SUPPORTING STATEMENT – PART A
TRICARE Plus Enrollment and Disenrollment Application Forms – OMB Control Number 0720-0028
Summary of Changes from Previously Approved Collection
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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. sections 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 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 percentage of the responses are collected electronically. A higher electronic submission rate is not possible because of the nature of the TRICARE Plus program. Because 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
This information is not being collected by any other agency or component nor is it currently available in any other format. These forms have simplified and standardized the process for collecting the required information. Duplication of information to be collected has been eliminated.
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
Part A: PUBLIC NOTICE
A 60-Day Federal Register Notice (FRN) for the collection published on Monday, April 22, 2024. The 60-Day FRN citation is 89 FR 29315.
No comments were received during the 60-Day Comment Period.
A 30-Day Federal Register Notice for the collection published on Wednesday, June 26, 2024. The 30-Day FRN citation is 89 FR 53405.
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 Assessment (PIA) for the Composite Health Care System (CHCS) can be accessed using the following URL:
https://health.mil/Reference-Center/Forms/2022/08/12/Composite-Health-Care-System-PIA
The Privacy Impact Assessment (PIA) the Defense Enrollment Eligibility Reporting System (DEERS) can be accessed using the following URL:
https://www.dhra.mil/Portals/52/Documents/Privacy/PIA/DEERS_PIA_2021_Public.pdf
Records Retention and Disposition
FILE NUMBER: 911-01
DISPOSITION: Temporary. Cut off at end of the calendar year in which received. Destroy 10 years after cutoff.
AUTHORITY: DAA-0330-2014-0014-0001
PRIVACY ACT: EDTMA 04
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 is provided separately.
12. Respondent Burden and its Labor Costs
Part A: ESTIMATION OF RESPONDENT BURDEN
Collection Instruments
DD Form 2853 TRICARE Plus Enrollment Application
Number of Respondents: 5,843
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 5,843
Response Time: 7 minutes
Respondent Burden Hours: 681.7 hours
DD Form 2854 TRICARE Plus Disenrollment Application
Number of Respondents: 291
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 291
Response Time: 7 minutes
Respondent Burden Hours: 34 hours
2) Total Submission Burden
Total Number of Respondents: 6,134
Total Number of Annual Responses: 6,134
Total Respondent Burden Hours: 716 hours
Part B: LABOR COST OF RESPONDENT BURDEN
Collection Instruments
DD Form 2853
Number of Total Annual Responses: 5,843
Response Time: 7 minutes
Respondent Hourly Wage: $7.25
Labor Burden per Response: $.85
Total Labor Burden: $4,942.20
DD Form 2854
Number of Total Annual Responses: 291
Response Time: 7 minutes
Respondent Hourly Wage: $7.25
Labor Burden per Response: $.85
Total Labor Burden: $246.14
2) Overall Labor Burden
Total Number of Annual Responses: 6,134
Total Labor Burden: $5,188
We used the federal minimum wage of $7.25 per hour to estimate respondent hourly wage. Respondents hourly rate could range greatly from much higher to near nothing as most are retirees who we don’t have an accounting of their current job situation.
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
Part A: LABOR COST TO THE FEDERAL GOVERNMENT
Collection Instruments
DD Form 2853
Number of Total Annual Responses: 5,843
Processing Time per Response: 5 minutes
Hourly Wage of Worker(s) Processing Responses: $31.48
Cost to Process Each Response: $2.62
Total Cost to Process Responses: $15,328.14
DD Form 2854
Number of Total Annual Responses: 291
Processing Time per Response: 5 minutes
Hourly Wage of Worker(s) Processing Responses: $31.48
Cost to Process Each Response: $2.62
Total Cost to Process Responses: $763.39
2) Overall Labor Burden to Federal Government
Total Number of Annual Responses: 6,134
Total Labor Burden: $16,092
Part B: OPERATIONAL AND MAINTENANCE COSTS
Cost Categories
Equipment: $0
Printing: $0
Postage: $0
Software Purchases: $0
Licensing Costs: $0
Other: $0
Part C: TOTAL COST TO THE FEDERAL GOVERNMENT
Total Operational and Maintenance Costs: $0
Total Labor Cost to the Federal Government: $16,092
Total Cost to the Federal Government: $16,092
15. Reasons for Change in Burden
The burden has increased since the last request due to an increase in the number of respondents. The new numbers reflect 2023 estimates of form completions.
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 | 2024-07-26 |