SUPPORTING STATEMENT A
STATE HOME PROGRAMS FOR VETERANS
VA
Forms 10-5588, 10-5588A, and 10-10SH
OMB CONTROL
NUMBER 2900-0160
[AR61]
Summary of Changes:
This collection will be revised through AR61 by allowing resubmission of previously denied claims
There will be associated minor increases in the number of responses and burden hours
No PRA comments were received on the AR61 proposed rule
1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
The information collection under OMB Control Number 2900-0160 includes VA Forms 10-5588, 10-5588A, and 10-10SH and has a current Paperwork Reduction Act (PRA) clearance with an expiration date of 10/31/2026. VHA is implementing a new regulation that will add another element to this information collection. Specifically, the new reg will allow State homes to submit a list of veteran names to VA for reconsideration of previously denied claims. This will be a time limited opportunity that must occur within 30 days of the effective date of the rule.
Under section 3007(a) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 (Pub. L. 116-315, January 5, 2021) the Secretary is authorized “to waive the requirements under such section 51.51(b) for a veteran to be eligible for per diem payments for domiciliary care at a State home if … such waiver would be in the best interest of the veteran.” It also continues to provide for the payment of per diem to State homes that provide care to eligible veterans in accordance with Title 38, CFR Part 51.
The intended effect of these provisions is to provide a safeguard that veterans are receiving a high quality care in State homes. To ensure that high quality care is furnished veterans, VA requires those facilities providing domiciliary, nursing home care and adult day health care programs to veterans to supply various kinds of information. The information required includes an application for recognition based on certification; application and justification for payment; records and reports which facility management must maintain regarding payment activities of residents or participants; the records and reports which facilities management and health care professionals must maintain regarding eligible residents or participants; and various types of documents pertaining to the management of the facility. [VA Form 10-10EZ/EZR (OMB approval 2900-0091) is used in conjunction with the VA Form 10-10SH.]
As noted, OMB Control Number 2900-0160 currently contains three forms: VA Forms 10-5588, 10-5588A, and 10-10SH. This information collection will now include the one-time submission of a list of veteran names whose claims were previously denied by VA, pursuant to the proposed regulation [38 CFR 51.42(c)]. VA anticipates that this new element of the information collection will add minimally to the overall burden hours currently approved for this OMB control number.
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 new information collection element for this OMB control number will allow State homes to submit a list of veteran names to VA for reconsideration of previously denied claims. This is a time limited opportunity – the list of names must be received within 30 days of the effective date of the rule. The State home submission will be limited to veteran names only and will not contain the original forms required at time of admission or enrollment, as VA has all original claims records. VA estimates that very few State homes from only a couple of states will actually submit lists of veteran names for reconsideration of denied claims. At this time, VA has indications only from the states of Alaska and Maine that they will submit lists of veteran names to VA. The program estimates that Alaska will submit a list of 6 veteran names, and Maine will submit a list of 100 veteran names for VA reconsideration of these previously denied claims.
The information collected under 2900-0160 is necessary to ensure that VA per diem payments are limited to facilities providing high quality care. To verify the provision of this level of care, VA requires those facilities providing nursing home care, domiciliary, and adult day health care programs to veterans to supply various kinds of information. The information required includes an application/eligibility for admission and justification for payment; records and reports which facility management must maintain regarding activities of payment for eligible residents or participants; the records and reports which facilities management and health care professionals must maintain regarding the level of care approved for residents or participants.
VA form 10-5588: State Home Report and Statement of Federal Aid Claimed– 38 CFR 51, 52 and Title 38, U.S.C., Sections 1741, 1742, 1743 and 1745 – is used to assess and provide per diem to State homes. This collection is used by the State home employees and VA staff.
VA form 10-5588A: Claim for Increased Per Diem Payment for Veterans Awarded Retroactive Service Connection – 38 CFR 51, 52 and Title 38, U.S.C., Sections 1741, 1742, 1743 and 1745, is used to assess and provide per diem to State homes retroactively. This collection is used by the State home employees and VA Staff.
VA Form 10-10SH: State Home Program Application for Veterans Care Medical Certification – 38 CFR 51, 52 and Title 38, U.S.C., Sections 1741, 1742, 1743 and 1745 – provides for the collection of information to apply for the benefits of this program.
List of Veteran Names for Claim Reconsideration: Proposed 38 CFR 51.42(c) provides for the one-time resubmission of names of veterans whose claims were previously denied by VA.
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.
To comply with the Government Paperwork Elimination Act, all forms in this group now appear on the One-VA Internet website in a fill and print mode which enables the user to electronically retrieve the latest version of a form, complete the form electronically, and save the filled form in *.pdf format. Once VA has developed an effective policy for electronic signature use and pending the availability of funds, we can begin the re-engineering process to allow electronic submission. The collection of information has been automated for internal fiscal and quality survey portions of data collection.
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.
There is no duplication associated with this collection of information. Under the new regulation, State homes that request reconsideration of previously denied claims will submit only a list of names of affected veterans and not the original forms required at time of admission or enrollment – to avoid unnecessary duplication of effort.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
The impact on small businesses and other small entitles is minimized by using “standard data” or data routinely maintained by health care facilities. The collection of information has been thoroughly analyzed to ensure that all requested data is essential.
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 VA does not require this information, the Department would be unable to assess the quality standards that are being utilized and evaluated. Therefore, the assessment of quality care indicators is critical to the VA to document whether high quality care is being provided to eligible veterans.
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 publications 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 PRA section of the proposed rule constitutes the requisite 60-day notice of Proposed Agency Information Collection Activity and was published in the Federal Register on Friday, September 1, 2023 at 88 FR 60417. VA did not receive comments in response to the proposed rule.
