SF2809OMBSuppStmt No B

OMB Supporting Statement

SF 2809 –Health Benefits Election Form
A. Justification
1. Chapter 89 of title 5, United States Code, authorizes the Office of Personnel Management (OPM) to
administer the Federal Employees Health Benefits (FEHB) Program, and to publish regulations to carry
out the provisions of the FEHB law. The law and regulations specify who is eligible to enroll and when
an individual may enroll or change enrollment. Standard Form (SF) 2809 - Health Benefits Election Form
- is the instrument by which eligible individuals may enroll or change their enrollment status under the
FEHB Program.
2. The SF 2809 is used by Federal employees, annuitants other than those under the Civil Service
Retirement System (CSRS) and the Federal Employees Retirement System (FERS) including individuals
receiving benefits from the Office of Workers' Compensation Programs, former spouses eligible for
benefits under the Spouse Equity Act of 1984 (P.L. 98-615), and separated employees and former
dependents eligible to enroll under the Temporary Continuation of Coverage (TCC) provisions of the
FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is used by CSRS and FERS annuitants whose
health benefit enrollments are administered by OPM's Retirement Services Program.
Clearance of this form for use by active Federal employees is not required according to the Paperwork
Reduction Act (P.L. 104-13). However, annuitants, former spouses of current or former Federal
employees who are eligible for enrollment under the Spouse Equity Act of 1984, and former employees
and former dependents who are eligible for enrollment under the TCC provisions of FEHB law use the
SF 2809. Use of this form by these individuals is subject to the Paperwork Reduction Act. The Public
Burden Statement meets the requirements of 5 CFR 1320.8(b) (3).
The SF 2809 is used as the official agency or retirement system record of the individual's coverage and
enrollment status under the FEHB Program and as acknowledgment and authorization by the individual
for collection from him or her of the appropriate premium contributions. A copy of the form is also
forwarded to the FEHB insurance carrier as a record of the individual's enrollment. The form provides the
carrier with information necessary to enable the carrier to pay and process claims for the individual and
any covered family members, which the carrier would otherwise have to obtain from the enrollee by other
means. The consequences of not collecting the information on the SF 2809 would be that some other
method of obtaining the same information would have to be developed, tested and implemented by
Federal agencies and FEHB Program health insurance carriers.
3. We are going to be using methods of information technology to collect the information from employees
and other individuals. However, that is not the audience for which we are submitting this request. New
methods of information technology would not reduce the burden on former spouses or individuals
applying for TCC since they do not have ready access to computer terminals as current employees do.
Although respondents could provide the information orally for direct entry into a computer database, we
do not believe that respondents would save time or that the process would be any less of a burden than it
is currently. Completion of the SF 2809 represents a voluntary election by the respondent, and the
information collected can only be obtained from the respondent. The form is available in PDF fillable
format on our electronic forms page at www.opm.gov/forms and it meets the GPEA requirements.

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4. Every effort is made to identify and avoid duplication. The number of times respondents are required to
complete this form is kept to a minimum. After initial enrollment, completion of a new form is required
only when the individual desires to make a change in his or her health insurance enrollment status.
5. This information is not collected from small businesses.
6. If this information is not collected, respondents cannot enroll in the FEHB Program nor make changes to
their health insurance enrollment. The only way to reduce the burden would be to restrict an individual's
freedom to make changes to his/her enrollment, which would require making changes in current
regulation.
7. This is a voluntary information collection. Respondents are never required to report information - it is
their choice to do so. However, if they choose not to do so, their FEHB enrollment may be delayed and
claims for services and supplies may not be processed. Specific events and criteria (such as marriage,
birth or acquisition of a child, move out of the area from which a health maintenance organization (HMO)
plan accepts enrollments) must be met in order to make changes at times of the year other than the annual
health benefits Open Season. Since these opportunities are set by regulation and represent changes in an
individual's circumstances which may or may not be under his or her control, there is no way to predict or
control how often changes are requested.
Respondents complete the SF 2809 which includes the original and four copies. These copies are
necessary to provide copies for the official case file, the new carrier, the old carrier, the payroll office and
the respondent.
No other circumstances listed in this question apply to this collection.
8. A request for extension of a currently approved information collection was published in the Federal
Register on May 29, 2007, giving persons outside the agency an opportunity to comment on the form.
No comments were received.
9. No such decision has been made.
10. The information collected is protected by the Privacy Act of 1974. The routine use of disclosure appears
in the Federal Register for OPM/Central-l.
11. The information collected does not include questions of a sensitive nature, such as sexual behavior
and attitudes, religious beliefs, and other matters that are commonly considered private.
12. Approximately 18,000 SF 2809 forms will be processed each year from employees, annuitants,
former spouses and individuals applying for TCC. The SF 2809 requires approximately 30 minutes
for the respondents to read the instructions and complete the form. A burden of 9,000 hours is
estimated and is not expected to vary substantially. Enrollment data collected semiannually since
1991 has shown no significant change in the numbers of respondents and frequency of responses
estimated previously in the prior request for OMB clearance submitted in that year.
13. There are no costs to respondents or record keepers resulting from the collection of information.
14. We estimate that the annualized cost to the Government is approximately $16,000, including
printing and distribution of the form.
15. There are no changes to the respondent burden.

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16. The results of this information collection are not published.
17. We are seeking approval to not display the expiration date for OMB approval of the information
collection. Too often, users of the form see the expiration date and erroneously assume that the
form itself is void after that date. These forms are printed and distributed through various agencies.
It is cost prohibitive to print new forms just to change the expiration date.
18. There are no exceptions.