Medical Expense Report (VA Form 21P-8416)

Forms and Documents

Document Name	Status
Form 21P-8416 Medical Expense Report Form and Instruction	Modified
2900-0161 SupportingStatement 20181029.docx Supporting Statement A	2018-10-30

IC Document Collections

IC ID	Document Title	Status
28397	Medical Expense Report Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0161	ICR Reference No: 201809-2900-002
Status: Active	Previous ICR Reference No: 201604-2900-020
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-NK
Title: Medical Expense Report (VA Form 21P-8416)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/31/2018
	Date Received in OIRA: 09/18/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved	01/31/2020
Responses	60,000	0	96,400
Time Burden (Hours)	30,000	0	48,200
Cost Burden (Dollars)	0	0	974,845

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Abstract: 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 by this form under the authority of 38 U.S.C. §1503(a)(8) regarding exceptions to countable income for needs-based benefits, specifically an amount equal to amounts paid by a claimant or beneficiary for unreimbursed medical expenses. In RIN 2900-AO73, VA proposes to amend its pension regulations to maintain the integrity of its needs-based pension program. VA has authority under 38 U.S.C. 501(a) to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by VA. VA would amend its information collections in conjunction with RIN 2900-AO73. This rulemaking is largely in response to a Government Accountability Office (GAO) report, GAO-12-50, Veterans’ Pension Benefits: Improvements Needed to Ensure Only Qualified Veterans and Survivors Receive Benefits. VA Form 21P-8416 is used by claimants and beneficiaries to report unreimbursed medical expenses for the purpose of reducing their countable income associated with needs-based benefit programs such as VA Pension and Parents’ Dependency and Indemnity Compensation (DIC). Unreimbursed medical expenses are deducted from otherwise countable income to determine eligibility for income-based benefits and the rate payable.

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Authorizing Statute(s): US Code: 38 USC 1503(a)(8) Name of Law: Determinations with respect to annual income
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO73	Final or interim final rulemaking	83 FR 47246	09/18/2018

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medical Expense Report	21P-8416	Medical Expense Report

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ICR Summary 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	60,000	96,400	0	-36,400	0	0
Annual Time Burden (Hours)	30,000	48,200	0	-18,200	0	0
Annual Cost Burden (Dollars)	0	974,845	0	-974,845	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The reduction in the number of estimated annual respondents was published in the Notice of Proposed Rulemaking 2900-AO73 (80 FR 3839 through 386, on January 23, 2015).

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Annual Cost to Federal Government: $3,351,400

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? Uncollected

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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: 09/18/2018

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