SF2809_OMB_Supporting_Statement-2019_04

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OMB Supporting Statement

SF 2809 –Health Benefits Election Form

1. Justification

1. Chapter 89 of title 5, United States Code, authorizes the Office of Personnel Management (OPM) to administer the Federal Employees Health Benefits (FEHB) Program, and to publish regulations to carry out the provisions of the FEHB law. The law and regulations specify who is eligible to enroll and when an individual may enroll or change enrollment. Standard Form (SF) 2809 - Health Benefits Election Form - is the instrument by which eligible individuals may enroll or change their enrollment status under the FEHB Program.
   
   

2. The SF 2809 is used by Federal employees, annuitants other than those under the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FERS) including individuals receiving benefits from the Office of Workers' Compensation Programs, former spouses eligible for benefits under the Spouse Equity Act of 1984 (P.L. 98-615), and separated employees and former dependents eligible to enroll under the Temporary Continuation of Coverage (TCC) provisions of the FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is used by CSRS and FERS annuitants whose health benefit enrollments are administered by OPM's Retirement Services Program. The Privacy Act Statement has been revised due to a general systematic review by our Chief Privacy Officer. The Public Burden Statement meets the requirements of 5 CFR 1320.8(b) (3).
   
   The SF 2809 is used as the official agency or retirement system record of the individual's coverage and enrollment status under the FEHB Program and as acknowledgment and authorization by the individual for collection from him or her of the appropriate premium contributions. A copy of the form is also forwarded to the FEHB insurance carrier as a record of the individual's enrollment. The form provides the carrier with information necessary to enable the carrier to pay and process claims for the individual and any covered family members, which the carrier would otherwise have to obtain from the enrollee by other means.
   
   

3. New methods of information technology would not reduce the burden on former spouses or individuals applying for TCC since they do not have ready access to computer terminals as current employees do. Although respondents could provide the information orally for direct entry into a computer database, we do not believe that respondents would save time or that the process would be any less of a burden than it is currently. Completion of the SF 2809 represents a voluntary election by the respondent, and the information collected can only be obtained from the respondent. The form is available in PDF fillable format on our website and it meets the Government Paperwork Elimination Act requirements.
   
   

4. Every effort is made to identify and avoid duplication. The number of times respondents are required to complete this form is kept to a minimum. After initial enrollment, completion of a new form is required only when the individual desires to make a change in his or her health insurance enrollment status.
   
   

5. This information collection request has no impact on small businesses and organizations.
   
   

6. If this information is not collected, respondents cannot enroll in the FEHB Program nor make changes to their health insurance enrollment. The only way to reduce the burden would be to restrict an individual's freedom to make changes to his/her enrollment, which would require making changes in current regulation.
   
   

7. There are no special circumstances involved in the collection if this information.

8. On December 4, 2018, a 60 Day Federal Register Notice was published at 83 FR 62630 requesting comment. No comments were received.
   
   

9. No gift or payment is awarded to respondents based on return of this form.
   
   

10. This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 831.106). The routine uses of disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008, effective April 21, 2008).

11. The information collected does not include questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.
    
    

12. Approximately 18,000 SF 2809 forms will be processed annually. SF 2809 requires approximately 30 minutes for the respondents to read the instructions and complete the form. A burden of 9,000 hours is estimated and is not expected to vary substantially.

Form Name	Form Number	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Annual Burden (in hours)	Average Hourly Wage Rate	Total Annual Respondent Cost
Health Benefits Election Form	SF 2809	18,000	1	30 minutes	9,000	$10.75	$242,999

The cost to respondents is $242,999.

13. There is no change in the respondent burden.
    
    

14. We estimate that the annualized cost to the Government is approximately $16,000. The cost is derived from employee salaries, staff hours required to process the forms and the cost of publishing, storing and shipping forms.

15. N/A
    
    

16. The results of this information collection are not published.
    
    

17. The Healthcare and Insurance/Federal Employees Insurance Operations (FEIO) program office is the lone processor of the data collected on this ICR. The substance of this information collection does not substantively change at each OMB renewal cycle, but according to changes in law and regulation. These forms are published (internet, intranet and on-board systems) through various agencies for distribution to and implementation by Government customers. Pursuant to title 5 CFR 1320.8(b)(1), it would not be appropriate to display the OMB clearance expiration date where the form will not be revised for the foreseeable future (e.g., because it is used to collect applicant information required by long-standing statutory provisions. Lastly, by adding the OMB clearance expiration date to the existing format, the end users of OPM’s ICRs may erroneously assume that the expiration date affects the validity of the information collection when it is the OMB clearance expiration date and not reflective of the substance. This may lead to additional submissions by customers, possible litigation and increasing pressures on our operations workloads. Therefore, we seek approval to not display the OMB clearance expiration date on the forms and to communicate version changes to the public via the revision date.
    
    

18. There are no exceptions to the certification statement.