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PROGRAM INSTRUCTION

ACL-PI-14-05 

AOA-MI-14-001(FR 36528 / Vol. 79, No. 124 / Friday, June 27, 2014)

TO: State Agencies on Aging and State Departments of Insurance 

Administering Plans under section 119 of The Medicare 

Improvements for Patients and Providers Act of 2008 – 

reauthorized by section 110 of the Protecting Access to Medicare 

Act of 2014. 

 

SUBJECT: Guidance on the Development and Submission of MIPPA State 

Plans

LEGAL REFERENCES: The Medicare Improvements for Patients and Providers Act of 

2008 – Section 119, Public Law (PL) 110-275 as amended by the 

Patient Protection and Affordable Care Act of 2010 (Affordable 

Care Act), reauthorized by the American Taxpayer Relief Act of 

2012 (ATRA) and reauthorized by section 110 of the Protecting 

Access to Medicare Act of 2014. 

The purpose of this Program Instruction (PI) as referenced in the Federal Register Notice above

is to provide State Units on Aging and State Departments of Insurance who administer the State 

Health Insurance Assistance Programs with guidelines for use in developing and submitting FY 

2014 MIPPA State Plans. 

I. State Plan Purpose 

The purpose of the funding is to enhance efforts through statewide and local coalition building 

focused on intensified outreach activities to help beneficiaries likely to be eligible for the Low 

Income Subsidy program (LIS), Medicare Savings Program (MSP), Medicare Prescription Drug 

Coverage (Part D) and in assisting beneficiaries in applying for benefits. ACL will provide 

funding to State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging 

(AAAs), and Aging and Disability Resource Center programs (ADRCs), to inform older 

Americans about available Federal and State benefits. ACL seeks plans from states that will 

describe how the MIPPA funds will be used for beneficiary outreach and education over the next 

three years.

ACL requests that states submit a three year state plan with specific project strategies to expand, 

extend, or enhance the outreach efforts to beneficiaries on Medicare Part D and for those with 

limited incomes. States should describe how the SHIP, AAA, and ADRC efforts will be 

coordinated to provide outreach to beneficiaries with limited incomes statewide, for general 

Medicare Part D outreach and assistance to beneficiaries in rural areas, and for outreach 

activities aimed at Medicare prevention and wellness benefits as well as the improvements in the 

Part D program under the Affordable Care Act as mandated by Section 3306 of the Act. States 

are asked to review their 2013 MIPPA plans and update these plans to reflect successes achieved 

to date and direct their efforts to enhance and expand their MIPPA outreach activities. 
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State agencies may prepare either one statewide plan or separate plans for each eligible State 

agency. If one statewide plan is submitted, funds will be disbursed to the lead state agency. 

II. Award Information 

Priority Area 1 – State Health Insurance Assistance Programs: $7.5 million in FY 2014 to 

State Agencies that Administer the SHIP to provide outreach to eligible Medicare beneficiaries 

regarding their benefits and outreach to individuals who may be eligible for the Low Income 

Subsidy or for the Medicare Savings Program.

• State allocations are based on the following percentages: 

o 2/3 of the total amount to existing State SHIP Grant Recipients based on estimates of 

individuals who may be eligible but not enrolled for LIS or for Medicare Savings 

Programs; 

o 1/3 of the total amount to provide outreach on Medicare Part D to beneficiaries in rural 

areas.

Priority Area 2 – Area Agencies on Aging and Native American Programs: $7.5 million in 

FY 2014 to State Agencies for AAAs and for Native American programs to provide outreach to 

eligible Medicare beneficiaries regarding their benefits and outreach to individuals who may be 

eligible for the Low Income Subsidy or for the Medicare Savings Program.

• Of the total $7.5 million, $264,000 is reserved to tribal organizations (total 264 grantees). 

This portion of the funding will be allocated using a separate process. 

• State allocations are based on the following percentages: 

o 2/3 of the total amount to States for AAAs to provide outreach to individuals who may be 

eligible but not enrolled for LIS or for Medicare Savings Accounts; 

o 1/3 of the total amount to provide outreach on Medicare Part D to beneficiaries in rural 

areas).

Priority Area 3 – Aging and Disability Resource Center Programs: $5 million in FY 2014 to 

state agencies that administer the ADRC programs to provide outreach to individuals regarding 

the benefits available under Part D and under Medicare Savings Programs:

• State allocations are based on: 

• Total Part D beneficiaries by ADRC coverage area from the funded ADRC 

discretionary grants for the states.

III. MIPPA State Plan Content

The State plan should include: 

1. MIPPA Project Narrative (no more than 10 pages); 

2. 3 year Work Plan detailing anticipated activities; 

3. SF 424 – Application for Federal Assistance; 

4. SF 424B – Assurances; and 

5. Lobbying Certification
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Narrative: 

States should submit a three year state plan with specific project strategies to expand, extend, or 

enhance the outreach efforts to beneficiaries on Medicare Part D and for those with limited 

incomes. The MIPPA State Plan narrative should be comprised of no more than 10 pages. The 

plan narrative should clearly address the following areas: 

• The major highlights accomplished under your states 2013 MIPPA plan and major 

partners involved in your project. 

• How funds allocated based on the percentage of low income beneficiaries will be used to 

support outreach and assistance efforts directed toward Medicare beneficiaries with 

limited incomes who may be eligible for LIS or MSP programs. 

• How funds allocated based on the percentage of rural beneficiaries will be used to 

support outreach and assistance efforts directed toward Medicare beneficiaries residing in 

a rural area relative to the total number of such individuals in each state.

• How funds directed toward Medicare beneficiaries will be used for outreach activities

aimed at preventing disease and promoting wellness.

• How activities described by the SHIP to reach people likely eligible for LIS or MSP 

programs will be above and beyond those regular activities that the SHIP has planned in 

response to funding provided under the 2014 Basic SHIP Grant Award.

• Where applicable, how the State will coordinate with the Native American programs on 

LIS, MSP, Medicare Part D or prevention and wellness outreach. 

• How activities described by the State to reach Medicare Part D eligible beneficiaries in 

rural areas will be above and beyond those regular activities that the State has planned in 

response to other funding, e.g., 2013 Basic SHIP Grant Award, OAA outreach. 

Three Year work plan

States should submit a three (3) year MIPPA project work plan. The Project Work Plan should 

reflect and be consistent with the Project Narrative and should cover all three (3) years of the 

project period. It should include a statement of the project’s overall goal, anticipated outcome(s), 

key objectives, and the major tasks / action steps that will be pursued to achieve the goal and 

outcome(s). For each major task / action step, the work plan should identify timeframes involved 

(including start- and end-dates), and the lead person responsible for completing the task. Please 

see pages 5-7 for a sample template.

SF 424 – Application for Federal Assistance

Please see pages 8-10 for assistance. 
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SF 424B – Assurances 

This form will be available as an electronic document on the GrantSolutions system. Be sure to 

complete this form according to instructions and have it signed and dated by the authorized 

representative (see item 18d of the SF 424). This form contains assurances required of applicants 

under the discretionary funds programs administered by the Administration for Community 

Living. Please note that a duly authorized representative of the applicant organization must 

certify that the organization is in compliance with these assurances. 

Lobbying Certification 

This form will have to be downloaded from GrantSolutions, filled out and signed. This form 

contains certifications that are required of the applicant organization regarding lobbying. Please 

note that a duly authorized representative of the applicant organization must attest to the 

applicant’s compliance with these certifications. ACL requires physical signature and date over 

the text fields since this is an uploaded submission to GrantSolutions not grants.gov. 

IV. Submission Process: 

An Application Kit has been created in GrantSolutions for each grantee to submit the required 

information. 

Please see the Grantee Instructions PowerPoint that was e-mailed to eligible applicants. If you 

did not receive the Grantee Instructions, please contact Katherine Glendening by calling 202–

357–3859, or by e-mail Katherine.Glendening@acl.hhs.gov. 

An Authorized Organization Representative (AOR) for the applicant organization submits a 

grant on behalf of a company, organization, institution, or government. AORs have the authority 

to sign grant applications and the required certifications and/or assurances that are necessary to 

fulfill the requirements of the application process. The AOR must “verify” the submission of the 

application in the GrantSolutions System. See slides 16 and 17 of the instructions document.

V. Inquiries

Direct inquiries regarding programmatic issues to U.S. Department of Health and Human 

Services, Administration on Aging, Office of Supportive and Caregiver Services, Washington, 

DC 20201, attention: Katherine Glendening or by calling 202–357–3859, or by e-mail 

Katherine.Glendening@acl.hhs.gov. 
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Project Work Plan – Sample Template

NOTE : Applicants requesting funding for a multi-year grant program are REQUIRED to provide a Project Work Plan for 

EACH potential year of grant funding requested.

Goal: 

Measurable Outcome(s):

* Time Frame (Start/End Dates by Month in Project Cycle)

Major Objectives Key Tasks Lead Person 1* 2* 3* 4* 5* 6* 7* 8* 9* 10* 11* 12*

1.

2.
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Project Work Plan, Page 2 – Sample Template

Goal: 

Measurable Outcome(s):

* Time Frame (Start/End Dates by Month in Project Cycle)

Major Objectives Key Tasks Lead Person 1* 2* 3* 4* 5* 6* 7* 8* 9* 10* 11* 12*

3.

4.
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Project Work Plan, Page 3 – Sample Template

Goal: 

Measurable Outcome(s): 

* Time Frame (Start/End Dates by Month in Project Cycle)

Major Objectives Key Tasks Lead Person 1* 2* 3* 4* 5* 6* 7* 8* 9* 10* 11* 12*

5.

6.

NOTE: Please do note infer from this sample format that your work plan must have 6 major objectives. If you need more pages, 

simply repeat this format on additional pages.
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Instructions for Completing Required Forms 

SF 424 

This section provides step-by-step instructions for completing the standard Federal form required as 

part of your grant application, including special instructions for completing the Standard Budget 

Form (SF) 424. Standard Forms are used for a wide variety of Federal grant programs, and Federal 

agencies have the discretion to require some or all of the information on these forms. ACL does not 

require all the information on these Standard Forms. Accordingly, please use the instructions below 

in lieu of the standard instructions attached to SF 424 to complete this form.

