Terms of Clearance

TERMS of CLEARANCE

State Health Insurance Assistance Program (SHIP)

CMS Form/Collection #: CMS-10028 A, B, C

OMB Control #: 0938-0850

CMS will report to OMB on the progress made in examining the use states/grantees make of race, ethnicity, age, and other beneficiary demographic data collected with these forms. CMS will also continue to update OMB on progress toward coordination with AoA’s, NAPIS system. Lastly, CMS will submit copies of revised forms and instructions, as agreed upon 02/11/04 to OMB within 7 days for addition to the docket file. (Dated 02/12/2004, OMB Authorizing Official: Donald, R. Arbuckle, Deputy Administrator, Office of Information and Regulatory Affairs)

CMS Responses:

1. SHIPs continue to report demographic data on the individual clients to whom they provide SHIP services. The data on age and race/ethnicity are requested on the Client Contact Form under Section 2-Beneficiary Demographics. The SHIP Grant Announcements in 2005 and 2006 requested that SHIPs increasingly serve hard-to-reach populations. Demographic data reported on the Client Contact Form helps SHIPs to identify areas where hard-to-reach populations based on race or ethnicity for example may not currently be served and where they might target their outreach activities. Counselors are instructed to explain to the beneficiary that demographic data are confidential and used for statistical purposes. Instructions for completing the Client Contact form state the following:

“Steps

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.

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.

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.”

2. Regarding AoA’s NAPIS system, CMS has had preliminary conversations with members of the Aging network about their data system with the idea of trying to determine if some reduction in duplication of reporting might be achieved by SHIPs who also report using the Aging networks’ reporting system. CMS is currently working with individual SHIPs, who also report data into the Aging network’s data system, on their data specifications with the goal to streamline data input into the CMS reporting system yet try to alleviate duplication of effort with data systems of the Aging network. Given the magnitude of the AoA data systems, this state by state approach appears to be most feasible at this point in time.

3. The revised forms were submitted by Eric Lang to John Burke and Melissa Musotta via an e-mail dated 3/16/04.

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