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###### Department of Veterans Affairs

          - [OMB Control No. 2900-0091]

# AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

# ACTION:

Notice.

# SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995, this notice announces that the Veterans Health Administration, Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden, and it includes the actual data collection instrument.

# DATES:

                        Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to                         *www.reginfo.gov/​public/​do/​PRAMain.*                         Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function. Refer to “OMB Control No. 2900-0091.                    

# FOR FURTHER INFORMATION CONTACT:

                        Maribel Aponte, Office of Enterprise and Integration, Data Governance Analytics (008), 1717 H Street NW, Washington, DC 20006, (202) 266-4688 or email                         *maribel.aponte@va.gov.*                         Please refer to “OMB Control No. 2900-0091” in any correspondence.                    

# SUPPLEMENTARY INFORMATION:

*Authority:*44 U.S.C. 3501-21.                

*Title:*                     VA Health Benefits: Application, Update, and Hardship Determination, VA Forms 10-10EZ, 10-10EZR and 10-10HS.                

*OMB Control Number:*                     2900-0091.                

*Type of Review:*                     Extension of a currently approved collection.                

*Abstract:*                     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. Title 38 U.S.C. 1722 establishes eligibility assessment procedures for cost-free VA medical care, based on income levels, which determines whether nonservice-connected and 0% service-connected non-compensable Veterans are able to defray the necessary expenses of care for nonservice-connected conditions. Further, when the Veteran projects that his or her attributable income for the current calendar year would be substantially below the applicable income thresholds, the Veteran would be considered unable to defray the expenses of care and VA may exempt the Veteran from the requirement to pay copayments for hospital or outpatient care.                

This collection of information is required to properly administer health benefits to eligible Veterans.

a. VA Form 10-10EZ, Application for Health Benefits, is used to collect Veteran information during the initial application process for VA medical care, nursing home, domiciliary, dental benefits, etc.

b. VA Form 10-10EZR, Health Benefits Update Form, is used to update a Veteran's personal information, such as marital status, address, health insurance and financial information, for renewal of health benefits.

c. VA Form 10-10HS, Request for Hardship Determination, is used to collect information from Veterans who are in a copay required status for hospital care and medical services, but due to a loss of income project their income for the current year will be substantially below the VA means test limits.

These forms collect information to enroll a Veteran for health benefits, establish basic eligibility, identify 3rd party health insurance coverage, identify prescription copayment, provide for income verification, and serve as a mechanism to make changes upon admission for benefits or yearly financial updates.

                    An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The                     **Federal Register**                     Notice with a 60-day comment period soliciting comments on this collection of information was published at 85 FR 209 on October 28, 2020, pages 68418 and 68419.                          ( print page 9426)    

## VA Form 10-10EZ 

*Affected Public:*                     Individuals and households.                

*Estimated Annual Burden:*                     270,000 hours.                

*Estimated Average Burden per Respondent:*                     30 minutes.                

*Frequency of Response:*                     Annually.                

*Estimated Number of Respondents:*                     540,000.                

## VA Form 10-10EZR 

*Affected Public:*                     Individuals and households.                

*Estimated Annual Burden:*                     343,600 hours.                

*Estimated Average Burden per Respondent:*                     24 minutes.                

*Frequency of Response:*                     Annually.                

*Estimated Number of Respondents:*                     859,000.                

## VA Form 10-10HS 

*Affected Public:*                     Individuals and households.                

*Estimated Annual Burden:*                     1,750 hours.                

*Estimated Average Burden per Respondent:*                     15 minutes.                

*Frequency of Response:*                     Annually.                

*Estimated Number of Respondents:*                     7,000.                

By direction of the Secretary.

Maribel Aponte,

VA PRA Clearance Officer, Office of Enterprise and Integration, Data Governance Analytics, Department of Veterans Affairs.

[FR Doc. 2021-02885 Filed 2-11-21; 8:45 am]

BILLING CODE 8320-01-P