State Health Insurance Assistance Program (SHIP) Client Contact Form, Pubic and Media Activity Form, and Resource Report Form

ICR 201302-0938-008

OMB: 0938-0850

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Form
Modified
Supplementary Document
2013-02-22
Supplementary Document
2013-02-22
Supporting Statement A
2013-02-22
IC Document Collections
ICR Details
0938-0850 201302-0938-008
Historical Active 201006-0938-006
HHS/CMS 18891
State Health Insurance Assistance Program (SHIP) Client Contact Form, Pubic and Media Activity Form, and Resource Report Form
Revision of a currently approved collection   No
Regular
Approved without change 06/10/2013
Retrieve Notice of Action (NOA) 02/26/2013
  Inventory as of this Action Requested Previously Approved
06/30/2016 36 Months From Approved 07/31/2013
2,346,465 0 1,672,454
195,642 0 139,475
0 0 0

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 supplement policies, managed care options including Medicare Advantage, 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 paid and volunteer staff, by distributing written informational materials, or by holding group educational seminars and presentations and outreach events. The current Client Contact Form, Public and Media Activity Report Form, and Resource Report Form have been used to collect data to evaluate program effectiveness and improvement, and these forms expire July 31, 2013.

US Code: 42 USC 1395b-4 Name of Law: Health insurance information, counseling, and assistance grants
   PL: Pub.L. 101 - 508 4360(F) Name of Law: Health Insurance Information, Counseling, and Assistance Grants
  
None

Not associated with rulemaking

  77 FR 35981 06/15/2012
78 FR 12320 02/22/2013
No

3
IC Title Form No. Form Name
Client Contact Form CMS-10028 CMS-10028.Client Contact Form
Public and Media Activity Report Form (PAM) CMS-10028 Public and Media Activity Form (PAM)
RESOURCE REPORT CMS-10028 Resorurce Report

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,346,465 1,672,454 0 674,011 0 0
Annual Time Burden (Hours) 195,642 139,475 0 56,167 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The Client Contact form and Public and Media Activity form of the National Performance Reporting (NPR) system contains 10 National Special Use Fields (SUFs) and will need to be expanded to capture the data elements for the Duals Financial Alignment Program. The NPR contractor will create the 20 Special Use Fields and will design the NPR web entry screens and the NPR batch upload protocols to allow for the collection of the designated data elements for Duals. See bottom of page 2 of the CC Form: SUFs being added are 11 - 30.

$453,045
No
No
No
No
No
Uncollected
Kayla Williams 410 786-5887 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
02/26/2013


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