2900-0823_Expanded Access to Non-VA Care - VCCP_Supp Statement A_updated Feb 2021

SUPPORTING STATEMENT A

EXPANDED ACCESS TO NON-VA CARE THROUGH THE MISSION ACT:

VETERANS COMMUNITY CARE PROGRAM

OMB 2900-0823

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

Section 101 of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 requires VA to implement the Veterans Community Care Program (VCCP) to furnish care in the community to covered Veterans through eligible entities and providers, under circumstances as further prescribed in the MISSION Act. VA currently collects information that will be required to implement the Veterans Community Care Program under the Veterans Choice Program, through an OMB approved collection 2900-0823.

OMB collection 2900-0823 now includes VA Form 10-10143, Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Community Care Program; VA Form 10-10143a, Veterans Community Care Health Insurance Certification; VA Form 10-10143b, Submission of Medical Record Information under the Veterans Community Care Program; VA Form 10-10143c, Submission of Information on Credentials and Licenses by Eligible Entities and Providers; and VA Form 10-10143e, Secondary Authorization Request for VA Community Care. Two new forms have been added to this collection: VA Form 10-10143f, Community Care Document Cover Sheet and VA Form 10-10143g, Non-VA Hospital Emergency Notification.

VA seeks to update OMB collection 2900-0823 to implement the Veterans Community Care Program by updating the title of VA forms and any associated statutory citations to be consistent with the new program and the MISSION Act, by adding a new cover sheet to use when submitting documentation from providers of non-VA emergent care, by adding a new 72-hour notification form to be used when a Veteran receives emergent care from a non-VA provider, and by updating burden hours to account for estimated increased use of community care under the new program.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

Approval of this collection of information is required to properly adjudicate and implement the requirements of the MISSION Act.

1. VA Form 10-10143 will collect veteran information on whether covered veterans would elect to receive authorized care under the Veterans Community Care Program (VCCP) if certain conditions are met, as required by 38 U.S.C. 1703(d)(3). This form also will allow a covered veteran to specify a particular non-VA entity or provider.

2. VA Form 10-10143a will collect other health insurance information from covered veterans who elect to participate in the VCCP, as required by 38 U.S.C. 1705A. This information also is required by 38 U.S.C. 1703(j), which requires VA to recover or collect reasonable charges for community care that is furnished from a health care plan contract described in 38 U.S.C. 1729.

3. VA Form 10-10143b will collect health records of covered veterans from non-VA health care entities and providers for care authorized under the VCCP, as required by 38 U.S.C. 1703(a)(2)(A), which requires VA to establish a mechanism to receive medical records from non-VA providers. A copy of all medical and dental records (including but not limited to images, test results, and notes or other records of what care was provided and why) related to a Veteran's care provided under the VCCP must be submitted to VA, including any claims for payment for the furnishing of such care.

4. VA Form 10-10143c will collect information from non-VA entities and providers concerning relevant credentials and licenses, as required for such entities or providers to furnish care and services generally. This information is authorized by section 133 of the MISSION Act, which requires VA to establish competency standards for non-VA providers, as well as 38 U.S.C. 1703C(a)(1), which requires VA to establish certain standards of quality for furnishing care and services (including through non-VA providers).

5. VA Form 10-10143e will collect secondary authorization requests from non-VA entities and providers to furnish care and services in addition to or supporting the original authorization for care. This information is required by 38 U.S.C. 1703(a)(3), which establishes that a covered veteran may only receive care or services under the VCCP upon VA’s authorization of such care or services.

6. VA Form 10-10143f will allow for the submission of paper documents in support of a non-VA provider claim for emergency care rendered in the community when not accompanied by a paper Health Care Claim form. This Community Care Document Cover Sheet will be used exclusively for the submission of medical documentation for unauthorized emergent services for patients otherwise covered by VA.

7. VA Form 10-10143g will be used to provide 72-hour notification to VA when a Veteran receives emergent care from a non-VA provider. This form should be completed within 72 hours of the beginning of treatment.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

In accordance with the Government Paperwork Elimination Act (GPEA), this collection meets the established goals, as respondents are permitted to submit information electronically via the internet or by phone. Electronic versions of these forms will reduce the amount of outgoing paper from the agency. Similarly, such an adjustment will reduce the costs acquired from printing and storage of hard copy forms, postage, and hours required in delivering these forms to the public.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

The information gathered from respondents will be unique and is not readily available from other VA sources. As a result, there would be no duplication of information already collected.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This collection may burden small businesses who choose to participate in the program. For providers who currently participate in Choice, this information is the same as VA has collected under the Choice Program since 2014, so we do not believe any new burdens are being created. We acknowledge that newly participating small entities will incur some burden but believe this will be outweighed by the benefit of their participation in the program, as reflected by their choice to participate. This information is also what is minimally required to ensure that licensed and competent individuals furnish approved treatment, which is the same basic information these same entities or providers would submit to any third-party insurer or any other Federal health care entity for payment of claims. Every effort has been made to minimize the burden by keeping questions simple and to an absolute minimum.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

Failure to collect this information would prohibit VA from properly implementing the requirements of section 101 of the MISSION Act. Specifically, failure to collect this information would prevent VA from determining whether covered veterans elect to participate in the VCCP. Failure to collect this information also would make it impossible for VA to ensure community providers are properly licensed to provide medical services. Additionally, VA would be unable to make payments on claims related to care or services furnished under the VCCP if it does not have medical records information.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

VA statute at 38 U.S.C. 1703(a)(3) establishes that a covered Veteran may only receive care or services under the VCCP upon VA’s authorization of such care or services. This authorization can cover care for a duration of up to one year, but to the extent additional authorizations within the year are required, the following information may need to be collected more often than quarterly: VA Form 10-10143b, related to the health care records of covered Veterans, and VA Form 10-10143e, related to secondary authorization requests.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The 60-day notice of Proposed Agency Information Collection Activity was published in the Federal Register on August 14, 2020 (85 FR 49720). VA received no comments in response to this notice.

The 30-day notice of Agency Information Collection Activity under OMB Review was published in the Federal Register on December 2, 2020 (85 FR 77487). VA received no comments in response to this notice, to date.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

Outside consultation for updates to the form titles and any associated statutory citations and changes to the burdens for this information collection will be conducted with the public through the Federal Register notice and comment period.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gifts will be provided to respondents.

10. Describe any assurance of privacy, to the extent provided by law, to respondents and the basis for the assurance in statute, regulation, or agency policy.

Information collected on these forms is protected by the Privacy Act of 1974, VA confidentiality statutes 38 USC § 5701 and 38 USC § 7332, and 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act. Respondents are informed that the information collected will be included as a part of the system of records identified as 54VA16, Health Administration Center Civilian Health and Medical Program Records-VA, as set forth in the 2005 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html and disclosures made in accordance with the statute.

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

This collection requires a provider to furnish claim-specific medical information, including information that is considered sensitive but would be known to the Veteran based on the consultation with the non-VA health care provider. Examples of documentation are identified within the document.

12. Estimate of the hour burden of the collection of information:

1. The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:

The number of respondents for VA Form 10-10143 and 10-10143a is estimated at 3,655,000 covered Veterans annually for each form and is based on the number of covered Veterans who are estimated to be found eligible for the Veterans Community Care Program and likely to elect to receive such care, based on the first-year estimate in the accompanying regulatory impact analysis for AQ46.

• The response rate of one time per year for VA form 10-10143 is based on the estimated need to submit one election to receive an episode of care per year, as each such episode can last up to one year. The response rate of one time per year for VA Form 10-10143a is based on the annual requirement to submit information about other health insurance a covered Veteran many have. The submission of this information will take 10 minutes on average, as we believe both forms merely request information that Veterans have on hand already and would replicate (i.e., a known election to receive care under the VCCP on form 10-10143, and a known source of other health insurance as applicable on form 10-10143a).

The number of respondents for VA Forms 10-10143b, 10-10143c, and 10-10143e is estimated at 366,823 eligible entities and providers annually for each form and is based on the number of eligible providers furnishing eligible services to covered veterans through a third-party administer. The estimate is based on the number of providers who are recorded as being under VA’s network of providers in the expansion of its community care contract. The response rates and average times to submit information for each form are as follows:

• VA Form 10-10143b: VA estimates an average response rate of 34 times annually in which a provider will need to submit medical records and claims-related data to VA, related to approved episodes of care for covered Veterans who elect to receive care under the VCCP. This response rate is based on the last approved response rate of 29 (for OMB control number 2900-0823), estimating an increase in 5 responses annually per provider to account for the increased estimated number of Veterans who will use community care. Taking the increased estimated number of Veterans as 3,665,000, VA estimated each Veteran would need to use VCCP services 3.4 times on

average annually. VA then divided this estimated total number of times VCCP care would be used by the new estimated number of providers at 366,823. The resulting basic equation for

purposes of this estimated increase is 3,666,000 x 3.4 /366,823 = 33.9, which VA rounded up to a total of 34 estimated annual responses per provider to submit medical records and claims-related data to VA. VA estimates the submission of information will take 5 minutes on average, as this was the last approved estimate of this same information, and represents information the provider would already have on hand and would merely need to transmit to VA.

