SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION
TRICARE Prime Enrollment, Disenrollment and Primary Care Manager (PCM) Change Form (DD Form 2876) for the TRICARE Prime Program
A. Justification
1. Necessity for Information Being Collected
This collection instrument serves as the application for Enrollment, Primary Care Manager (PCM) Change and Disenrollment from the Department of Defense’s TRICARE Prime program established in accordance with title 10 U.S.C. 1099 (which calls for a healthcare enrollment system). Monthly payment options for retiree enrollment fees for TRICARE Prime are established in accordance with title 10 U.S.C. 1097a(c). The information collected on the TRICARE Prime Enrollment Application provides the necessary data to determine beneficiary eligibility, to identify the selection of a health care option, to assign or change a PCM when the beneficiary is relocating or merely requests a local PCM change, or to disenroll a beneficiary from TRICARE Prime.
This new DD Form 2876 combines the previous DD Form 2876 (TRICARE Prime Enrollment Application and Primary Care Manager (PCM) Change Form) and DD Form 2877 (TRICARE Prime Disenrollment Request)
2. Purpose and Users of Information
The Department of Defense established TRICARE Prime as a managed-care option, similar to a civilian HMO (health maintenance organization). Active duty service members are required to enroll in TRICARE Prime or TRICARE Prime Remote. They must take action to enroll by completing the enrollment form and submitting it to the Managed Care Support Contractor (MCSC). TRICARE Prime is also available to other TRICARE beneficiaries who are also required complete the enrollment form. TRICARE Prime enrollee’s health care is coordinated by a primary care manager (PCM) whom could be a part of a military treatment facility, a civilian network or TRICARE Prime Remote where eligible. In order to carry out this program, it is necessary that all beneficiaries electing to enroll, change enrollment, or disenroll in TRICARE Prime complete an enrollment application request. Completion of the enrollment form is an essential element of the TRICARE Prime program.
3. Information Techniques
The information collected on this form is entered into the Composite Health Care System (CHCS) database, which must be updated on a regular basis to ensure that the information is current and accurate. The form itself serves as documentation that the requirements of the law have been satisfied.
A web-based version of the form is available for beneficiaries who wish to enroll, disenroll, or make a PCM change online (BWE, Beneficiary Web Enrollment). Beneficiaries will have the option to complete the form either hardcopy or electronically.
4. Duplication or Similar Information
This information is not being collected by any other agency or component nor is it currently available in any other format. This form has simplified and standardized the process for collecting the required information. Duplication of information to be collected has been eliminated.
5. Small Business
No small business or other small entities are involved in this collection of information.
6. Less Frequent Collections
Data cannot be collected on a less frequent basis. Currently this form is the only means of collecting enrollment, disenrollment or change information. It is crucial to collect the most up-to-date information on beneficiaries to ensure all systems recognize their TRICARE plan of choice.
The form serves as documentation that the requirements of the law have been satisfied. Since the information is readily available to the respondents, we feel the completion of the form is not unduly burdensome.
7. Special Circumstances
There are no special circumstances for the collection of information for this program.
8. Federal Register Notice
The Federal Register Notice for this collection of information was published on 03 November 2009 (74 FR 56822). No comments were received.
9. Payments/Gifts to Respondents
There will be no payment or gifts provided to respondents.
10. Confidentiality
A Privacy Act Statement is provided on the form. The specific uses for the information are provided on the form; respondents are advised that disclosure is voluntary and made aware of the consequences of non-disclosure.
11. Sensitive Questions
DD Form 2876 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 22,317 is based on an annual projected use of the form by 72,905 applicants for enrollment in TRICARE Prime. The burden is based on an estimate to complete the Form as: 20 minutes or .33% of an hour to enroll or change enrollment and 5 minutes or .083% of an hour to disenroll. Average burden per response for completing the form is 18.36 minutes or .30% of an hour.
The cost to the respondent for providing the information is negligible and beyond our ability to calculate.
13. Cost to Respondents
There is no cost to Respondents.
14. Cost to the Federal Government
The average annualized costs are:
$ 15,337 (printing = $.03 x 511,232)
$270,953 (clerical costs = $.53 x 511,232)
$400,000 (contractor costs)
$686,290
15. Change in Burden
This is a revision of a previously approved collection. Slight decrease due to recalculation of burden.
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 | pltoppings |
| File Modified | 2012-12-07 |
| File Created | 2012-07-18 |