SUPPORTING STATEMENT – PART A
TRICARE Plus Enrollment/Disenrollment Application - OMB#0720-0028
A. JUSTIFICATION
1. Need for the Information Collection
The information collection is necessary to enroll and disenroll eligible TRICARE beneficiaries in the TRICARE Plus Health Plan. These collected instruments serve as an application for enrollment and disenrollment in the Department of Defense’s TRICARE Plus Health Plan established in accordance with Title 10 U.S.C. section 1099, Health Care Enrollment System and 1086, Contracts for health benefits for certain members, former members and their dependents (which authorizes TRICARE eligibility of Medicare Eligible persons and has resulted in the development of a new enrollment option called TRICARE Plus) and for the Assistant Secretary of Defense for Health Affairs Policy Memorandum to Established the TRICARE Plus Program, June 22, 2001.
2. Use of the Information
These collected instruments serve as an application for enrollment and disenrollment in the Department of Defense’s TRICARE Plus Health Plan established in accordance with Title 10 U.S.C. sections 1099. The information hereby provides the TRICARE contractors with the necessary data to determine beneficiary eligibility and to identify the selection of a health care option. A beneficiary can enroll in TRICARE Plus if they are confirmed to be TRICARE-eligible and are not enrolled in a TRICARE Prime Plan or the US Family Health Plan option. Additionally, a dependent parent or parent-in-law may request TRICARE Plus enrollment. The beneficiary may get these forms online or at a Military Treatment Facility (MTF). The beneficiary is required to complete the forms to request TRICARE Plus enrollment or disenrollment and return them to the MTF where they desire TRICARE Plus enrollment. If the MTF approves the enrollment/disenrollment request, the form is sent to the contractor who enters the TRICARE Plus enrollment into the Defense Enrollment Eligibility Reporting System (DEERS). DEERS sends the Composite Health Care System (CHCS) host a Patient Information Transfer (PIT) message which registers the patient in the CHCS (if not previously registered), updates CHCS with their PCM assignment, and allows Plus enrollee booking to take place.
3. Use of Information Technology
Zero percentage of the responses are collected electronically. A higher electronic submission rate is not possible because of the nature of the TRICARE Plus program. Because each MTF has to approve the TRICARE Plus enrollment/disenrollment request, before the contractor can enter the TRICARE Plus enrollment into the Defense Enrollment Eligibility Reporting System (DEERS).
4. Non-duplication
This information is not being collected by any other agency or component nor is it currently available in any other format. These forms have simplified and standardized the process for collecting the required information. Duplication of information to be collected has been eliminated.
No small business or other small entities are involved in this collection of information.
6. Less Frequent Collection
The information collection is a one-time submission; therefore, the data cannot be collected on a less frequent basis.
7. Paperwork Reduction Act Guidelines
There are no special circumstances for this program that would require the collection of information 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 60-Day Federal Register Notice for the collection published on Tuesday, December 27, 2016. The 60-Day FRN citation is 81 FRN 95121-95122. No comments were received.
Part B: CONSULTATION
These forms are reviewed at least every three years or when policies or processes are changed that impact the form. This revision was made with input from the Uniformed Services and the TRICARE Regional Offices.
Respondents are not receiving payments or gifts for responding to this information collection.
10. Confidentiality
A Privacy Act Statement is provided on the forms. The specific uses for the information are provided on the forms; respondents are advised that disclosure is voluntary and made aware of the consequences of non-disclosure.
The applicable System of Records Notice (SORN) is DHA-07, Military Health Information System, located at:
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570672/edha-07/
Records Retention and Disposition: Close out at end of the calendar year in which received. Destroy 10 years after cut off (DAA-0330-2014-0014).
The Privacy Impact Assesment (PIA) the Composite Health Care System (CHCS) can be accessed using the following URL:
The Privacy Impact Assesment (PIA) the Defense Enrollment Eligibility Reporting System (DEERS) can be accessed using the following URL:
https://www.dmdc.osd.mil/appj/dwp/documents.jsp
11. Sensitive QuestionsThe collection instruments, DD Form 2853 & DD Form 2854 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). 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. The SSN Justification is provided separately.
