SUPPORTING STATEMENT - PART A
TRICARE SELECT Enrollment, Disenrollment and Change Form, 0720-XXXX
Need for the Information Collection
The information collection requirement is necessary to obtain non-active duty TRICARE beneficiary’s personal information needed to: (1) complete his/her enrollment into the “new” TRICARE Select health plan option as created by SEC. 701. TRICARE SELECT AND OTHER TRICARE REFORM of the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017, (2) dis-enroll a beneficiary, or (3) change the beneficiary’s enrollment (e.g., address, add a dependent, report other health insurance. This information is required to ensure the beneficiary’s benefits and claims are administered based on their plan of choice. Without the DD Form 3043 enrollment form, each non-active duty TRICARE beneficiary is automatically defaulted into direct care only, limiting their health care options to military hospitals and clinics. These beneficiaries would have no TRICARE coverage when using the TRICARE network of providers for services not available at their local military hospital or clinic.
The TRICARE Select health plan replaces the TRICARE Standard and Extra plan option on January 1, 2018. The Code of Federal Regulations and TRICARE policy manuals are being updated now to reflect this new plan option as required by the NDAA FY2017. All non-active duty TRICARE beneficiaries, not eligible for Medicare, have the option of enrolling into TRICARE Select by using the DD Form 3043, the online Beneficiary Web Enrollment (BWE) portal, or by calling their Managed Care Support Contractor (Regional Contractor). Although the online BWE portal and telephonic enrollment/change options are available, some beneficiaries will prefer using the form to document their enrollment date and preferences.
2. Use of the Information
Each respondent (any non-active duty TRICARE beneficiary not eligible for Medicare) has the option of using the DD Form 3043, BWE or a telephone call to their Regional Contractor to enroll, dis-enroll or change their enrollment. If they choose to use the DD Form 3043, they must complete the four page form and mail the form to their appropriate Regional Contractor. No other form is required to enroll, dis-enroll or change an enrollment. If the respondent chooses to use the DD Form 3043, they must complete the appropriate page(s) of the four page form and mail the form to their Regional Contractor. Respondents can download a copy of the form from the TRICARE.mil website or their Regional Contractor’s website or obtain a copy from their local military hospital or clinic. The mailing address and toll-free customer service number for their Regional Contractor are included on the DD Form 3043. If using either website option, the respondent can type in the information on the form prior to printing it or handwrite the information after printing the blank form.
The respondents can use the form to enroll or change the enrollment of all non-active duty family members or just to enroll, dis-enroll or change the enrollment of a single family member. With few exceptions, all respondents eligible for TRICARE must enroll in the TRICARE plan option best for themselves and any family members starting January 1, 2018: TRICARE Prime or TRICARE Select. If a beneficiary does not enroll in either plan option, they would have no TRICARE coverage when using the TRICARE network of providers for services not available at their local military hospital or clinic.
The information is used only by the Regional Contractor to formally enroll, dis-enroll or change an enrollment for the beneficiary(ies) listed on the form. That contractor is responsible for completing the requested action. The form is not provided to any other party, although when the requested action is updated, it is electronically shared with other TRICARE contractors as appropriate, i.e., the pharmacy contractor, to ensure benefits and claims are correctly administered. The action is also stored in the government’s Defense Enrollment Eligibility Reporting System (DEERS).
3. Use of Information Technology
All non-active duty TRICARE beneficiaries (not eligible for Medicare) have the option of enrolling, dis-enrolling or changing their TRICARE Select enrollment using the DD Form 3043, the BWE portal, or by calling their Regional Contractor. The large majority of all transactions are initiated by the beneficiary calling their Regional Contractor. They prefer this method since the action requested is immediately updated, with confirmation of completion provided by the Customer Service Representative taking the call. It also gives the beneficiary an opportunity to ask any questions they may have regarding their TRICARE Select benefits.
To utilize DD Form 3043, the beneficiary(ies) manually completes the form and signs and mails to the Regional Contractor as described in section 2 above.
The other option available for beneficiaries to request enrollment, disenrollment or a change is to use the BWE portal. BWE is accessible to all TRICARE beneficiaries 24x7, with links to the BWE portal on www.tricare.mil and the Regional Contractors’ websites. The portal is an application that validates the eligibility of the beneficiary using each beneficiary’s PII stored in the DEERS. PII is not collected and stored by the BWE application, only validated with DEERS and then used to notify the appropriate Regional Contractor of the action requested. The BWE pages mirror the DD Form 3043 to ensure the information needed is available to the Regional Contractor. The information is validated by DEERS which stores all PII. The Regional Contractor has six days to approve and process the requested action or to request additional information. Approximately 70,000 enrollment, disenrollment or enrollment changes are initiated through BWE today from the TRICARE Prime enrollees and we expect a similar number from the future TRICARE Select enrollees. Periodic articles are published reminding beneficiaries of the BWE portal.
4. Non-duplication
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
The information collected ensures the beneficiary is eligible for TRICARE and his/her TRICARE Select enrollment is correctly updated to reflect their TRICARE plan of choice, address, etc. If the form, BWE, or telephone call is not made by the beneficiary to enroll in the TRICARE Select plan option, the TRICARE beneficiary is defaulted into direct care only, limiting their health care options to only military hospitals and clinics.
5. Burden on Small Businesses
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
6. Less Frequent Collection
Collection is on an as needed basis. The non-active duty TRICARE beneficiary submits the DD Form 771 only when initially enrolling in TRICARE Select, dis-enrolling or changing their enrollment. The form is not used for any other purpose.
7. Paperwork Reduction Act Guidelines
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
Part A: PUBLIC NOTICE
A Federal Register Notice for the collection published on Friday, December 8, 2017. The FRN citation is 82 FRN 57962.
Part B: CONSULTATION
No additional consultation apart from soliciting public comments through the 60-Day Federal Register Noticed was conducted for this submission.
9. Gifts or Payment
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
10. Confidentiality
A Privacy Act Statement (PAS) is provided on the form.
The applicable System of Record Notice (SORN) is DHA-07, Military Health Information System, located at: http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570672/edha-07.aspx
The Privacy Impact Assessment (PIA) the Defense Enrollment Eligibility Reporting System (DEERS) can be accessed using the following URL: https://www.dmdc.osd.mil/appj/dwp/documents.jsp
Records Retention and Disposition Schedule:
Records are maintained until no longer needed for current business.
11. Sensitive Questions
The form requests the applicant provide a personal identifier number, which may be either the individual’s social security number (SSN) or their DoD Benefit Number (DBN). The DBN has yet to be widely used and known by beneficiaries or the providers for healthcare transactions. Additionally, the main data source to find the DBN is the Uniformed Services identification card (ID card). Since some applicants are former dependent children who never obtained a new ID Card with the DBN included or they no longer have access to their DBN when they turned in their ID card after aging out of military benefits, the SSN can still be used. Still other beneficiaries may not have requested a new ID Card, so only their sponsor’s SSN is on their current card. For these reasons, DHA has justified the continued use of the SSN until such time the DBN is readily known by beneficiaries through repeated use and through means of knowing the DBN from documents other than the ID card.
12. Respondent Burden and its Labor Costs
a. Estimation of Respondent Burden
1. TRICARE Select Enrollment, Disenrollment and Change Form
a. Number of Respondents: 99,300
b. Number of Responses Per Respondent: 1
c. Number of Total Annual Responses: 99,300
d. Response Time: 15 minutes
e. Respondent Burden Hours: 24,825 hours
2. Total Submission Burden (Summation or average based on collection)
a. Total Number of Respondents: 99,300
b. Total Number of Annual Responses: 99,300
c. Total Respondent Burden Hours: 24,825 hours
b. Labor Cost of Respondent Burden
1. TRICARE Select Enrollment, Disenrollment and Change Form
a. Number of Total Annual Responses: 99,300
b. Response Time: 15 minutes
c. Respondent Hourly Wage: $7.25
d. Labor Burden per Response: $1.81
e. Total Labor Burden: $179,981.25
2. Overall Labor Burden
a. Total Number of Annual Responses: 99,300
b. Total Labor Burden: $179,981.25
The Respondent hourly wage was determined by using the Department of Labor Wage Website (http://www.dol.gov/dol/topic/wages/index.htm)
13. Respondent Costs Other Than Burden Hour Costs
We estimate 99,300 respondents will annually complete the form and mail it to their Regional Contractor for processing. Based on the 2016 Postage Rate of $0.49 per first class letter, the total costs for the mailings is $48,657.
14. Cost to the Federal Government
a.
Labor Cost to the Federal Government
1. TRICARE Select Enrollment, Disenrollment and Change Form
a. Number of Total Annual Responses: 99,300
b. Processing Time per Response: 15 minutes
c. Hourly Wage of Worker(s) Processing Responses: $7.25
d. Cost to Process Each Response: $ 1.8125
e. Total Cost to Process Responses: $179,981.25
2. Overall Labor Burden to Federal Government
a. Total Number of Annual Responses: 99,300
b. Total Labor Burden: $ 179,981.25
b. Operational and Maintenance Costs
Equipment: $0
Printing: $0
Postage: $0
Software Purchases: $0
Licensing Costs: $0
Other: $0
g. Total: $0
1. Total Operational and Maintenance Costs: $0
2. Total Labor Cost to the Federal Government: $179,981.25
3. Total Cost to the Federal Government: $179,981.25
15. Reasons for Change in Burden
This is a new collection with a new associated burden.
16. Publication of Results
The results of this information collection will not be published.
17. Non-Display of OMB Expiration Date
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
18. Exceptions to “Certification for Paperwork Reduction Submissions”
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
Version 1.1 – Effective 11/1/2016
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | TRICARE Select Enrollment Disenrollment and Change |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |