State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report

Instructions for Completing the
Client Contact Form for the
State Health Insurance Assistance Program (SHIP)
Submitted to CMS Quarterly

Contents
Definition of Client Contacts ...................................................................................2
When NOT to use the Client Contact Form.............................................................2
Who Completes the Client Contact Form? ..............................................................2
Contact Information .................................................................................................3
SECTION 1–Beneficiary Information .....................................................................6
SECTION 2–Beneficiary Demographics .................................................................7
SECTION 3–Topics Discussed..............................................................................10

According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is
0938-0850. The time required to complete this information collection is
estimated to average 5 minutes per response for the Client Contact Form,
including the time to review instructions, search existing data resources, and
gather the data needed, and complete and review the information collection. If
you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

This document provides definitions and instructions
for the information that is collected and reported on
each contact with a client. All fields in all sections
must be completed, except where noted.
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Definition of Client Contacts
Client Contacts: "Client Contacts" includes all contacts between counselors or staff and clients
which may include elders, Medicare or Medicaid beneficiaries, family members, or others
working on behalf of a client. These contacts can be over the telephone, in person (site), in
person (at home), or via postal mail, e-mail, or fax.
If a SHIP counselor or coordinator works directly with a beneficiary, during or after a Public and
Media Activity Event, to assist him or her with an enrollment or provide other substantial oneon-one assistance, two data elements should be collected:
• a client contact form should be completed to collect as much information as possible about that
counseling contact, AND
• if the SHIP counselor assisted with an enrollment, that person should be included in the
aggregate count for “Estimate # of people enrolled” data field in the section of the PAM form
for that event.

Do NOT use the Client Contact Form for
•

persons reached at public events such as presentations or health fairs. Questions asked
during or after a presentation are not considered individual client contacts unless one-onone counseling occurs.

•

unsuccessful attempts to reach a client (e.g., leaving messages on an answering machine).

Who Completes the Client Contact Form?
The Client Contact Form is used by registered SHIP counselors only, i.e., individuals who have
received counselor training and have signed some type of Counselor Agreement or Memorandum
of Understanding. SHIP counselors may include volunteers, staff, toll-free helpline counselors,
local coordinators/sponsors, etc.

Client Contact Forms are considered confidential. They
must be treated by counselors as confidential information. THE
COUNSELOR MUST ASSURE THE CLIENT THAT ALL
PERSONAL INFORMATION COLLECTED IS CONFIDENTIAL.

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Instructions for Completing the Client Contact Form
All fields in all sections must be completed, except where noted.
Contact Information (top section of page, before "Section 1–Beneficiary Information")
Counselor Name. Enter the name of the registered counselor who provided SHIP services to the
client for this contact. If a team of two counselors helped the client, enter the name of the primary
counselor (only complete one form). You may enter “NC” (not collected) if you do not have the
counselor’s name.

Zip Code of Counseling Location. Enter the zip code of the location where counseling
occurred. If the contact occurred in more than one location or more than once, enter the location
where the first contact occurred. Be sure to enter all five digits of the zip code. Please note this
field will not accept ‘zip plus 4’.

Type of Client/Assistance Requested by. Check the box or boxes that best describe the type of
client or clients who request information or assistance. Check "couple" only if both require SHIP
services for the same issue. If both individuals require assistance, but for different issues,
complete a separate client contact form for each individual. Check “agency” for professionals
calling on behalf of a client or for general information.

How Did Client Learn About the SHIP? Select one source.
• Centers for Medicare and Medicaid Services—CMS (1-800-Medicare,
www.medicare.gov, Medicare & You, CMS Mailing). Check this box if the client
learned about the SHIP from a CMS publication, a Medicare hotline counselor, CMS
website, CMS regional office, or other CMS-sponsored source.
• Presentations/Fairs. Check this box if the client learned about the SHIP at a
presentation or health fair sponsored by the SHIP or other organization.
• State-specific mailings/brochures/posters. Check this box if the client learned about
the SHIP from publicity that your SHIP conducted via mail or SHIP brochures left in
community locations, or distributed by another agency. (e.g. a SHIP brochure enclosed
with a mailing from the Alzheimer’s Association).
• Agency. Check this box if the client was referred by another agency, such as a disability
organization, a senior organization, or an advocacy organization.
• Friend/Relative. Check this box if a friend or relative referred the beneficiary to the
SHIP.

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• Media. Check this box if the client learned about the SHIP from a public service
announcement, radio, newspaper, or other media advertisement.
• Other. Check this box ONLY if the response cannot fit into one of the previous
categories. Please specify the source.
• Not collected. Check this box if client is unsure, does not know, or is not asked.

Date of Initial Client Contact. Enter the date on which the first counseling/assistance session
occurred. Do not count contact with a client to merely set up an appointment for a later date. If
more than one session occurs on the same day, that is considered the same contact. Remember to
include all time spent for multiple contacts on the same day under ‘time spent.’

Date if Multiple Contacts. Enter the date on which an additional contact or
counseling/assistance occurred. Counseling sessions occurring on separate days should be
entered as a separate contact date, even if the counseling session is a follow-up session on the
same topic. You may need to use additional forms if more than two separate contacts occur on
two separate days. You may not enter additional dates unless an initial contact date has been
entered. Also, the additional date must be later than the initial contact date.

Type of Contact. This section reports on the five ways in which counselors provide services to
help the client resolve his/her insurance-related problem(s). Check whether the contact was:
• Quick call (<10 minutes),
• Telephone (>10 minutes),
• In person (site),
• In person (home visit), or
• E-mail/fax/postal mail.
Please collect as much beneficiary information as possible. If the contact was a Quick Call, at a
minimum, try to get Beneficiary Zip Code, Counseling Location Zip Code, and Topic Discussed.
Note: If you have a substantial, one-on-one discussion with a
beneficiary at another location such as the grocery store or church,
you may count this as a contact and check ‘in-person (site)’ as the
type of contact.

Time Spent. Time spent represents the total hours/minutes a counselor spent counseling or
working directly on behalf of the client for each contact.

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This includes the total number of hours/minutes spent on the following activities to resolve the
client's issue(s) related to each contact:
• Counseling
• Researching
• Referring
• Advocating (calling agencies on the client's behalf)
• Trying to reach the client
• Waiting to meet with a client
• Traveling
• Preparing materials to send to the client, and
• Completing paperwork/forms to report the client contact.
In the blank line(s) provided, write in the total number of hours or minutes spent on the case.
Note that some of the time spent may take place on a day other than the contact date. For
example, you may spend 1 hour with the client on the contact date, 1 hour the next day
researching information on behalf of the client and another 20 minutes the following day
completing paperwork. Two hours and 20 minutes should be entered as the total time spent next
to the initial client contact date. Do not include time spent on non-SHIP activities.

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SECTION 1–Beneficiary Information
Enter the name, zip code, and telephone number of the Medicare beneficiary (or pre-Medicare
beneficiary) who is the recipient of SHIP services. This information may be needed to contact the
client with follow-up information and to assist with their particular issue or problem. Identifying
information such as beneficiary name or telephone number do not appear in any analytic
database. If the beneficiary is deceased, information on the beneficiary’s representative should be
entered instead.
Note: Please remember to include area code when recording the
telephone number.
You may enter “NC” (not collected) if you do not have the beneficiary’s name. A SHIP
designated code may be used instead of the beneficiary’s name.
For couples needing assistance with the same issue(s), enter the name of the individual who the
counselor spent more time speaking with. Reminder: if both individuals need assistance with
separate issues, please complete a separate form for each individual.
If an agency professional contacts you for information that is not in reference to a specific
beneficiary, enter N/A (not applicable) in this field and skip to Section 3. Check “agency” for
type of client.

Representative name. If appropriate, enter the name of the person (spouse, relative, friend,
agency staff) helping or representing the beneficiary.

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SECTION 2–Beneficiary Demographics
Beneficiary demographic information shall be completed
only if a client is contacting SHIP for the first time since
April 1. If the beneficiary is deceased, complete this section
for the beneficiary’s representative you are helping.

Steps
1.

First, ask the client if he/she has received SHIP services since April 1. If not, complete the
Beneficiary Demographics Section. Take the word of the client; no check of past records is
necessary. If a client is unsure whether they have received SHIP services since April 1,
complete this section.

2.

Assure the client that the data gathered in this section are confidential and are used for
statistical analysis purposes only. Counselors may read the following statement to the
client: “The program uses this information to get an idea of which clients we are reaching
and which we are not. We can also use this information to demonstrate how many people
we reach so that we can continue to get funding to help Medicare beneficiaries. All
information we collect is strictly confidential--no names will be attached when reported as
totals.”

