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

Forms and Documents

Document Name	Status
Form CMS-10028 RESOURCE REPORT Form and Instruction	Modified
Form CMS-10028 Public and Media Activity Report Form (PAM) Form and Instruction	Modified
Form CMS-10028 Client Contact Form Form	Modified
PAM Crosswalk.pdf Supplementary Document	2013-02-22
CC Crosswalk.pdf Supplementary Document	2013-02-22
CMS 10028 (Supporting Statement)Updated.pdf Supporting Statement A	2013-02-22

IC Document Collections

IC ID	Document Title	Status
193279	RESOURCE REPORT Form and Instruction	Modified
193278	Public and Media Activity Report Form (PAM) Form and Instruction	Modified
193277	Client Contact Form Form	Modified

ICR Details

OMB Control No: 0985-0040	ICR Reference No: 201503-0985-001
Status: Historical Active	Previous ICR Reference No: 201006-0938-006
Agency/Subagency: HHS/ACL	Agency Tracking No: 18891
Title: State Health Insurance Assistance Program (SHIP) Client Contact Form, Pubic and Media Activity Form, and Resource Report Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/24/2015
	Date Received in OIRA: 03/24/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved
Responses	2,346,465	0	1,672,454
Time Burden (Hours)	195,642	0	139,475
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 35981	06/15/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 12320	02/22/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 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

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: 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.

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Annual Cost to Federal Government: $453,045

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 02/26/2013

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