Help) Claims/Billing	Additional detail and differentiation requested by state SHIPs
	Part D Low Income Subsidy (LIS/Extra Help) Appeals/Grievances	Additional detail and differentiation requested by state SHIPs
Prescription Assistance: Other Sources of Prescription Drug Coverage/Assistance:	Other Prescription Assistance
Medicare-Approved Drug Discount Card	Dropped	Program no longer exists
State Pharmacy Assistance Program	State Pharmaceutical Assistance Programs	Slight re-wording
Union/Employer plan	Union/Employer Plan	Same
Manufacturer’s Assistance Program	Manufacturer Programs	Reworded
Discount plans	Dropped	Per State SHIP request
	Military Drug Benefits	Added per State SHIP request
Other: ______________________	Other ______________________________	Same
Medicare (Parts A and B)	MEDICARE (Parts A & B)	Reworded
Enrollment, eligibility, benefits	Eligibility	Additional detail and differentiation requested by state SHIPs
	Benefit Explanation	Additional detail and differentiation requested by state SHIPs
Claims/billing	Claims/Billing	Same
Appeals/quality of care/complaints	Appeals/Grievances	Additional detail and differentiation requested by state SHIPs
	Fraud and Abuse	Additional detail and differentiation requested by state SHIPs
	Quality of Care	Additional detail and differentiation requested by state SHIPs
Medicare Health Plans (HMOs, PPOs, PFFS, Special Needs Plans):	MEDICARE ADVANTAGE (HMO, POS, PPO, PFFS, SNP, MSA, Cost)	Reworded
Enrollment, disenrollment, eligibility, comparisons	Eligibility/Screening	Additional detail and differentiation requested by state SHIPs
	Benefit Explanation	Additional detail and differentiation requested by state SHIPs
	Plans Comparison	Additional detail and differentiation requested by state SHIPs
	Plan Enrollment/Disenrollment	Additional detail and differentiation requested by state SHIPs
		Additional detail and differentiation requested by state SHIPs
Plan or benefit changes/non-renewals	Plan Non-Renewal	Additional detail and differentiation requested by state SHIPs, rewording
Claims/billing	Claims/Billing	Same
Appeals/quality of care/complaints	Appeals/Grievances	Additional detail and differentiation requested by state SHIPs
	Fraud and Abuse	Additional detail and differentiation requested by state SHIPs
	Marketing/Sales Complaints or Issues	Additional detail and differentiation requested by state SHIPs
	Quality of Care	Additional detail and differentiation requested by state SHIPs
Medigap/Supplement/SELECT:	MEDICARE SUPPLEMENT/SELECT	Re-worded
Enrollment, eligibility, comparisons	Eligibility/Screening	Additional detail and differentiation requested by state SHIPs
	Benefit Explanation	Additional detail and differentiation requested by state SHIPs
	Plans Comparison	Additional detail and differentiation requested by state SHIPs
Change coverage	Plan Non-Renewal	Additional detail and differentiation requested by state SHIPs
Claims/appeals	Claims/Billing	Additional detail and differentiation requested by state SHIPs
	Appeals/Grievances	Additional detail and differentiation requested by state SHIPs
	Fraud and Abuse	Additional detail and differentiation requested by state SHIPs
	Marketing/Sales Complaints or Issues	Additional detail and differentiation requested by state SHIPs
	Quality of Care	Additional detail and differentiation requested by state SHIPs
Medicaid (enrollment, eligibility, benefits):	MEDICAID	Reworded
QMB/SLMB/QI	Medicare Savings Programs (MSP) Screening (QMB, SLMB, QI)	Additional detail and differentiation requested by state SHIPs
	MSP Application Assistance	Additional detail and differentiation requested by state SHIPs
Other Medicaid	Medicaid (SSI, Nursing Home, MEPD, Elderly Waiver) Screening	Additional detail and differentiation requested by state SHIPs
	Medicaid Application Assistance	Additional detail and differentiation requested by state SHIPs
	Medicaid/QMB Claims	Additional detail and differentiation requested by state SHIPs
	Fraud and Abuse	Additional detail and differentiation requested by state SHIPs
Other:	OTHER
Long-Term Care	Long Term Care (LTC) Insurance	Additional detail and differentiation requested by state SHIPs
	LTC Partnership	Additional detail and differentiation requested by state SHIPs
	LTC Other	Additional detail and differentiation requested by state SHIPs
Military Health Benefits	Military Health Benefits	Same
Employer Health Plan or Federal Employee Health Benefits Program	Employer/Federal Employee Health Benefits (FEHB)	Reworded
	COBRA	Additional detail and differentiation requested by state SHIPs
	Other Health Insurance	Additional detail and differentiation requested by state SHIPs
Customer Service issues/complaints	Dropped	Sufficiently covered among other topics
Fraud and Abuse	Dropped	Sufficiently covered among other topics
Other: _________________	Other __________________________	Same
	Status General Information and Referral Detailed Assistance - In Progress Detailed Assistance - Fully Completed Problem Solving / Problem Resolution - In Progress Problem Solving / Problem Resolution - Fully Completed	Qualitative description of contact (for descriptive categorization, intensity of service analysis, and for stratification of outcome expectations) and documentation of proximal outcomes of services.
	Nationwide and CMS Special Use Fields	10 future use fields for temporary coding of unanticipated mandates (such as DMD) or programs (such as MIPPA). To be defined as needed by CMS.
	State and Local Special Use Fields	10 fields to be used as the discretion of states and local agencies for documentation of state-required or state-desired data elements.