Instructions for Completing the
Resource Report Form for the
State Health Insurance Assistance Program (SHIP)
Submitted to CMS every 6 months
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 90 minutes per response for the Resource Report 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.
The following data elements are contained on the SHIP Resource Report Form.
SECTION 1–Number of Active Counselors and Hours 4
a. # Volunteer Counselors 4
b. # SHIP-Paid Counselors 4
c. # In-kind Paid Counselors 5
TOTAL # Counselors 5
d. Volunteer Counselor Hours 5
e. SHIP-Paid Counselor Hours 6
f. In-kind Paid Counselor Hours 6
SECTION 2–Number of Local Coordinators/Sponsors and Hours 7
a. # Volunteer (unpaid) Coordinators 7
b. # SHIP-Paid Coordinators 8
c. # In-kind Paid Coordinators 8
TOTAL # Coordinators 8
d. Volunteer (unpaid) Coordinator Hours 8
e. SHIP-Paid Coordinator Hours 8
f. In-kind Paid Coordinator Hours 9
SECTION 3–Number of Other Paid Staff and Hours 10
a. # SHIP-Paid Other Staff 10
b. # In-kind Paid Other Staff 10
c. SHIP-Paid Other Staff Hours 10
d. In-kind Paid Other Staff Hours 11
SECTION 4–Counselor Trainings 12
a. # Initial Training(s) for New SHIP Counselors 12
b. # New SHIP Counselors Attending Initial Training(s) 12
c. TOTAL # Counselor Hours in Initial Training(s) 12
d. # Update Training(s) for SHIP Counselors 12
e. # SHIP Counselors Attending Update Training(s) 13
f. TOTAL # Counselor Hours in Update Training(s) 13
SECTION 5–Number of Active Counselors with the Following Characteristics 14
a. Years of SHIP service 14
b. Age 14
c. Disability Status 14
d. Gender 14
e. Ethnicity/Race 14
SECTION 6–Web Site Visitors 14
SECTION 7–Key Partnership Activities 14
SECTION 8–Activities, Lessons Learned, Significant Events 15
EXPLANATION OF DATA ITEMS
The following data items should be completed for the entire state for the 6-month report period indicated.
State Office. The state SHIP office is the central office for the SHIP program, where the state SHIP project director, trainers, administrative staff, and/or state toll-free helpline counselors are usually based. These personnel provide counseling to clients from the entire state, not necessarily from only one area/region of the state. Counselors (volunteer or paid) and other personnel who are based in the state office should be counted in the State Office columns.
Local and Field Sites. Local and field sites refer to locations outside the state SHIP office where counselors, coordinators/sponsors, other SHIP staff, or volunteers may be based and/or provide counseling. Examples. A local/regional SHIP program may serve one or more cities/counties and may be located in a local hospital, RSVP (Retired Senior Volunteers Program), senior center, Area Agency on Aging, Senior Information and Referral program, a senior legal services program, a library, or an independent non-profit agency. Counselors (volunteer or paid) and other personnel who are based in these local or field sites should be counted in the “All Other Local and Field Site” columns.
Note: The number of persons working or volunteering for a SHIP may be counted more than once since some coordinators or staff also provide counseling. If this is the case, then include them in both the counselor section (Section 1) and the coordinator section (Section 2). However, their number of hours for the reporting period should not be double-counted. Estimate the hours a person provides towards counseling separate from the hours spent on other tasks such as coordinating a program.
Example: if a coordinator works 4 hours per week for the SHIP program, but spends half of this time counseling clients, then count her as providing 54 hours (2 hours per week x 26 weeks) coordinating and 54 hours (2 hours per week x 26 weeks) counseling.
The name of the grantee agency reporting, the state, the reporting period, the person completing the report, and their phone number are required fields (i.e., you must enter something in this field in order to proceed).
SECTION 1–Number of Active Counselors and Hours
Active
Counselor. Any person who provided counseling, information, or
assistance related to Medicare or other health insurance for a SHIP
during the reporting period. Do not count counselors who did not
provide any counseling during the reporting period, even if they were
trained. The three most common types of counselors utilized by SHIP
programs include:
1) volunteer, 2) SHIP-paid, and 3) in-kind
paid. These include telephone help-line counselors.
It is important to capture all of the work SHIP counselors do to assist beneficiaries including work performed during special campaigns or outreach activities. Active counselors include any temporary counselors or other counselors trained to provide assistance on specific topics (e.g., Medicare Prescription Drug Coverage). These counselors may not have received the full initial training required for new SHIP counselors, but must be a SHIP registered counselor (they have signed some type of Counselor Agreement or Memorandum of Understanding (MOU) with the SHIP). The associated counselor hours should also be included in the number of active counselor hours submitted through NPR reporting.
a. # of Volunteer Counselors. The number of persons who:
provided SHIP counseling hours during the reporting period; AND
were registered volunteer counselors (they have signed some type of Counselor Agreement or Memorandum of Understanding (MOU)); AND
did not receive paid compensation for their time or services (but may have received travel reimbursement).
