SF2809_OMB_Supporting_Statement_2022_0505

OMB SUPPORTING STATEMENT

SF 2809 Health Benefits Election Form

1. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

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. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

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 is current 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. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

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 at www.opm.gov/forms and it meets the Government Paperwork Elimination Act requirements.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

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.  If the collection of information impacts small businesses or other small entities
   (Item 5 of OMB Form 83-I), describe any methods used to minimize.

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

6. Describe the consequence to Federal/DHS program or policy activities if the collection of information is not conducted, or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

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. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which is unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secrets, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information’s confidentiality to the extent permitted by law.

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

8. Federal Register Notice: Provide a copy and identify the date and page number of the publication in the Federal Register of the agency’s notice soliciting comments on the information collection prior to submission to OMB.

On November 1, 2021, a 60 Day Federal Register Notice was published at
86 FR 60304 requesting comment. No comments were received. On May 3, 2022 the 30 day FRN was published (Vol. 87, No. 85).
Written comments and recommendations for the proposed information
collection should be sent within 30 days of publication of this notice to http://www.reginfo.gov/public/do/PRAMain. Find this particular information collection by selecting “Currently under Review — Open for Public Comments” or by using the search function.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No gifts or payments of any kind have been provided to any individuals who are connected to this collection.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

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. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

This information collection 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. Provide estimates of the hour burden of the collection of information. The statement
should:

a. Indicate the number of respondents, frequency of response, annual hour burden,
and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desired. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

b. If this request for approval covers more than one form, provide separate hour
burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-I.

c. Provide estimates of annualized cost to respondents for the hour burdens for
collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

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 Total Annual Respondent Cost is $242,999.

13. Provide an estimate of the total annual cost burden to respondents or record-keepers
resulting from the collection of information. (Do not include the cost of any hour burden
shown in Items 12 and 14.)

The cost estimate should be split into two components: (1) a total capital and start-up cost component (annualized over its expected useful life); and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection as appropriate.

Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information to keep records for the government, or (4) as part of customary and usual business or private practices.

There is no change in the respondent burden.

14. Provide estimates of annualized cost to the Federal Government. Also, provide a
description of the method used to estimate cost, which should include quantification of
hours, operational expenses (such as equipment, overhead, printing and support staff),
and any other expense that would have been incurred without this collection of
information. You may also aggregate cost estimates for Items 12, 13, and 14 in a single
table.

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. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of
the OMB Form 83-I. Changes in hour burden, i.e., program changes or adjustments made
to annual reporting and recordkeeping hour and cost burden. A program change is the
result of deliberate Federal government action. All new collections and any subsequent
revisions of existing collections (e.g., the addition or deletion of questions) are recorded
as program changes. An adjustment is a change that is not the result of a deliberate
Federal government action. These changes that result from new estimates or actions not
controllable by the Federal government are recorded as adjustments.

There is no change in the hour or cost burden.

16. For collections of information whose results will be published, outline plans for
tabulation and publication. Address any complex analytical techniques that will be used.
Provide the time schedule for the entire project, including beginning and ending dates of
the collection of information, completion of report, publication dates, and other actions.

No information collected from the form will be published.

17. If seeking approval to not display the expiration date for OMB approval of the
information collection, explain reasons that display would be inappropriate.

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. Explain each exception to the certification statement identified in Item 19 “Certification
for Paperwork Reduction Act Submissions,” of OMB Form 83-I.

There are no exceptions to the certification statement.