View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
3206-0160
ICR Reference No:
202410-3206-002
Status:
Historical Active
Previous ICR Reference No:
202204-3206-001
Agency/Subagency:
OPM
Agency Tracking No:
Title:
SF 2809 Federal Employees Health Benefits Program Election Form; OPM 2809 Health Benefits Election Form
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
11/12/2024
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/11/2024
Terms of Clearance:
This collection is approved based on the revised materials provided by the Agency.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2027
36 Months From Approved
07/31/2025
Responses
48,000
0
18,000
Time Burden (Hours)
20,667
0
9,000
Cost Burden (Dollars)
477,514
0
242,999
Abstract:
The SF 2809 is used to enroll, elect not to enroll, change, suspend or cancel your health insurance coverage in the Federal Employees Health Benefits (FEHB) Program which includes FEHB and Postal Service Health Benefits (PSHB) plans. A different form (OPM 2809) is used by annuitants retired under the Civil Service Retirement System (CSRS) or Federal Employees' Retirement System (FERS), electing or changing either there FEHB or Postal Service Health Benefit (PSHB) coverage under the FEHB Program as well as the following: children and former spouses who are eligible for temporary continuation of coverage; former spouses; survivor annuitants under CSRS or FERS; an OPM appointed representative payee or court appointed guardian of the eligible member.
Authorizing Statute(s):
US Code:
5 USC 8905a
Name of Law: Continued Coverage
US Code:
5 USC 89
Name of Law: Health Insurance
PL:
Pub.L. 98 - 615 CSRS
Name of Law: Spouse Equity Act of 1984
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
3206-AO43
Final or interim final rulemaking
89 FR 37061
05/06/2024
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
89 FR 37269
05/06/2024
30-day Notice:
Federal Register Citation:
Citation Date:
89 FR 77899
09/24/2024
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Health Benefits Election Form
OPM 2809, SF 2809
Federal Employees Health Benefits Program Election Form
,
Health Benefits Election Form
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
48,000
18,000
0
30,000
0
0
Annual Time Burden (Hours)
20,667
9,000
0
11,667
0
0
Annual Cost Burden (Dollars)
477,514
242,999
0
234,515
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Changing Regulations
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The Postal Service Health Benefit Act requires changes in burden due to Congressional act. We are also including another collection in this ICR.
Annual Cost to Federal Government:
$107,944
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Yes
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Yes
Agency Contact:
Alexys Stanley 202 606-1183 alexys.stanley@opm.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
10/11/2024
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