View Information Collection Request (ICR) Package
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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:
2900-0629
ICR Reference No:
202412-2900-007
Status:
Active
Previous ICR Reference No:
202107-2900-006
Agency/Subagency:
VA
Agency Tracking No:
2900-0629
Title:
Application for Extended Care Services, VA Form 10-10EC
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
05/20/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/18/2025
Terms of Clearance:
OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2028
36 Months From Approved
05/31/2025
Responses
2,000
0
2,000
Time Burden (Hours)
3,000
0
3,000
Cost Burden (Dollars)
0
0
0
Abstract:
Title 38 U.S.C. Chapter 17 authorizes VA to provide hospital care, medical services, domiciliary care, and nursing home care to eligible Veterans. Title 38 U.S.C. § 1705 requires VA to design, establish, and operate a system of annual patient enrollment in accordance with a series of stipulated priorities. A consequence of this is that many groups of Veterans who are in a lower priority group (WWI Veterans, Veterans with disabilities rated as 0% service-connected seeking treatment for other than their service-connected conditions, Veterans exposed to a toxic substance, radiation, or environmental hazard and nonservice-connected Veterans) may request that they be allowed to be income tested in order to gain a higher priority. Title 38 U.S.C. § 1722 establishes eligibility assessment procedures for cost-free VA medical care, based on income levels, which will determine whether nonservice-connected and 0% service-connected non-compensable Veterans are able to defray the necessary expenses of care for nonservice-connected conditions. Title 38 U.S.C. § 1722A establishes the eligibility assessment procedures, based on income levels, for determining Veterans’ eligibility for cost-free medications. Title 38 U.S.C. § 1710B defines the procedures for establishing eligibility for cost-free Extended Care benefits. Title 38 U.S.C § 1729 authorizes VA to recover from Veterans’ health insurance carriers the cost of care furnished for their nonservice-connected conditions. VA Form 10-10EC, Application for Extended Care Services, is used to collect financial information necessary to determine a Veteran’s copayment obligation for extended care services, also known as long term care (LTC). The 10-10EC design and formatting have been revised to clarify the instructions and make it easier to understand and complete the form. However, there are no changes to the anticipated annual number of responses or burden hours for this information collection.
Authorizing Statute(s):
US Code:
38 USC 1729
Name of Law: Recovery by the United States of the cost of certain
US Code:
38 USC 1705
Name of Law: Management of health care: patient enrollment system
US Code:
38 USC 1722
Name of Law: Eligibility assessment procedures for cost-free VA medical care
US Code:
38 USC 1722A
Name of Law: Determination of inability to defray necessary expenses;
US Code:
38 USC 1710B
Name of Law: Eligibility for hospital, nursing home, and domiciliary
Citations for New Statutory Requirements:
None
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:
89 FR 105177
12/26/2024
30-day Notice:
Federal Register Citation:
Citation Date:
90 FR 16595
04/18/2025
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Application for Extended Care Services
10-10EC
Application for Extended Care Benefits
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
2,000
2,000
0
0
0
0
Annual Time Burden (Hours)
3,000
3,000
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:
$70,150
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?
No
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:
04/18/2025
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