0990-New_Title X Family PlanningOutreach and Enrollment Version ss. 2

The Title X Family Planning Program (“Title X program” or “program”) is the only Federal grant program dedicated solely to providing individuals with comprehensive family planning and related preventive health services (e.g., screening for breast and cervical cancer, sexually transmitted diseases (STDs), and human immunodeficiency virus [HIV]). The program’s purpose is to assist individuals in determining the number and spacing of their children, thereby contributing to positive birth outcomes and healthy families. The program is designed to provide access to contraceptive services, supplies, and information to all who want and need them. By law, priority is given to persons from low-income families (Section 1006[c] of Title X of the Public Health Service Act, 42 USC 300).² The Office of Population Affairs (OPA) within the Office of the Assistant Secretary for Health administers the Title X program.

In fiscal year 2013, Congress appropriated approximately $296.8 million for Title X family planning activities. In accordance with the statute and regulations (42 Code of Federal Regulations [CFR] Part 59),³ at least 90% of the appropriation is used for clinical family planning services.²In 2011, 91 Title X grantees provided family planning services to five million women and men through a network of 4,400 community-based clinics that include state and local health departments, tribal organizations, and other public and private nonprofit agencies. There is at least one clinic that receives Title X funds and provides services as required under the Title X statute in 73% of U.S. counties.⁵

Sixty percent of the clients seen at Title X funded service sites self-identify as being uninsured. Seventy percent of the total clients are under the age 30. Thus Title X service sites serve a large proportion of young and uninsured individuals. In addition to the affordable insurance programs made available through the marketplaces and Medicaid expansions, many States have expanded Medicaid coverage of family planning through a Section 1115 demonstration waiver or through a State Plan Amendment (SPA). Over the past years, OPA has encouraged grantees to develop enrollment programs to ensure that clients who are currently uninsured understand new health insurance options that are available as a result of the ACA. Assisting clients with getting insurance is an important component to assuring the long term sustainability of Title X service sites as insured clients provide more consistent revenue sources for these safety net providers. Some sites already assist individuals with enrolling in Medicaid and other public insurance programs. With the availability of the health insurance marketplace, many more service delivery sites are assisting clients enroll in health insurance programs. OPA has authorized grantees to use funding available through the Title X program to provide onsite enrollment assistance. However, we are not collecting any data to understand how many sites are providing onsite outreach and enrollment.

JUSTIFICATION

This is a request to the Office of Management and Budget (OMB) for approval of a new data collection form to collect information on how many individuals were assisted and enrolled into health insurance programs. This annual reporting requirement is for family planning services delivery projects authorized and funded by the Title X Family Planning Program ["Population Research and Voluntary Family Planning Programs" (Public Law 91-572)], which was enacted in 1970 as Title X of the Public Health Service Act (Section 1001 of Title X of the Public Health Service Act, 42 United States Code [USC] 300).¹

Circumstances Making the Collection of Information Necessary

The implementation of the Patient Protection and Affordable Care Act (ACA)—PL 111-148 has increased the insurance options available to uninsured individuals through; 1) expansions in Medicaid eligibility; and 2) the creation of a health insurance marketplace that provides affordable insurance options and subsidies for low income individuals. The majority of clients seen in Title X service delivery sites are young (70%) and uninsured (60%). In order to assure the long term sustainability of Title X programs, beyond federal funding, OPA has encouraged grantees to build capacity to bill third party payers. With the increased availability of health insurance programs for low income populations, enrolling existing Title X clients into health insurance will increase revenue sources for service delivery sites.

Many service sites already assist clients in enrolling into public insurance programs. Due to the varying resources available at the State and local level, OPA has authorized grantees to use funding to conduct outreach and enrollment activities. However, OPA is not currently collecting data on how many sites are conducting such activities, the impact of those activities in enrolling clients into health insurance programs, and the need for additional resources to conduct outreach and enrollment.

Attachment A to this statement contains a copy of the authorizing Title X program regulations that necessitate the collection of the information, Attachment B is the proposed data collection form.

Purpose and Use of Information Collection

OPA does not have any data on how many sites are assisting and enrolling clients into health insurance programs. Thus we seek to collect this data in order to understand the impact of Title X funded service sites on assisting and enrolling clients into insurance programs. We will utilize this information to guide strategic planning around how Title X service sites prepare for, and assist with, the full implementation of the ACA. Through a separate data collection process called the Family Planning Annual Report (FPAR) (OMB No. 0990-0221, expiration January 31, 2016), OPA collects information on the insurance status of the clients served. With the implementation of the ACA, many of the traditional clients served by Title X service sites will qualify for health insurance. By collecting information on how many clients are assisted and enrolled in health insurance programs, OPA can; 1) measure the impact of Title X service sites in enrolling clients into insurance programs; 2) design strategic initiatives to encourage outreach and enrollment; and 3) better understand the impact of the Affordable Care Act on Title X service delivery sites. This data will help explain trends and variations amongst service sites in terms of client insurance status and revenue (data already collected through the FPAR process).

In addition, the data will also be used to respond to inquiries from policymakers and Congress about the program, and to estimate program impact on identifying and getting people enrolled in health insurance. Central and regional HHS/OPA staff will use the data to set priorities for the program, to inform strategic planning and budget efforts, and to develop and justify efforts to expand and increase access to outreach and enrollment resources and technical assistance for grantees.

Outreach and Enrollment Data Collection Form

The outreach and enrollment form (provided in appendix B) includes the data fields that will be collected. Data will be collected semi-annually. Data points marked (OPTIONAL) will not be required:

1a.	Number of O/E assistance workers^¹ that have successfully completed all required federal and/or state training.
	Number of O/E assistance workers that have successfully completed all required federal and/or state training for full Medicaid (only).
	Number of O/E assistance workers that have successfully completed all required federal and/or state training for partial Medicaid programs (ex: Family Planning Waiver Program).
	Number of O/E assistance workers that have successfully completed all required federal and/or state training for other state special programs.
	Number of O/E assistance workers that have successfully completed all required federal and/or state training for the Health Insurance Marketplace.
	Number of O/E assistance workers that have successfully completed all required federal and/or state training for all of the above.
1b.	Number of individuals assisted^² by a trained O/E assistance worker.
	Number of individuals assisted by a trained O/E assistance worker for Medicaid only. (OPTIONAL)
	Number of individuals assisted by a trained O/E assistance worker for partial Medicaid (Family Planning Waiver Program or SPA). (OPTIONAL)
	Number of individuals assisted by a trained O/E assistance worker for the health insurance marketplace only. (OPTIONAL)
1c.	Number of individuals who receive an eligibility determination^³ for the Marketplace, Medicaid, or CHIP with the assistance of a trained O/E assistance worker.
	Number of individuals who receive an eligibility determination with the assistance of a trained O/E assistance worker for Medicaid only. (OPTIONAL)
	Number of individual who receive an eligibility determination with the assistance of a trained O/E assistance worker for partial Medicaid (Family Planning Waiver Program or SPA). (OPTIONAL)
	Number of individuals assisted by a trained O/E assistance worker for the health insurance marketplace only. (OPTIONAL)
1d.	Number of individuals who enroll in any plan (e.g., select a qualified health plan or Medicaid/CHIP) with the assistance of a trained O/E assistance worker.
	Number of individuals who enroll in a partial Medicaid with the assistance of a trained O/E assistance worker.^⁴ (OPTIONAL)
	Number of individuals who enroll in full Medicaid or other public insurance plan (e.g., select a qualified health plan or Medicaid/CHIP) with the assistance of a trained O/E assistance worker.⁴ (OPTIONAL)
	Number of individuals who enroll in a private plan (e.g., select a plan purchased in an exchange/marketplace or through private insurance) with the assistance of a trained/OE assistance worker.⁴(OPTIONAL)

In addition we will ask grantees to identify barriers to conducting activities and any key lessons learned.

The form will be provided to grantees and service sites electronically for completion.

Use of Improved Information Technology (IT) and Burden Reduction

To minimize reporting burden, OPA will collect the data annually. Data will be requested by HHS/OPA regional and central staff who will review and approves each data form. OPA staff will create a web-based system to collect the information and auto-populate data from previous reports to generate cumulative totals.

Efforts to Identify Duplication and Use of Similar Information

We have contacted the Center for Consumer Information and Insurance Oversight (CCIIO) at the Centers for Medicare and Medicaid (CMS), the Assistant Secretary for Planning and Evaluation (ASPE), and the Health Resources and Services Administration (HRSA) to identify existing data collection efforts. None of the aforementioned entities are collecting this information from Title X grantees. HRSA has OMB clearance for an outreach and enrollment form “O&E Progress Report” and “O&E supplemental” of the Health Center Program Application Forms (OMB Control Number: 0915-0285).

This data collection form uses similar data definitions in order to facilitate comparisons across different Federal agencies.

OPA consulted HRSA about adding Title X as a respondent to their data collection form, however, HRSA was told by OMB that the addition of Title X grantees would constitute a significant change to their application and recommended a separate application.

Impact on Small Businesses or Other Small Entities

No small business will be involved in this study.

Consequences of Not Collecting the Information or Less Frequent Collection

The inability to collect this information will hamper OPA’s ability to provide needed technical assistance and resources to grantees. As a result of the ACA, there will be changes to the clients served within the Title X service delivery network. We anticipate that a significant number of Title X clients will be eligible for Medicaid. Current Title X sites are in an important position to enroll these clients into Medicaid. OPA needs to understand to what extent Title X sites are able to enroll individuals into affordable health insurance programs. In the absence of this information, we cannot explain the dynamics of changing payer mix in the Title X network.

Further, many Title X clients may be unaware that Section 1902(a)(23)(A) of the Social Security Act requires States to allow Medicaid-eligible individuals to receive services from "any institution, agency, community pharmacy, or person, qualified to perform the service or services required . . . who undertakes to provide him such services." These "freedom of choice" protections are expanded for family planning as they are not allowed to be waived for family planning providers. This means that Medicaid managed care enrollees can receive family planning services from any provider, even if their provider of choice is outside of their managed care network. Conducting onsite enrollment is one opportunity where Title X providers can communicate this provision to their clients.

Insured clients will help ensure the long term sustainability of the Title X service delivery network through more consistent revenue streams. OPA needs to collect information on current enrollment efforts to better assist grantees with sustaining their delivery network.

There are no legal obstacles to reduce the burden.

Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

The proposed data collection will be consistent with guidelines set forth in 5 CFR 1320.5.

Comments in Response to the Federal Register Notice/Outside Consultation

Comments in Response to the Federal Register Notice.

A 60-day Federal Register Notice was published in the Federal Register on November 5, 2013, vol. 78, No. 214; pp.66360-61. There was one public comment requesting information on how data would be collected.. More specifically, the commenter wanted to know if grantees would collect the information, or if the information would be submitted directly to OPA. Via e-mail, Tasmeen Weik clarified that both options will be possible. Grantees can either choose to collect the data from service sites, then aggregate it and send it to OPA. Alternatively, grantees can elect to ask their service sites to submit the information directly to OPA themselves.

The commenter also wondered what the specific data points are, due to the fact that HRSA already collects much of this information from Federally Qualified Health Centers (FQHCs), which many Title X grantees are, as well. Again via email, Tasmeen Weik confirmed that OPA will be collecting the same data points as HRSA, to avoid further burden on the respondents.

No external consultations were made to address the public comment.

Explanation of Any Payment/Gift to Respondents

No payments or gifts will be provided to respondents.

Assurance of Confidentiality Provided to Respondents

Data will be collected, aggregated and published by grantee or region. Data will not be collected at the client level to protect the confidentiality of individuals who receive Title X-funded services (42 CFR Part 59).³ No individual identifiers will be collected on the form, and no person can be identified based on the aggregate totals.

Justification for Sensitive Questions

There are no sensitive questions on the form.

Estimates of Annualized Burden Hours (Total Hours and Wages)

12A. Estimated Annualized Burden Hours

The estimated annualized hour burden of responding to this information collection is 2,100 hours, or a weighted average of 10 minutes to 1 hour per respondent (see Exhibit 1). The hour-burden estimates include the time spent by grantee or service site staff to retrieve, compile, verify, and report the data and exclude any hour burden associated with customary and usual practices that the grantee or service site would carry out in the absence of the reporting requirement (for example regular communications with service sites). The range of respondents, responses, and burden per response is based on the differences that would occur if a grantee is the respondent vs. if a service site is the respondent. For example, it would arguably take a grantee longer to complete the tool if they are collecting and aggregating the information from their service sites. If a service site is submitting their information directly to OPA, it would most likely take them less time to complete.

Note: these burden estimates are based on similar burden estimates calculated by HRSA for a similar data collection effort under “O&E Progress Report” and “O&E supplemental” of the Health Center Program Application Forms (OMB CONTROL NUMBER: 0915-0285) .

