Opm2809 Ss

OMB SUPPORTING STATEMENT

OPM Form 2809 – Health Benefits Election Form

1. Justification

1. Title 5, U. S. Code, Chapter 89, sections 8905 and 8905a specify the opportunities and conditions under which a retiree, survivor annuitant, or former spouse of a retiree is eligible to enroll or to change enrollment in the Federal Employees Health Benefits Program (FEHBP). OPM Form 2809 is completed by the person who wishes to enroll or to make an enrollment change, other than an open season change. The circumstances which allow these actions are explained on the form.

2. The Office of Personnel Management (OPM), Office of Retirement Programs determines whether all conditions permitting enrollment or change in enrollment are met and implements the action. If this information were not collected, OPM could not comply with the provisions of title 5, U. S. Code, Chapter 89. The Public Burden Statement meets the requirements of 5 CFR 1320.8(b)(3). This form has been revised to bring it up-to-date and to parallel the Standard Form 2809.

3. Respondents are no longer required to use this form to make changes in their coverage. We accept changes based on telephone conversations or requests in letters, as well as those made using OPM Form 2809. The information collected can only be obtained from the respondents. However, this form is available in a PDF fill-able format on our website and meets our GPEA requirements.

4. These forms are filed individually. Similar information is not available from any other source. Duplication is minimized.

5. This information collection does not involve small businesses.

6. This information is collected as needed to administer the Federal Employees Health Benefits Program, giving eligible persons an opportunity to enroll or change enrollment in accordance with the provisions of title 5, U. S. Code, Chapter 89.

7. This information collection is consistent with the guidelines in 5 CFR 1320.6, except that to retain eligibility, the respondent must reply within 31 days in many instances.

8. A notice of proposed information collection was published in the Federal Register on December 1, 2008, giving persons outside the agency an opportunity to comment on the form. No comments were received.

9. There is no payment or gift to respondents in connection with this collection.

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10. This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 831.106). The routine uses for disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008, effective April 21, 2008).

11. The information collection 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. There are approximately 30,000 changes to health benefits coverage per year. Of these, 20,000 are submitted on OPM Form 2809 and 10,000 verbally or in written correspondence. Each form takes approximately 45 minutes to complete; data collection by telephone or mail takes approximately 10 minutes. The annual burden for the form is 15,000 hours; the burden not using the form is 1,667 hours. The total burden is 16,667 hours.

13. There is no cost to the respondents.

14. The annualized cost to the Federal government is $81,000. This cost includes employee salary hours devoted to the program, forms cost, and overhead.

15. There is no change to the respondent burden.

16. The results of this information collection are not published.

17. It is not cost-effective to reprint the whole supply of forms to change the OMB clearance expiration date. Therefore, we seek approval not to display the date on the form.

18. There are no exceptions to the certification statement.