• VA Form 10-10143c: A response rate of 1 time every three years, which VA has presented here as an annual average, in which a provider will need to submit licensure and other competency information. Taking the estimated number of providers at 366,823 / 3 =122,274. The response rate is based on the last approved response rate of 1 for OMB control number 2900-0823, no estimated increases. VA estimates the submission of information will take 5 minutes on average, as this was the last approved estimate of this same information, and represents information the provider would already have on hand and would merely need to transmit to VA.

• VA Form 10-10143e: A response rate of 5 times annually in which a provider will need to submit requests for secondary authorizations, or authorizations for care or services that may extend beyond the original authorized episode of care. This response rate is based on the last approved response rate of 5 for OMB control number 2900-0823, no estimating increases. VA estimates the submission of information will take 20 minutes on average, as this was the last approved estimate of this same information and represents information the provider may need to separately gather (e.g., that may not be readily on hand), as this is a secondary authorization for care and services that may extend beyond the initially approved episode of care.

The number of respondents for VA Forms 10-10143f and 10-10143g is estimated at 500,000 eligible entities and providers annually for each form and is based on the number of non-VA providers furnishing eligible services to covered veterans. The estimate is based on the number of providers who are recorded as being under VA’s network of providers in the expansion of its community care contract. The response rates and average times to submit information for each form are as follows:

• (NEW) VA Form 10-10143f: An estimated response rate of 500,000 times annually in which this cover sheet will be used when submitting documents for emergent care rendered by a non-VA provider. This is a new form that will be used for care rendered in the community when not accompanied by a paper Health Care Claim form. VA estimates the submission of information will take 5 minutes on average. The form will be used exclusively for the submission of medical documentation for unauthorized emergent services for patients otherwise covered by VA.

• (NEW) VA Form 10-10143g: An estimated response rate of 500,000 times annually in which this 72-hour notification will be used for emergent care rendered by a non-VA provider. This is a new form will be completed and submitted by the non-VA provider within 72 hours of the beginning of care. VA estimates the submission of information will take 10 minutes on average. The form will be used exclusively for unauthorized emergent services for patients otherwise covered by VA.

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13.

Form #	Respondents	Responses	Annual Number of Responses	x Minutes (÷ 60)	Annual Hours
10-10143	3,665,000	1	3,665,000	10	610,833
10-10143a	3,665,000	1	3,665,000	10	610,833
10-10143b	366,823	34	12,471,982	5	1,039,332
10-10143c	122,274	1	122,274	5	10,190
10-10143e	366,823	5	1,834,115	20	611,372
10-10143f	500,000	1	500,000	5	41,667
10-10143g	500,000	1	500,000	10	83,333
TOTALS	9,365,920		22,758,371		3,007,560

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

VA uses general wage data to estimate the respondents’ costs associated with completing the information collection.  In accordance with the Bureau of Labor Statistics (BLS) May 2019 Occupational Wage Code Median Hourly, the mean hourly wage is $25.72 based on the BLS wage code – “00-0000 All Occupations.”  This information was taken from the following website: https://www.bls.gov/oes/current/oes_nat.htm#00-0000

.

VA estimates the total annualized cost to respondents at $77,354,443.20 (3,007,560 total hours x $25.72 per hour).

13. Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

1. This collection does not have capital, start-up, operation or maintenance costs.

2. Cost estimates are not expected to vary widely. The only estimated cost is that for the time of respondents.

2. There is no anticipated recordkeeping burden beyond that which is considered usual and customary.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

VA has determined that no additional FTEs or administrative costs will be required to collect this information; VA has current FTE and administrative processes to collect this information and will adjust workload accordingly.

15. Explain the reason for any burden hour changes since the last submission.

Section 101 of the MISSION Act establishes different and broader eligibility to receive care in the community than the current Veterans Choice Program. This accounts for the estimated increase in covered Veterans who will use community care under the VCCP.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish the results of this information collection.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

VA is not seeking approval to omit the expiration date.

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

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