Supporting Stmt OMB 1240-0006 2016

Claim for Reimbursement Form

1240-0006 (CA-278)

December 2016

SUPPORTING STATEMENT

Claim for Reimbursement-Form CA-278

OMB NO: 1240-0006

1. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.

The Office of Workers’ Compensation Programs (OWCP) is the federal agency responsible for administration of the War Hazards Compensation Act (WHCA), 42 U.S.C. 1701 et seq. Under section 1704(a) of the WHCA, an insurance carrier or self-insured who has paid workers’ compensation benefits to or on account of any person for a war-risk hazard may seek reimbursement for benefits paid (plus expenses) out of the Employees’ Compensation Fund for the Federal Employees’ Compensation Act(FECA) at 5 U.S.C. 8147.

https://www.gpo.gov/fdsys/pkg/USCODE-2013-title42/pdf/USCODE-2013-title42-chap12-subchapI.pdf

https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm#8147

Form CA‑278 is used by insurance carriers and the self-insured to request reimbursement. The regulations that implement the WHCA permit OWCP to collect the information needed to consider an insurance carrier’s or self-insured’s reimbursement request at 20 CFR 61.101 and 61.104

https://www.gpo.gov/fdsys/pkg/CFR-2010-title20-vol1/pdf/CFR-2010-title20-vol1-part61-subpartB.pdf

For collection of this information under WHCA statutes.

See 42 U.S.C. 1704 and 1706

https://www.gpo.gov/fdsys/pkg/USCODE-2013-title42/pdf/USCODE-2013-title42-chap12-subchapI.pdf

For collection of this information under FECA statutes.

See 5 U.S.C. Sections 8121, 8145, and 8149

https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The information collected is used by OWCP staff to process requests for reimbursement of WHCA benefit payments and claims expenses submitted by insurance carriers and the self-insured. The information is also used by OWCP to decide whether it should opt to pay ongoing WHCA benefits directly to the injured worker.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

Form CA-278 is currently posted on the internet at http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm for downloading by insurance carriers and self-insured.  However, since Form CA-278 must be accompanied by documentation in support of the request for reimbursement, providing for the submission of this information electronically is not considered to be practicable.

4. Describe efforts to identify duplication. Show specifically why any similar Information already available cannot be used or modified for use for the purposes described in Item 2 above.

The information collected on this form is not duplicative of any information available elsewhere. The respondent is the only source of the benefit payment and claims expenses data that is needed to process the request for reimbursement.

5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information collection has been streamlined to obtain the minimum information needed for OWCP to process a request for reimbursement while imposing the minimum burden on respondents, and does not have a significant economic impact on a substantial number of small entities.

6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

Please refer to Nos. 1 and 2 above. The information collected from both insurance carriers and self-insured is the minimum needed to evaluate whether a reimbursement request meets the statutory requirements in the WHCA. Reimbursement requests cannot be processed by OWCP without the information collected.

7. Explain any special circumstance.

There are no special circumstances for conducting this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

No outside consultations have been conducted concerning the use of Form CA-278. However, reimbursement for benefit payments and claims expense has been available since the WHCA was passed in 1942, and OWCP has received a sufficient number of requests for reimbursement to develop the proposed collection instrument.

A notice inviting public comment on this information collection was published in the Federal Register on October 12, 2016 (81FR70443). Comments were not received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

Respondents do not receive any gifts or payments to furnish the requested information.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

All information contained in FECA claim files is fully protected under the Privacy Act in the system of records known as DOL/GOVT-1 (Office of Workers' Compensation Programs, Federal Employees' Compensation Act File, (http://www.dol.gov/sol/privacy/dol-govt-1.htm).

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature on this form.

12. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

OWCP receives an average of 345 new WHCA reimbursements claims annually (total of 1,034 received during calendar years 2013-2015, which are opened when an insurance carrier or self-insured submits a request for reimbursement to OWCP. These 345 responses are submitted by seven respondents through attorney firms, which equates to 49.3 responses per year per respondent), as each reimbursement request is for a single beneficiary). It is estimated that each Form CA-278 will take approximately 30 minutes to prepare, for an annual hour burden of 173 hours (345 responses annually x 30/60 = 172.5 or 173 rounded up).

Estimated Annualized Respondent Burden Hours and Costs

Form	Number of Respondents		Frequency of Responses		Total Number of Responses		Avg. Burden per Response (in hours)	Total Burden Hours	Avg. Hourly Wage Rate*	Total Burden Costs
CA-278	345		1		345		.50	173	$19.02	$3,290

Using the current median hourly wage for insurance claims and policy processing clerks (reported by the Bureau of Labor Statistics)* http://www.bls.gov/oes/current/oes439041.htm of $19.02 per hour, the respondent annualized cost estimate for this collection is $3,382 (173 x $19.02 = $3,290.46 or $3,290, rounded down).

13. Annual Costs to Respondents (capital/start-up & operation and maintenance).

There are no startup costs for this information collection. Operation and maintenance costs consist solely of mailing costs.

The mailing costs are calculated as follows:

Total claimant costs Forms CA-278

[$1.57 (2016 postal rates for first class mail, a 4oz large envelope to accommodate attachments) x 345 (forms) =$541.65 or $542, rounded up.

14. Provide estimates of annualized cost to the Federal government.

Review Costs:

Reimbursement requests/claims under the WHCA are processed by a “Special Claims” unit, located in the FECA program’s district office in Cleveland, Ohio which is composed of a staff of six Claims Examiners: (4) GS 12, Step 10, (1) GS-12, Step 2, and (1) GS-13, Step 10, with hourly salaries of $45.98, $36.55, and $54.98, respectively. The average hourly wage for the reviewer is $45.86 based on the following calculation.

Average hourly wage = $45.86 ($45.98 x 4 + $36.55 +$54.68) = 278.15 divided by 6.

Reference: (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2016/CLE_h.pdf)

Form	Time to Review	Total Responses	Costs
CA-278	30 minutes	345	$7,911

Their review costs is calculated as $45.86 X 30 min X 345/60 = $7,910.85 or $7,911, rounded up.

Federal Cost Estimates:

Printing Cost: Due to the small number of respondents that OWCP contemplates will submit a Form CA-278; there are no plans to print the form in bulk for distribution.

Mailing and Envelope Cost:

[$1.57 (2016 postal rates for first class mail, a 4oz large envelope to accommodate attachments) x 345 (forms) =$541.65 or $542, rounded up.

Total Federal Cost: 7,911 + $542 = $8,453.

15. Explain the reasons for any program changes or adjustments.

The previous approved number of annual respondents 393 is now 345, which represents a decrease of 48. The previously approved number for burden hours was 197, and the requested number now is 173, a decrease of 24.00. This decrease is a result of reduction in claims for reimbursement of benefit payments and claim expenses under the WHCA. The costs burden for maintenance and reporting costs postage and envelope) decreased from $1,407 to $542, which is an adjustment of $865.00.

Revision to the forms solely involved the accommodation language.

The following accommodation language was placed on the bottom of the form:

1. If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP. See instructions for additional details.

2. The accommodation language in the Instructions page was revised.

Prior Version

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this assistance.

Revision

Request for Accommodations or Auxiliary Aids and Services

If you have a disability, federal law gives you the right to receive help from the OWCP in the form of communication assistance, accommodation(s) and/or modification(s) to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to accommodate your disability. Please contact our office or your claims examiner to ask about this assistance.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.

There are no plans to publish any data collected by Form CA-278.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

This information collection request does not seek a waiver from the requirement to display the expiration date.

18. Explain each exception to the certification statement in ROCIS.

This request is in compliance with 5 CFR 1320.9.

2. Collections of Information Employing Statistical Methods:

Statistical methods are not used in these collections of information.