Department of Health and Human Services (HHS)

Administration for Community Living (ACL)

State Health Insurance Assistance Program (SHIP)

Delivery:

November 26th, 2019

SHIP Tracking and Reporting System (STARS) Final 

Form Fields
STARS Final Form Fields

1

Contents

Team Member Form ....................................................................................................................................2 

Team Member Activity Form .......................................................................................................................4 

Beneficiary Contact Form.............................................................................................................................5 

Beneficiary Contact: Additional Beneficiary Session Form........................................................................11 

Group Outreach & Education Form ...........................................................................................................14 

Group Outreach & Education: Additional Team Members Form ..............................................................17 

Media Outreach & Education Form ...........................................................................................................17 

Media Outreach & Education: Additional Team Members Form..............................................................20 

Training Form.............................................................................................................................................20 

Additional Training Day Form ....................................................................................................................24 
STARS Final Form Fields

2

Team Member Form

Object Name Required Object Type Input Options/Functions

First Name R Text Field N/A

Middle Initial N Text Field N/A

Last Name R Text Field N/A

Nickname N Text Field N/A

Primary Phone Number R Numbers Field N/A

Primary Phone Number Ext. N Numbers Field N/A

Secondary Phone Number N Numbers Field N/A

Secondary Phone Number Ext. N Numbers Field N/A

Email Address N Text Field N/A

Address N Text Field N/A

City N Text Field N/A

Zip Code R Numbers Field N/A

State/ Territory R Drop Down

Options:

• 54 States and Territories

County R Drop Down Auto-populated based on “Zip 

Code”

Start Date R Date Picker N/A

End Date N Date Picker N/A

Status R Drop Down

Options:

• Active

• Inactive

• Retired

Partner Organization Affiliation R Drop Down

Options:

• Organizations

Paid Status R Drop Down

Options:

• In-Kind-Paid

• SHIP-Paid

• Volunteer

Race R Multi-select Field

Options: 

• American Indian or Alaskan

Native

• Asian

• Black or African American

• Hispanic or Latino
STARS Final Form Fields

3

• Native Hawaiian or Other

Pacific Islander

• White

• Not collected

Date of Birth R Date Picker N/A

Gender R Drop Down

Options:

• Male

• Female

• Other

• Not Collected

Primary Language R Drop Down

Options:

• English

• Chinese

• Korean

• Russian

• Spanish

• Vietnamese

• Other

Secondary Language N Drop Down

Options:

• English

• Chinese

• Korean

• Russian

• Spanish

• Vietnamese

• Other

Role R Drop Down

Options:

• SHIP Director

• SHIP Assistant Director

• SHIP State Staff

• SHIP Sub-State Manager

• SHIP Sub-State Staff

• SHIP Site Manager

• SHIP Site Staff

• SHIP Team Member

• STARS Submitter

• SHIP T/A Center

SHIP eFile ID R Read Only Populated after saving

Send Login Credentials N Radio Button

Options:

• Yes

• No
STARS Final Form Fields

4

Revoke Login N Radio Button

Options:

• Yes

• No

Send SHIP eFile ID N Radio Button 

Options:

• Yes

• No

Revoke SHIP eFile ID N Radio Button

Options:

• Yes

• No

Program R Multi-select Field

Options:

• SMP

• SHIP

• MIPPA

Auto-populate with SHIP

SIRS eFile ID N Numbers Field N/A

Create 1-800-Medicare Unique 

ID number R Radio Button

Options:

• Yes

• No

Send 1-800-Medicare ID N Radio Button

Options:

• Yes

• No

Status of 1-800-Medicare Unique 

ID Number R Drop Down

Options:

• Active

• Inactive

Number of 1-800-Medicare 

Unique ID N Read Only Populated after saving

Notes N Text Box N/A

Attach File N Button 5 attachment fields

User ID N Read Only Populated after saving

Team Member Activity Form

Object Name Required Object Type Input Options/Functions

Month R Drop Down

Options:

• January

• February

• March

• April

• May

• June
STARS Final Form Fields

5

• July

• August

• September

• October

• November

• December

Year R Drop Down

Options:

• 2017

• 2018

• 2019

• 2020

Administrative Support 

(minutes) N Numbers Field Utilizes the Total Time Spent calculator 

SHIP Program Management/ 

Team Member Management 

(minutes)