12. Respondent Burden and its Labor Costs
a. Estimation of Respondent Burden
1.a. DD Form 2853
a. Number of Respondents: 1652
b. Number of Responses Per Respondent: 1
c. Number of Total Annual Responses: 1652
d. Response Time: 7 minutes
e. Respondent Burden Hours: 193 hours
1.b. DD Form 2854
a. Number of Respondents: 1652
b. Number of Responses Per Respondent: 1
c. Number of Total Annual Responses: 1652
d. Response Time: 7 minutes
e. Respondent Burden Hours: 193 hours
2. Total Submission Burden
a. Total Number of Respondents: 3305
b. Total Number of Annual Responses: 3305
c. Total Respondent Burden Hours: 386 hours
b. Labor Cost of Respondent Burden
1.a. DD Form 2853
a. Number of Total Annual Responses: 1653
b. Response Time: 7 minutes
c. Respondent Hourly Wage: $7.25
d. Labor Burden per Response: $.84
e. Total Labor Burden: $1388.52
1.b. DD Form 2854
a. Number of Total Annual Responses: 1652
b. Response Time: 7 minutes
c. Respondent Hourly Wage: $7.25
d. Labor Burden per Response: $.84
e. Total Labor Burden: $1387.68
2. Overall Labor Burden
a. Total Number of Annual Responses: 3305
b. Total Labor Burden: $2776.20
We used the federal minimum wage of $7.25 per hour as cited on the Department of Labor website (http://www.dol.gov/dol/topic/wages/index.htm). In actuality, the respondents hourly rate could range greatly from much higher to near nothing as most are retirees who we don’t have an accounting of their current job situation.
13. Respondent Costs Other Than Burden Hour Costs
Respondents have no upfront cost associated with this collection.
14. Cost to the Federal Government
a.
Labor Cost to the Federal Government
1. a. DD Form 2853
a. Number of Total Annual Responses: 1653
b. Processing Time per Response: 7 minutes
c. Hourly Wage of Worker(s) Processing Responses : $7.25
d. Cost to Process Each Response: $8.64
e. Total Cost to Process Responses: $14272
1. b. DD Form 2854
a. Number of Total Annual Responses: 1652
b. Processing Time per Response: 7 minutes
c. Hourly Wage of Worker(s) Processing Responses: $7.25
d. Cost to Process Each Response: $8.64
e. Total Cost to Process Responses: $14273
2. Overall Labor Burden to Federal Government
a. Total Number of Annual Responses: 3305
b. Total Labor Burden: $28545
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: $28,545
3. Total Cost to the Federal Government (P: Add 1 and 2 in this section): $28,545
We used the federal minimum wage of $7.25 per hour as cited on the Department of Labor website (http://www.dol.gov/dol/topic/wages/index.htm). In actuality, the workers hourly wage rate could range some based on the contract employees job situation (i.e., additional duties).
15. Reasons for Change in Burden
This is a reinstatement with change to an expired collection. There has been a change in burden estimates since the last time this collection was approved. Variations in burden hours are due to the ever changing availability to access to TRICARE Plus. TRICARE Plus is only available within the direct care system (military treatment facilities). Recently, there have been multiple military treatment facility closures which directly impacted (reduced) TRICARE Plus enrollment.
16. Publication of Results
There are no plans to publish or tabulate the information collected.
17. Non-Display of OMB Expiration Date
Approval is not sought for avoiding display of the expiration date.
18. Exceptions to "Certification for Paperwork Reduction Submissions"
No exceptions to the certification statement are being sought
| File Type | application/msword |
| File Title | 0720-0028 TRICARE Plus Enrollment |
| Author | Patricia Toppings |
| Last Modified By | SYSTEM |
| File Modified | 2018-02-01 |
| File Created | 2018-02-01 |