State Health Insurance Assistance Program (SHIP) Client Contact Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
STARS Activity Form	Form and Instruction	Modified	Available
SHIP Activity Form	Form and Instruction	Modified	Repair queued
STARS Training Form	Form and Instruction	Modified	Available
SIRS Individual Interaction-Complex Form	Form and Instruction	Modified	Repair queued
SIRS Team Member	Form and Instruction	Modified	Repair queued
SIRS Team Member Form	Form and Instruction	Modified	Repair queued
STARS Team Member	Form and Instruction	Modified	Available
SMP Team Member Form	Form and Instruction	Modified	Repair queued
SIRS Individual Interaction	Form and Instruction	Modified	Available
SMP Individual Interaction-Basic	Form and Instruction	Modified	Repair queued
STARS GOE	Form and Instruction	Modified	Available
SMP Group Outreach & Education	Form and Instruction	Modified	Repair queued
SIRS MOE	Form and Instruction	Modified	Available
SMP Media Outreach & Education	Form and Instruction	Modified	Repair queued
STARS GOE	Form and Instruction	Modified	Available
SHIP/MIPPA Group Outreach Education Form	Form and Instruction	Modified	Repair queued
SIRS Team Member Form	Form and Instruction	Modified	Available
SHIP/MIPPA Team Member Form	Form and Instruction	Modified	Repair queued
STARS MOE	Form and Instruction	Modified	Available
SHIP/MIPPA Media Outreach Education Form	Form and Instruction	Modified	Repair queued
STARS BCF	Form and Instruction	Modified	Available
SHIP/MIPPA Beneficiary Client Form	Form and Instruction	Modified	Repair queued
0040 OMB SS Dec 2023 - 12.18.23 PRA KJG Edits.docx	Supporting Statement A	Uploaded 2023-12-29	Repair queued

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 0985-0040	ICR Reference No: 202310-0985-004
Status: Active	Previous ICR Reference No: 202009-0985-002
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: State Health Insurance Assistance Program (SHIP) Client Contact Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/19/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/29/2023
Terms of Clearance: Approved consistent with the understanding that in the next revision/extension of this package, the agency will update race/ethnicity questions to be in compliance with the updated SPD 15 (effective as of March 28, 2024). Additionally, prior to the re-submission of the next revision/extension of this package, the agency will assess linguistic preferences across the respondent population and translate beneficiary-facing forms into languages as appropriate in order to increase accessibility. It is the expectation that the agency will translate this form into more languages than English and Spanish, but the number of additional languages will be based on the agency’s assessment of population needs. These could include, for example, the top languages as spoken by more than 1 million individuals (in addition to Spanish and English) identified by the 2019 ACS Language Use Report (e.g., French, Chinese, Korean, Vietnamese, Tagalog, Arabic). This request is supported by the principles and priorities set forth in Executive Order 13985 on “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government” (January 20, 2021) and Executive Order 13166, "Improving Access to Services for Persons with Limited English Proficiency" (August, 11, 2000).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	3,981,613	0	3,981,613
Time Burden (Hours)	329,244	0	329,244
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. 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.

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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:
	88 FR 73345	10/25/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 89697	12/28/2023
Did the Agency receive public comments on this ICR? Yes

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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 Activity Form	NA	STARS Activity Form
SHIP/MIPPA Beneficiary Client Form	NA	STARS BCF
SHIP/MIPPA Media Outreach Education Form	NA	STARS MOE
SHIP/MIPPA Group Outreach Education Form	NA	STARS GOE
SHIP/MIPPA Team Member Form	NA	SIRS Team Member Form
SIRS Individual Interaction-Complex Form	NA	STARS Training Form
SIRS Team Member Form	NA	SIRS Team Member
SMP Group Outreach & Education	NA	STARS GOE
SMP Individual Interaction-Basic	NA	SIRS Individual Interaction
SMP Media Outreach & Education	NA	SIRS MOE
SMP Team Member Form	NA	STARS Team Member

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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	3,981,613	0	0	0	0
Annual Time Burden (Hours)	329,244	329,244	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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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: 12/29/2023

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