3.

Even though you may be uncomfortable asking these questions, demographic information
is important data. These data help the SHIP determine whether they are reaching
beneficiaries in various demographic groups and if outreach efforts to specific populations
is warranted. Also, CMS uses this information to gain an understanding of the populations
served by the SHIP program.
The client often communicates demographic information during the course of the
counseling session. In these cases, the counselor does not need to ask for it directly.
Hint: If the contact is in person, the counselor may ask the client to
fill in the demographics him/herself. This can be accomplished
easily by turning the form around to them and giving them a few
minutes to complete it before the counselor continues.
Hint: For couples needing assistance with the same issue(s), for
whom you are completing one client contact form, complete this
section for the individual you spend more time talking with.

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Age or Date of Birth. The counselor may collect either of these items. For the age categories,
check the box that applies to the client. For date of birth, simply record this information in the
allotted space.
Hint: If the client has not volunteered information about his/her
age, it may be easier to ask for date of birth.

Gender. Check the appropriate box.

Monthly income. Check the appropriate box that applies to the client. Check “Not Collected” if
the client refuses to reveal his/her income. While income is a sensitive topic, knowledge of a
client’s income may help the counselor assess whether the client is eligible for Medicaid, QMB,
SLMB, or any other needs-based programs. The Federal Poverty Level (or FPL) varies from state
to state and is adjusted annually. Your SHIP Program Director will provide you with the FPL
income figure for your state to use as reference. Check the appropriate box to indicate whether
the beneficiary’s income is below or equal to/above 150% of this figure. Use the $______ line
either to insert the beneficiary’s actual income (if you are so told—in this case you still must
check a box) or, to insert 150% of FPL for your state, in which case you have the option of
turning the form around to the client, and asking him/her to indicate if their income is below or
equal to/above this figure. Again, your SHIP Program Director will instruct you as to what to
insert on this line.
Note: This category refers to the monthly "household" income of
the client or the client and spouse only, not relatives with whom
the client might be living.
Hint: If the counselor is feeling uncomfortable with this topic, the
counselor might tell the client that there are different programs
available for different income levels. The counselor can provide a
list of the income levels and the programs that correspond with
them and ask the client to report which programs sound appropriate
to his/her income level. The counselor can then explain these
specific programs to the client.
Hint: The counselor might show the client income that is 150% of
the FPL and ask the client whether their income is above or below
this amount.

Disabled. Check “Yes” if the client is currently receiving or applying for Medicare/Social
Security benefits due to disability or End Stage Renal Disease (ESRD).

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Race/Ethnicity. Check the race/ethnicity category that applies to the client.
Hint: It may be helpful to explain to the client that this information
is being collected to ensure that SHIP services are accessible to all
members of the Medicare community, such that no group is under
served.

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SECTION 3–Topics Discussed
Many clients need assistance with more than one issue. Section 3 is designed to reflect all major
topics discussed during the course of the client contact. For example, if a counselor discusses
three topics with a client, then the boxes for all three topics should be checked. Thus, this section
provides a list of the specific issues that require counselor assistance to resolve or understand.
Please note that The Centers for Medicare and Medicaid Services (CMS) will apply a formula to
the data submitted in order to estimate the amount of money the beneficiary will potentially save
as a result of the counseling session. This formula is based on the topics you indicate were
discussed. Topics listed in “other (specify)” are not included in this formula. Please make every
effort to use the categories listed below to ensure accuracy and avoid using the “other” category,
if at all possible.

PRESCRIPTION ASSISTANCE
Medicare Prescription Drug Coverage (PDP/MA-PD)
Plan eligibility, benefit comparisons. Includes helping someone understand Medicare
Prescription Drug Coverage; what the plans do or do not pay for; and answering eligibility and
enrollment questions. Medicare prescription drug coverage is available to all people with
Medicare and is provided through a Prescription Drug Plan (PDP) or a Medicare Health Plan
with Prescription Drug Coverage (MA-PD).

Low-income assistance (also referred to as extra help for persons with limited income and
resources)—eligibility, benefit comparisons. A Medicare-eligible person with income below a
certain limit (below 150% of the federal poverty level--FPL) is eligible for assistance to help pay
for their prescription drugs. This includes helping someone understand what Medicare does and
does not pay for, or answering eligibility and enrollment questions.

