Supporting Statement Outline
NOTE: Complete Part A for all ICR Requests
TRICARE Prime Enrollment, Disenrollment and Primary Care Manager (PCM) Change Form – 0720-0008
A. JUSTIFICATION
1. Need for the Information Collection
The information collection requirement is necessary to obtain the TRICARE beneficiary’s personal information needed to: (1) complete his/her enrollment into TRICARE Prime health plan, (2) to change the beneficiary’s enrollment (new Primary Care Manager, enrolled region, add a dependent, etc.), or (3) dis-enroll the beneficiary. All TRICARE beneficiaries have the option of enrolling, changing their enrollment or dis-enrolling using the DD Form 2876, the Beneficiary Web Enrollment (BWE) portal, or by calling their regional Managed Care Support Contractor (MCSC). Although the telephonic enrollment/change is the preferred method by the large majority of beneficiaries, many beneficiaries prefer using the form to document their enrollment date and preferences. The DD Form 2876 allows enrollment per the TRICARE Policy Manual, Chapter 10, Section 2.1.
2. Use of the Information
The information is used only to complete the beneficiary’s enrollment, enrollment change or dis-enrollment. The Form is provided to the beneficiary’s TRICARE Managed Care Support Contractor’s enrollment department, who are contractually required to complete all enrollment transactions. The enrollment is stored in the government’s Defense Enrollment Eligibility Reporting System (DEERS) and the Contractor’s system to ensure benefits and claims processing are correctly accomplished. The enrollment is shared only with other TRICARE contractors (i.e., pharmacy, Uniformed Services Health Plan providers).
3. Use of Information Technology
All TRICARE beneficiaries have the option of enrolling, changing their enrollment or disenrolling using the DD Form 2876, the Beneficiary Web Enrollment (BWE) portal, or by calling their regional Managed Care Support Contractor (MCSC). Although the telephonic enrollment/change is the preferred method by the large majority of beneficiaries, many beneficiaries prefer using the form to document their enrollment date and preferences.
4. Non-duplication
The information collected ensures the beneficiary is eligible for TRICARE and his/her TRICARE health plan record is correctly updated with his TRICARE plan of choice.
All respondents are individual TRICARE eligible beneficiaries. There is no burden on Small Business as a result of this information collection.
6. Less Frequent Collection
Collection is on an as needed basis. The TRICARE beneficiary submits the DD Form 2876 only when initially enrolling in the TRICARE Prime health plan, changing their enrollment (i.e., primary care manager, location, add/drop a dependent) or dis-enrolling. Less frequent collection would result in beneficiaries not having the appropriate coverage or having coverage when they no longer desire or need it.
7. Paperwork Reduction Act Guidelines
There are no special circumstances that require the collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
a. A 60-day notice published in the Federal Register on November 25, 2015; 80 FR 73740. One comment was received.
Public Comment:
The use of a form 2876 is appropriate, to provide an alternate pathway and documentation for Tricare enrollment, particularly for senior veterans who may not be familiar with and easily able to use a web portal. The form, in whatever documentary form adopted, should be relatively easy to fill out, and should be able to be processed by the Veterans Administration and any associated healthcare organization quickly, so that it does not get lost in any system, and the veteran using the form can be notified quickly of the completion and acceptance of the form. There should be a target date for notification of form completeness and acceptance of within 30 days or less after filling out the form. There should be clear instructions so that if necessary local county Veterans Service Organizations can be familiar with and assist in completion of this important form.
Response to Public Comment: The DD Form 2876 is only used by "TRICARE eligible" beneficiaries to enroll, disenroll or change their TRICARE Prime program. It captures the information needed to complete the requested action. The form cannot be used by non-TRICARE eligible veterans and is not provided to the Veterans Administration. The form is completed by the TRICARE eligible beneficiary and mailed to their Regional Contractor for processing. The forms are typically updated within 1-5 days of receipt, with each beneficiary receiving a notice of completion either via a postcard mailed to their residential mailing address or an email that refers them to the MilConnect website to review the confirmation letter.
b. The DD Form 2876 is 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 TRICARE Health Plan, TRICARE Regional Offices and the Managed Care Support Contractors.
No gifts or payments are provided to respondents.
10. Confidentiality
DD Form 2876 is provided to and exclusively used by the Managed Care Support Contractors, who are contractually required to keep information private to the extent permitted by law. The form is not shared with any other entity and is secured, stored and maintained by each Managed Care Support Contractor. Respondents are provided information regarding the use of the form in the Privacy Act Statement on page 1 of the Form.
The applicable System of Record Notice (SORN) is DHA-07, Military Health Information System, located at: http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570690/dmdc-02-dod.aspx
11. Sensitive Questions
The form 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 for healthcare transactions. Additionally, the main data source to find the DBN is the Uniformed Services identification card (ID card). Since some applicants are former dependent children, they either never had access to their DBN on an ID card in the first place or no longer have access to their DBN when they turned in their ID card after aging out of military benefits. For these reasons, 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.
12. Respondent Burden, and its Labor Costs
a. Estimation of Respondent Burden
The estimated number of respondents and annual burden hours was taken from the enrollment reports submitted by the Managed Care Support Contractors for the months of May 2014 and Apr 2014. Those are representative months following the winter months, fewer transactions, and just before the military permanent change of station summer months (highest number of transactions).
It takes approximately 30 minutes to complete the demographic data and enrollment change or disenrollment fields. Forms involving initial enrollments or transactions involving large families will take up to an hour to complete since those require most of the form to be completed.
b. Labor Cost of Respondent Burden
We estimate 148,033 respondents will annually complete the form and mail it to the Managed Care Support Contractor for their TRICARE Region for processing. Using the federal minimum wage of $7.25 for all covered, non exempt workers, the total labor costs for completing the form is $1,073,239.20 (http://www.dol.gov/whd/minwage/chart.htm).
13. Respondent Costs Other Than Burden Hour Costs
We estimate 148,033 respondents will annually complete the form and mail it to the Managed Care Support Contractor for their TRICARE Region for processing. Based on the 2016 Postage Rate of $0.49 per first class letter, the total costs for the mailings is $72,536.17.
14. Cost to the Federal Government
The Department of Defense contracts with regional managed care support contractors to process the completed DD Forms 2876. Completion of the form is not a specific tasking priced separately, but included in the “per member per month (PMPM)” fees paid to the contractor for completing administrative actions. The PMPM fees include collecting, auditing and processing forms received. It also includes providing beneficiaries a copy of the form as requested. And independent cost estimate study calculated the cost to the government for processing the form to be approximately $8.64 per form.
15. Reasons for Change in Burden
There has been a slight increase in the number of TRICARE Prime enrolment, disenrollment and change transactions since the previous approval.
16. Publication of Results
There are no plans to publish or tabulate the information collected.
17. Non-Display of OMB Expiration Date
Approval is not sought for avoiding display of the expiration date..
18. Exceptions to "Certification for Paperwork Reduction Submissions"
There are no exceptions to the certification statement in Item 19, “Certification for Paperwork reduction Act Submission,” of OMB Form 83-1.
| File Type | application/msword |
| Author | Patricia Toppings |
| Last Modified By | Dennis, Sandra, CTR, DHA |
| File Modified | 2016-03-04 |
| File Created | 2016-03-02 |