CMS-10028 2006 Statement of Supporting Statement

SUPPORTING STATEMENT for Extension of State Health Insurance Assistance Program (SHIP) Reporting--Client Contact Form, Public and Media Activity Form, and Resource Report Form

OMB Approval Number: 0938-0850

CMS Form Number: 10028A, B, and C

November 17, 2006

A. Background

The State Health Insurance Assistance Program (SHIP), created under Section 4360 of OBRA 1990 (P. L. 101-508) (42 USC 1395b-4, attached), authorizes the Secretary of the Department of Health and Human Services (DHHS) to make grants to states to establish and maintain health insurance advisory services programs for Medicare beneficiaries. The purpose of the program is to develop and strengthen the capability of states to provide beneficiaries with information, counseling and assistance on adequate and appropriate health insurance coverage.

Grant funds are awarded by the Centers for Medicare & Medicaid Services (CMS) to states to provide information, counseling and assistance to beneficiaries relating to Medicare and Medicaid matters as well as Medicare supplemental policies, managed care options including Medicare + Choice, long-term care insurance, and other health insurance benefit information. States may carry out the objective of the grants by providing one-on-one counseling, either face-to-face or over the telephone, by trained volunteer staff, by distributing written informational materials, or by holding group educational seminars and presentations and outreach events.

The enabling legislation initially authorized up to $10 million in annual appropriations for the grants for fiscal years 1991, 1992, and 1993. While no funds were appropriated for fiscal 1991, $10 million or more was awarded in SHIP grants annually from fiscal years 1992 to 2001. In fiscal years 2002 and 2003, SHIPs received $12.5 million in funding. In fiscal year 2004 funding was increased to $21.5 million. Funding increased over the next two years from $31.6 million in fiscal year 2005 to $32.7 million in fiscal year 2006. Increased funding supported activities related to the outreach and education requirements of the Balanced Budget Act of 1997 (BBA), and the requirements of the Medicare Modernization Act of 2003 (MMA). Activities included those related to the Prescription Drug Card and the Part D Prescription Drug Program. CMS remains committed to supporting this program in future periods.

B. Justification

1. Circumstances that make information collection necessary

Section 4360(f) of OBRA 1990 requires the Secretary to provide a series of reports the U.S. Congress on the performance of the program and its impact on beneficiaries and to obtain important informational feedback from beneficiaries. Further, in response to requirements of the Balanced Budget Act of 1997, CMS launched a comprehensive five-year campaign, the National Medicare Education Program (NMEP), to raise awareness among beneficiaries about their Medicare health plan options and help them assess the advantages and disadvantages each choice holds for them. The Medicare Modernization Act (MMA) of 2003 required SHIPs to be actively engaged in the implementation of the Medicare Prescription Drug Program (Part D). The goal is to ensure that beneficiaries are making an informed choice, regardless of whether they stay in Original Medicare or choose new options. CMS is responsible to Congress for demonstrating improvement over time in the level of awareness and understanding beneficiaries have about health plan options. The SHIPs are an integral component of this initiative.

2. Purposes and use of information

The information collected is used to fulfill the reporting requirements described in Section 4360(f) of OBRA 1990. Also, the data will be accumulated and analyzed to measure SHIP performance in order to determine whether and to what extent the SHIPs have met the goals of improved CMS customer service to beneficiaries and better understanding by beneficiaries of their health insurance options. Further, the information will be used in the administration of the grants, to measure performance and appropriate use of the funds by the state grantees, to identify gaps in services and technical support needed by SHIPs, and to identify and share best practices.

3. Use of improved technology

While the forms are primarily completed manually by the individual SHIP volunteer counselors, virtually all of the states use an automated or electronic data transfer technology to accumulate the data and transmit it to CMS. In order to minimize the burden, CSM has created an internet-based data collection tool for entry of the accumulated data by the state grantees. The forms used are relatively simple to use, in an electronic fill-in format.

