VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR, 10-10HS

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-10EZR Health Benefits Update Form	Form and Instruction	Modified	Available
Form 10-10EZR VA Form 10-10EZR	Form and Instruction	Modified	Repair queued
Form 10-10EZ Application for Health Benefits	Form and Instruction	Modified	Available
Form 10-10EZ VA Form 10-10EZ	Form and Instruction	Modified	Repair queued
Form 10-10HS VA Request for Hardship Determination	Form and Instruction	Modified	Available
Form 10-10HS VA Form 10-10HS	Form and Instruction	Modified	Repair queued
30-Day FRN_2900-0091_VA Health Benefits - Application Update Hardship Determ_10-10EZ 10-10EZR 10-10HS_pub 06032024.pdf	Supplementary Document	Uploaded 2024-06-03	Repair queued
60-Day FRN_2900-0091_VA Health Benefits - Application Update Hardship Determ_10-10EZ 10-10EZR 10-10HS_pub 03222024.pdf	Supplementary Document	Uploaded 2024-04-26	Repair queued
SSA_2900-0091_VA Health Benefits Forms_10-10EZ 10-10EZR 10-10HS_updated Jun 2024.docx	Supporting Statement A	Uploaded 2024-06-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
256200	VA Form 10-10EZR	Form and Instruction	Modified	Health Benefits Update Form
256200	VA Form 10-10EZR	Form and Instruction	Modified
256198	VA Form 10-10EZ	Form and Instruction	Modified	Application for Health Benefits
256198	VA Form 10-10EZ	Form and Instruction	Modified
244175	VA Form 10-10HS	Form and Instruction	Modified	VA Request for Hardship Determination
244175	VA Form 10-10HS	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0091	ICR Reference No: 202403-2900-006
Status: Historical Active	Previous ICR Reference No: 202402-2900-023
Agency/Subagency: VA	Agency Tracking No: 2900-0091
Title: VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR, 10-10HS
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/05/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/03/2024
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	1,406,000	0	1,406,000
Time Burden (Hours)	703,300	0	703,300
Cost Burden (Dollars)	0	0	0

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Abstract: 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. In addition, 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 U.S.C. Section 1710(e) (3), by expanding the health care eligibility benefit for Veterans who participated in a toxic exposure risk activity (TERA) while serving on active duty, active duty for training, or inactive duty training. 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 Veteran’s 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, determine TERA benefit 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.

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Authorizing Statute(s): US Code: 38 USC Chapter 17 Name of Law: HOSPITAL, NURSING HOME, DOMICILIARY,
   PL: Pub.L. 117 - 168 103 Name of Law: Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act
  

Citations for New Statutory Requirements: PL: Pub.L. 115 - 182 101 Name of Law: MISSION Act of 2018

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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:
	89 FR 20537	03/22/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 47684	06/03/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
VA Form 10-10EZ	10-10EZ	Application for Health Benefits
VA Form 10-10EZR	10-10EZR	Health Benefits Update Form
VA Form 10-10HS	10-10HS	VA Request for Hardship Determination

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	1,406,000	1,406,000	0	0	0	0
Annual Time Burden (Hours)	703,300	703,300	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $11,934,520

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: 06/03/2024

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