Standard Form 424 

1. Type of Submission: (REQUIRED): Select Application 

2. Type of Application: (REQUIRED) Select New 

3. Date Received: Leave this field blank 

4. Applicant Identifier: Leave this field blank 

5. Federal Identifiers

a. Federal Entity Identifier: Leave this field blank 

b. Federal Award Identifier: Leave this field blank 

6. Date Received by State: Leave this field blank. 

7. State Application Identifier: Leave this field blank. 

8. Applicant Information: Enter the following in accordance with agency instructions: 

a. Legal Name: (REQUIRED): This should be pre-populated with information in the 

GrantSolutions System. If it is not, or if it is incorrect, enter the name that the organization 

has registered with the System for Award Management (SAM), formally the Central 

Contractor Registry. Information on registering with SAM may be obtained by visiting the 

Grants.gov website (http://www.grants.gov) or by going directly to the SAM website 

(www.sam.gov).

b. Employer/Taxpayer Number (EIN/TIN): (REQUIRED): This should be pre-populated 

with information in the GrantSolutions System. If it is not, or if it is incorrect, enter the 

Employer or Taxpayer Identification Number (EIN or TIN) as assigned by the Internal 

Revenue Service. In addition, we encourage the organization to include the correct suffix 
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used to identify your organization in order to properly align access to the Payment 

Management System.

c. Organizational DUNS: (REQUIRED): This should be pre-populated with information in 

the GrantSolutions System. If it is not, or if it is incorrect, enter the organization’s DUNS or 

DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS 

number may be obtained by visiting the Grants.gov website (http://www.grants.gov). Your 

DUNS number can be verified at http://www2.zapdata.com/CompanyLookup.do. 

d. Address: (REQUIRED): This should be pre-populated with information in the 

GrantSolutions System. If it is not, or if it is incorrect, Enter the complete address including 

the county. 

e. Organizational Unit: Enter the name of the primary organizational unit (and department or 

division, if applicable) that will undertake the project.

f. Name and contact information of person to be contacted on matters involving this 

application: Enter the name (First and last name required), organizational affiliation (if 

affiliated with an organization other than the applicant organization), telephone number 

(Required), fax number, and email address (Required) of the person to contact on matters 

related to this application.

9. Type of Applicant: (REQUIRED): This field should be preselected as A. State Government. 

10. Name of Federal Agency: (REQUIRED): This field will be prepopulated as ACLAdministration on Aging. 

11. Catalog of Federal Domestic Assistance Number/Title: This field will be prepopulated with 

the CFDA Number 

12. Funding Opportunity Number/Title: This field will be prepopulated with the Funding 

Opportunity Number and Title

13. Competition Identification Number/Title: This field will be prepopulated with the Funding 

Opportunity Number and Title 

14. Areas Affected By Project: Leave this field blank. 

15. Descriptive Title of Applicant’s Project: (REQUIRED): Enter a brief descriptive title of the 

project (This is not a narrative description). Please us the state name in the title.

16. Congressional Districts Of: (REQUIRED)

a. Enter the applicant’s Congressional District, and 

b. Enter all district(s) affected by the program or project. Enter in the format: 2 characters State 

Abbreviation – 3 characters District Number, e.g., CA-005 for California 5th district, CA012 for California 12th district, NC-103 for North Carolina’s 103rd district. If all 
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congressional districts in a state are affected, enter “all” for the district number, e.g., MD-all 

for all congressional districts in Maryland. If nationwide, i.e. all districts within all states are 

affected, enter US-all. See the below website to find your congressional district: 

http://www.house.gov/Welcome.shtml

17. Proposed Project Start and End Dates: (REQUIRED) 

a. Start Date: Enter September 30, 2014 

b. End Date: Enter September 30, 2017 

18. Estimated Funding: (REQUIRED) Enter 0 in 18a – 18g. Please do not use dollar signs ($). 

19. Is Application Subject to Review by State Under Executive Order 12372 Process? Select c. 

Program is not covered by E.O. 12372 

20. Is the Applicant Delinquent on any Federal Debt? (Required) This question applies to the 

applicant organization, not the person who signs as the authorized representative. If yes, include 

an explanation on the continuation sheet. 

21. Authorized Representative: (Required) Enter the First Name, Last Name, Title, Telephone 

Number, and E-mail address of the Authorized Representative of the applicant organization. A 

copy of the governing body’s authorization for you to sign this application as the official 

representative must be on file in the applicant’s office. (Certain Federal agencies may require 

that this authorization be submitted as part of the application). 

NOTE: Submitting the online SF424 and SF424B is the signature mechanism for this grant for the 

two standard forms. ACL requires physical signature and date for the lobbying form. The signed 

document must be uploaded into the GrantSolutions application as an attachment.