4. Duplication of similar information

The data to be collected from the SHIP grantees are unique to this grant program and are based significantly on the legislatively mandated reporting requirements. The data is being gathered from and applies only to these Federally mandated grant programs.

5. Impact on small entities

This information collection will not impact any small entities.

6. Frequency of collection

This information collection is necessary to enable fulfillment of the Congressional reporting requirements in Section 4360 of OBRA 1990. There are three forms required as part of this data collection, a Client Contact Form, a Public and Media Activity Form, and a Resource Report Form. When the grants were first issued, quarterly reporting by the grantees was required. Although not in any specific required format, those reports summarized program activities for the period as well as reported financial status information. The reporting burden was reduced to semi-annually during an interim period, but with the implementation of the Medicare Modernization Act of 2003, the reporting requirement was returned to quarterly, effective July 1, 2005, so that CMS could have real time data available in order to assess the work of SHIPs, respond to beneficiary needs, and for reporting to Congress on the activities required under MMA.

The frequency in reporting for the Client Contact Form and the Public and Media Activity Form is quarterly, and for the Resource Report Form, is semi-annually.

7. Special circumstances

There are no special circumstances.

8. Federal Register notice/Outside consultations

A 60-day Federal Register notice was published on January 12, 2007.

9. Payment or gift to respondents

Respondents are primarily volunteers working for recipients of grants from CMS. The terms and conditions of the grants require collection of this information. No specific funds are being paid to respondents for furnishing this information.

10. Confidentiality provision

The information will be collected with a guarantee that identifying information will be held in strict confidence by the program collecting the information. SHIPs are required as a condition of the grant to maintain appropriate security measures to assure the privacy of individuals that receive SHIP services. None of the individual identifying information will be passed beyond the state program, i.e., no individual identifying information will be forwarded to CMS. Any results of the information collection will be made public in aggregate statistical form only.

11. Inclusion of sensitive questions

The information to be collected includes age, income, gender, disability, and ethnicity/race. These items are to be collected on a strictly voluntary basis. This information is necessary to evaluate whether a SHIP is adequately making its services available to populations that are hard-to- reach and underserved due to language, literacy, location and culture. This information will be aggregated at the state level and will not be identified or associated with any individuals.

12. Estimate of cost burden to respondents

This information collection will occur quarterly for the Client Contact and Public and Media Activity forms. Each SHIP staff or counselor is required to fill out a form for each counseling or outreach event as appropriate. Also, semi-annually, the SHIP Program Director is required to fill out the Resource Report Form. All of the forms are to be filled out and submitted electronically through the SHIP web site, µwww.shiptalk.org§. Data will be accumulated electronically by CMS and shared with the respective SHIPs.

While there is no specific required cost burden to the respondents other than their time committed to participate with a SHIP, it is estimated that the cost per response is $10.00 per response. However, these forms will be prepared, primarily, by volunteers at no actual cost.

Most of the data being requested in this instrument, under the mandate in Section 4360 of OBRA 1990, is information that any prudent manager of a public sector program would normally collect and publish in the course of managing the program. In fact, most of the programs are or will be required by their own State leaders to provide information similar to that being solicited by the instrument. This instrument is designed to combine with any state level information collection in order to simultaneously fulfill any existing or anticipated state level reporting requirements.

CMS and its NPR contractor are currently working with several SHIPs on their state proprietary systems so that they can meet the specifications for NPR reporting, and studying other innovative approaches to the data collection process in several other states. Such is neither required nor necessary to fulfill the reporting requirements on these forms. Any training or other preparation, or resources needed will be provided through SHIP grant funds.

13. Capital costs

There are no capital or operational costs.

14. Estimate of cost to federal government

Costs to the Federal Government include contractor time for development of the performance measurement process for the SHIPs, any updated design of the forms, and for maintenance of a database to facilitate accumulation, analysis and feedback of the data. The total future cost is estimated at $400,000 per year.