N Numbers Field Utilizes the Total Time Spent 

calculator 

Other SHIP Activities (minutes) N Numbers Field Field will utilize the 

minutes/hours calculator

Total (minutes) N Read Only Calculator for Minutes Fields

Notes N Text Box N/A

Activity Reference Number R Read only Populated after saving

Beneficiary Contact Form

Object Name Required Object Type Input Options /Functions

MIPPA R Radio Button 

Options:

• Yes

• No

Send to SMP N Radio Button

Options:

• Yes

• No

(Read Only field after

submission)

SIRS eFile ID N Numbers Field

Auto-populated based on the 

Team Member logged in 

Read Only field after 

submission

SIRS Reference Number N Read Only Populated after saving

SHIP Reference Number R Read only Populated after saving
STARS Final Form Fields

6

Session Conducted by R Drop Down Auto-populated based on the 

Team Member logged in

Partner Organization Affiliation R Read Only Auto-populated based on the 

Team Member logged in

Zip Code of Session Location R Numbers Field N/A

State of Session Location R Drop Down

Auto-populated based on “Zip 

Code of Session Location”

List of States and Territories

County of Session Location R Drop Down Auto-populated based on “Zip 

Code of Session Location”

Beneficiary First Name N Text Field N/A

Beneficiary Last Name N Text Field N/A

Beneficiary Phone Number N Number Field N/A 

Beneficiary Email N Text Field N/A

Representative First Name N Text Field N/A

Representative Last Name N Text Field N/A

Representative Phone Number N Numbers Field N/A

Representative Email N Text Field N/A

State of Beneficiary Residence R Drop Down

Auto-populated based on the 

Team Member logged in

Options:

• 54 States and Territories

Zip Code of Beneficiary 

Residence R Numbers Field N/A

County of Beneficiary Residence R Drop Down Auto-populated based on “Zip 

Code of Beneficiary Residence”

Date of Contact R Date Picker • Default to today’s date

How Did Beneficiary Learn About 

SHIP R Drop Down 

Options:

• CMS Outreach

• Congressional Office

• Friend or Relative

• Health/Drug Plan

• Partner Agency

• Previous Contact

• SHIP Mailings

• SHIP Media

• SHIP Presentation

• SHIP TA Center

• SSA

• State Medicaid Agency

• State SHIP Website
STARS Final Form Fields

7

• 1-800 Medicare

• Other

• Not Collected

Method of Contact R Drop Down

Options: 

• Email

• Face to Face at Beneficiary

Home or Facility

• Face to Face at Counseling

Location or Event Site

• Phone Call

• Post Mail/Fax

• Web Based

Beneficiary Age Group R Drop Down

Options:

• 64 or Younger

• 65-74

• 75-84

• 85 or Older

• Not Collected

Beneficiary Gender R Drop Down 

Options:

• Male

• Female

• Other

• Not Collected

Beneficiary Race R Multi-select Field

Options:

• American Indian or Alaskan

Native

• Asian

• Black or African American

• Hispanic or Latino

• Native Hawaiian or Pacific

Islander

• White

• Not Collected

English as a Primary Language? R Radio Button 

Options:

• Yes

• No

Beneficiary Monthly Income R Drop Down 

Options:

• At or Above 150% FPL

• Below 150% FPL

• Not Collected
STARS Final Form Fields

8

Informational Message: (The 

150% FPL monthly income 

limit for 2019 is $1,561.25 for 

an individual, and $2,113.75 

for a couple.)

Beneficiary Assets R Drop Down

Options: 

• Above LIS Asset Limits

• Below LIS Asset Limits

• Not Collected

Informational Message: (The 

2019 LIS asset limit is $14,390 

for an individual, and $28,720 

for a couple.)

Receiving or Applying for Social 

Security Disability or Medicare 

Disability

R Drop Down

Options:

• Yes

• No

To select Yes, 64 or younger 

must be selected in the 

beneficiary age group field

Original Medicare (Parts A & B) N Multi-select Field

Options:

• Appeals/Grievances

• Benefit Explanation

• Claims/Billing

• Coordination of Benefits

• Eligibility

• Enrollment/Disenrollment

• Fraud and Abuse

• QIO/Quality of Care

Medigap and Medicare Select N Multi-select Field

Options:

• Benefit Explanation

• Claims/Billing

• Eligibility/Screening

• Fraud and Abuse

• Marketing/Sales Complaints

and Issues

• Plan Non-Renewal

• Plans Comparison

Medicare Advantage (MA and 

MA-PD) N Multi-select Field

Options:

