Reserve Component Health Coverage Request

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD Form 2896-1 RESERVE COMPONENT HEALTH COVERAGE REQUEST	Form	New	Available
Form DD Form 2896-1 Reserve Component Health Coverage Request	Form	New	Repair queued
0720-RCHC_SSA_6.6.2024 .docx	Supporting Statement A	Uploaded 2024-06-06	Repair queued
0720-RCHC_SSNJ Memo_4.2.2024.pdf	Supplementary Document	Uploaded 2024-06-06	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
267518	Reserve Component Health Coverage Request	Form	New	RESERVE COMPONENT HEALTH COVERAGE REQUEST
267518	Reserve Component Health Coverage Request	Form	New
267518	Reserve Component Health Coverage Request	Other-Beneficiary Web Enrollment	New

ICR Details

OMB Control No: 0720-0081	ICR Reference No: 202405-0720-003
Status: Active	Previous ICR Reference No:
Agency/Subagency: DOW/DODOASHA	Agency Tracking No: 0720-RCHC
Title: Reserve Component Health Coverage Request
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/12/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/10/2024
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved
Responses	197,774	0	0
Time Burden (Hours)	49,444	0	0
Cost Burden (Dollars)	358,465	0	0

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Abstract: DD Form 2896-1 “Reserve Component Health Coverage Request” is used by certain Reserve Component members and retired members to purchase or make changes to coverage under the TRICARE Reserve Select and TRICARE Retired Reserve (TRR) health plan. Please see 32 CFR 199.24(c) and 199.25(b) for a list of eligible beneficiaries. Eligible beneficiaries can complete this form using the online Beneficiary Web Enrollment (BWE) portal. Although the online BWE portal submission option is available, some beneficiaries will prefer using the physical form to document their enrollment date and preferences.

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Authorizing Statute(s): US Code: 10 USC 1076d Name of Law: TRICARE program: TRICARE Reserve Select coverage for members of the Selected Reserve
   US Code: 10 USC 1076e Name of Law: TRICARE program:TRICARE Standard coverage for certain members of the Retired Reserve who are qualify
  

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:
	89 FR 19301	03/18/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 48409	06/06/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Reserve Component Health Coverage Request	DD Form 2896-1	RESERVE COMPONENT HEALTH COVERAGE REQUEST

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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	197,774	0	0	197,774	0	0
Annual Time Burden (Hours)	49,444	0	0	49,444	0	0
Annual Cost Burden (Dollars)	358,465	0	0	358,465	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is an existing collection currently in use without an OMB Control Number.

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Annual Cost to Federal Government: $670,885

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: 06/10/2024

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