Enrollment/application assistance. Includes providing information to and assisting someone,
or a personal representative acting on behalf of an individual, with enrollment in a Medicare
Prescription Drug Coverage plan either on-line with a computer or by assisting with filling out a
paper application.
Claims/billing. Includes any problems with a Medicare Prescription Drug Coverage Plan (PDP
or MA-PD) covering a provider bill or with understanding the claims process that is not resulting
in a review, reconsideration, or appeal. Helping a person sort bills and teaching them how to
organize billings and claims papers fit into this category.

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Appeals/quality of care/complaints. Includes contacts associated with a review,
reconsideration, or formal appeal regarding an original statement from Medicare for Medicare
Prescription Drug Coverage.

Other Sources of Prescription Drug Coverage/Assistance
Medicare-Approved Drug Discount Card. Check here if you discuss any aspect of the
Medicare-Approved Drug Discount Card, including enrollment, low-income assistance, appeals,
etc.

State Pharmacy Assistance Program (SPAP). Includes programs that are administered by
states to provide education and prescription drug coverage to qualified individuals. SPAPs
provide wrap-around coverage and may provide the same or better coverage as other plans.
Costs incurred by SPAPs are counted toward out-of-pocket cost limits when enrolling in a PDP
or MA-PD.

Union/Employer plan. A union or private employer is considered a plan sponsor if they provide
prescription drug coverage to their employees and retirees. They can provide drug coverage in
place of Medicare prescription drug coverage; provide drug coverage that supplements the
Medicare prescription drug coverage; or pay part or all of Medicare prescription drug plan
premiums.

Manufacturer’s Assistance Program. Includes prescription drugs provided by pharmaceutical
manufacturing companies at no or low cost to individuals uninsured for prescription drugs.

Discount plans. Includes private companies that offer prescription drugs at discounted prices.
A discount card can help save on outpatient prescription drug costs. Each drug discount card has
a list of pharmacies where the discount card can be used.
Other. Includes local sources of assistance such as American Red Cross, Salvation Army,
churches, etc. that might be available to help beneficiaries pay for prescription drugs.

MEDICARE (Parts A and B)
Enrollment, eligibility, and benefits. Includes helping someone understand what Medicare
does and does not pay for, or answering eligibility and enrollment questions.

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Claims/billing. Includes any problems with Medicare covering a provider bill or with
understanding the claims process that is not resulting in a review, reconsideration, or appeal.
Helping a person sort bills and teaching them how to organize billings and claims papers fit into
this category.

Appeals/quality of care/complaints. Includes contacts associated with a review,
reconsideration, or formal appeal regarding an original statement from Medicare.

MEDICARE HEALTH PLANS (HMOs, PPOs, PFFS, Special Needs
Plans)
Enrollment, disenrollment, eligibility, comparisons etc. Includes helping someone understand
how Medicare Health Plans (formerly known as Medicare Advantage Plans) work, answering
eligibility and enrollment questions, reviewing similar insurance policies being considered by a
client, and comparing different Medicare Health Plans. It can include any mention of “Medicare
Health Plans” by the client or the need for assistance on any of the expanded health plan choices
including Medicare Health Maintenance Organizations (HMOs), Medicare Preferred Provider
Organizations (PPOs), Medicare Private Fee-For-Service Plans (PFFS plans), or Medicare
Special Needs Plans.

Plan or benefit changes/non-renewals. Includes any changes in a client’s coverage due to plan
non-renewals/terminations, changes in provider participation, changes in premiums, or changes
in covered benefits.

Claims/billing. Includes any problems with a Medicare Health Plan covering a provider bill or
with understanding the claims process that is not resulting in a review, reconsideration, or appeal.
Helping a person sort bills and teaching them how to organize billings and claims papers fit into
this category.

Appeals/quality of care/complaints. Includes contacts associated with an appeal, quality of
care complaint or grievance related to HMOs or other choices authorized under Medicare Health
Plans.

MEDICAID (enrollment, eligibility, benefits)

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All of these categories include helping someone understand what services are covered under a
particular Medicaid program, answering general eligibility and enrollment questions, such as
income and resource limits, and possibly helping clients complete enrollment forms.

QMB/SLMB/QI:
QMB. Includes discussion of eligibility for the Qualified Medicare Beneficiary program that
pays for Medicare premiums, deductibles, and coinsurance.

SLMB. Includes discussion of eligibility for the Specified Low Income Medicare Beneficiary
program that pays for the Medicare Part B premium.

