TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form

Forms and Documents

Document	Type	Status	Availability
Form DD 2876 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form and Instruction	Modified	Repair queued
TRICARE Policy Manual Chp10Sec2.1.PDF	Supplementary Document	Uploaded 2016-02-26	Available
DD Form 2876_SSN Justification_final_20160223.PDF	Supplementary Document	Uploaded 2016-02-26	Available
OMB Supporting Statement-Part A_0720-0008_final_RevSec8_ 2Mar2016.doc	Supporting Statement A	Uploaded 2016-03-08	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
5574	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0720-0008	ICR Reference No: 201602-0720-001
Status: Historical Active	Previous ICR Reference No: 201303-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/09/2016
	Date Received in OIRA: 02/29/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2019	36 Months From Approved	05/31/2016
Responses	148,033	0	72,905
Time Burden (Hours)	37,008	0	22,317
Cost Burden (Dollars)	268,310	0	0

---

Abstract: These collection instruments serve as application for enrollment, disenrollment, and Primary Care Manager (PCM) Change for the Department of Defense's TRICARE Prime program. The information collected provides the necessary data to determine beneficiary eligibility, to identify the selection of a health care option. This revision updates the DD Form 2876 fields to ease completion by the TRICARE beneficiary and to expedite processing by the TRICARE regional contractors.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 73740	11/25/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 10222	02/29/2016
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	DD 2876	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	148,033	72,905	0	0	75,128	0
Annual Time Burden (Hours)	37,008	22,317	0	0	14,691	0
Annual Cost Burden (Dollars)	268,310	0	0	0	268,310	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There has been a increase in the number of TRICARE Prime enrollment, disenrollment and change transactions since the previous approval. We do not expect the number of forms received by the MCSCs to increase due to the TRICARE beneficiaries now having two other options to enroll, dis-enroll or change their enrollment. Those options (calling their MCSC or using the BWE web portal) can be completed much quicker, with the call providing immediate confirmation the action was completed and BWE being available 24x7. There was an error in the original burden calculation at the time the 60-day FRN published.

---

Annual Cost to Federal Government: $1,279,005

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/29/2016

---