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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
2900-0091
ICR Reference No:
201410-2900-005
Status:
Historical Active
Previous ICR Reference No:
201407-2900-006
Agency/Subagency:
VA
Agency Tracking No:
2900-0091
Title:
Application and Renewal for Health Benefits
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
02/26/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/24/2014
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2017
01/31/2017
01/31/2017
Responses
2,034,000
0
2,034,000
Time Burden (Hours)
455,750
0
455,750
Cost Burden (Dollars)
0
0
0
Abstract:
Collects information to enroll for health care benefits, establishes basic eligibility, identifies 3rd party health insurance coverage, identifies prescription copayment, provides for income verification and serves as a mechanism to make changes upon admission or yearly financial updates.
Authorizing Statute(s):
US Code:
38 USC Chapter 17
Name of Law: HOSPITAL, NURSING HOME, DOMICILIARY,
US Code:
38 USC 111(c)(1)
Name of Law: Payments or allowances for beneficiary travel
Citations for New Statutory Requirements:
PL: Pub.L. 112 - 154 105 Name of Law: Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012
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:
78 FR 127
07/02/2013
30-day Notice:
Federal Register Citation:
Citation Date:
78 FR 213
11/04/2013
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Application and Renewal for Health Benefits
VA Form 10-10HS
Request for Hardship Determination
Applications and Renewal for Health Benefits
10-10EZ, 10-10EZR, 10-10EC, 10-10d
Application for Extended Care Benefits
,
Application for CHAMPVA
,
Enrollment Application for Health Benefits
,
Health Benefits Update Form
ICR Summary 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
2,034,000
2,034,000
0
0
0
0
Annual Time Burden (Hours)
455,750
455,750
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:
Annual Cost to Federal Government:
$4,263,550
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]?
No
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:
Crystal Rennie 202 632-7492 crystal.rennie@va.gov
Common Form ICR:
No
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:
11/24/2014
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