SUPPORTING STATEMENT – PART A
TRICARE Plus Enrollment/Disenrollment Application – OMB Control Number 0720-0028
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 (available at https://www.esd.whs.mil/Directives/forms/ or https://www.tricare.mil/Plans/SpecialPrograms/Plus) 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 percent of the responses are collected electronically. A higher electronic submission rate is not possible because of the nature of the TRICARE Plus program. 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
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
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
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
A 60-Day Federal Register Notice (FRN) for the collection published on Monday, March 1, 2021. The 60-Day FRN citation is 86 FRN 11952-11953.
No comments were received during the 60-Day Comment Period.
A 30-Day Federal Register Notice for the collection published on Wednesday, April 21, 2021. The 30-Day FRN citation is 86 FRN 20672-20673.
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.
No payments or gifts are being offered to respondents as an incentive to participate in the 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/
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
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 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 Memorandum has been provided as a part of this ICR submission.
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 pay rate varies widely as respondents include retirees.
13. Respondent Costs Other Than Burden Hour Costs
There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete 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: $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 range varies based on the contract employees job situation (e.g. additional duties).
15. Reasons for Change in Burden
There has been no change in burden since the last approval.
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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | 0720-0028 TRICARE Plus Enrollment |
| Author | Patricia Toppings |
| File Modified | 0000-00-00 |
| File Created | 2021-04-28 |