• Appeals/Grievances

• Benefit Explanation

• Claims/Billing

• Disenrollment
STARS Final Form Fields

9

• Eligibility/Screening

• Enrollment

• Fraud and Abuse

• Marketing/Sales Complaints

and Issues

• Plan Non-Renewal

• Plans Comparison

• QIO/Quality of Care

Medicare Part D N Multi-select Field

Options:

• Appeals/Grievances

• Benefit Explanation

• Claims/Billing

• Disenrollment

• Eligibility/Screening

• Enrollment

• Fraud and Abuse

• Marketing/Sales Complaints

and Issues

• Plan Non-Renewal

• Plans Comparison

Part D Low Income Subsidy 

(LIS/Extra Help) N Multi-select Field

Options:

• Appeals/Grievances

• Application Assistance

• Application Submission

• Benefit Explanation

• Claims/Billing

• Eligibility/Screening

• LI NET/BAE

Other Prescription Assistance N Multi-select Field

Options:

• Manufacturer Programs

• Military Drug Benefits

• State Pharmaceutical

Assistance Programs

• Union/Employer Plan

• Other

Medicaid N Multi-select Field

Options:

• Application Submission

• Benefit Explanation

• Claims/Billing

• Eligibility/Screening

• Fraud and Abuse
STARS Final Form Fields

10

• Medicaid Application

Assistance

• Medicare Buy-in

Coordination

• Medicaid Managed Care

• MSP Application Assistance

• Recertification

• Other

Other Insurance N Multi-select Field

Options:

• Active Employer Health

Benefits

• COBRA

• Indian Health Services

• Long Term Care (LTC)

Insurance

• LTC Partnership

• Other Health Insurance

• Retiree Employer Health

Benefits

• Tricare For Life Health

Benefits

• Tricare Health Benefits

• VA/Veterans Health Benefits

• Other

Additional Topic Details N Multi-select Field

• Ambulance

• Dental/Vision/Hearing

• DMEPOS

• Duals Demonstration

• Home Health Care

• Hospice

• Hospital

• New Medicare Card

• New to Medicare

• Preventive Benefits

• Skilled Nursing Facility

Time Spent in Hours N Numbers Field Utilizes the Total Time Spent 

calculator 

Time Spent in Minutes N Numbers Field Utilizes the Total Time Spent 

calculator

Total Time Spent (Minutes) R Numbers Field Calculator for Hours and 

Minutes Fields

Status R Drop Down Options:
STARS Final Form Fields

11

• In Progress

• Completed

Special Use Fields N Text Field 5 free text special use fields

Notes N Text Field N/A

Attach File N Button 5 attachment fields

Beneficiary Contact: Additional Beneficiary Session Form

Object Name Required Object Type Input Options /Functions

MIPPA R Radio Button 

Options:

• Yes

• No

Session Conducted by R Drop Down Auto-populated based on the 

Team Member logged in

Partner Organization Affiliation R Read Only Auto-populated based on the 

Team Member logged in

Zip Code of Session Location R Numbers Field N/A

State of Session Location R Drop Down

Auto-populated based on “Zip 

Code of Session Location”

List of States and Territories

County of Session Location R Drop Down Auto-populated based on “Zip 

Code of Session Location”

Date of Contact R Date Picker • Default to today’s date

Method of Contact R Drop Down

Options: 

• Email

• Face to Face at Beneficiary

Home or Facility

• Face to Face at Counseling

Location or Event Site

• Phone Call

• Post Mail/Fax

• Web Based

Original Medicare (Parts A & B) N Multi-select Field

Options:

• Appeals/Grievances

• Benefit Explanation

• Claims/Billing

• Coordination of Benefits

• Eligibility

• Enrollment/Disenrollment

• Fraud and Abuse
STARS Final Form Fields

12

• QIO/Quality of Care

Medigap and Medicare Select N Multi-select Field

Options:

• Benefit Explanation

• Claims/Billing

• Eligibility/Screening

• Fraud and Abuse

• Marketing/Sales Complaints

and Issues

• Plan Non-Renewal

• Plans Comparison

Medicare Advantage (MA and 

MA-PD) N Multi-select Field

Options:

• Appeals/Grievances

• Benefit Explanation

• Claims/Billing

• Disenrollment

• Eligibility/Screening

• Enrollment

• Fraud and Abuse

• Marketing/Sales Complaints

and Issues

• Plan Non-Renewal

• Plans Comparison

• QIO/Quality of Care

Medicare Part D N Multi-select Field

Options:

• Appeals/Grievances

• Benefit Explanation

• Claims/Billing

• Disenrollment

• Eligibility/Screening

• Enrollment

• Fraud and Abuse

• Marketing/Sales Complaints

and Issues

• Plan Non-Renewal

• Plans Comparison

Part D Low Income Subsidy 

(LIS/Extra Help) N Multi-select Field

Options:

• Appeals/Grievances

• Application Assistance

• Application Submission

• Benefit Explanation

• Claims/Billing
STARS Final Form Fields

13

• Eligibility/Screening

• LI NET/BAE

Other Prescription Assistance N Multi-select Field

Options:

• Manufacturer Programs

• Military Drug Benefits

• State Pharmaceutical

Assistance Programs

• Union/Employer Plan

• Other

Medicaid N Multi-select Field

Options:

• Application Submission

• Benefit Explanation

• Claims/Billing

• Eligibility/Screening

• Fraud and Abuse

• Medicaid Application

Assistance

• Medicare Buy-in

Coordination

• Medicaid Managed Care

• MSP Application Assistance

• Recertification

• Other

Other Insurance N Multi-select Field

Options:

• Active Employer Health

Benefits

• COBRA

• Indian Health Services

• Long Term Care (LTC)

Insurance

• LTC Partnership

• Other Health Insurance

• Retiree Employer Health

Benefits

• Tricare For Life Health

Benefits

• Tricare Health Benefits

• VA/Veterans Health Benefits

• Other

Additional Topic Details N Multi-select Field

• Ambulance

• Dental/Vision/Hearing

• DMEPOS
STARS Final Form Fields

14

• Duals Demonstration

• Home Health Care

• Hospice

• Hospital

• New Medicare Card

• New to Medicare

• Preventive Benefits

• Skilled Nursing Facility

Time Spent in Hours N Numbers Field Utilizes the Total Time Spent 

calculator 

Time Spent in Minutes N Numbers Field Utilizes the Total Time Spent 

calculator

Total Time Spent (Minutes) R Numbers Field Calculator for Hours and 

Minutes Fields

Special Use Fields N Text Field 5 free text special use fields

Notes N Text Field N/A

Attach File N Button 5 attachment fields

Additional Session Reference 

Number R Read only Populated after saving

Group Outreach & Education Form

Object Name Required Object Type Input Options/Functions

MIPPA R Radio Button 

Options:

• Yes

• No

Send to SMP N Radio Button

Options:

• Yes

• No

(Read Only field after

submission)

SIRS eFile ID N Numbers Field

Auto-populated based on the 

Team Member logged in 

Read Only field after 

submission

SIRS Reference Number N Read Only Populated after saving

SHIP Reference Number R Read Only Populated after saving

Session Conducted By R Drop Down Auto-populated based on the 

Team Member logged in
STARS Final Form Fields

15

Users will have the ability to 

track additional Time Spent for 

Other contributors on an 

additional tab

Partner Organization Affiliation R Read Only Auto-populated based on the 

Team Member logged in

Time Spent in Hours N Numbers Field Utilizes the Total Time Spent 

calculator 

Time Spent in Minutes N Numbers Field Utilizes the Total Time Spent 

calculator

Total Time Spent (Minutes) R Numbers Field Calculator for Hours and 

Minutes Fields

Title of Interaction R Text Field N/A

Type of Event R Drop Down

Options:

• Booth or Exhibit (Health

Fair, Senior Fair, or

Community Event)

• Enrollment Event

• Interactive Presentation to

Public (In-Person, Video

Conference, Web based

Event, Tele Conference)

Number of Attendees R Numbers Field N/A

Start Date of Activity R Date Picker Default to today’s date

End Date of Activity N Date Picker Allows future dates 

State of Event R Drop Down Auto population based on the 

Team Member profile

Zip Code of Event R Numbers Field N/A

County of Event R Drop Down Auto population based on “Zip 

Code of Event”

Event Contact First Name N Text Field N/A

Event Contact Last Name N Text Field N/A

Event Contact Phone Number N Numbers Field N/A

Event Contact Email N Text Field N/A

Intended Audience R Multi-select Field 

Options

• Beneficiaries

• Employer-Related Groups

• Family Members/Caregivers

• Limited-English Proficiency

• Medicare Pre-Enrollees

• Partner Organizations
STARS Final Form Fields

16

• People with Disabilities

• Rural Beneficiaries

• Other

Target Beneficiary Group R Multi-select Field 

Options:

• American Indian or Alaskan

Native

• Asian

• Black or African American

• Disabled

• Hispanic/Latino

• Languages Other Than

English

• Low Income

• Native Hawaiian or other

Pacific Islander

• Rural

• N/A

• Not Collected

Topics Discussed R Multi-select Field 

Options:

• Duals Demonstration

• Extra Help/LIS

• General SHIP Program

Information

• Long-Term Care Insurance

• Medicaid

• Medicare Advantage

• Medicare Fraud and Abuse

• Medicare Part D

• Medicare Savings Program

• Medigap or Supplemental

Insurance

• Original Medicare (Parts A

and B)

• Other Prescription Drug

Coverage

• Partnership Recruitment

• Preventive Services

• Volunteer Recruitment

• Other

Special Use Fields N Text Field 5 free text special use fields

Notes N Text Field N/A

Attach File N Button 5 Attach File fields
STARS Final Form Fields

17

Group Outreach & Education: Additional Team Members Form

Object Name Required Object Type Input Options /Functions

Session Conducted By R Drop Down Team Members in the system 

Partner Organization Affiliation R Read Only

Auto-populated based on the 

Team Member selected in 

Session Conducted by

Time Spent in Hours N Numbers Field Utilizes the Total Time Spent 

calculator 

Time Spent in Minutes N Numbers Field Utilizes the Total Time Spent 

calculator

Total Time Spent (Minutes) R Numbers Field Calculator for Hours and 

Minutes Fields

Additional Team Member 

Reference Number R Read Only Populated after saving

Media Outreach & Education Form

Object Name Required Object Type Input Options/Functions

MIPPA R Radio Button 

Options:

• Yes

• No

Send to SMP N Radio Button

Options:

• Yes

• No

(Read Only field after

submission)

SIRS eFile ID N Numbers Field

Auto-populated based on the 

Team Member logged in 

Read Only field after 

submission

SIRS Reference Number N Read Only Populated after saving

SHIP Reference Number R Read Only Populated after saving

Session Conducted By R Drop Down Auto-populated based on the 

Team Member logged in
STARS Final Form Fields

18

Users will have the ability to 

track additional Time Spent for 

Other contributors on an 

additional tab

Partner Organization Affiliation R Read Only Auto-populated based on the 

Team Member logged in

Time Spent in Hours N Numbers Field Utilizes the Total Time Spent 

calculator 

Time Spent in Minutes N Numbers Field Utilizes the Total Time Spent 

calculator

Total Time Spent (Minutes) R Numbers Field Calculator for Hours and 

Minutes Fields

Title of Interaction R Text Field N/A

Type of Media R Drop Down

Options:

• Billboard

• Email

• Magazine

• Newsletter

• Newspaper

• Radio

• Social Media

• Television

• Website

• Other

Estimated Number of People 

Reached N Numbers Field N/A

Geographic Coverage N Drop Down

Options:

• County or Counties

• Multi-State

• National

• Regional

• Statewide

• Zip Code

Start Date of Activity R Date Picker Default to today’s date

End Date of Activity N Date Picker Allows future dates 

State of Event R Drop Down Auto population based on the 

Team Member profile

Zip Code of Event R Numbers Field N/A

County of Event R Drop Down Auto population based on “Zip 

Code of Event”

Media Contact First Name N Text Field N/A
STARS Final Form Fields

19

Media Contact Last Name N Text Field N/A

Media Contact Phone Number N Numbers Field N/A

Media Contact Email N Text Field N/A

Intended Audience R Multi-select Field 

Options

• Beneficiaries

• Employer-Related Groups

• Family Members/Caregivers

• Limited-English Proficiency

• Medicare Pre-Enrollees

• Partner Organizations

• People with Disabilities

• Rural Beneficiaries

• Other

Target Beneficiary Group R Multi-select Field 

Options:

• American Indian or Alaskan

Native

• Asian

• Black or African American

• Disabled

• Hispanic/Latino

• Languages Other Than

English

• Low Income

• Native Hawaiian or other

Pacific Islander

• Rural

• N/A

• Not Collected

Topics Discussed R Multi-select Field 

Options:

• Duals Demonstration

• Extra Help/LIS

• General SHIP Program

Information

• Long-Term Care Insurance

• Medicaid

• Medicare Advantage

• Medicare Fraud and Abuse

• Medicare Part D

• Medicare Savings Program

• Medigap or Supplemental

Insurance
STARS Final Form Fields

20

• Original Medicare (Parts A

and B)

• Other Prescription Drug

Coverage

• Partnership Recruitment

• Preventive Services

• Volunteer Recruitment

• Other

Special Use Fields N Text Field 5 free text special use fields

Notes N Text Field N/A

Attach File N Button 5 Attach File fields

Media Outreach & Education: Additional Team Members Form

Object Name Required Object Type Input Options /Functions

Session Conducted By R Drop Down Team Members in the system 

Partner Organization Affiliation R Read Only

Auto-populated based on the 

Team Member selected in 

Session Conducted by

Time Spent in Hours N Numbers Field Utilizes the Total Time Spent 

calculator 

Time Spent in Minutes N Numbers Field Utilizes the Total Time Spent 

calculator

Total Time Spent (Minutes) R Numbers Field Calculator for Hours and 

Minutes Fields

Additional Team Member 

Reference Number R Read Only Populated after saving

Training Form

Object Name Required Object Type Input Options/Functions

Title of Training R Text Field N/A

Training Month R Drop Down

Options

• January to December

Training Day NR Drop Down

Options

• 1

st to the 31st

The drop down will filter 

options based on the month 
STARS Final Form Fields

21

selected. Validation will 

prevent invalid dates from 

being selected during leap 

years

Training Year R Numbers Field

Options:

• 2017

• 2018

• 2019

• 2020

Validation will prevent 

years outside of those 

identified above from being 

entered

Part of a Multi-Day Series R Radio Button

Options:

• Yes

• No

Delivery Method R Multi-Select

Options:

• In person

• Online – Self Paced

• Webinar

• Other

Type of Training R Dropdown

Options:

• Orientation

• Initial

• Update

Submitted by R Drop Down 

Auto-populated based on 

the Team Member logged 

in

Partner Organization 

Affiliation R Read Only Auto-populated after saving.

Trainer 1 First Name and Last 

Name NR Text Field

The field will be used to 

capture the trainer’s first 

and last name

Trainer 1 Additional 

Information NR Text Field

Blank text field used to 

collect the following 

information:

• Contact Info (email &

phone)

• Organization
STARS Final Form Fields

22

Trainer 2 First Name and Last 

Name NR Text Field

The field will be used to 

capture the trainer’s first 

and last name

Trainer 2 Additional 

Information NR Text Field

• Contact Info (email &

phone)

• Organization

Number of Attendees R Numbers Field N/A

Attach Attendee List NR Button • 1 attachment field

Length of Training (hours) NR Numbers Field N/A

Length of Training (minutes) NR Numbers Field N/A

Total Length of Training 

(minutes) R Read Only N/A

Training Location NR Heading N/A

Location

Zip Code NR Numbers Field N/A

State/ Territory R Drop Down

Options:

• 54 States and

Territories

County of Training Location NR Drop Down Auto-populated based on 

“Location Zip Code”

Address NR Text Field N/A

Location Contact First Name NR Text Field N/A

Location Contact Last Name NR Text Field N/A

Location Contact Email NR Text Field N/A

Location Contact Phone NR Text Field N/A

Geographic Coverage NR Dropdown

Options

• Municipality

• County

• Regional

• Statewide

Training Topics R Heading

Additional Guidance 

Message: “At least one 

Training Topic selection is 

required. Multiple 

selections allowed)

Benefits Topics NR Multi-Select

• Original Medicare

(Parts A & B)

• Medicare Advantage

(MA and MA-PD)

• Medicare Part D
STARS Final Form Fields

23

• Part D Low Income

Subsidy (LIS/Extra Help)

• Other Prescription

Assistance

• Other Health Insurance

• Duals Demonstration

• Preventive Services

• Medigap or Medicare

Select

• Long-term Care

Insurance

• Medicaid

• Medicare Savings

Programs

• Medicare Plan Finder

• Coordination of

Benefits

• Marketing Regulations

• Veterans Health

Benefits

• Employer Health

Benefits

Administrative Topics

NR Multi-Select

Options:

