VA Health Benefits Application and Update - VA Forms 10-10EZ and 10-10EZR

Forms and Documents

Document Name	Status
Form VA Form 10-10HS Application and Renewal for Health Benefits Form and Instruction	Removed
Form 10-10EZR VA Form 10-10EZR -- Health Benefits Update Form Form and Instruction	New
Form 10-10EZ VA Form 10-10EZ -- Application for Health Benefits Form and Instruction	New
Form 10-10EZ Applications and Renewal for Health Benefits Form and Instruction	Removed
Summary of Updates to VA Forms 10-10EZ and 10-10EZR_Sept 2019.docx Supplementary Document	2019-10-11
Non-Substantive Change Memorandum_2900-0091_Sept 2019.pdf Supplementary Document	2019-10-01
20180614 Non Substantive Change Memo - 10-10EZ Spanish Version.pdf Justification for No Material/Nonsubstantive Change	2018-07-10
2900-0091 White Paper_August 2017.docx Supplementary Document	2017-08-24
2900-0091 60dayFRN VACO-0001-0021.pdf Supplementary Document	2017-02-09
White Paper_VA Form 10-10EC_10.24.16.doc Justification for No Material/Nonsubstantive Change	2017-02-09
2900-0091_Justification Statement A_20180614.doc Supporting Statement A	2018-07-10

IC Document Collections

IC ID	Document Title	Status
28251	Application and Renewal for Health Benefits Form and Instruction	Removed
237785	VA Form 10-10EZR -- Health Benefits Update Form Form and Instruction	New
237784	VA Form 10-10EZ -- Application for Health Benefits Form and Instruction	New
212005	Applications and Renewal for Health Benefits Form and Instruction	Removed

ICR Details

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
	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

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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.

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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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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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

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
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
Application and Renewal for Health Benefits	VA Form 10-10HS	Request for Hardship Determination
VA Form 10-10EZR -- Health Benefits Update Form	10-10EZR	Health Benefits Update Form
VA Form 10-10EZ -- Application for Health Benefits	10-10EZ	Application for Health Benefits

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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.

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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

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Common Form ICR:  No

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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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