Supporting Statement A_2900-0798_Veteran-Beneficiary Claim for Reimbursement of Travel Expenses_10-3542 and BTSSS_updated 02082024

SUPPORTING STATEMENT A

Veteran/Beneficiary Claim for Reimbursement of Travel Expenses

VA Form 10-3542

OMB Control Number 2900-0798

Summary of Changes from Previously Approved Collection:

• The number of annual respondents and burden hours have increased

• The number of minutes to complete the form has been increased to 10 minutes

• VA requests an emergency PRA clearance and reinstatement of this information collection while we follow the regular 3-year clearance process

A. JUSTIFICATION

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

Through the Beneficiary Travel (BT) program, Veterans Health Administration (VHA) provides mileage reimbursement to qualified Veterans or other claimants (referred to as “claimant” hereafter) who incur expense in traveling to healthcare services. Determination criteria for claimant qualification and trip reimbursement are stated in 38 U.S.C. Section 111 and require certain information to be gathered. Claimants may apply verbally, in writing (using VA Form 10-3542) or electronically (using the Beneficiary Travel Self Service System (BTSSS)). The same information is gathered in all instances. This collection of information is necessary to enable the VHA to provide this benefit and appropriately ensure that funds are being paid to the correct claimant.

VA respectfully requests OMB review and approval of an emergency PRA clearance to reinstate this information collection while VA is processing a regular three-year PRA clearance renewal.

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.

The purpose of the information collection is for beneficiaries to apply for the BT mileage reimbursement benefit in an efficient, convenient, and accurate manner. VHA must determine the identity of the claimant, the dates and length of the trip being claimed based on addresses of starting and ending points, and whether expenses other than mileage are being claimed. The form includes a penalty statement and a statement indicating the claimant has traveled at their own expense and not used Government or cost-free resources for this purpose. The claimant is required to sign the form. The form is used only when the claimant chooses not to apply verbally or electronically. Once the information is obtained it is entered into a software program that calculates the mileage and resulting reimbursement.

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.

The use of the paper form allows claimants to apply for reimbursement indirectly (at remote locations and outside of business hours), but use of information technology has enhanced the process. The BT Mileage Reimbursement Application was made available to claimants via self-serve kiosks located in VA facilities in April of 2015. However, these legacy kiosks have been removed due to outdated software. Claimants may now apply via the Beneficiary Travel Self Service System (BTSSS) which is a web-based application portal accessible via internet connected devices (smart phone, tablet, laptop, etc.) that allow claimants further convenience.

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 form allows claimants to apply for mileage reimbursement for trips unique in time, and only information required to define the unique trip is requested. The average number of trips for which a unique Veteran submits a claim annually is 5. Some of that information is stored in VA systems. Each time the claimant submits the required information it is used to identify the claimant and establish eligibility for the benefit requested unique to the current application.

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

No small businesses or other small entities are impacted by this information collection.

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.

Without the information the BT mileage reimbursement benefit, established in law, could not be dispersed. Some claimants would be unable to meet the expense of travel to healthcare impacting their health and quality of life. Preventative healthcare would be impacted, and some claimant’s conditions could worsen, causing more expensive treatment including emergency care.

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.

There are no such special circumstances. The information will be voluntary and will not be used for statistical purposes.

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 Information Collection Activity was published in the Federal Register on XXXXX (Vol. XX, No. XX, page XXXXX). VA received __ 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 XXXXX (Vol. XX, No. XX, page XXXXX).

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.

1. Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices.

2. VA meets with Veteran Service Organizations and public advocacy organizations on a regular basis. The BT mileage reimbursement program is discussed and feedback on any changes is solicited.

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

The BT mileage reimbursement program is established in 38 U.S.C. Section 111. The information gathered by use of the form allows for dispersal of the BT mileage benefit, for which the reimbursement rate is currently $.415 per mile traveled or actual cost of travel when using common carrier (public transportation).

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

Assurances of confidentiality are contained in 38 U.S.C. 5701 and 7332. Respondents are informed that the information collected will become part of the Consolidated Health Record which complies with the Privacy Act of 1974. This is part of the system of records identified as 24VA136 “Patient Medical Record – VA” as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html

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.

There are no questions of a sensitive nature.

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

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

VA Form 10-3542 (paper or through BTSSS)

Estimated number of annual respondents	1,460,000
Frequency of response (annually)	5
Total number of annual responses	7,300,000
Average estimated response time	10 min.
Estimated annual burden hours	1,216,667 hours

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.

This request covers only one form.

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 cannot make assumptions about the population of respondents because of the variability of factors, such as the educational background and wage potential of respondents.  Therefore, VHA used general wage data to estimate the respondents’ costs associated with completing the information collection.

The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers.  According to the latest available BLS data, the mean hourly wage is $29.76 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.  

Legally, respondents may not pay a person or business for assistance in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VHA estimates the total cost to all respondents to be $36,208,009.90 ( burden hours x $29.76 per hour)

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

a. There are no capital, start-up, operational, or maintenance costs.

b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.

c. 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.

The cost to the Federal Government is estimated at $29,205,840 for processing the Veteran’s in person and paper-based claims for Beneficiary Travel reimbursement.

Claim processing	10 min per claim x 7,300,000 annual applications (paper and verbal)/ 60 min per hour x GS-6/step 5 @ $24/ hr	$29,200,000 (approx.)
Printing, Stocking and Distribution of Forms	7,500,000 forms printed annually	$16,875

15. Explain the reason for any burden hour changes or adjustments reported in items 13 or 14.

Changes stem from the impact of COVID-19 which suppressed face-to-face visits. Claim processing grades increased from GS5 to GS6 step 5. Due to a previous miscalculation in the claim processing time. The per hour rate was not converted to per min rate. Thus, the drastic change in the dollar amount. Due to the introduction of BTSSS the number of 10-3542 hard copies has decreased.

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.

Data collected from the form is entered into VA information systems during the process of evaluating the claim. Data is later pulled from the system to report the number of claims, average amount per claim, and other data for Medical Centers and VISNs to be used as a tool in management of the benefit including reports to Congress.

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 will include the expiration date on all forms.

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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