SF 2809 Federal Employees Health Benefits Program Election Form; OPM 2809 Health Benefits Election Form

Forms and Documents

Document Name	Status
Form SF 2809 Health Benefits Election Form Form and Instruction	Modified
Health Benefit Election Forms (Supporting Statement Part A)_final.docx Supporting Statement A	2024-10-09
E8-5659.pdf Supplementary Document	2022-04-28
Citations for SF 2809.pdf Supplementary Document	2022-04-28

IC Document Collections

IC ID	Document Title	Status
33632	Health Benefits Election Form Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0160	ICR Reference No: 202410-3206-002
Status: Received in OIRA	Previous ICR Reference No: 202204-3206-001
Agency/Subagency: OPM	Agency Tracking No:
Title: SF 2809 Federal Employees Health Benefits Program Election Form; OPM 2809 Health Benefits Election Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/11/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2025
Responses	48,000	18,000
Time Burden (Hours)	20,667	9,000
Cost Burden (Dollars)	477,514	242,999

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Abstract: The SF 2809 is used to enroll, elect not to enroll, change, suspend or cancel your health insurance coverage in the Federal Employees Health Benefits (FEHB) Program which includes FEHB and Postal Service Health Benefits (PSHB) plans. A different form (OPM 2809) is used by annuitants retired under the Civil Service Retirement System (CSRS) or Federal Employees' Retirement System (FERS), electing or changing either there FEHB or Postal Service Health Benefit (PSHB) coverage under the FEHB Program as well as the following: children and former spouses who are eligible for temporary continuation of coverage; former spouses; survivor annuitants under CSRS or FERS; an OPM appointed representative payee or court appointed guardian of the eligible member.

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Authorizing Statute(s): US Code: 5 USC 8905a Name of Law: Continued Coverage
   US Code: 5 USC 89 Name of Law: Health Insurance
   PL: Pub.L. 98 - 615 CSRS Name of Law: Spouse Equity Act of 1984
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
3206-AO43	Final or interim final rulemaking	89 FR 37061	05/06/2024

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 37269	05/06/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 77899	09/24/2024
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Health Benefits Election Form	OPM 2809, SF 2809	Federal Employees Health Benefits Program Election Form ,   Health Benefits Election Form

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ICR Summary of Burden

	Total Request	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	48,000	18,000	0	30,000	0	0
Annual Time Burden (Hours)	20,667	9,000	0	11,667	0	0
Annual Cost Burden (Dollars)	477,514	242,999	0	234,515	0	0

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

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: The Postal Service Health Benefit Act requires changes in burden due to Congressional act. We are also including another collection in this ICR.

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Annual Cost to Federal Government: $107,944

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]? Yes

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? Yes

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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: 10/11/2024

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