CMS 10028 (Supporting Statement)Updated

Supporting Statement – Part A
State Health Insurance Assistance Program (SHIP) Client Contact Form, Public
and Media Activity Report Form, and Resource Report Form (CMS-10028)
0938-0850

Specific Instructions
A. Background
The State Health Insurance Assistance Program (SHIP), created under Section 4360 of the
Omnibus Budget Reconciliation Act (OBRA) of 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 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 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 from CMS’ annual
appropriation (Program Management Account) increased over the next four years from
$31.7 million in fiscal year 2005 to $45 million in fiscal year 2009. In fiscal year 2012,
SHIPs received $50 million in funding.
Increased funding supported activities related to the outreach and education requirements
of the Balanced Budget Act of 1997 (BBA), the requirements of the Medicare
Modernization Act of 2003 (MMA), the requirements of the Medicare Improvements for
Patients and Providers Act of 2008 (MIPPA) and requirements of the Patient Protective
and Affordable Care Act of 2010 (ACA). Activities included those related to the Part D
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Prescription Drug Program, Medicare Advantage, and the Low-Income Subsidy and
Medicare Savings Programs (LIS/MSP). CMS remains committed to supporting this
program in future periods.
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. The 2007-2009 SHIP Performance Assessment Workgroup (comprised of
SHIP Directors and representatives from external organizations such as the Administration
on Aging), in a report to CMS in September 2009, recommended that changes be made to
the forms in order to enhance the ability to measure performance and program evaluation
for each SHIP; add additional data collection elements as requested by Congress and
SHIPs (Limited English Proficiency and Dual Mentally Disabled); and reduce the burden
of data submission by counselors as a result of the ability to pre-populate certain data cells.
All recommended changes were captured in the last OMB submission package. These
forms were approved by OMB effective through July 31, 2013. In this submission, no
changes will be made to these forms.
In April 2011, the Medicare-Medicaid Coordination Office awarded design contracts to 15
states to implement State Demonstrations to Integrate Care for Medicare-Medicaid
Individuals (Dual eligible). The overall goal of this initiative is to develop, test and
validate fully integrated delivery system and care coordination models. The Financial
Alignment Initiative is a unique Federal-state partnership to test aligning the service
delivery and financing of the Medicare and Medicaid programs to better serve MedicareMedicaid individuals. As part of this effort, there is a need for strong beneficiary support,
education and outreach in each State that is implementing a Financial Alignment model,
including options counseling for beneficiaries. State Health Insurance Assistance Programs
(SHIPs) and Aging and Disability Resource Centers (ADRCs) have longstanding history
and relationships with beneficiaries and are well situated to provide this service locally in
each State.
A key component of this initiative will be tracking and reporting on the types of questions
being asked and the type of information and assistance SHIPs/ADRCs are providing to
these dually eligible beneficiaries. This information will be reported through the SHIP
National Performance Reporting System and shared with the Medicare-Medicaid
Coordination Office on a quarterly basis to ensure services to dual eligibles are within the
scope of the cooperative agreement requirements and support the Financial Alignment
models.

B. Justification
1.

Need and Legal Basis
Section 4360(f) of OBRA 1990 requires the Secretary to provide a series of reports to the
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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 fiveyear 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). MIPPA legislation and Affordable Care
Act legislation required SHIPs to provide enrollment assistance for the Limited Income
Subsidy (LIS) and Medicare Savings Program (MSP). 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.

Information Users
The information collected is used to fulfill the reporting requirements described in Section
4360(f) of OBRA 1990. CMS will utilize this data. 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 Information Technology
While the forms are completed manually by many individual SHIPS paid and 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 are relatively simple to use, in an
electronic fill-in format. No signatures are required for these forms. 20 additional SUFs
will be added to the electronic format of the CC and PAM.

4.

Duplication of Efforts
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.

Small Businesses
This information collection will not impact any small entities.
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6.

Less Frequent 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 Report
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
Report Form is quarterly, and for the Resource Report Form, is annually. The move to
annual from semi-annual submission of the Resource Report Form represented a change in
reporting frequency.

7.

Special Circumstances
There are no special circumstances.

8.

Federal Register/Outside Consultation
The 60-day Federal Register notice published on [OSORA/PRA will insert the date].

9.

Payments/Gifts 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
The information collected will be held private to the extent provided by law. The 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 personally identifying
information will be passed beyond the state program, i.e., no personally identifying
information will be forwarded to CMS for analysis. Any results of the information
collection will be made public in aggregate statistical form only.

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11. Sensitive Questions
The information to be collected includes beneficiary zip code, age, income, gender,
disability, and ethnicity/race. 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. Burden Estimates (Hours & Wages)
A respondent be a counselor, coordinator, or data entry specialist that is employed by the SHIP.
The estimated hourly total compensation rate is $29.02920 per hour. CMS estimates the respondent
burden hours to complete the Client Contact Form is 0.0833 (5 minutes) per submission. CMS
estimates the respondent burden hours to complete the Public and Media Activity Report Form is
0.0833 (5 minutes) per submission. (Note: We did multiple time trials entering forms from a paper
stack and entering directly into the web form. We tested with naïve and experienced users. And we
tested records for new clients’ vs. existing clients. On average, both the Client Contact Form and
Public and Media Activity Report Form were entered in under 5 minutes (which we rounded up to
5 minutes). CMS estimates the respondent burden hours to prepare and complete the Resource
Report Form is 2 hours per submission. These estimates are based on an internal assessment of the
materials and feedback from the end users’ evaluations.