Volunteer counselors can also include local/area coordinators/sponsors if they also provided SHIP counseling AND were not paid by the SHIP program.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
b. # of SHIP-Paid Counselors. The number of persons who:
provided SHIP counseling hours during the reporting period; AND
Received any compensation for their time and services from the SHIP program, regardless of whether their salary was funded by CMS, the state, or some other funding agency.
Examples: state project directors, receptionists, telephone operators, and paid local/regional coordinators/sponsors, as long as they provided counseling during the reporting period as part of their normal duties.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
c. # of In-kind Paid Counselors. The number of persons who:
provided SHIP counseling during the reporting period; AND
were registered SHIP counselors who have signed some type of Counselor Agreement or MOU; AND
received compensation for their time and services from a program other than SHIP.
Examples include: RSVP staff, hospital staff, senior center staff, Senior Information and Referral staff, Area Agency on Aging staff, and outreach social workers, who may or may not also be local/regional coordinators/sponsors.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
TOTAL # Counselors (a+b+c). Add the numbers of the three types of counselors. This total should be the same as the totals in Section 5.
Note: The hours reported in the next data items should be from the same persons counted in a), b), and c).
d. Volunteer Counselor Hours. The total number of hours the volunteer SHIP counselors (counted in a.) contributed to the SHIP program counseling or working directly on behalf of clients. This includes the total number of hours spent on the following activities to resolve clients’ issues:
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.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
e. SHIP-Paid Counselor Hours. The total number of hours the SHIP-paid counselors (counted in b.) spent in counseling activities described in d) above.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
f. In-kind Paid Counselor Hours. The total number of hours the in-kind paid counselors (counted in c.), spent in counseling activities described in d) above.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
SECTION 2–Number of Local Coordinators/Sponsors and Hours
Coordinator/sponsor definition. A person from a local or field SHIP site (see above definitions) who may do one or more of the following:
supervises counselors,
recruits counselors,
trains counselors,
meets with counselors,
provides administrative support (schedules meetings, provides travel reimbursement),
publicizes the SHIP program,
oversees data reporting,
distributes informational materials,
conducts public and media activities such as presentations or health fairs.
Do NOT include persons/organizations that:
only provide meeting or office space (these can be described in Section 8),
contribute no time to the SHIP program,
provide the same services as a SHIP coordinator for another similar program that is not considered part of the SHIP program.
NOTE: Coordinators can also counsel clients, and thus may also be included both in the number of counselors in Section 1 a), b), or c) and in the number of coordinators in Section 2 a), b), or c). However, do not double count their hours by including total hours in both Section 1 d), e) or f) and Section 2 d), e) or f). Rather, separate counseling hours from coordinator hours if possible. For example, if a coordinator spends 8 hours per week counseling and the remaining 32 hours per week performing SHIP coordinator functions, you would indicate 8 hours x 26 weeks = 208 hours in Section 1 d), e), or f) and 32 x 26 weeks = 832 hours in Section 2 d), e), or f).
a. # of Volunteer (unpaid) Coordinators. The number of persons who:
performed the SHIP coordinator functions defined above AND
did not receive compensation for their time or services (but may have received travel reimbursement).
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
b. # of SHIP-paid Coordinators. The number of persons who:
performed the SHIP coordinator functions defined above AND
Received compensation for their time from the SHIP program, regardless of whether their salary was funded by CMS, the state, or some other funding agency.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
c. # of In-kind Paid Coordinators. The number of persons who:
performed the SHIP coordinator functions defined above AND
received compensation from a program other than SHIP.
Examples include: RSVP paid staff, hospital staff, senior center staff, Senior Information and Referral staff, Area Agency on Aging staff, and outreach social workers.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
TOTAL # Coordinators (a+b+c): Add the numbers of the three types of coordinators.
d. Volunteer (unpaid) Coordinator hours. The total number of hours the volunteer (unpaid) coordinators (counted in a.) contributed to the SHIP program performing the functions of a coordinator, as defined above.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
e. SHIP-Paid Coordinator Hours: The total number of hours the SHIP-Paid coordinators (counted in b.) contributed to the SHIP program performing the functions of a coordinator, as defined above.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
f. In-kind Paid Coordinator Hours. The total number of hours that the In-kind paid coordinators (counted in c.) contributed to the SHIP program performing the functions of a coordinator, as defined above.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
SECTION 3–Number of Other Paid Staff and Hours
Other paid staff definition. Persons who performed other functions for the SHIP aside from the counselor and coordinator functions described above. These persons can include: state project directors, trainers, receptionists, administrative staff, etc. These types of paid staff can work in the state office or local/field sites.
a. # SHIP-Paid Other Staff. The number of persons who:
performed the functions of other paid staff defined above AND
Received compensation for their time and services from the SHIP program, regardless of whether their salary was funded by CMS, the state, or some other funding agency.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
b. # In-kind Paid Other Staff. The number of persons who:
performed the functions of other paid staff defined above AND
received compensation for their time and services by a program other than SHIP.
