 I&R  Caregiver MIPPA SMP  DSS issue

Counselor Name:______Date of Contact: ____/_____/

______

Consumer's First Name Last Name Phone

______

Representative' NameAddress Phone

______

Street Address City State Zip Code

Contact Information:

First vs Continuing Contact:  First Contact for Issue Continuing Contacts for issue

How Did Client Learn About Ship:Previous Contact CMS / Medicare Presentations

Mailings Another Agency Friend or RelativeMedia

State Website Other ______Billboard

Method of Contact:Client Age Group:Client Gender:

Phone Call64 or Younger Female

Face to Face at Counseling65-74 Male

Location or Event Site75-84

Face to Face at Client's Home85 or Older

or Facility

Email

Postal Mail or Fax

Client Race-Ethnicity:Client Primary Language:

Hispanic, Latino, or Spanish Origin Primary Language Other Than English

White, Non-HispanicEnglish is Client's Primary Language

Black, African American

American Indian or Alaska Native

Native Hawaiian

Asian ______

Other______

Client Monthly Income:Client Assets:

Below 150% FPL ( under $1,458/mo. or $1966/ mo. couple)Below LIS-$13,300/ $26,580(couple)

At or Above 150% FPL anything over aboveAbove LIS

Receiving or Applying for Social Security Dual Eligible with Mental Illness

Disability or Medicare Disability:/ Mental Disability :

YesYes

NoNo

To be Mailed:

 Medicare Book  Medigap Rate sheet  PDP “QuickGuide  PIF  QMB app  Other _____

TOPICS DISCUSSED

Medicare Prescription DrugMedicare Advantage

Coverage (Part D):(HMO, POS, PPO, SNP)

Eligibility/ScreeningEligibility/Screening

Benefit ExplanationBenefit Explanation

Plans ComparisonPlans Comparison

Plan Enrollment/DisenrollmentPlan Enrollment/Disenrollment

Claims/BillingClaims/Billing

Appeals/GrievancesAppeals/Grievances

Other ______Fraud and Abuse

Marketing/Sales Complaints or Issues

Part D Low Income Subsidy

(LIS/Extra Help):Medicaid & MSP

Eligibility/ScreeningMSP screening (QMB, SLMB)

Benefit ExplanationMSP Application Assistance

 Claims/ BillingMedicaid Application Assistance

Medicaid/QMB Claims

Fraud and Abuse

Other Prescription Assistance:Medicaid (waiver screening),

Union/Employer Plan

Military Drug BenefitsDSS Calls:

Manufacturer ProgramsBenefits Explanation

Other ______Lost Redetermination

 lost Initial application

 DSS Referrals to SHIP

 Unable to reach DSS

MEDICARE (Parts A & B):

EligibilityOther:

Benefit Explanation COBRA

Claims/BillingLTC Insurance/ Partnership

Appeals/GrievancesMilitary Health Benefits

Fraud and AbuseEmployer/Federal Employee

Health Benefits (FEHB)

Medicare Supplement/Select:

DMEPOS

Eligibility/Screening Healthcare Market Place

Benefit Explanation

Plans Comparison

Claims/ Billing

 Preventive Benefits

Total Time Spent on This Contact Date:Status:

General Information and Referral

______Hours______MinutesDetailed Assistance - In Progress

Detailed Assistance - Fully Completed

Problem Solving / Problem Resolution - In Progress

Problem Solving / Problem Resolution - Completed

CMS Special Use Fields

MIPPA CLIENT: 1=LIS  2=MSP

State and Local Special Use Fields

MIPPA AGENCY:  1= CHOICES 2= AAA

MEDICARE B ISSUE:  Y= Yes (left blank is a No)

ESCALATION UNIT:  1=MSP problems 2=Expediting new application IPad Uses:  Y= Yes (If Medicare Part D enrollment or MSP Application/redetermination)