Justification A_Camp Lejeune (clean)

Reimbursement of Certain Medical Expenses
for Camp Lejeune Family Members

RIN 2900-AO79

OMB 2900-XXXX

VA Forms:
10-10068 Camp Lejeune Family Member Program Application

10-10068a Camp Lejeune Family Member Program Claim Form

10-10068b Camp Lejeune Family Member Program Treating Physician Form

10-10068c Camp Lejeune Family Member Program Information Update Form

A. JUSTIFICATION

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

Under 38 U.S.C. 1787, VA is required to furnish hospital care and medical services to the family members of certain veterans who were stationed at Camp Lejeune between 1957 and 1987. In order to furnish such care, VA must collect certain information from the family members to ensure that they meet the requirements of the law. VA cannot furnish the statutorily-mandated hospital care and medical services until the collection of information is approved. The specific hospital care and medical services that VA must provide are for a number of illnesses and conditions connected to exposure to contaminated drinking water while at Camp Lejeune. Many of these conditions are life-threatening and require immediate medical attention. Therefore, VA certifies that the collection of information meets each of the listed criteria for the following reasons:

(i) The collection is needed prior to the expiration of time periods established under this Part, because we anticipate that the regulations authorizing VA to furnish hospital care and medical service to Camp Lejeune family members will publish and become effective prior to the expiration of the time periods established under this Part.

(ii) The collection is essential to the mission of the agency, because VA cannot begin to furnish the hospital care and medical services set forth in regulation and required by law, to Camp Lejeune family members without forms without first collecting required information.

(iii) VA cannot reasonably comply with the normal clearance procedures because public harm is reasonably likely to result if normal clearance procedures are followed. VA will furnish Camp Lejeune family members with hospital care and medical services for 15 illnesses and conditions that are life threatening and require immediate medical intervention.

VA requests approval from OMB concurrent with publishing of the IFR.

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.

VA will use the new information collection to begin to furnish hospital care and medical services to Camp Lejeune family members. VA will use the 10-10EZ (2900-0091) to confirm Veteran self-election check box for serving at Camp Lejeune. VA will also use CMS 1500 and UB-04 (not on file as a common form in ROCIS) to file with Medicare/Medicaid.

CLFMP application form 10-10068: CL family members will use this form to apply for acceptance for benefits under the Camp Lejeune Family Member Program.

CLFMP claim form 10-10068a: CL family members will use this form to submit medical bills for reimbursement.

CLFMP Treating Physician Report 10-10068b: the physician for the family members will use this form if the FM has one of the 15 covered conditions.

CLFMP information update form 10-10068c: the CL family members will use this form to update their information for the program

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.

At program startup, there will be limited functionality for electronic means to apply for the program and for physicians to submit claims via EDI. In future phases of the system to be used for the program, more electronic functionality will be available to provide information updates.

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.

1. . Form 10-10068: No other method currently exists for obtaining correct CL family member identifiers, demographics and other information needed for processing applications.

2. Form 10-10068a: No other method currently exists for obtaining correct CL family member identifiers, demographics and other information needed for processing medical claims.

3. Form 10-10068b: No other method currently exists for obtaining correct CL family member identifiers, demographics and other information needed for identifying the medical conditions that are being applied for.

4. Form 10-10068c: No other method currently exists for obtaining correct CL family member identifiers, demographics and other information needed for updating family member information.

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

The collection of information will have no impact on small businesses or other small entities.

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.

If the collection is not conducted, then VA cannot appropriately identify Camp Lejeune family members or furnish hospital care and medical services to these individuals through the payment or reimbursement of care related to the illnesses and conditions specified in 38 U.S.C. 1787.

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.

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.

VA will seek public comments through the publication of the interim final rule.

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.

Outside consultation will be conducted with the public through the Emergency Federal Register notice.

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

No payment or gift is provided to respondents.

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 privacy 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 that complies with the Privacy Act of 1974. These forms are part of the system of records identified as 23VA16 “Patient Medical Record – VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.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 number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:

VA Form(s)	No. of respondents	Times per year	x No. of responses	x No. of minutes	÷ by 60=	Number of Hours
10-10068	1,629	1/yr	1,629	30 min		815
10-10068a	1,629	11/yr	17,919	15 min		4,480
10-10068b	1,629	1/yr	1,629	15 min		407
10-10068c	543	1/yr	543	15 min		136
	5,430		21,720			5,838

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 of OMB 83-I.

This request covers 4 forms, See chart in subparagraph 12a 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 does not require any additional recordkeeping. The cost to the respondents for completing these forms is $ 140,112.00 ($24 per hour - Department of Labor x 5,838 burden hours).

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 is no capital, start-up, operation 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.

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.

(Based on the hourly salary of a GS 4 Step 5.)

The estimated annual cost of VA Form 10-10068 to the Federal Government is $8,343.

The estimated annual cost of VA Form 10-10068a to the Federal Government is $72,576.

The estimated annual cost of VA Form 10-10068b to the Federal Government is $6,593.

The estimated annual cost of VA Form 10-10068c to the Federal Government is $3,823.

Form	Hourly Salary	Responses	Time to Complete	Total Hours	Cost
10-10068	$16.20	1,629	30 minutes	815	$8,343
10-10068a	$16.20	17,919	15 minutes	4,480	$72,576
10-10068b	$16.20	1,629	15 minutes	407	$6,593
10-10068c	$16.20	543	15 minutes	136	$3,823
	TOTAL				$91,335

15. Explain the reason for any burden hour changes or adjustments reported in items 13 or 14 of the OMB form 83-1.

This is a new collection and all burden hours are considered a program increase.

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.

VA does not intend to publish this data.

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 display 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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