• CMS Unique ID

• Customer

Service/Counseling

Skills

• Performance Measures

• Forms & Reporting

• Program Information

• Outreach

• Confidentiality

• Presentation Skills

• Program Management

Notes NR Long Text Box N/A

Attach File NR Button 5 attachment fields

Training Reference Number NR Text Field

Auto-Populated after 

saving. State abbreviation 

will be based on the 

State/Territory selected.
STARS Final Form Fields

24

Additional Training Day Form

T (Training) will be 

appended to differentiate 

the form in the Reference 

Number

Example: 

BTO: “OR-18-41529-T-API”

Object Name Required Object Type Input Options/Functions

Title of Training R Text Field N/A

Training Month R Drop Down

Options

• January to December

Training Day NR Drop Down

Options

• 1

st to the 31st

The drop down will filter 

options based on the 

month selected. Validation 

will prevent invalid dates 

from being selected during 

leap years

Training Year R Numbers Field

Options:

• 2017

• 2018

• 2019

• 2020

Validation will prevent 

years outside of those 

identified above from being 

entered

Delivery Method R Multi-Select

Options:

• In person

• Online – Self Paced

• Webinar

• Other

Type of Training R Dropdown Options:

• Orientation
STARS Final Form Fields

25

• Initial

• Update

Submitted by R Drop Down 

Auto-populated based on 

the Team Member logged 

in

Partner Organization 

Affiliation R Read Only

Auto-populated after 

saving.

The record will be aligned 

to the Partner Organization 

Affiliation of the user 

selected in the Submitted 

by field of the CTO.

Trainer 1 First Name and Last 

Name NR Text Field

The field will be used to 

capture the trainer’s first 

and last name

Trainer 1 Additional 

Information NR Text Field

Blank text field used to 

collect the following 

information:

• Contact Info (email &

phone)

• Organization

Trainer 2 First Name and Last 

Name NR Text Field

The field will be used to 

capture the trainer’s first 

and last name

Trainer 2 Additional 

Information NR Text Field

• Contact Info (email &

phone)

• Organization

Number of Attendees R Numbers Field N/A

Attach Attendee List NR Button • 1 attachment field

Length of Training (hours) NR Numbers Field N/A

Length of Training in (hours) NR Numbers Field N/A

Total Length of Training 

(minutes) R Read Only N/A

Training Location NR Heading N/A

Location

Zip Code NR Numbers Field N/A

State/ Territory R Drop Down

Options:

• 54 States and

Territories
STARS Final Form Fields

26

County of Training Location NR Drop Down Auto-populated based on 

“Location Zip Code”

Address NR Text Field N/A

Location Contact First Name NR Text Field N/A

Location Contact Last Name NR Text Field N/A

Location Contact Email NR Text Field N/A

Location Contact Phone NR Text Field N/A

Geographic Coverage NR Dropdown

Options

• Municipality

• County

• Regional

• Statewide

Training Topics R Heading

Additional Guidance 

Message: “At least one 

Training Topic selection is 

required. Multiple 

selections allowed)

Benefits Topics NR Multi-Select

• Original Medicare

(Parts A & B)

• Medicare Advantage

(MA and MA-PD)

• Medicare Part D

• Part D Low Income

Subsidy (LIS/Extra Help)

• Other Prescription

Assistance

• Other Health Insurance

• Duals Demonstration

• Preventive Services

• Medigap or Medicare

Select

• Long-term Care

Insurance

• Medicaid

• Medicare Savings

Program

• Medicare Plan Finder

• Coordination of

Benefits

• Marketing Regulations

• Veterans Health

Benefits
STARS Final Form Fields

27

• Employer Health

Benefits

Administrative Topics

NR Multi-Select

Options:

• CMS Unique ID

• Customer

Service/Counseling

Skills

• Performance Measures

• Forms & Reporting

• Program Information

• Outreach

• Confidentiality

• Presentation Skills

• Program Management

Notes NR Long Text Box N/A

Attach File NR Button 5 attachment fields

Additional Training Day 

Reference Number NR Text Field

Auto-Populated after 

saving. 

The CTO will derive the 

Reference Number from 

the BTO, regardless of the 

state selected on the CTO. 

This ensures consistency 

between Reference 

Numbers. 

ATD (Additional Training 

Day) will be appended to 

differentiate the form in the 

Reference Number

Example: 

BTO: “OR-18-41529-T-API”

CTO: “OR-18-41529-143-

ATD”))