Examples include: RSVP staff, hospital staff, senior center staff, Senior Information and Referral staff, Area Agency on Aging staff, and outreach social workers.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
c. SHIP-Paid Other Staff Hours. The total number of hours that the SHIP-Paid other staff (counted in a.) contributed to the SHIP program in activities defined above.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
d. In-kind Paid Other Staff Hours. The total number of hours that the In-kind paid other staff (counted in b.) contributed to the SHIP program in activities defined above.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
SECTION 4–Counselor Trainings
a. # Initial Training(s) for New SHIP Counselors. The total number of initial training sessions held throughout the state during the reporting period for new counselors, including volunteer or paid counselors. For example, if 20 local sites in the state conduct one initial training each during the reporting period, report 20 initial trainings. If 4 local sites hold 2 initial trainings each, report 8 initial trainings. Initial trainings that last several days should be counted as one training.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
b. # New SHIP Counselors Attending Initial Training(s). The total number of new counselors, including volunteer or paid counselors, who attended an initial training session for new counselors.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
c. TOTAL # Counselor Hours in Initial Training(s). Multiply the number of counselors who attended initial training (counted in b.) by the number of hours of the initial training session. For example, if ten counselors attended a two day (totaling 16 hours) initial training session, then report 160 total counselor hours in initial training.
d. # Update Training(s) for SHIP Counselors. The total number of update training sessions held throughout the state during the reporting period for counselors, including volunteer or paid counselors. An update training includes regular meetings or training sessions during which counselors are given updates on topics including but not limited to: Medicare changes, health insurance plan choices, counselor skills development, and SHIP program procedures. For example, if 20 local sites in the state conduct one update training each during the reporting period, report 20 update trainings. If 4 local sites hold 2 update trainings each, report 8 update trainings. Update trainings that last several days should be counted as one training.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
e. # SHIP Counselors Attending Update Training(s). The total number of counselors, including volunteer or paid counselors, who attended an update training session.
This is a required field (i.e., you must enter something in this field in order to proceed), however, zero is an acceptable entry.
f. TOTAL # Counselor Hours in Update Training(s). Multiply the number of counselors who attended update training (counted in e.) by the number of hours of the update training session. For example, if ten counselors attend a two hour update training session, then report 20 total counselor hours in update training. If three monthly meetings are held during which you spend 30 minutes on updates and ten counselors attend each meeting, then report 3 X 0.5 hours X 10 = 15 counselor hours in update training.
SECTION 5–Number of Active Counselors with the Following Characteristics
Note: Characteristics should be reported for all active counselors counted in Section 1.
a. Years of SHIP service. Enter the number of counselors who (at the end of the reporting period) had participated in the SHIP program (regardless of which state) for less than 1 year, 1 up to 3 years, 3 up to 5 years, or over 5 years. Also enter the number of counselors for whom this information is not known (not collected).
b. - e. Counselor demographic information (ethnicity/race, age, disability status, gender). The number of counselors with each characteristic plus the number for whom this information is not known (not collected) for each characteristic should equal the total number of counselors entered in Section 1. This includes any persons who provided counseling (volunteers, staff paid by SHIP, or in-kind staff), who may or may not have also performed other duties for the SHIP (coordinator, project director, trainer, receptionist, etc.).
SECTION 6–Web Site Visitors (if applicable)
If your SHIP has its own web site, fill in the number of visitors. Visitors means the number of people who viewed any page of your web site, NOT the total number of pages viewed by that individual. Some duplication of people may occur if someone visits your web site several times during each quarter in the reporting period.
SECTION 7–Key Partnership Activities
In this section, the SHIP director identifies the work done with key partners, including training, counseling, presentations, outreach enrollment/application assistance, etc. In addition to checking which activities were performed, the SHIP director is strongly encouraged to attach a narrative (as part of Section 8) that offers details on key partnership activities, e.g., names of the significant partnership organizations, description of the activity, etc. Key partnerships and partnership activities are those that SHIP directors may want to share with other SHIP programs and CMS. Examples of such partnership events are: a general Medicare training with the local chapter of the National Multiple Sclerosis Society or a prescription drug coverage enrollment event with AARP.
SECTION 8–Activities, Lessons Learned, Significant Events
In this section, SHIP directors are asked to describe activities, lessons learned (including challenges and problems encountered), significant events or developments that they want to share with other SHIP programs and CMS. Please organize the narrative by using the following headings: Outreach (including strategies for under-served populations), Information Access and Dissemination, Training of Staff and Volunteers, and Partnership and Networking (including relationship with carriers, CMS regional offices, etc.) This document should be attached to the Resource Report Form.
Instructions 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;
4. 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.
These “optional notes” should be included in Section 8 of the Resource Report Form.
12/06
| File Type | application/msword |
| File Title | DEFINITIONS FOR SHIP PUBLIC AND MEDIA ACTIVITY FORM |
| Author | Abt Associates Inc. |
| Last Modified By | CMS |
| File Modified | 2006-12-05 |
| File Created | 2006-12-05 |