QI. Includes discussion of the Qualifying Individual program that pays for the Medicare Part B
premium.

Other Medicaid (some of these may not apply to all states). Includes discussion of the Regular
Medicaid program, Medicaid for Aged or Disabled, Medically Needy Medicaid, dual eligibility,
LTC/home & community-based waivers, nursing home/spousal impoverishment, or
Supplemental Security Income (SSI).

MEDIGAP/SUPPLEMENT/SELECT
Enrollment, eligibility, comparisons. Includes contacts associated with explaining Medicare
supplement coverage, answering questions about eligibility and enrollment, comparing policies,
or providing information to help someone make a decision on the best policy to meet their
financial needs.

Change coverage. Includes discussion of the way a client can secure comparable or better
insurance coverage, reduce coverage, cancel coverage, or not purchase unnecessary insurance.
This also includes discussion of the Medicaid suspension option, which allows for the
discontinuation of Medicare supplement premiums.

Claims/appeals. Includes problems with Medigap covering a provider bill or with
understanding the claims process. This section also includes contact associated with a review,
reconsideration, or formal appeal regarding a Medigap decision or finding.

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OTHER
Long-Term Care: May include explaining long-term care insurance; discussing eligibility;
reviewing policies; providing someone with the information necessary to make a decision about
whether or not to purchase a LTC policy; discussion of the way a client can secure comparable or
better insurance coverage, reduce coverage, cancel coverage, or not purchase unnecessary
insurance; and claims/appeals.

Fraud and Abuse. May include Medicare fraud and any problems associated with unethical,
illegal, or abusive sales practices by a provider, an insurer, insurance representative, or managed
care sales representative in regard to selling a client insurance policies or health plans. If a
complaint based on abuse or fraud is filed, this category should be checked also.

Military health benefits. May include explaining military health benefits, comparing them to a
Medicare Supplement or referral to a Military Retiree Benefits Information Officer/program. A
retiree may have health benefits through the military, including VA benefits or
TRICARE/CHAMPUS (Civilian Health and Medical Program of the Uniformed Services)
coverage.

Employer health plan or Federal Employee Health Benefits Program (FEHB). May include
explaining an employer group plan or federal employee health plan, comparing one to a Medicare
Supplement, or assisting a client with filing a claim or appeal.

Customer service issues/complaints. May include discussions with clients who experienced
inadequate service when contacting an agency, such as CMS, Social Security Administration,
state Medicaid agency, or a Peer Review Organization. This may include receiving wrong
information, not being treated courteously by a representative, or not receiving assistance with an
issue with which a representative is expected to help them. This also includes problems
associated with unethical, illegal, or abusive sales practices. This does not include claims issues.
Other. Includes any other type of assistance provided by the counselor which is not listed within
the major topic areas, such as COBRA, ERISA (Employee Retirement Income Security Act of
1974), free care, or state specific topics. This can be written in on the blank line provided.
Note: Before checking this category, please verify that the type of
assistance provided doesn’t fit into a pre-existing Topic Discussed
category.

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OPTIONAL NOTES
You may jot down additional notes on this form for the benefit of the counselor only. This
information will not be entered or uploaded to www.SHIPtalk.org, nor will it be used in any way
by CMS. This suggestion is for the convenience of the counselor who may want to keep such
notes.
This can include information helpful to the counselor or coordinator such as a summary of the
question or problem that the client described to the counselor; the type of insurance coverage and
policy numbers if needed for counseling purposes; what action was taken by the counselor and
the outcome or resolution to the problem; referrals to other agencies; whether materials were
mailed to the client; and status of the contact.

EXTRAORDINARY CLIENT SAVINGS
Instructions for counselors to summarize extraordinary savings to clients:
If:
1. A client specifies the exact dollar amount of savings associated with discussion of a
particular topic with the counselor (no calculations necessary by counselor), AND
2. This amount is $10,000 or more, AND
3. The counselor is reasonably sure that the discussion did in fact lead to this amount of
financial savings for the client; then counselors should attach a separate page to the client
contact form to summarize this case as part of their "optional notes".
This summary should include:
• Summary of the question or problem that the client described to the counselor;
• What action was taken by the counselor;
• Outcome or resolution to the problem; and
• Status of the client contact.
SHIP project directors should report these cases in the narrative portion of the Resource Report
Form (Section 8).

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