Supporting Statement for VA Form 21-8416
Medical Expense Report
(2900-0161)
A. Justification
1. The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for veterans, service personnel, and their dependents and/or beneficiaries. Information is requested under the authority of 38 U.S.C. 1503. 38 U.S.C. 1503 provides that unreimbursed medical expenses paid by a beneficiary or claimant may be excluded from their countable income. The regulatory basis is found at 38 CFR 3.262 and 38 CFR 3.272.
2. VA From 21P-8416 is used by beneficiaries and claimants to report medical expenses paid in connection with claims for pension and other income-based benefits. Unreimbursed medical expenses may be deducted from otherwise countable income in determining eligibility for income-based benefits and the rate payable. It would be impossible to administer these programs without the collection of the information.
3. VA Form 21P-8416 is available on the One-VA Website in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the form to be incorporated with an existing centralized legacy database.
4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency that maintains the necessary information, nor is it available from other sources within our department.
5. The collection of information does not involve small businesses or entities.
6. This form solicits information that is necessary to determine the amount of deductible medical expenses paid by the claimant in order to calculate the correct rate of payment. Without this information, VA would be unable to authorize and properly pay income-based benefits.
7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.
8. The Department notice was published in the Federal Register on January 15, 2014, Vol. 79, No. 10, page 2755. No comments were received in response to this notice.
9. No payments or gifts to respondents have been made under this collection of information.
10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22/28,‘‘Compensation, Pension, Education, and Rehabilitation Records—VA ’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).
11. There are no questions of a sensitive nature.
12. Estimate of Information Collection Burden.
a. Number of Respondents is estimated at 96,400 per year.
b. Frequency of Response is annually for most beneficiaries.
c. Annual burden hours is 48,200.
d. The estimated completion time of 30 minutes is based on review by staff personnel and previous usage of this form.
e. According to the U.S. Bureau of Labor Statistics Average Hourly Earnings, the cost to the respondent is $24, making the total cost to the respondents an estimated $1,156,800, (48,200 hours x $24 per hour).
13. This submission does not involve any record keeping costs.
14. Estimated Costs to the Federal Government:
a. Processing/Analyzing costs $2,489,208
(GS-9/5 @ $28.04 x 96,400 x 50/60 minutes = $2,252,546)
(GS-3/5 @ $14.73 x 96,400 x 10/60 minutes = $ 236,662)
b. Printing and production cost $3,750
c. Total cost to government $2,492,958
15. There is no change in the reporting burden. The expiration date placeholder has been
added to the form.
16. The information collection is not for publication or tabulation use.
17. We are not seeking approval to omit the expiration date for OMB approval.
18. This submission does not contain any exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
1. This collection of information does not employ statistical methods.
| File Type | application/msword |
| File Title | Supporting Statement for VA Form 21-8416b |
| Author | David K. Abbot |
| Last Modified By | Kessinger, Nancy, VBAVACO |
| File Modified | 2014-04-29 |
| File Created | 2014-04-29 |