Exhibit 1–Estimated Hour Burden

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Annualized Burden per Response (Hours)	Annualized Total Burden (Hours)
Grantees	Outreach and Enrollment	4200 service sites	1	0.2 hours	840

12.B. Estimated Annualized Respondent Cost Burden

The estimated total annualized labor cost to respond to the outreach and enrollment form is $33,701 or an average of $8.02 per respondent (see Exhibit 2). The estimated hourly wage rate ($40.12) is a weighted average based on the distribution of the hour burden across four different categories of grantee labor (i.e., clerical/unskilled, skilled/technical, managerial or professional, and executive). This hour burden across labor categories is based on findings from the 2009 FPAR Burden Study²² which was conducted for a larger data collection effort by an OPA contractor. The average wage rate for each labor category was obtained from the U.S. Bureau of Labor Statistics 2011 wage rates for the health care and social assistance sector.²³

Exhibit 2–Estimated Annualized Cost to Respondents for Information Collection

Type of Respondent	Total Burden Hours	Average (Weighted) Hourly Wage Rate	Total Respondent Cost
Service sites	840	$40.12	$33,701

Estimated Annualized Respondent Nonlabor Cost Burden

The estimated total annualized non-labor cost of this reporting are negligible because grantees are already expected to collect data for reporting to the Family Planning Annual Report (FPAR) (OMB No. 0990-0221, expiration January 31, 2016) and have the infrastructure (computer, phone lines etc.) to do so.

Annualized Cost to Federal Government

The estimated annualized cost to the federal government for collecting this data is $18,000. Exhibit 2 presents a breakdown of this total. The estimate includes costs by federal staff at the regional and central levels and by a contractor for the following activities:

Regional Office–To review, correct, and approve grantee submissions and assisting grantees in understanding data definitions.
Central OPA Staff–To review and final submissions, oversee and coordinate the work of the contractor, analyze and report collected data.
Data Contractor–To develop a web-based form for data entry.

Exhibit 3–Annualized Cost of FPAR Reporting to Federal Government

Source	Amount ($)
FPAR review/approval and validation resolution, seed data review by OPA central and Regional Office Staff (100 hours x $40/hour) $25,200	$4,000
Development of a web-based tool.	$14,000
Total Annualized Cost	$18,000

Explanation for Program Changes or Adjustments

This is a new data collection.

Plans for Tabulation and Publication and Project Time Schedule

Annually, OPA may tabulate, analyze, and disseminates the data in the form of a national summary and a regional summary for each HHS region. The data may also be analyzed for publication in a peer reviewed format such as a medical journal. All data will be presented in aggregate form with no individual information presented.

This request is for a 3-year clearance. Data will be submitted semi-annually each year. The data collection period will include prior open outreach and enrollment periods. Exhibit 4 presents the timetable for key activities following OMB approval.

Exhibit 6–Timetable for Data Collection, Analysis, and Publication

Activity	Expected Date of Completion
End of reporting period	0 months following OMB approval
Due date for data submission	1.5 months following OMB approval
Export initial data to regional staff for review and validation	2 months following OMB approval
Resolve validation issues	2-3 months following OMB approval
Analyze and report final data	3-4 months following OMB approval

Reason(s) Display of OMB Expiration Date Is Inappropriate

The 3-year expiration date for OMB approval will be displayed on all versions of the form (i.e., electronic, Web-based, and hard-copy).

Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.

REFERENCES

1. 42 USC 300 Section 1001 [300], Project Grants and Contracts for Family Planning Services. Retrieved March 1, 2013, from http://www.hhs.gov/opa/pdfs/title-x-statute-attachment-a.pdf;1970.

2. 42 USC 300 Section 1006 [300a-4], Regulations and Payments. Retrieved March 1, 2013, from http://www.hhs.gov/opa/pdfs/title-x-statute-attachment-a.pdf; 1970.

3. 42 Code of Federal Regulations (CFR) Part 59, Grants for Family Planning Services (October 1, 2000). Retrieved March 1, 2013, from http://www.hhs.gov/opa/pdfs/42-cfr-59-b.pdf.

4. Frost JJ, Henshaw SK, Sonfield A. Contraceptive Needs and Services, National and State Data, 2008 Update. New York: Guttmacher Insitute; 2010.

5. Frost JJ, Frohwirth L, Purcell A. The Availability and Use of Publicly Funded Family Planning Clinics: U.S. Trends, 1994–2001. Perspectives on Sexual and Reproductive Health 2004;36:206-15.

