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

Forms and Documents

Document Name	Status
Form 2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form Form	Modified
0720-0008_SSA_08.15.19 version.docx Supporting Statement A	2019-08-19
DD Form 2876_SSN Justification_final_20160223.pdf Supplementary Document	2019-05-22

IC Document Collections

IC ID	Document Title	Status
5574	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form Form	Modified
236142	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- phone Instruction	New
236141	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- web portal Other-Web Portal	New

ICR Details

OMB Control No: 0720-0008	ICR Reference No: 201905-0720-001
Status: Active	Previous ICR Reference No: 201602-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/26/2019
	Date Received in OIRA: 05/23/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2022	36 Months From Approved	08/31/2019
Responses	3,040,100	0	148,033
Time Burden (Hours)	760,026	0	37,008
Cost Burden (Dollars)	5,510,181	0	268,310

---

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, complete enrollment, change beneficiary's enrollment (new Primary Care Manager, enrolled region, add a dependent, etc.), or dis-enroll the beneficiary.

---

Authorizing Statute(s): US Code: 10 USC 1099 Name of Law: Health Care Enrollment System
  

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:
	84 FR 10481	03/21/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 23038	05/21/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- web portal
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- phone
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	2876-1, 2876-3, 2876-2	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form ,   TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form ,   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	3,040,100	148,033	0	0	2,892,067	0
Annual Time Burden (Hours)	760,026	37,008	0	0	723,018	0
Annual Cost Burden (Dollars)	5,510,181	268,310	0	0	5,241,871	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: In the past, only the burden for responses collected through the DD Form 2876 and the web portal were taken into consideration, not the responses via telephone. This oversight is now being corrected and the burden more accurately reflects the popular use of TRICARE Prime, specifically the enrollment, disenrollment, and primary care manager change form. In addition, ease of the online system and allowance of enrolling via telephone has caused a significant increase from past collections. However, the individual burden has decreased from 30 minutes to 15 minutes due to revisions of the form.

---

Annual Cost to Federal Government: $16,221,845

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 05/23/2019

---