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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:
201909-2900-005
Status:
Historical Active
Previous ICR Reference No:
201807-2900-003
Agency/Subagency:
VA
Agency Tracking No:
2900-0091
Title:
VA Health Benefits Application and Update - VA Forms 10-10EZ and 10-10EZR
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:
01/21/2020
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/01/2019
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2020
12/31/2020
12/31/2020
Responses
1,010,000
0
1,017,000
Time Burden (Hours)
454,000
0
455,750
Cost Burden (Dollars)
0
0
0
Abstract:
Non-substantive updates have been made to VA Forms 10-10EZ and 10-10EZR to bring these forms into compliance with the MISSION Act of 2018. The forms collect information to enroll for health care benefits, establish basic eligibility, identify 3rd party health insurance coverage, identify prescription copayment, provide for income verification, and serve as a mechanism to make changes upon admission or yearly financial updates. A signed Non-substantive Change Memorandum has been added to the supplementary documents section.
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. 115 - 182 101 Name of Law: MISSION Act of 2018
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
VA Form 10-10EZ -- Application for Health Benefits
10-10EZ
Application for Health Benefits
VA Form 10-10EZR -- Health Benefits Update Form
10-10EZR
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
1,010,000
1,017,000
-1,010,000
1,010,000
-7,000
0
Annual Time Burden (Hours)
454,000
455,750
-454,000
454,000
-1,750
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Non-substantive updates have been made to VA Forms 10-10EZ and 10-10EZR to bring these forms into compliance with the MISSION Act of 2018. The burden has not changed for either form as a result of these updates.
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:
Frances O'Donnell 703 405-2449 fran.odonnell@cathexiscorp.com
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:
10/01/2019
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