SUPPORTING STATEMENT A
OMB Control Number: 2900-0629
APPLICATION FOR EXTENDED CARE SERVICES
VA FORM 10-10EC
1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
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. A consequence of this is that many groups of Veterans who are in a lower priority group (WWI Veterans, Veterans with disabilities rated as 0% service-connected seeking treatment for other than their service-connected conditions, Veterans exposed to a toxic substance, radiation, or environmental hazard and nonservice-connected Veterans) may request that they be allowed to be income tested in order to gain a higher priority. Title 38 U.S.C. § 1722 establishes eligibility assessment procedures for cost-free VA medical care, based on income levels, which will determine whether nonservice-connected and 0% service-connected noncompensable Veterans are able to defray the necessary expenses of care for nonservice-connected conditions. Title 38 U.S.C. § 1722A establishes the eligibility assessment procedures, based on income levels, for determining Veterans’ eligibility for cost-free medications and Title 38 U.S.C. § 1710B defines the procedures for establishing eligibility for cost-free Extended Care benefits. Title 38 U.S.C § 1729 authorizes VA to recover from Veterans’ health insurance carriers the cost of care furnished for their nonservice-connected conditions
VA Form 10-10EC, Application for Extended Care Services, is used to collect financial information necessary to determine a Veteran’s copayment obligation for extended care services, also known as long term care (LTC).
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.
The VA Form 10-10EC, Application for Extended Care Services, collect financial information from Veterans and Veteran’s spouses in order to determine the LTC copayment obligations for Veterans who require extended care services. The LTC copayments also apply to extended care services provided to Veterans through community resources that are paid for by VA through contractual arrangements. The VA Form 10-10EC is generally completed by the Veteran, or an individual to whom the Veteran has delegated their Power of Attorney, with the assistance of the Social Worker involved in the placement of the Veteran. VA Form 10-10EC is used to gather a Veteran’s current financial information to determine the calculated monthly LTC copayment amount. VA Form 10-10EC establishes the following:
Veteran’s financial liability, if any, for receipt of extended care services.
Veteran’s agreement to make the applicable copays for extended care services as required.
VA Form 10-10EC will only be completed when a non-service connected Veteran requires extended care services and has been determined to be non-exempt for LTC copayments. This form will be updated at least annually or at any time during the year, when financial commitments have changed that would change or eliminate copayments for extended care services.
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.
The burden to the public has been kept to a minimum. Under 38 CFR §17.111, Veterans who require extended care services and are subject to the copayment requirement must submit current financial information on VA Form 10-10EC at the following times:
Initial request for an episode of extended care services;
After a break in provision of extended care services for more than 30 days;
Each year at the time of submission of VA Form 10-10EZ; and
When there are changes that might change the Veteran’s copayment obligation. (i.e., changes regarding marital status, fixed assets, liquid assets, expenses, income (when received), or whether the Veteran has a spouse or dependents residing in the community).
After completion of a risk analysis and a cost benefit analysis, it was determined that it was not cost effective to automate submission of the form by the Veteran as it is generally completed with the assistance of a Social Worker.
4. Describe effort to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purpose described in Item 2 above.
Under 38 CFR § 17.111, when a non-exempt Veteran initially request extended care services, and at other specified times, VA Form 10-10EC is required to collect the Veteran’s current financial information. Veterans who do not require extended care services will not complete this form. VA Form 10-10EC collects the Veteran’s current financial information, including income, liquid and fixed assets and subsistence expenses for the Veteran, Veteran’s spouse, and Veteran’s dependents, if applicable, in order to calculate the monthly copayment amount due (if any) for extended care services. Financial information will be obtained and retained locally. The information for living and subsistence expenses is not currently obtained in any other format.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
No small business or other small entities are impacted by this information collection.
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 reduce burden.
The VA Form 10-10EC will only be completed when a Veteran, with prior year income above the single Veteran non-service connected disability pension income amount in effect under 38 U.S.C. § 1521(b), requests placement or treatment for the following:
Institutional Nursing Home Care.
