View Information Collection Request (ICR) Package

OMB Control No: 0938-0850	ICR Reference No: 201006-0938-006
Status: Historical Active	Previous ICR Reference No: 200704-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
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: 07/16/2010
	Date Received in OIRA: 06/15/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2013	36 Months From Approved	07/31/2010
Responses	1,672,454	0	1,056,000
Time Burden (Hours)	139,475	0	87,965
Cost Burden (Dollars)	0	0	0

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 supplemental 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 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 have been used to collect data to evaluate program effectiveness and improvement, and these forms expire June 30, 2010. In addition, the 2007-2009 SHIP Performance Assessment Workgroup (comprised of SHIP Directors and representatives from external organizations such as the Administration on Aging), in a report to CMS, recommended that changes be made to the forms in order to enhance the ability to measure performance and program evaluation for each SHIP; add additional data collection elements as requested by Congress and SHIPs (Limited English Proficiency and Dual Mentally Disabled); and reduce the burden of data submission by counselor as a result of the ability to pre-populate certain data cells.

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

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

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 67227	12/18/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 27785	05/18/2010
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Client Contact Form	CMS-10028
Public and Media Activity Report Form (PAM)	CMS-10028
RESOURCE REPORT	CMS-10028
State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report	CMS-10028-A, CMS-10028-C, CMS-10028-B	, ,

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	1,672,454	1,056,000	-1,056,000	1,672,454
Annual Time Burden (Hours)	139,475	87,965	-87,965	139,475
Annual Cost Burden (Dollars)	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The time estimate to complete the Client Contact Form and the time estimate to complete the Public and Media Activity Form remain unchanged since the last OMB submission. The current time estimate to complete the Resource Report Form is 30 minutes longer than the previous estimate, even though the current Resource Report Form is shorter. The diligence and quality of the Resource report data submitted by the State Directors has improved over recent years, thus accounting for the increased time estimate. However, the Resource Report reporting requirements have changed, resulting in only one Resource Report submission annually.

Annual Cost to Federal Government: $422,311

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]? Uncollected

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

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: William Parham 4107864669

View ICR - OIRA Conclusion