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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4 Group Outreach and Education Form	Form	New	Available
Form 3 Resource Report	Form	Modified	Available
Form 2 Media Group Outreach Events Form	Form	Modified	Available
Form 1 Beneficiary Client Form	Form	Modified	Available
Non-Substantive Change - SHIP 2018 8.10.18.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-08-14	Available
SHIP PRA - Supporting Statement - Passback4 (2).docx	Supporting Statement A	Uploaded 2017-03-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
232707	Group Outreach Education Form	Form	New	Group Outreach and Education Form
193279	Team Member Form	Form	Modified	Resource Report
193278	Media Outreach Education Form	Form	Modified	Media Group Outreach Events Form
193277	Beneficiary Client Form	Form	Modified	Beneficiary Client Form

ICR Details

OMB Control No: 0985-0040	ICR Reference No: 201808-0985-002
Status: Historical Active	Previous ICR Reference No: 201606-0985-003
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: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/17/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/15/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	03/31/2020	03/31/2020
Responses	3,722,025	0	3,700,038
Time Burden (Hours)	215,288	0	326,872
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:
	81 FR 22983	04/19/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 41973	06/28/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Beneficiary Client Form	1	Beneficiary Client Form
Group Outreach Education Form	4	Group Outreach and Education Form
Media Outreach Education Form	2	Media Group Outreach Events Form
Team Member Form	3	Resource Report

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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	3,722,025	3,700,038	0	-27,134	49,121	0
Annual Time Burden (Hours)	215,288	326,872	0	-112,556	972	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This request relates to the State Health Insurance Assistance Program (SHIP) (OMB Control Number 0985-0040 - Expiration date 3/31/2020). As part of OMB’s original approval for ACL to evaluate program effectiveness and improvement of this program, the following data collection tools were approved by OMB: Client Contact Form, Public and Media Activity Report Form, and Resource Report Form. Subsequent to receiving approval, the Administration for Community Living (ACL) has been in development of a new data system, one which will reduce the time burdens on volunteers and grantees. The Department is requesting approval for slight alterations to the current collection tools. These alterations are based on ACL’s analysis of the data collected and serve as a means to eliminate duplication, simplify questions, and to reduce time spent on text entry fields. ACL believes that the changes we are requesting are not substantive, would not change the nature of information being collected, and do not require republication in the Federal Register. The current approved collection tools are text and direct entry. ACL seeks to change the average time to complete these forms by changing some of the current direct entry items to a dropdown selection format. We estimate that this will result in an overall reduction in the amount of time it takes to complete a form by nearly 33%: from 326,860.34 hours to 214,404.50 hours. ACL also seeks to separate the Public and Media Activity Report Form into two separate forms. They are as follows: • Media Outreach & Education Form • Group Outreach & Education Form This separation will increase clarity and reduce inefficiencies by simplifying entry to focus on the necessary elements for each activity and reducing duplicate data entry. The information that follows includes an overview of the existing collection tool and the proposed changes.

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Annual Cost to Federal Government: $893,969

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: 08/15/2018

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