The PRA section of the final rule constitutes the requisite 30-day notice of Agency Information Collection Activity under OMB Review and was published in the Federal Register on Wednesday, October 30, 2024 at 89 FR 86245.
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 is conducted with the public through publication of the proposed rule and final rule, which constitute the required 60- and 30-day Federal Register notices.
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.
VA Form 10-10SH collects individually identifiable information covered by the Privacy Act. Assurances of confidentiality for this form 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 24VA136 “Patient Medical Record – VA” as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/2003.html. The other forms in this group contain information that is not protected by the Privacy Act. The forms are filed at VA Central Office for initial recognitions of the new State Homes and fiscal forms are maintained at the VA Medical Center (VAMC) of jurisdiction for the State Home Per Diem Program (SHPDP).
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.
VA Form 10-10SH collects individually identifiable information covered by the Privacy Act. Assurances of confidentiality for this form 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 24VA136 “Patient Medical Record – VA” as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/2003.html. The other forms in this group contain information that is not protected by the Privacy Act. The forms are filed at VA Central Office for initial recognitions of the new State Homes and fiscal forms are maintained at the VA Medical Center (VAMC) of jurisdiction for the State Home Per Diem Program (SHPDP).
12. Estimate of the hour burden of the collection of information:
The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:
VA estimates 4,819 total burden hours and 13,616 responses annually.
VA
Form 10-5588 --
State Home Report and Statement of Federal Aid Claimed
=
834 hours annually.
Respondents |
Frequency |
Annual Responses |
Min. Each |
Burden Hours |
139 State homes |
Monthly |
1,668 |
30 |
834 |
VA Form 10-5588A -- Claim for Payment for Nursing Home Care Provided to
Veterans Awarded Retroactive Service Connection = 180 hours annually.
Respondents |
Frequency |
Annual Responses |
Min. Each |
Burden Hours |
45 State homes |
Monthly |
540 |
20 |
VA Form 10-10SH -- State Home Program Application for Veteran Care Medical
Certification = 3,802 hours annually.
Program |
Respondents |
Frequency |
Annual Responses |
Min. Each |
Burden Hours |
State Nursing Home |
9,048 |
1 |
9,048 |
20 |
3,016 |
State Domiciliary |
2,355 |
1 |
2,355 |
20 |
785 |
Adult Day Health Care (ADHC) |
3 |
1 |
3 |
20 |
1 |
Totals: |
11,406 |
1 |
11,406 |
|
List of Veteran Names for Claim Reconsideration – Resubmission of names of veterans whose claims were previously denied = 3.0 hours annually. This will be a one-time burden, as State home administrators must submit a list of names within 30 days of the effective date of the rule.
Respondents -- State Home Administrators |
Frequency |
Annual Responses |
Minutes per Response |
Burden Hours |
Alaska (6 names) |
1 |
1 |
30 |
0.5 |
Maine (100 names) |
1 |
1 |
150 |
2.5 |
Total |
|
2 |
|
3.0 hours |
b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens.
This request for approval is for three forms plus the submission of a list of veteran names for reconsideration of claims previously denied by VA -- see 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.
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 $28.01 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, and a person or business may not accept payment for assisting a respondent in completing the information collection. Therefore, there are no expected overhead costs. VHA estimates the total annualized cost to respondents for VA Forms 10-5588, 10-5588A and 10-10SH to be $134,980.19 (4816 burden hours x $28.01 per hour).
VHA estimates the total annualized cost to respondents for the List of Veteran Names for Claim Consideration to be $166.23 (3 burden hours x $55.41). VHA used the mean hourly wage of $55.41, based on BLS wage code – “11-1021 General and Operations Managers.”
The total cost to respondents is: $134,980.19 + $166.23 = $135,146.42
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).
There are no capital, start-up, operation or maintenance costs.
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. 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.
The estimated total cost to the Federal Government is: $212,777.40
Data Source: http://www.fedsdatacenter.com/gs-pay-calculator/
a. Review by VAMC officials - $10,441.80
Items 12.a. (2)
[180 hours x $58.01(FY 2022) (average GS-13 step 5 hourly salary)]
This amount includes burden hours to review State Home Per Diem forms
b. Clerical support - $148,940.60
Items 12.a. (1),(3)
[834 hours x $40.70 (average GS-11 step 5 hourly salary) = $33,943.80]
[3,802 hours x $27.5 (average GS-7 step 5 hourly salary) = $104,555]
This amount includes burden hours to review State Home Per Diem forms.
c. VA Headquarters oversight review - $53,395
10/Hours/Week = 500 per year x $58.01 = $29,005 (average GS- 13 step 5)
10/Hours/Week = 500 per year x $48.78 = $24,390 (average GS- 12 step 5)
d. Printing costs - $0 we are completely digital now.
15. Explain the reason for any burden hour changes or adjustments reported in items 13 or 14.
New authority granted by section 3007(a) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 (Pub. L. 116-315, January 5, 2021). Under Pub. L. 116-315, section 3007(a), the Secretary is authorized “to waive the requirements under such section 51.51(b) for a veteran to be eligible for per diem payments for domiciliary care at a State home if … such waiver would be in the best interest of the veteran.” It also continues to provide for the payment of per diem to State homes that provide care to eligible veterans in accordance with Title 38, CFR Part 51. payment of per diem to State homes that provide State home care to eligible veterans. Thus, VA now includes a List of Veteran Names for Claim Reconsideration: 38 CFR 51.42(c) provides for the resubmission of names of veterans whose claims were previously denied by VA.
The federal government cost reduction is the result of the reduction in printing costs.
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.
There are no plans to publish the results of this information collection.
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 on all forms.
18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions.”
There are no exceptions.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Bold black = OMB questions |
| Author | Department of Veterans Affairs |
| File Modified | 0000-00-00 |
| File Created | 2024-10-31 |