National Beneficiary Survey of State Health Insurance Assistance Program (SHIP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 National Beneficiary Survey State Health Insurance Assistance Program (SHIP)	Form	New	Available
SHIP Supporting Statement - B - Final - 082817.docx	Supporting Statement B	Uploaded 2017-08-28	Available
SHIP Supporting Statement-A-Final- 082817.docx	Supporting Statement A	Uploaded 2017-08-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
225703	National Beneficiary Survey State Health Insurance Assistance Program (SHIP)	Form	New

ICR Details

OMB Control No: 0985-0057	ICR Reference No: 201702-0985-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: National Beneficiary Survey of State Health Insurance Assistance Program (SHIP)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/28/2017
	Date Received in OIRA: 02/23/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved
Responses	1,350	0	0
Time Burden (Hours)	180	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Abstract (2000 characters maximum) The National Beneficiary Surveys will gauge individuals’ satisfaction with the services they receive from the State Health Insurance Assistance (SHIP) and Senior Medicare Patrol (SMP) Programs. The survey will be the first of its kind to ascertain the quality and effectiveness of the services provided by the SHIP and SMP and to determine if beneficiaries are receiving accurate, relevant and timely information. The survey will be conducted over a three-year period beginning in Fiscal Year (FY) 2017, with multiple sites in each of the 50 states and the territories of Guam, Puerto Rico and the Virgin Islands being surveyed once. The SHIP program satisfaction survey will be conducted on a sample of beneficiaries who received assistance/counseling during two points in the year (one week in the spring and one week during the Annual Medicare Open Enrollment Period). The SMP program satisfaction survey will focus on education session presentations to determine if the target audience is satisfied with the information they are receiving. The results from these surveys will be used to measure satisfaction among individuals who receive assistance/counseling or among individuals who attend SMP education sessions, as well, as how the program can be improved to provide better service to its target population.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

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:
	81 FR 41974	06/28/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 78601	11/08/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
National Beneficiary Survey State Health Insurance Assistance Program (SHIP)	1	SHIP Phone Counseling Survey

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ICR Summary of Burden

table that charts list 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	1,350	0	0	1,350	0	0
Annual Time Burden (Hours)	180	0	0	180	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: This is a new data collection for the SHIP program.

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Annual Cost to Federal Government: $214,952

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 02/23/2017

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