15. Burden Changes

The burden changed from the initial application as a result of spreading the responsibility for filing the forms from the SHIP Program Director to each of the counselors and staff conducting the counseling and outreach events. Previously, the SHIP Program Director had full responsibility. The amount of data being collected has not changed. Only the collection process has been changed to simplify and make easier the entire process.

Based on testing conducted in the course of development of these information collection forms, it is estimated that it takes a respondent about 5 minutes to complete the Client Contact Form, 5 minutes to complete the Public and Media Activity Form, and 90 minutes to complete the Resource Report Form. There are approximately 12,000 respondents with approximately 88 responses per respondents, or , 1 million (1,056,000) individual counseling and outreach events and 108 Resource Reports filed annually.

The number of annual responses increased since the last reporting period by 56,000 (from 1,000,000 to 1,056,000) since the estimated number of responses per respondent is 88 vs. 84. However, the total annual hourly burden to complete the three forms was reduced from 116,747 to 87,965. This represents a reduction of 28,782 annual hours burden from prior estimates of 116,747 (in 2003) because prior estimates used an average of 7 minutes for completion of the Client Contact Form and Public and Media Activity Form vs. 5 minutes used in this calculation. Five minutes is stated on the instructions for completing the forms. (See attached instructions.).

The following non-substantive changes in the data elements were made, effective 2005, in order to clarify responses or to capture activities performed in response to the implementation of MMA. While there was a reduction in the annual hour burden, this change in burden is not due to the changes in the forms, but rather, the estimates used in completing the forms. In some instances data elements were clarified, added, or eliminated. The non-substantive changes are found in the attached chart titled, Attachment A, Non-substantive Changes to SHIP National Performance Report (NPR) Forms, Effective July 1, 2005

The process for filling out the forms is now totally automated and SHIPs are expected to file the forms electronically through the SHIP web site, µwww.shiptalk.org§. All SHIPs have access to this web site. There is no further burden or obligation beyond filling out each form on-line. For some SHIPs with State level electronic data collection systems, arrangements have been made to directly upload the necessary data to µwww.shiptalk.org§. No further burden is required in this case either.

16. Time schedule, tabulation and publication plans

Data collection: Quarterly for Client Contact and Public and Media Activity; semi-annually for Resource Report. The SHIP grant year is April 1-March 31.

Data processing: Quarterly

Data Analysis: Quarterly, semi-annually, and annually

Report preparation: Quarterly, semi-annually, and annually

17. Display of expiration date

Displaying the expiration date is not problematic.

