SUPPORTING STATEMENT - PART A
Continued Health Care Benefit Program Application (CHCBP) – 0720-0066
1. Need for the Information Collection
The information collected on the Department of Defense (DD) Form 2837, Continued Health Care Benefit Program (CHCBP) Application, is needed to determine a former military beneficiary’s eligibility to purchase CHCBP coverage, which is optional continuation coverage after the former member or former beneficiary loses entitlement to military health benefits coverage under Title 10 United States Code (10 USC), Chapter 55. Provision of the information requested on the DD Form 2837 is required to obtain or retain benefits, or eligibility for CHCBP coverage cannot be determined and must be denied.
Federal statutes and regulation mandate the requirement for a written election of CHCBP coverage via an enrollment form to be completed by the respondent. The CHCBP was directed by Congress in Section 4408 of the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 1993 (Public Law 12-484), which amended 10 USC, Chapter 55, by adding Section 1078a, Continued Health Benefits Coverage. Subsection (d) of 1078a mandates the following for an election of coverage into the CHCBP: “In order to obtain continued coverage under this section, an appropriate written election (submitted in such manner as the Secretary of Defense may prescribe) shall be made.”
The Department of Defense (DoD) published a final rule regarding the CHCBP in a Federal Register (FR) notice on September 30, 1994, (59 FR 49817) which amended Code of Federal Regulations 32 Part 199.20 to include the requirements for the CHCBP. The specific requirements for a CHCBP enrollment application are contained in Section (d)(5) of 32 CFR Part 199.20 which reads as follows: “Enrollment. Enrollment in the Continued Health Care Benefit Program will be accomplished by submission of an application.”
2. Use of the Information
The information supplied via the DD Form 2837 by respondents is used by the Department of Defense and its civilian managed care support contractor to determine a respondent’s eligibility to enroll in and receive health care coverage under the CHCBP.
Respondents are individuals who were entitled to health care benefits from the Military Health System (MHS) under 10 USC, Chapter 55, and who wish to apply for, and enroll in DoD’s CHCBP upon loss of eligibility for MHS health care coverage.
These individuals include service members or former service members, an unremarried former spouse of a service member or former service member, a spouse who ceases to meet the requirements for being considered a dependent, an unmarried child of a service or former service member who ceases to meet the requirements for being considered a dependent, and a child placed for adoption or legal custody with the service member or former member.
Individuals desiring CHCBP coverage must complete and submit DD Form 2837 to a designated DoD regional managed care support contractor to determine eligibility for CHCBP coverage and if eligible for CHCBP, the contractor enrolls the applicants in CHCBP coverage.
The regional managed care support contractor for the TRICARE East region is designated by contract as the CHCBP contractor responsible for the administration of the CHCBP worldwide on behalf of the DoD. The current CHCBP contractor is Humana Military Health Services (HMHS). Respondents may contact HMHS by calling a toll-free number to have a blank paper DD Form 2837 mailed to them. Respondents may obtain a blank DD Form 2837 from the designated DoD regional contractor’s website, or from military medical treatment facilities located on military installations. CHCBP information is provided to respondents during out processing. Additionally, the form is available online at the tricare.mil website and available to download as an electronic version in portable document format (.pdf) from the DoD Forms Management Website.
Respondents can complete the form in a variety of ways. They can use free .pdf software to type in the information requested on the electronic .pdf file, and after its complete, print and sign the form. Respondents can also print a blank form from the electronic .pdf file, and then handwrite the requested information with a pen. Finally, if provided a paper version of the form, respondents can handwrite the information to complete the form with pen. Once the application is completed, the respondent mails the completed application form along with a check or money order to pay for the first 3 months of coverage to the CHCBP contractor. Upon receipt, the CHCBP contractor uses DoD directed methods to determine eligibility for CHCBP coverage. If eligible, the CHCBP contractor enrolls the applicant which starts their CHCBP coverage and processes the payment received for the first 3 months of coverage. If not eligible based on the information provided on the form, the CHCBP contractor denies enrollment and returns the required initial payment received from the applicant.
A Privacy Act Statement is prominently displayed on the first page of the form and provides the authorities (statutory and regulatory) to collect the information, the principal purposes that require the data collection, and routine uses for the data collected.
No invitations or other communications are sent by the CHCBP contractor. Each Uniformed Service is responsible to educate service member and their dependents upon loss of MHS benefits that they have up to 60 days to apply for CHCBP coverage if desired.
The form requests the following information be provided:
Applicant Information: Name of applicant, telephone numbers, e-mail address, and social security number (SSN) or Department of Defense Benefits Number (DBN)
Sponsor Information: Name of service member (sponsor) and SSN or DBN
Person(s) To Be Enrolled: Names of service member and/or dependents to be enrolled, SSNs or DBNs, dates of birth, and sex; indication of either single or family coverage desired
Premiums: Applicants enter the amount of the required three months of initial premiums and how paid (check or money order)
Applicant’s Signature and Date: A certification statement is provided for the applicant’s review, and then the applicant signs the application.
3. Use of Information Technology
The DD Form 2837 is only available for download via the DoD Forms Management Website http://www.esd.whs.mil/Directives/forms/. The TRICARE website at www.tricare.mil/forms and the CHCBP contractor website at https://www.humanamilitary.com/beneficiary/resources/#forms both provide links to download the DD Form 2837 from the aforementioned DoD Forms Management Website. DoD does not support the form being loaded on any other web sites to ensure the online information about CHCBP is correct.
The percent of responses collected electronically is zero percent. Electronic submission of the CHCBP application is not feasible for a variety of reasons. CHCBP applications are only submitted in hardcopy because applicants must submit an original signature and other important documentation with their application (e.g., final divorce decrees; DD Form 214, Certificate of Release or Discharge From Active Duty; letters from accredited educational facilities regarding student status; etc.). Additionally, respondents must submit a check or money order for their first premium payment with their application.
The application process does not readily incorporate the use of electronic signature, as handling and management of separate documentation by contractors could adversely impact the beneficiary being able to obtain program benefits in the allotted 60-day time frame.
While most applicants are still registered in the Defense Enrollment Eligibility Reporting System (DEERS), for military benefits eligibility and health plan enrollment information, applicants no longer have DoD approved automated credentials to access DEERS in a secure manner. DEERS is DoD’s electronic database of record for eligibility. Therefore, DoD has no future plans to improve or increase the level of information technology to collect CHCBP applications electronically.
4. Non-duplication
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source. The information that is being collected is a one-time submission by a qualified former MHS beneficiary who is applying for CHCBP coverage. All CHCBP enrollment information is centralized and not being collected by any other entity.
5. Burden on Small Businesses
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
6. Less Frequent Collection
The information collection is a one-time submission; therefore, less frequent collections are not applicable.
7. Paperwork Reduction Act Guidelines
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
Part A: PUBLIC NOTICE
A 60-Day Federal Register Notice (FRN) for the collection published on Thursday, June 22, 2023. The 60-Day FRN citation is 88 FRN 40792.
No comments were received during the 60-Day Comment Period.
A 30-Day Federal Register Notice for the collection published on Monday, August 28, 2023. The 30-Day FRN citation is 88 FRN 58572.
Part B: CONSULTATION
The DD Form 2837 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, Private Sector Integration Section, and the regional CHCBP contractor.
9. Gifts or Payment
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
10. Confidentiality
The DD Form 2837, CHCBP Application, includes a Privacy Act Statement on the first page of the form. It is provided to the applicant as an integral part of the form itself.
The CHCBP contractor with whom DoD has contracted to perform CHCBP enrollment functions is contractually required to adhere to the legal requirements associated with the Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA) as well as the TRICARE instructions and guidelines that have been furnished the contractor regarding the confidentiality of information and data collected under the contract and the penalties for unauthorized release of that information. This contractor is a seasoned contractor that is well aware of the Privacy Act and HIPAA, and includes such training in initial and recurring employee training. The contractor likewise has significant private sector experience handling confidential patient information for their commercial line of business.
APPLICABLE SORN: DMDC 02 DoD, Defense Enrollment Eligibility Reporting System (“DEERS”) (May 31, 2022; 87 FR 32384) is the system of records notice. The SORN can be found at https://www.federalregister.gov/documents/2022/05/31/2022-11610/privacy-act-of-1974-system-of-records
A Privacy Impact Assessment (PIA) is not required for this collection because PII is not being collected electronically.
Records Retention and Disposition: Close out at end of the calendar year in which received; destroy 10 years after cutoff. DAA-0330-2014-0014.
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 the 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 the applicants are former service members or former dependents, 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 losing 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. The SSN Justification memo has been completed and provided separately for this information collection.
12. Respondent Burden and its Labor Costs
Part A: ESTIMATION OF RESPONDENT BURDEN
Collection Instrument
Continued Health Care Benefit Program (CHCBP) Application- DD Form 2837
Number of Respondents: 1,475
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 1,475
Response Time: 15 min
Respondent Burden Hours: 368.75 hours
Total Submission Burden
Total Number of Respondents: 1,475
Total Number of Annual Responses: 1,475
Total Respondent Burden Hours: 368.75 hours
Part B: LABOR COST OF RESPONDENT BURDEN
Collection Instrument
CHCBP Application- DD Form 2837
Number of Total Annual Responses: 1,475
Response Time: 15 min
Respondent Hourly Wage: $7.25
Labor Burden per Response: $1.81
Overall Labor Burden
Total Number of Annual Responses: 1,475
Total Labor Burden: $2,673.44
The Respondent hourly wage was determined by using the Department of Labor Wage Website (http://www.dol.gov/dol/topic/wages/index.htm).
13. Respondent Costs Other Than Burden Hour Costs
There are no capital or start-up costs annualized over the expected useful life of the form.
The total operations and maintenance costs is $1408.85, is estimated at 738 responses at 15 cents per page for 3 pages (assumes 50% of the applicants print their own form versus having it mailed to them by the servicing contractor). We anticipate 10 cents per mailing envelope and 63 cents for postage for all 1,475 submitted forms. The increase in costs are related to applicants printing out application forms versus having them provided to them by the servicing contractor, providing their own mailing envelope, and the increase in postage costs since the last submission.
14. Cost to the Federal Government
Part A: LABOR COST TO THE FEDERAL GOVERNMENT
Collection Instrument
CHCBP Application- DD Form 2837
Number of Total Annual Responses: 1,475
Processing Time per Response: 15 minutes
Hourly Wage of Worker(s) Processing Responses: $23.06
Cost to Process Each Response: $5.76
Total Cost to Process Responses: $8,503.37
Overall Labor Burden to the Federal Government
Total Number of Annual Responses: 1,475
Total Labor Burden: $8503.37
Part B: OPERATIONAL AND MAINTENANCE COSTS
Cost Categories
Equipment: $0
Printing: $0
Postage: $0
Software Purchases: $0
Licensing Costs: $0
Other: $0
Total Operational and Maintenance Cost:$0
Part C: TOTAL COST TO THE FEDERAL GOVERNMENT
Total Labor Cost to the Federal Government: $8,503.37
Total Operational and Maintenance Costs: $0
Total Cost to the Federal Government: $8,503.37
15. Reasons for Change in Burden
There has been no change in burden since the last approval.
16. Publication of Results
The results of this information collection will not be published.
17. Non-Display of OMB Expiration Date
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
18. Exceptions to “Certification for Paperwork Reduction Submissions
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2023-09-01 |