VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR and 10-10HS
No material or nonsubstantive change to a currently approved collection
No
Regular
Approved with change
03/01/2024
02/29/2024
OMB is approving this information collection change request. This approval does not alter the current expiration date of 6/30/2024. VA will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond that date.
table that charts list comparision
Inventory as of this Action
Requested
Previously Approved
06/30/2024
06/30/2024
06/30/2024
1,406,000
0
1,406,000
703,300
0
615,350
0
0
0
Section 103 of Public Law 117-168, titled the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act of 2022, amended Title 38, United States Code (U.S.C.), Section 1710(e) (3), by expanding the period of eligibility for health care for Veterans who participated in a toxic exposure risk activity while serving on active duty, active duty for training, or inactive duty training. VA Forms 10-10EZ and 10-10EZR require updates to capture the expanded eligibility for the three cohorts of Veterans listed in Section 103. The established rollout for this expanded eligibility is March 5, 2024. The form changes have been completed, and VA respectfully requests OMB review and PRA approval of the updated 10-10EZ and 10-10EZR forms.
VA notes that this information collection has a current PRA clearance until June 30, 2024, and VA is processing a regular three-year PRA clearance renewal that will be completed before the expiration date.
Title 38 U.S.C. Chapter 17 authorizes VA to provide hospital care, medical services, domiciliary care, and nursing home care to eligible Veterans. Title 38 U.S.C. § 1705 requires VA to design, establish, and operate a system of annual patient enrollment in accordance with a series of stipulated priorities. Title 38 U.S.C. § 1722 establishes eligibility assessment procedures for cost-free VA medical care, based on income levels, which determines whether nonservice-connected and 0% service-connected non-compensable Veterans are able to defray the necessary expenses of care for nonservice-connected conditions. Further, when the Veteran projects that his or her attributable income for the current calendar year would be substantially below the applicable income thresholds, the Veteran would be considered unable to defray the expenses of care and VA may exempt the Veteran from the requirement to pay copayments for hospital or outpatient care.
This collection of information is required to properly administer health benefits to eligible Veterans:
a. VA Form 10-10EZ, Application for Health Benefits, is used to collect Veteran information during the initial application process for VA medical care, nursing home, domiciliary, dental benefits, etc.
b. VA Form 10-10EZR, Health Benefits Update Form, is used to update a Veteranâs personal information, such as marital status, address, health insurance and financial information, for renewal of health benefits.
c. VA Form 10-10HS, Request for Hardship Determination, is used to collect information from Veterans who are in a copay required status for hospital care and medical services, but due to a loss of income project their income for the current year will be substantially below the VA means test limits.
These forms collect information to enroll a Veteran for health benefits, establish basic eligibility, identify 3rd party health insurance coverage, identify prescription copayment, provide for income verification, and serve as a mechanism to make changes upon admission for benefits or yearly financial updates.
US Code:
38 USC 111(c)(1)
Name of Law: Payments or allowances for beneficiary travel
US Code:
38 USC Chapter 17
Name of Law: HOSPITAL, NURSING HOME, DOMICILIARY,
PL: Pub.L. 115 - 182 101 Name of Law: MISSION Act of 2018
The burden has increased as a result of additional fields added to VA Forms 10-10EZ and 10-10EZR to capture information for the expanded health care benefit under Section 103 of the PACT Act.
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:
(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;
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.
Updated VA Form 10-10EZR (2022)