18. Explain each exception to the Certification Statement

N/A

C. Collection of information employing statistical methods

N/A

Attachment A

Non-Substantive Changes to SHIP National Performance Report (NPR) Forms

Effective July 1, 2005

CLIENT CONTACT FORM

Current Form	Changes to Form
TOP OF FORM
Not currently included.	Added new section: How Did Client Learn About the SHIP: CMS (1-800 Medicare, Medicare & You, www.medicare.govCMS 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
Counselor Zip Code/Location	Counseling Location Zip Code
Check here for a quick telephone call (less than 10 minutes)	Quick call (< 10 min) is now included in the box labeled “Type of Contact”.
Date if Multiple Contact—currently has two boxes	Now has one box for completion (to reflect one additional contact per form).
Type of Contact—currently has three boxes	Now has two boxes for completion (to reflect two contacts per form).
Time Spent – currently has three boxes.	Now has two boxes for completion (to reflect two contacts per form).
Status of Client Contact(s) : ___Open _____Closed	This was deleted.
SECTION 1-BENEFICIARY INFORMANTION	No changes.
Current Form	Changes to Form
SECTION 2-BENEFICIARY DEMOGRAPHICS
This section is recommended for completion.	This section is now required to be completed.
Monthly Income: Less than or equal to SLMB rate (individual = $_______) Greater than SLMB Not Collected	Monthly Income: Below 150% of FPL At or greater than 150% of FPL Not collected $__________
SECTION 3-TOPICS DISCUSSED
Medicare: Discussed Enrollment, eligibility, benefits Claims/billing Appeals/quality of care	Medicare (Parts A&B): Enrollment, eligibility, benefits Claims/billing Appeals/quality of care/complaints
Medicare+Choice (HMOs, PFFS, managed care): Discussed Enrollment, disenrollment, eligibility, comparisons, etc. Plan or benefit changes/non-renewals Claims/billing Appeals/quality of care/grievances	Medicare Health Plans (HMOs, PPOs, PFFS, Special Needs Plans): Enrollment, disenrollment, eligibility, comparisons Plan or benefit changes/non-renewals Claims/billing Appeals/quality of care/complaints
Discussed Long-Term Care Insurance	Moved as a category under “Other”.
Current Form	Changes to Form
Medigap/Supplement/SELECT Discussed: Enrollment, eligibility, comparisons Change coverage Claims/appeals	No changes.
Discussed Medicaid QMB SLMB QI SSI Other Medicaid	Medicaid (enrollment, eligibility, benefits) QMB/SLMB/QI Other Medicaid
Discussed Prescription Assistance	Prescription Assistance: Medicare Prescription Drug Coverage (PDP/MA-PD): Plan eligibility, benefit comparisons Low-income assistance – eligibility, benefit comparisons Enrollment / application assistance Claims/billing Appeals/quality of care/complaints Other Sources of Prescription Drug Coverage/Assistance Medicare-Approved Drug Discount Card State Pharmacy Assistance Program Union/Employer plan Manufacturer’s Assistance Program Discount plans Other
Current Form	Changes to Form
Other: Discussed Medicare Fraud/Abuse Employer health plan or Federal Employee Health Benefits Program COBRA Military health benefits Customer service issues/complaint Other_________ Other_________	Other Moved Long-Term Care under this heading. Fraud and Abuse (deleted Medicare) Deleted COBRA Military Health Benefits Employer Health Plan or Federal Employee Health Benefits Program Customer Service issues/complaint Other:___________-

PUBLIC AND MEDIA ACTIVITY FORM (PAM)

Current Form	Changes to Form
Instructions at top reference REACH.	Instructions at top delete references to REACH.
SECTION 1 Type of Activity (Check only one type of activity A-F)	Activities are now A-G.
SECTION 1 - Type of Activity REACH: Yes___ No___	Deleted REACH: Yes___ No___
Sections A-E	Under A. Interactive presentation to public; B. Booth/exhibit at health/senior fair, etc.; added a line for: Estimated # of people enrolled (if any):_________
Section F. Other is now Section G.	Added new Section F: Enrollment Event Estimated # of people enrolled:________
SECTION 3—Topic Focus (Select up to 3)	Check all that apply. Changed Original/traditional/basic Medicare to Medicare (Pars A and B) Changed Home Health, long term care to Long-Term Care Changed Medicare Fraud & Abuse to Fraud and Abuse Changed Prescription assistance to Medicare Prescription Drug Coverage (PDP/MA-PD) Added Other Prescription Drug Coverage/Assistance Changed Managed care/Medicare+Choice to Medicare Health Plans Changed Dual eligible, QMB/SLMB, Medicaid to QMB/SLMB/QI Added Other Medicaid Deleted Preventive benefits
SECTION 4-Target Audience (Rank up to 3	Check all that apply.
	Deleted Low-education Use same Ethnic/Racial categories as on Client Contact Form.

RESOURCE REPORT FORM

Current Form	Changes to Form
TOP OF FORM	Changed 12 month to 6 month Report Period.
SECTION 5 e. Race/Ethnicity	Use same Ethnic/Racial categories as on Client Contact Form.
SECTION 7 - Three Case Summaries (Please attach additional pages.)	SECTION 7 Deleted request for three case summaries. Changed to: Did You Work With Any Partners in Providing Any SHIP Services? __Yes___No If yes, check the type of partner involvement (check all that apply): Training Counseling Enrollment/application assistance (e.g. Medicare Prescription Drug Coverage activities) Presentations Outreach Other You are encouraged to include details of your partnership involvement in narrative form. Include names of key partnership organizations when possible.

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