View Information Collection Request (ICR) Package

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
	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).

	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

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.

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:
	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

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	3,981,613	3,981,613
Annual Time Burden (Hours)	329,244	329,244
Annual Cost Burden (Dollars)	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:

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

Agency Contact: Tomakie Washington 202 795-7336 tomakie.washington@acl.hhs.gov

View ICR - OIRA Conclusion