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The total annual hours requested is calculated as follows:
Table 1
Summary of Hours Burden by Type of Forms
(Estimates for CY2013)

In total, CMS estimates that it will receive 2,346,465 responses. This would amount to 195,642.25
total annual hours.
Responses

Expected
Responses
Overall Hours
Per
submission
Annual
Burden Hours

Client Contact
Form

Public and
Media Activity
Report Form

Resource Report
Form

Summary

2,269,848.00

76,563.00

54

2,346,465.00

0.083333

0.0833333

2

NA

189,154.00

6,380.25

108

195,642.25

Table 2
Total Cost Burden by Forms
(Estimates for CY2013)

The estimated wage burden for the all three forms (Client Contact, Public and Media Activity
Report and Resource Report) is $5,679,338.00. The wage burden is based on an estimated total
compensation rate of $29.02920* per hour.
Responses

Client Contact
Form

Public and
Media Activity
Report Form

Resource Report
Form

Total

Annual Burden
Hours

189,154.00

6,380.250

108

195,642.25

Hourly
Compensation

$29.02920

$29.02920

$29.02920

$29.02920

$5,490,989.30

$185,213.55

$3,135.15

$5,679,338.00

Total Cost
Burden

* Source of value of volunteer time = Independent Sector.

http://www.independentsector.org/volunteer_time. The estimated dollar value of volunteer time for 2011 is
$21.79 per hour. The value of volunteer time is based on the average hourly earnings of all production and
nonsupervisory workers on private nonfarm payrolls (as determined by the Bureau of Labor Statistics).

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Independent Sector takes this figure and increases it by 12 percent to estimate for fringe benefits. For
SHIPs, 25.8% of all counselors, coordinators, and other staff hours were volunteer hours for a 12 month
period ending 31 Mar 2011. The remaining 74.2% of hours were SHIP-Paid or In-Kind paid at an average
hourly wage of $20.76 plus fringe of 44.61% = $30.02 total compensation per hours. Combining volunteer
and paid hour’s rates yields a weighted total compensation rate of $27.90 per hour. Projected to 2013, the
estimated hourly total compensation rate is $29.02920 per hour.

Table 3
Summary of Burden Hours Comparison CY2011 to CY2013

The overall estimated burden hours will increase by 7,667 (CY2011 Burden hours - CY2013
Burden hours). The overall number of expected respondents will increase by 444. The expected
number of responses will increase by 91,107. These increases are based on projected future service
growth and projected future increases in staffing to accommodate the increased service demand.

Client
Contact
Form
Public and
Media
Form
Resource
Report
Form
Total

CY2011
Number of
Respondents

CY2011
Number of
Responses

CY2011
Annual
Burden
Dollars
$5,070,462

CY 2013
Number of
Respondents

CY2013
Number of
Responses

CY2013
Annual
Burden
Hours

CY2013
Annual
Burden
Dollars

2,181,714

CY2011
Annual
Burden
Hours
181,737

10,991

11,435.00

2,269,848

189,154.00

$5,490,989.30

6,102

73,590

6,130

$171,027

6,349.00

76,563.00

6,380.25

$185,213.55

54

54

108

$3,013

54.00

54.00

108.0000

$3,135.15

17,147

2,255,358

187,975

$5,244,502

17,838

2,346,465.00

195,642.25

$5,679,338.00

*Please note that we are using the 2011 data because the 2012 data is still being collected.
**Also note that the number of respondents is not summed across the three forms since the same
individuals can complete all three forms.

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 National Performance Reporting (NPR) System contractor are currently working
with several SHIPs on their state proprietary systems so that they can meet the specifications for
NPR reporting. These states do however have the option to submit data directly into the internetbased data system. Any training or other preparation, or resources needed, will be provided
through SHIP grant funds.
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These forms will be completed, primarily, by volunteers at no actual cost.
13. Capital Costs
No capital or operational costs.
14. Cost to Federal Government
Costs to the Federal Government include contractor time for development of the
performance measurement process for the SHIPs, and for maintenance of a database to
facilitate accumulation, analysis and feedback of the data. The total future cost is
estimated at $453,045 per year.
15. Changes to Burden
Overall Burden hours and expected number of respondents (Increase in burden):
The overall burden of hours and expected number of respondents increase is based on
projected future service growth and projected future increases in staffing to accommodate
the increased demand to utilize the SHIP network to raise awareness about new CMS
policies and /or outreach initiatives.
Time to complete all forms (No Increase in burden):
The time estimate to complete each Client Contact Form, Public and Media Activity
Report Form, and Resource Report Form all remain unchanged since the last OMB
submission. 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 and 5 minutes to complete the Public and Media Activity Report
Form. Based on direct communication with State SHIP Directors, it takes a respondent a
median of 120 minutes to complete the Resource Report Form. There are approximately
2,269,848 client contacts per year, approximately 76,563 public and media events per year,
and 54 state-level resource reports per year.
Process for submitting forms (No Increase in burden):
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 http://www.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
http://www.shiptalk.org. No further burden is required in this case either.

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16. Publication/Tabulation Dates
Data collection:

Data processing:
Data Analysis:
Report preparation:

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

17. Expiration Date
Displaying the expiration date is not problematic.
18. Certification Statement
N/A

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