OMB Supporting Statement
SF 2809 –Health Benefits Election Form
Justification
Chapter 89 of title 5, United
States Code, authorizes the Office of Personnel Management (OPM) to
administer the Federal Employees Health Benefits (FEHB) Program, and
to publish regulations to carry out the provisions of the FEHB law.
The law and regulations specify who is eligible to enroll and when
an individual may enroll or change enrollment. Standard Form (SF)
2809 - Health Benefits Election Form - is the instrument by which
eligible individuals may enroll or change their enrollment status
under the FEHB Program.
The SF 2809 is used by
Federal employees, annuitants other than those under the Civil
Service Retirement System (CSRS) and the Federal Employees
Retirement System (FERS) including individuals receiving benefits
from the Office of Workers' Compensation Programs, former spouses
eligible for benefits under the Spouse Equity Act of 1984 (P.L.
98-615), and separated employees and former dependents eligible to
enroll under the Temporary Continuation of Coverage (TCC) provisions
of the FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is
used by CSRS and FERS annuitants whose health benefit enrollments
are administered by OPM's Retirement Services Program. The Privacy
Act Statement has been revised due to a general systematic review by
our Chief Privacy Officer. The Public Burden Statement meets the
requirements of 5 CFR 1320.8(b) (3).
The SF 2809 is used
as the official agency or retirement system record of the
individual's coverage and enrollment status under the FEHB Program
and as acknowledgment and authorization by the individual for
collection from him or her of the appropriate premium contributions.
A copy of the form is also forwarded to the FEHB insurance carrier
as a record of the individual's enrollment. The form provides the
carrier with information necessary to enable the carrier to pay and
process claims for the individual and any covered family members,
which the carrier would otherwise have to obtain from the enrollee
by other means.
New methods of information
technology would not reduce the burden on former spouses or
individuals applying for TCC since they do not have ready access to
computer terminals as current employees do. Although respondents
could provide the information orally for direct entry into a
computer database, we do not believe that respondents would save
time or that the process would be any less of a burden than it is
currently. Completion of the SF 2809 represents a voluntary election
by the respondent, and the information collected can only be
obtained from the respondent. The form is available in PDF fillable
format on our website and it meets the Government Paperwork
Elimination Act requirements.
Every effort is made to
identify and avoid duplication. The number of times respondents are
required to complete this form is kept to a minimum. After initial
enrollment, completion of a new form is required only when the
individual desires to make a change in his or her health insurance
enrollment status.
This information collection
request has no impact on small businesses and organizations.
If this information is not
collected, respondents cannot enroll in the FEHB Program nor make
changes to their health insurance enrollment. The only way to reduce
the burden would be to restrict an individual's freedom to make
changes to his/her enrollment, which would require making changes in
current regulation.
There are no special circumstances involved in the collection if this information.
On December 4, 2018, a 60 Day
Federal Register Notice was published at 83 FR 62630 requesting
comment. No comments were received.
No gift or payment is awarded
to respondents based on return of this form.
This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 831.106). The routine uses of disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008, effective April 21, 2008).
The information collected
does not include questions of a sensitive nature, such as sexual
behavior and attitudes, religious beliefs, and other matters that
are commonly considered private.
Approximately 18,000 SF 2809 forms will be processed annually. SF 2809 requires approximately 30 minutes for the respondents to read the instructions and complete the form. A burden of 9,000 hours is estimated and is not expected to vary substantially.
Form Name |
Form Number |
No. of Respondents |
No. of Responses per Respondent |
Average Burden per Response (in hours) |
Total Annual Burden (in hours) |
Average Hourly Wage Rate |
Total Annual Respondent Cost |
Health Benefits Election Form |
SF 2809 |
18,000 |
1 |
30 minutes |
9,000 |
$10.75 |
$242,999 |
The cost to respondents is $242,999.
There is no change in the
respondent burden.
We estimate that the annualized cost to the Government is approximately $16,000. The cost is derived from employee salaries, staff hours required to process the forms and the cost of publishing, storing and shipping forms.
N/A
The results of this
information collection are not published.
The Healthcare and
Insurance/Federal Employees Insurance Operations (FEIO) program
office is the lone processor of the data collected on this ICR. The
substance of this information collection does not substantively
change at each OMB renewal cycle, but according to changes in law
and regulation. These forms are published (internet, intranet and
on-board systems) through various agencies for distribution to and
implementation by Government customers. Pursuant to title 5 CFR
1320.8(b)(1), it would not be appropriate to display the OMB
clearance expiration date where the form will not be revised for the
foreseeable future (e.g., because it is used to collect applicant
information required by long-standing statutory provisions. Lastly,
by adding the OMB clearance expiration date to the existing format,
the end users of OPM’s ICRs may erroneously assume that the
expiration date affects the validity of the information collection
when it is the OMB clearance expiration date and not reflective of
the substance. This may lead to additional submissions by customers,
possible litigation and increasing pressures on our operations
workloads. Therefore, we seek approval to not display the OMB
clearance expiration date on the forms and to communicate version
changes to the public via the revision date.
There are no exceptions to the certification statement.
| File Type | application/msword |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |