SSA_2900-0798_Veteran-Beneficiary Claim for Reimbursement of Travel Expenses_10-3542 and BTSSS_updated Sep 2024

SUPPORTING STATEMENT A

Veteran/Beneficiary Claim for Reimbursement of Travel Expenses

VA Form 10-3542 and BTSSS

OMB Control Number 2900-0798

Summary of Changes from Previously Approved Collection:

• The number of estimated annual respondents and burden hours have increased.

• The number of minutes to complete a claim has been increased to 10 minutes.

• VA Form 10-3542 has been updated with an additional Instruction item (#6) noting that travel expense claims for VA-authorized appointments with non-VA providers in the community must include documentation providing proof that care/services were received from the provider.

• Online submission options also have been clarified in the Instructions for VA Form 10-3542.

• The BTSSS electronic system for submitting claims is described and included in the SSA.

• 26 public FedReg comments and one email comment were received on the 60-day FRN. A document with program office responses to all comments is included in the ROCIS ICR.

A. JUSTIFICATION

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

Pursuant to 38 U.S.C. 111 and 38 C.F.R. Part 70, Subpart A, the Veterans Health Administration (VHA) Beneficiary Travel (BT) Program, provides payments for authorized travel expenses to help Veterans and other beneficiaries obtain care or services from VHA and VA authorized non-VA providers in the community. VHA must administer payments according to statutory mandates, including the Payment Integrity Information Act of 2019 (PIIA) (Public Law 116-117). In compliance with the PIIA and other program requirements, VHA must gather certain information to determine whether BT eligibility and other criteria for approval have been met, and the amount of payment or reimbursement that is authorized under the BT program. Claimants may include Veterans and other BT beneficiaries, and entities or individuals who provided or paid for travel. Claimants may apply for BT reimbursement orally or in writing through VA Form 10-3542 or the Beneficiary Travel Self Service System (BTSSS). This standard collection of information is necessary to enable VHA to provide this benefit and appropriately ensure that funds are being paid to the correct claimant.

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 claimant may provide self-attestation of their attendance at a VA authorized appointment with a non-VA provider. The claim 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 10-3542 form. The form is used only when the claimant chooses not to apply verbally or electronically, through the BTSSS. If VA determines that additional information is needed to make a determination concerning an application for benefits, VA will notify the claimant in writing in accordance with 38 CFR 70.20(e). Once the claim 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 10-3542 form and BTSSS allow claimants to apply for mileage reimbursement for trips that are 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 collected 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.

A 60-Day Federal Register Notice (FRN) for the collection published on Tuesday, March 5, 2024. The 60-Day FRN citation is 89 FR 15928.

26 comments and one comment email were received during the 60-Day comment period. VA made some edits to the Instructions section of the 10-3542 form to clarify reimbursement claim documentation requirements and online submission options. A document with the VHA program office responses to all comments is included in the ROCIS entry for this ICR.

A 30-Day Federal Register Notice for the collection published on Wednesday, September 18, 2024. The 30-Day FRN citation is 89 FR 76623.

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:

Total VA Form 10-3542 and BTSSS Claims

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 claims submitted using a paper form and the BTSSS – see chart in 12.a above.

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 $31.48 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 $38,300,677.20 (1,216,667 burden hours x $31.48 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 $29,216,875 for processing the Veterans’ 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.

The burden time per claim submission has been increased to 10 minute per response. Other changes to numbers of claims stem from the impact of COVID-19, which suppressed face-to-face visits.

Claims processing grades of staff 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 form 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.

Page 1