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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:
201807-2900-003
Status:
Historical Active
Previous ICR Reference No:
201702-2900-006
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 without change
Conclusion Date:
07/13/2018
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/10/2018
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2020
12/31/2020
12/31/2020
Responses
1,017,000
0
1,017,000
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:
82 FR 8971
02/01/2017
30-day Notice:
Federal Register Citation:
Citation Date:
82 FR 19313
04/26/2017
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
10-10EZR, 10-10EZ, 10-10EZ - Spanish Version
Enrollment Application for Health Benefits
,
Health Benefits Update Form
,
INSTRUCCIONES PARA SOLICITAR LA AFILIACIÓN A LOS BENEFICIOS MÉDICOS
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
1,017,000
1,017,000
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:
The financial reporting requirements for the 10-10EZR have been removed. It is now optional. The respondent total for 10-10EZR updates is estimated to reduce by 691,500, based enhanced system changes, which automates this annual requirement through electronic data matching with the Internal Revenue Service and Social Security Administration. It is estimated that only twenty percent of veterans will actually provide updates The 10-10HS respondent total has doubled, from 3500 to 7000. The burden total remains at 15 minutes. Adjustments were made to the GS 5/5 pay per hour processing. The time for processing 10-10EZ was reduced from 45 minutes to 15 minutes. Processing 10-10EZR was reduced from 24 minutes to 10 minutes, but the quantity increased by 10,000. Form 10-10HS quantity was reduced from 50,000 to 7,000 for processing at 15 minutes
Annual Cost to Federal Government:
$4,263,550
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.
Yes
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.
Yes
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:
Cynthia Harvey - Pryor 202 461-5870 cynthia.harvey-pryor@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:
07/10/2018
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