Early Retiree Reinsurance Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10321 ERRP Application	Form	New	Available
Form CMS-10321 ERRP Application	Form	New	Available
CMS-10321.Emergency Justification.doc	Supplementary Document	Uploaded 2010-04-28	Available
CMS-10321.Supporting Statement Part A.doc	Supporting Statement A	Uploaded 2010-04-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
192771	Data Inaccuracies (Private)		New
192770	Reimbursement Requests (Private)		New
192769	Reimbursement Requests (Public)		New
192768	Change of Ownership (Private)		New
192767	Change of Ownership (Public)		New
192766	Data Inaccuracies (Public)		New
192765	Mainenance of Records (Private)		New
192764	Maintenance of Records (Public)		New
192763	Fraud and Abuse Procedures (Public) - Out Years		New
192762	Fraud and Abuse Procedures (Private) - Out Years		New
192761	Fraud and Abuse Procedures (Public) - Year 1		New
192760	Fraud and Abuse Procedures (Private) - Year 1		New
192759	Written Agreements (Private) - Out Years		New
192758	Written Agreements (Public) - Out Years		New
192757	Written Agreements (Private ) - Year 1		New
192756	Written Agreements (Public) - Year 1		New
192755	Early Retiree Reinsurance Program - Private Application	Instruction	New
192755	Early Retiree Reinsurance Program - Private Application	Form	New	ERRP Application
192754	Early Retiree Reinsurance Program - Public Application	Instruction	New
192754	Early Retiree Reinsurance Program - Public Application	Form	New	ERRP Application

ICR Details

OMB Control No: 0938-1087	ICR Reference No: 201004-0938-012
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Early Retiree Reinsurance Program
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 04/30/2010
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/03/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/29/2010
Terms of Clearance: CMS agrees to display the expiration date associated with this collection.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2010	6 Months From Approved
Responses	45,800	0	0
Time Burden (Hours)	854,675	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Under the Patient Protection and Affordable Care Act (P.L. 111-148) and implementing regulations at 45 CFR Part 149, employment-based plans that offer health coverage to early retirees and their spouses, surviving spouses, and dependents are eligible to receive tax-free reimbursement for a portion of the costs of health benefits provided to such individuals. To qualify, a plan sponsor must submit a complete application to HHS, and must submit reimbursement requests that consist of a list of individuals for whom reimbursement is sought, and documentation of the costs of health benefits provided.

Emergency Justfication: See the attached emergency justification.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1102 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1102 Name of Law: Patient Protection and Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 18

table that charts list of burden

IC Title	Form No.	Form Name
Change of Ownership (Private)
Change of Ownership (Public)
Data Inaccuracies (Private)
Data Inaccuracies (Public)
Early Retiree Reinsurance Program - Private Application	CMS-10321	ERRP Application
Early Retiree Reinsurance Program - Public Application	CMS-10321	ERRP Application
Fraud and Abuse Procedures (Private) - Out Years
Fraud and Abuse Procedures (Private) - Year 1
Fraud and Abuse Procedures (Public) - Out Years
Fraud and Abuse Procedures (Public) - Year 1
Mainenance of Records (Private)
Maintenance of Records (Public)
Reimbursement Requests (Private)
Reimbursement Requests (Public)
Written Agreements (Private ) - Year 1
Written Agreements (Private) - Out Years
Written Agreements (Public) - Out Years
Written Agreements (Public) - Year 1

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ICR Summary of Burden

table that charts list 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	45,800	0	45,800	0	0	0
Annual Time Burden (Hours)	854,675	0	854,675	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $20,000,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 04/29/2010

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