Institutional Domiciliary Care
Institutional Geriatric Evaluation
Institutional Respite Care
Non-institutional Respite Care
Non- institutional Adult Day Health Care, and
Non-institutional Geriatric Evaluation.
Failure to complete the VA Form 10-10EC, when required, would restrict determination of a Veteran’s copayment obligation for extended care services. Veterans may elect not to disclose financial information, but must agree to make the appropriate copayments for extended care services as required.
7. Explain any special circumstances that would cause information collection to be conducted more often than quarterly or require respondents to prepare written responses to 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 review and approved by OMB.
There are no such circumstances.
8a. 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.
The 60-day notice of Proposed Information Collection Activity was published in the Federal Register on December 27, 2021 (Vol. 86, No. 245, pages 73413-73414). VA received no comments in response to this notice.
The 30-day notice of Agency Information Collection Activity Under OMB review was published in the Federal Register on March 9, 2022 (Vol. 87, No. 46, page 13371).
8b. 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 record keeping, 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 is conducted with the public through the 60- and 30-day Federal Register notices. We received no response to these requests for comment.
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 confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.
Assurances of confidentiality 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, which complies with the Privacy Act of 1974. This form is part of the system of records identified as 24VA136 “Patient Medical Record – VA” as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html. Financial information gathered on VA Form 10-10EC will be maintained in the system identified as 89VA161 “Health Eligibility Records – VA” in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html. Obligation to respond is voluntary.
11. Provide additional justification for any questions of a sensitive nature, 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.
VA Form 10-10EC collects financial information relative to the income, assets, and expenses, for the Veteran, the Veteran’s spouse, and the Veteran’s dependents, if applicable, which may be considered sensitive. This information is necessary to determine the Veteran’s obligation to pay the copayment to the extent the Veteran and the Veteran's spouse, if applicable, have available resources as provided under 38 CFR § 17.111. This information is also requested in order to protect the Veteran’s spouse or dependent from financial hardship caused by copayments for extended care services.
Estimate of the hour burden of the collection of information:
a. The estimated annual hour burden for this collection is: 3,000 hours.
VA Form 10-10EC |
No. of respondents |
x No. of responses |
x No. of minutes |
÷ by 60 =
|
Number of Burden Hours |
Application |
2000 |
1 = 2000 |
90 |
3,000 hrs |
b. If this request for approval covers more than one form, provide separate hour estimates for each form and aggregate the hour burdens in Item.
This request covers only one form.
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 cannot make assumptions about the population of respondents because of the variability of factors, such as the educational background and wage potential of respondents. Therefore, VHA used general wage data to estimate the respondents’ costs associated with completing the information collection.
The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers. According to the latest available BLS data, the mean hourly wage is $27.07 based on the BLS wage code – “00-0000 All Occupations.” This information was taken from the following website: https://www.bls.gov/oes/current/oes_nat.htm.
Legally, respondents may not pay a person or business for assistance in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $81,210.00 (3,000 burden hours x $27.07 per hour).
13. Provide an estimate of the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
a. There are 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 beyond that which is considered usual and customary.
14. Provide estimates of annual cost to the Federal Government.
Printing and Distribution |
$2,500 |
||
(2,000 forms x 45 min to gather & enter data / 60 mins = 1500 hours) x $33.23 (GS 11/5 Social Worker) |
$49,845 |
||
|
|
TOTAL |
$52,345 |
15. Explain the reason for any program changes or adjustments reported in Items 13 or 14 of OMB 83-I.
VA does not project any changes since our last submission.
16. For collections of information whose results will be published, outline plans for tabulation and publication.
There are no plans to publish the result of the information collected.
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 include the expiration date for OMB approval.
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.
B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS
No statistical methods are used in this data collection.
Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | vhacobickoa |
| File Modified | 0000-00-00 |
| File Created | 2022-03-15 |