SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION
Enrollment Application Form (DD 2837) for the Continued Health Care Benefit Program
A. Justification
1. Necessity for Information Being Collected
The Continued Health Care Benefit Program (CHCBP) was directed by Congress in section 4408 of the National Defense Authorization Act of FY 93, Public Law 12-484, which amended title 10, United States Code, by adding section 1078a. Subsection (d) of 1078a mandates the following for an election of coverage into CHCBP: “In order to obtain continued coverage under this section, an appropriate written election (submitted in such manner as the Secretary of Defense may prescribe) shall be made…” DoD published a final rule regarding CHCBP in a Federal Register notice on September 30, 1994, (59 FR 49817) which amended 32 part 199.20 to include the requirements for the Continued Health Care Benefits Program. The specific requirements for a CHCBP enrollment application are contained in Section (d)(5) of 32 CFR Part 199.20 which reads as follows: “Enrollment. Enrollment in the Continued Health Care Benefit Program will be accomplished by submission of an application…”
2. Purpose and Users of Information
The information on a CHCBP Application Form (DD Form 2837) will be used to determine an applicant’s eligibility to enroll in and receive health care coverage under the CHCBP. The users of the forms will be individuals who are or were beneficiaries of the Military Health System (MHS) and who wish to enroll in CHCBP following their loss of entitlement to health care coverage in the MHS. These beneficiaries include the active duty service members or former service members, an unremarried former spouse of an active duty service member or former service member, an unmarried child of a service member who ceases to meet the requirements for being considered a dependent, and a child placed for adoption or legal custody with the service member.
3. Information Techniques
The DD Form 2837 is available on various well-publicized web sites and can be printed from those sites. Application forms are only being submitted in hardcopy because applicants must submit an original signature and other important documentation with their application (e.g., final divorce decrees, DD Form 214, letters from accredited educational facilities regarding student status, etc.). They must also submit a check or money order for their first premium payment with their application. This process does not readily incorporate the use of electronic signature, as handling and management of separate documentation by contractors could adversely impact the beneficiary being able to obtain program benefits in the allotted 60-day time frame.
4. Duplication or Similar Information
There is no duplication of data collection. The information that is being collected is a one-time submission by an eligible beneficiary who is enrolling in CHCBP. Once a beneficiary is disenrolled from CHCBP for nonpayment of premiums, they are not allowed by law to reenroll in CHCBP at any time in the future. All CHCBP enrollment information is centralized and not being collected by any other entity.
5. Small Business
The collection of this information does not impact small businesses.
6. Less Frequent Collections
As indicated under #4, the information collection is a one-time submission; therefore, less frequent collections are not applicable.
7. Special Circumstances
There are no special requirements that require the collection to be conducted in a manner inconsistent with the guidelines in 5 CFR 1320.5 (d)(2).
8. Federal Register Notice
The Federal Register notice for this collection of information was published on November 25, 2008 (Vol. 73, No. 228). No public comments have been received.
Consultations. Applicants for enrollment have been randomly queried regarding the enrollment process, to include the application process. No concerns or issues have been raised regarding the application or information collection process of submitting a written application with the accompanying documentation. TRICARE Management Activity believes the form is simple, clear and easy to complete and understand. It also provides applicants with basic information regarding the CHCBP that is of assistance to them.
9. Payments/Gifts to Respondents
No payments or gifts of any type are provided to the respondents.
10. Confidentiality
The CHCBP Application contains a section at the top of page one regarding the Privacy Act Statement. The entity with whom DoD has contracted to perform CHCBP enrollment functions is contractually required to adhere to the legal requirements associated with the Privacy Act, as well as the TRICARE instructions and guidelines that have been furnished the contractor regarding the confidentiality of information and data collected under the contract and the penalties for unauthorized release of that information. This contractor is a seasoned contractor that is well aware of the Privacy Act and includes Privacy Act training when they orient all new employees. The contractor likewise has significant private sector experience handling confidential patient information for their commercial line of business.
11. Sensitive Questions
DD Form 2837 does not require the collection or reporting of any sensitive issues or questions.
12. Burden Estimate (hours)
The total annual hour burden for the responses of 625 is based on an annual projected use of this form by 2500 applicants for enrollment in CHCBP. The burden is based on an estimate of 15 minutes to complete the form. Eligible applicants are only required to complete the form on initial enrollment into the CHCBP.
13. Cost to Respondents
The only cost to the respondents is the cost of postage for mailing the application and supporting documentation to the CHCBP enrollment contractor. The total annualized cost for this is $1,050 (2500 respondents x.42 cents postage). There is a preprinted envelope furnished to the applicants therefore eliminating any costs by the respondents for the envelope.
14. Cost to the Federal Government
The annualized government cost associated with this information collection is estimated to be $2,225 (2500 mailings @$.89 per mailing).
15. Change in Burden
There is an adjustment in the number of respondents due to more individuals enrolling in the CHCBP. In 2005, CHCBP only had 808 people enrolled. The program now has about 2,500 people enrolled. Since the number of respondents filling out the enrollment form has gone up, so has the number of burden hours. It still only takes a respondent 15 minutes to fill out the form, but we now 2,500 respondents filling out the form. The number of burden hours is now at 625 (2,500 x .25 of an hour).
16. Publication/Tabulation
There are no plans to publish or tabulate the information collected.
17. Expiration Date
We are not seeking approval to not display the expiration date for OMB approval of the information collection.
18. Exception to Certification Statement
No exception to the Certification Statement is requested.
B. Collection of Information Employing Statistical Methods
This information collection does not employ statistical methods.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION |
| Author | kstakes |
| Last Modified By | Patricia L Toppings |
| File Modified | 2009-05-31 |
| File Created | 2008-11-25 |