State Health Insurance Assistance Program (SHIP) Client Contact Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 13 SHIP Activity Form	Form and Instruction	New	Available
Form 12 SIRS Individual Interaction-Complex Form	Form and Instruction	New	Available
Form 11 SIRS Team Member Form	Form and Instruction	New	Available
Form 10 SMP Team Member Form	Form and Instruction	New	Available
Form 9 SMP Individual Interaction-Basic	Form and Instruction	New	Available
Form 8 SMP Group Outreach & Education	Form and Instruction	New	Available
Form 7 SMP Media Outreach & Education	Form and Instruction	New	Available
Form 4 SHIP/MIPPA Group Outreach Education Form	Form and Instruction	Modified	Available
Form 3 SHIP/MIPPA Team Member Form	Form and Instruction	Modified	Available
Form 2 SHIP/MIPPA Media Outreach Education Form	Form and Instruction	Modified	Available
Form 1 SHIP/MIPPA Beneficiary Client Form	Form and Instruction	Modified	Available
0040 OMB SS PB Dec 2020 EDITS.docx	Supporting Statement A	Uploaded 2020-12-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
243846	SHIP Activity Form	Form and Instruction	New
243845	SIRS Individual Interaction-Complex Form	Form and Instruction	New
243844	SIRS Team Member Form	Form and Instruction	New
243843	SMP Team Member Form	Form and Instruction	New
243842	SMP Individual Interaction-Basic	Form and Instruction	New
243841	SMP Group Outreach & Education	Form and Instruction	New
243840	SMP Media Outreach & Education	Form and Instruction	New
232707	SHIP/MIPPA Group Outreach Education Form	Form and Instruction	Modified
193279	SHIP/MIPPA Team Member Form	Form and Instruction	Modified
193278	SHIP/MIPPA Media Outreach Education Form	Form and Instruction	Modified
193277	SHIP/MIPPA Beneficiary Client Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0985-0040	ICR Reference No: 202009-0985-002
Status: Active	Previous ICR Reference No: 201808-0985-002
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: State Health Insurance Assistance Program (SHIP) Client Contact Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/30/2020
	Date Received in OIRA: 10/01/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	36 Months From Approved	12/31/2020
Responses	3,981,613	0	3,722,025
Time Burden (Hours)	329,244	0	215,288
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this data collection is to collect performance data from grantees, grantee team members and partners. Congress requires this data collection for program monitoring and Government Performance Results Act (GPRA) purposes. This data collection allows ACL and the Center for Innovation and Partnership (CIP) to communicate with Congress and the public on the SHIP, the SMP program, the Medicare Improvements for Patients & Providers Act (MIPPA) program, and the ADRC activities. In addition to the SHIP Data Performance Reports and Information Collection under OMB 0985-0040, ACL requests to incorporate the discontinued SMP Report collection OMB 0985-0024 and the ADRC collection OMB 0985-0062 into one tool. The SHIP, SMP, MIPPA, and ADRC programs are located in each of the 50 states, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands. In order to ensure that grantees report activity accurately and consistently it is imperative that these data collection tools remain active. The respondents for this data collection are grantees, grantee team members, and partners who meet with Medicare beneficiaries and older adults in group settings and in one-on-one sessions to educate them on Medicare enrollment, Medicare benefits and subsidy programs, the importance of being aware of Medicare fraud, error and abuse, and having the knowledge to protect the Medicare system. ACL is proposing to combine these four collection tools to reduce burden on the grantees, grantee team members, and partners as many of the individuals working on these programs, collecting information, and reporting results are the same at the local level. Combining these tools will reduce the need for duplicate or triplicate reporting of activities in separate tools further reducing the time and effort in reporting outcomes and activities. In addition, this combination will allow clarification on when, where, and how activities are being conducted across these ACL programs further informing performance outcomes.

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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:
	84 FR 71954	12/30/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 60805	09/28/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

table that charts list of burden

IC Title	Form No.	Form Name
SHIP/MIPPA Group Outreach Education Form	4	Group Outreach and Education Form
SHIP/MIPPA Beneficiary Client Form	1	Beneficiary Contact Form
SHIP/MIPPA Media Outreach Education Form	2	Media Outreach Education Form
SHIP/MIPPA Team Member Form	3	Team Member Form
SMP Media Outreach & Education	7	SMP Media Outreach and Education Form
SMP Group Outreach & Education	8	SMP Group Outreach and Education
SMP Individual Interaction-Basic	9	SMP Individual Interaction Basic Interaction Form
SIRS Team Member Form	11	SIRS Team Member Form
SIRS Individual Interaction-Complex Form	12	SIRS Individual Interaction-Complex Form
SHIP Activity Form	13	SHIP Activity Form
SMP Team Member Form	10	SMP Team Member Form

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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	3,981,613	3,722,025	0	259,588	0	0
Annual Time Burden (Hours)	329,244	215,288	0	113,956	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 revision request; ACL has modified several forms and combined several data elements due to the inclusion of the MIPPA and SMP programs. The addition of these programs have increased the previous time burden for this particular IC tool, however this combination has reduced the overall burden on respondents by reducing the need to track and report similar activities in separate systems eliminating the duplication action of accessing multiple systems. Taking into account previous collection year burden totals that have updated, there is a program change of 113,956 annual burden hours.

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Annual Cost to Federal Government: $40,048

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? No

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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: 10/01/2020

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