Supporting Statement TRICARE PRIME

SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION

Enrollment Application Form (DD 2876) and Disenrollment form (DD2877) for the TRICARE PRIME Program

A. Justification

1. Necessity for Information Being Collected

These collection instruments serve as applications for the Enrollment, Primary Care Manager (PCM) Change and Disenrollment for the Department of Defense’s TRICARE Prime program established in accordance with title 10 U.S.C. 1099 (which calls for a healthcare enrollment system). Monthly payment options for retiree enrollment fees for TRICARE Prime are established in accordance with title 10 U.S.C. 1097a(c). The information collected on the TRICARE Prime Enrollment Application/PCM Change Form provides the necessary data to determine beneficiary eligibility, to identify the selection of a health care option, and to change the designated PCM when the beneficiary is relocating or merely requests a local PCM change. The information collected on the TRICARE Prime Disenrollment Form provides the necessary data to disenroll a beneficiary from TRICARE Prime. The Disenrollment Application is needed to implement disenrollment from TRICARE Prime, TRICARE Prime Remote or the Uniformed Services Family Health Plan as requested by the enrollee. Failure to provide information will result in continued enrollment and beneficiaries’ responsibility for payment of an enrollment fee.

2. Purpose and Users of Information

The Department of Defense established TRICARE Prime as a managed-care option, similar to a civilian HMO (health maintenance organization). Active duty service members are required to be enrolled in TRICARE Prime or TRICARE Prime Remote. They must take action to enroll by filling out the appropriate enrollment form and submitting it to the Managed Care Support Contractor (MCSC). TRICARE Prime is also available to other TRICARE beneficiaries who are also required to fill out the appropriate enrollment or disenrollment forms. TRICARE Prime enrollee’s health care is coordinated by a primary care manager (PCM) whom could be a part of a military treatment facility, a civilian network or TRICARE Prime Remote where eligible. In order to carry out this program, it is necessary that certain beneficiaries electing to enroll/disenroll in TRICARE Prime, TRICARE Prime Remote or change a PCM complete an enrollment application request. Completion of the enrollment forms is an essential element of the TRICARE Prime program.

3. Information Techniques

The information collected on this form will be entered into the Composite Health Care System (CHCS) database, which must be updated on a regular basis to ensure that the information is current and accurate. The form itself will serve as documentation that the requirements of the law have been satisfied.

A web-based version of the forms are available for beneficiaries who wish to enroll, disenroll, or make a PCM change online. Beneficiaries will have the option to complete the form either hardcopy or electronically.

4. Duplication or Similar Information

This information is not being collected by any other agency or component nor is it currently available in any other format. This form has simplified and standardized the process for collecting the required information. Duplication of information to be collected has been eliminated.

5. Small Business

No small business or other small entities are involved in this collection of information.

6. Less Frequent Collections

Data cannot be collected on a less frequent basis. Currently these forms are the only means of collecting enrollment or disenrollment information. It is crucial to collect the most up-to-date information on beneficiaries.

The forms serve as documentation that the requirements of the law have been satisfied. Since the information is readily available to the respondents, we feel the completion of the form is not unduly burdenson.

7. Special Circumstances

There are no special circumstances for the collection of information for this program.

8. Federal Register Notice

The Federal Register Notice for this collection of information was published on 03 November 2009 (74 FR 56822). No comments were received.

9. Payments/Gifts to Respondents

There will be no payment or gifts provided to respondents.

10. Confidentiality

A Privacy Act Statement is provided on the form. The specific uses for the information are provided on the form; respondents are advised that disclosure is voluntary and made aware of the consequences of non-disclosure.

11. Sensitive Questions

DD Forms 2876 and 2877 does not require the collection or reporting of any sensitive issues or questions.

12. Burden Estimate (hours)

The total annual hour burden for the responses of 22,317 is based on an annual projected use of these forms by 72,905 applicants for enrollment in TRICARE PRIME. The burden is based on an estimate of TRICARE Prime Enrollment Application/PCM Change Form: 20 minutes or .33% of an hour/TRICARE Prime Disenrollment—5 minutes or .083%. Average burden per response for completing both forms is 18.36 minutes or .30% of an hour).

The cost to the respondent for providing the information is negligible and beyond our ability to calculate.

13. Cost to Respondents

There is no cost to Respondents.

14. Cost to the Federal Government

The average annualized costs are:

$ 15,337 (printing = $.03 x 511,232)

$270,953 (clerical costs = $.53 x 511,232)

$400,000 (contractor costs)

$686,290

15. Change in Burden

This is an extension of a previously approved collection.

16. Publication/Tabulation

There are no plans to publish or tabulate the information collected.

17. Expiration Date

We are not seeking approval to not display the expiration date for OMB approval of the information collection.

18. Exception to Certification Statement

No exception to the Certification Statement is requested.

B. Collection of Information Employing Statistical Methods

This information collection does not employ statistical methods.

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