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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2876-3 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form	Modified	Available
Form 2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form	Modified	Available
Form 2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form	Modified	Available
Form 2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form	Modified	Repair queued
0720-0008_SSA_8.22.22.docx	Supporting Statement A	Uploaded 2022-08-22	Repair queued
DD Form 2876_SSN Justification.pdf	Supplementary Document	Uploaded 2022-08-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
5574	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form	Modified	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form
5574	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form	Modified	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form
5574	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form	Modified	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form
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	Removed
236141	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- web portal	Other-Web Portal	Modified

ICR Details

OMB Control No: 0720-0008	ICR Reference No: 202204-0720-001
Status: Historical Active	Previous ICR Reference No: 201905-0720-001
Agency/Subagency: DOW/DODOASHA	Agency Tracking No:
Title: TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/26/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/22/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2025	36 Months From Approved	09/30/2022
Responses	517,798	0	3,040,100
Time Burden (Hours)	129,450	0	760,026
Cost Burden (Dollars)	938,509	0	5,510,181

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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.

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

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 25473	04/29/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 51390	08/22/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
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
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- phone
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- web portal

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ICR Summary of Burden

table that charts list 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	517,798	3,040,100	0	0	-2,522,302	0
Annual Time Burden (Hours)	129,450	760,026	0	0	-630,576	0
Annual Cost Burden (Dollars)	938,509	5,510,181	0	0	-4,571,672	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: The burden has decreased due to the removal of the TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager Change phone calls from the collection. The phone calls are not an information collection under the PRA.

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Annual Cost to Federal Government: $1,680,774

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? No

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Common Form ICR:  No

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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: 08/22/2022

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