Supporting Statement for VA Form 21-0779
Request for Nursing Home Information in Connection with Claim for Aid and Attendance
(2900-0652)
A. Justification
1. The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for veterans, service personnel, and their dependents and/or beneficiaries. 38 U.S.C. 1502 provides for payment of improved pension and aid and attendance to eligible veterans who are patients in nursing home. Parents and surviving spouses entitled to service-connected death benefits and spouses of living veterans receiving service connected compensation at 30 percent or higher are also entitled to aid and attendance based on status as nursing home patients (38 U.S.C. 1115(1)(E)), 38 U.S.C. 1311(c), 38 U.S.C 1315(h)). Under 38 U.S.C. 5503, if a veteran having neither spouse nor child, or a surviving spouse having no child, is receiving Medicaid-covered nursing home care, improved pension is limited to $90 per month. Regulatory authority is found in 38 CFR 3.351 and 3.551. Information is requested by this form under the authority of 38 U.S.C. 501(a)(2).
2. VA Form 21-0779 is used to gather the necessary information to determine eligibility for pension and aid and attendance based on being in a nursing home. This form also requests information of Medicaid status and nursing home care charges, so VA can determine the proper rate of payment.
3. The collection of information does not involve the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology. VA Form 21-0779 is partially completed by VA and then sent to nursing homes for completion. To avoid improper use by claimants who are not required to complete or submit this form, the form is not available on the VBA website for downloading. Information requested by VA Form 21-0779 can also be obtained by calling the nursing home and documenting the information. A faxed copy of a properly signed VA Form 21-0779 may be accepted if there are no questions as to its validity. Currently, there has been no consideration of using other information technology. The Department will reconsider using other information technology when the resources become available.
4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department.
5. The form used to collect the information is brief and can be completed by any administrator of a nursing home which may include small businesses.
VA Form 21-0779 is used to determine eligibility for pension and/or aid and attendance for veterans, spouses, surviving spouses, and surviving parents who are patients in nursing homes and determine the proper rate of payment. Without this information, entitlement to benefits would not be properly authorized.
7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.
8. The Department notice was published in the Federal Register on April 25, 2007, Volume 72, Number 79, pages 20582-20853. Outside consultations were not solicited as no major changes are being made to the form. Field stations have not reported any difficulty on the part of respondents in using the form. No comments were received.
9. No payments or gifts to respondents have been made under this collection of information.
10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22, "Compensation, Pension, Education and Rehabilitation Records - VA" as set forth in Privacy Act Issuances, 1993 compilation found in 42 Fed. Reg. 49726 (9/27//1977).
11. There are no questions of a sensitive nature.
12. Estimate of Information Collection Burden.
a. Number of Respondents is estimated at 50,000 per year.
b. Frequency of Response is one time for most beneficiaries.
c. Annual burden is 8,333 hours.
d. The estimated completion time of 10 minutes is based on review by staff personnel.
e. The total estimated cost to respondents is $124,995 (8,333 hours x $15 per hour).
13. This submission does not involve any recordkeeping costs.
14. Estimated Costs to the Federal Government:
a. Processing/Analyzing costs $1,285,374
(GS-11/5 @ $30.25 x 50,000 x 15 minutes = $378,125)
(GS-10/5 @ $27.53 x 50,000 x 30 minutes = $688,250)
(GS-3/5 @ $13.14 x 50,000 x 10 minutes = $218,999)
b. Printing and production cost $1,000
c. Total cost to government $1,286,374
15. There is no change in the reporting burden.
16. The information collection is not for publication or tabulation use.
17. The collection instrument, VA Form 21-0779, may be reproduced and/or stocked by the respondents and veterans service organizations. This VA form does not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of this form. This form is submitted to OMB every 3 years. As such, this date requirement would also result in an unnecessary burden on the respondents and would delay Department action on the benefit being sought. VA also seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date. For the reasons stated, VA seeks an exemption that waives the displaying of the expiration date on VA Form 21-0779.
18. This submission does not contain any exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
1. The Veterans Benefits Administration does not collect information employing statistical methods.
| File Type | application/msword |
| File Title | 38 U |
| Author | Sarah Price |
| File Modified | 2007-09-10 |
| File Created | 2007-09-10 |