Health Eligibility Center (HEC) Income Verification (IV) Forms

Forms and Documents

Document Name	Status
Form 10-304 Waiver Statement Form and Instruction	New
Form 10-303 Declaration of Representative Form and Instruction	New
Form 10-302a Spouse Additional Income Form and Instruction	New
Form 10-302 IRS-SSA Spouse Reported Income Form and Instruction	New
Form 10-301 IRS-SSA Veteran Reported Income Form and Instruction	New
Form 200-1A Income Verification Form	Removed
HEC IV Cases Created spreadsheet_OMB passback response_Aug 2021.xlsx Supplementary Document	2022-03-14
VA HEC Income Verification Division- Paper Reduction Feasibility Analysis_update 2021.docx Supplementary Document	2022-03-14
30-day FRN_HEC Income Verification (IV) Forms_2900-0867_published 03072022.pdf Supplementary Document	2022-03-11
60-day FRN_HEC Income Verification (IV) Forms_2900-0867_published 11232021.pdf Supplementary Document	2022-03-01
Supporting Statement A_HEC Income Verification Forms_2900-0867_updated Mar 2022.docx Supporting Statement A	2022-03-11

IC Document Collections

IC ID	Document Title	Status
249242	Waiver Statement Form and Instruction	New
249241	Declaration of Representative Form and Instruction	New
249240	Spouse Additional Income Form and Instruction	New
249239	IRS-SSA Spouse Reported Income Form and Instruction	New
249237	IRS-SSA Veteran Reported Income Form and Instruction	New
221774	Income Verification Form	Removed

ICR Details

OMB Control No: 2900-0867	ICR Reference No: 202010-2900-006
Status: Received in OIRA	Previous ICR Reference No: 201606-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0867
Title: Health Eligibility Center (HEC) Income Verification (IV) Forms
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/15/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	122,789	0
Time Burden (Hours)	49,758	0
Cost Burden (Dollars)	0	0

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Abstract: VHA Directive 1909 provides policy for the Income Verification (IV) Program. AUTHORITY: 38 United States Code (U.S.C.) 1722; 38 U.S.C. 5317. Title 38 U.S.C. 1722 established eligibility assessment procedures, based on income levels, for determining whether nonservice-connected (NSC) Veterans and non-compensable zero percent service-connected (SC) Veterans, who have no other special eligibility are eligible to receive Department of Veterans Affairs (VA) health care at no cost. Title 26 U.S.C. 6103 (l)(7) of the Internal Revenue Code, and 38 U.S.C. 5317 establish authority for VA to verify Veterans’ gross household income information against records maintained by the Internal Revenue Service (IRS) and Social Security Administration (SSA) when that information indicates the Veteran is eligible for cost-free VA health care. In accordance with VHA Directive 1909, it is VA policy that the Health Eligibility Center (HEC) is responsible for the Income Verification Program, i.e., verifying NSC and non-compensable zero percent SC Veterans’ gross household income through computer matching activity with IRS and SSA. The social security numbers (SSNs) of all Veterans and their spouses identified in the financial assessment will be verified under the Social Security Number Verification Information Exchange Agreement (IEA), between the SSA and VHA HEC, prior to income matching activity with IRS. If IRS and SSA income matching identifies discrepancies in the Veteran’s self-reported gross household income information that potentially impacts eligibility for VA health care benefits, HEC must independently verify the IRS and SSA income data. If the Veteran’s eligibility for VA health care benefits is changed as a result of the income verification process, HEC will transmit the updated eligibility information to those facilities that provided health services to the Veteran during the applicable income-reporting period. HEC’s Income Verification Division (IVD) sends Veterans and spouses, individual letters to confirm income information reported by IRS and SSA. HEC does not change the Veteran’s copay status until information supplied by IRS and SSA has been independently verified, either by the Veteran or through appropriate due process procedures.

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Authorizing Statute(s): US Code: 38 USC 1722 Name of Law: Determination of Income Thresholds
  

Citations for New Statutory Requirements: None

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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:
	86 FR 66619	11/23/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 12776	03/07/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Declaration of Representative	10-303	Declaration of Representative
IRS-SSA Spouse Reported Income	10-302	IRS-SSA Spouse Reported Income
IRS-SSA Veteran Reported Income	10-301	IRS-SSA Veteran Reported Income
Income Verification	340-1, 220-1, 200-1A	Income Verification Response ,   Spouse - Income Verification Response ,   Declaration of Representative
Spouse Additional Income	10-302a	Spouse Additional Income
Waiver Statement	10-304	Waiver Statement

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ICR Summary of Burden

	Total Request	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	122,789	0	0	122,789	-273,441	273,441
Annual Time Burden (Hours)	49,758	0	0	49,758	-119,993	119,993
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: Program burden adjustments are based upon actual data since the last submission.

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Annual Cost to Federal Government: $219,527

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

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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: 03/15/2022

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