6. 45 CFR Part 74, Uniform Administrative Requirements for Awards and Subawards to Institutions of Higher Education, Hospitals, Other Nonprofit Organizations, and Certain Grants and Agreements with States, Local Governments and Indian Tribal Governments. Retrieved March 1, 2013, from http://www.hhs.gov/opa/grants-and-funding/grant-forms-and-references/45-cfr-74.html.

7. 45 CFR Part 92, Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments. Retrieved March 1, 2013, from http://www.hhs.gov/opa/pdfs/45-cfr-92.pdf.

8. FY13 Announcement of Anticipated Availability of Funds for Family Planning Services Grants (CFDA: 93.217). 2013. Retrieved March 27, 2013, from https://www.grantsolutions.gov/gs/preaward/previewPublicAnnouncement.do?id=15585.)

9. 42 U.S. Code (USC) 300, Chapter 6A, Subchapter VIII-Title X of the Public Health Service Act, Population Research and Voluntary Family Planning Programs. Retrieved March 1, 2013, from http://www.hhs.gov/opa/pdfs/title-x-statute-attachment-a.pdf; 1970.

10. Office of Population Affairs. Program Guidelines for Project Grants for Family Planning Services. Bethesda, MD; 2001.

11. Office of Management and Budget. Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Fed Regist October 30, 1997;62:58782-90.

12. RTI International. Family Planning Annual Report: 2011 National Summary. Research Triangle Park, NC: RTI; 2012.

13. Bernstein J, Chollet D, Peterson S. How Does Insurance Coverage Improve Health Outcomes? Washington, DC: Mathematica Policy Research, Inc.; April 2010.

14. The Henry J. Kaiser Family Foundation. Women's Health Insurance Coverage. Washington, DC: The Henry J. Kaiser Family Foundation; October 2012.

15. Frost JJ. U.S. Women's Reliance on Publicly Funded Family Planning Clinics as Their Usual Source of Medical Care. 2008 NSFG Research Conference. Hyattsville, MD; 2008:18.

16. Summer L. The Impact of the Affordable Care Act on the Safety Net. Washington, DC: AcademyHealth; April 2011.

17. Witgert KE, Hess C. Issues and Policy Options in Sustaining a Safety Net Infrastructure to Meet the Health Care Needs of Vulnerable Populations. Washington, DC: National Academy for State Health Policy; October 2012.

18. Kenney GM, Zuckerman S, Dubay L, et al. Opting in to the Medicaid Expansion under the ACA: Who are the Uninsured Adults Who Could Gain Health Insurance Coverage? Washington, DC: Urban Institute; August 2012.

19. Contract No. HHSP 233200800516. Establishment of a Family Planning Sentinel Clinic Network; September 30, 2008-September 29, 2011.

20. RTI International. 2011 FPAR: Data Validation, Quality, and Transition Report. Research Triangle Park, NC: RTI; 2012.

21. RTI International. 2011 FPAR Submission Report. Research Triangle Park, NC: RTI; 2012.

22. RTI International. Family Planning Annual Report Burden Study. Research Triangle Park, NC: RTI; 2009.

23. Bureau of Labor Statistics. May 2011 National Industry-Specific Occupational Employment and Wage Estimates: Sector 62-Health Care and Social Assistance; March 2012.

1 Title X outreach and enrollment assistance workers are any grantee, sub recipient or service site staff, contractors, or volunteer assistance personnel who are trained to facilitate enrollment of individuals into the Marketplace, Medicaid and/or CHIP.

2 This should include in-person education about affordable insurance coverage options (one-on-one or small group) and any other assistance provided to facilitate enrollment, e.g., setting up an account, filing affordability assistance information, receiving an eligibility determination, and/or selecting a qualified health plan or Medicaid/CHIP plan.

3 Include all individuals who received an eligibility determination, even if the individual is not determined to be eligible for Medicaid/CHIP or for a subsidy through the Marketplace.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0915-0285. The time required to complete this information collection is estimated to average _1_hours/ minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

4 An individual is considered “enrolled” if they have selected a plan and enrolled in it, regardless of whether or not they have paid the premium for the plan yet. (http://aspe.hhs.gov/health/reports/2013/marketplaceenrollment/rpt_enrollment.pdf)

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Fowler, Christina I.
File Modified	0000-00-00
File Created	2021-01-27