Early Retiree Reinsurance Program

Forms and Documents

Document Name	Status
Form CMS-10321 Early Retiree Reinsurance Program Reopening Requests (Pub lic), for Program Years 2, 3, 4 Form	New
Form CMS-10321 Early Retiree Reinsurance Program Appeals (Public), for Program Years 2 and 3 Form	New
Form CMS-10321 Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 2 Form	New
Form CMS-10321 Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 4 Form	New
Form CMS-10321 Private CHOW Years 2_3_4 Form	Modified
Form CMS-10321 Public Fraud and Abuse Procedures Years 2_3_4 Form	Modified
Form CMS-10321 Early Retiree Reinsurance Program - Private Application Form	Removed
Form CMS-10321 Early Retiree Reinsurance Program - Public Application Form	Removed
0938-1087 Revised_Summary of Burden Estimates.docx Supplementary Document	2011-09-29
Revisions to PRA Package 0938-1087 Overview.docx Supplementary Document	2011-09-29
ERRP data inaccuracies and reopenings guidance (revised).pdf Supplementary Document	2011-06-29
ERRP Prima Facie Evidence Cover Sheet.pdf Supplementary Document	2011-06-29
ERRP Prima Facie Evidence Cover Sheet Instructions.pdf Supplementary Document	2011-06-29
ERRP Appeals Guidance.pdf Supplementary Document	2011-06-29
0938-1087 Revised_Crosswalk of Changes.pdf Supplementary Document	2011-06-29
0938-1087 Revised_Summary of Burden Estimates.pdf Supplementary Document	2011-06-29
0938-1087 Revised_Supporting Statement-1.doc Supporting Statement A	2011-09-29

IC Document Collections

IC ID	Document Title	Status
199567	Early Retiree Reinsurance Program Reopening Requests (Pub lic), for Program Years 2, 3, 4 Form	New
199566	Early Retiree Reinsurance Program Appeals (Public), for Program Year 4 Instruction	New
199565	Early Retiree Reinsurance Program Reopening Requests (Private), for Program Years 2, 3, 4 Instruction	New
199564	Early Retiree Reinsurance Program Appeals (Public), for Program Years 2 and 3 Form	New
199563	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 4 Instruction	New
199562	Early Retiree Reinsurance Program Appeals (Private), for Program Year 4 Instruction	New
199561	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 3 Instruction	New
199560	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 2 Form	New
199558	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 4 Form	New
199556	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3 Instruction	New
199543	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 2 Instruction	New
199541	Early Retiree Reinsurance Program Appeals (Private), for Program Years 2 and 3 Instruction	New
198340	Private Application Update Year 2_3_4 Instruction	New
198339	Public Application Update Year 2_3_4 Instruction	New
192771	Private Data Inaccuracies Years 2_3_4 Instruction	Modified
192770	Reimbursement Requests (Private)	Removed
192769	Reimbursement Requests (Public)	Removed
192768	Private CHOW Years 2_3_4 Form	Modified
192767	Public CHOW Years 2_3_4 Instruction	Modified
192766	Public Data Inaccuracies Years 2_3_4 Instruction	Modified
192765	Private Maintenance of Records Year 2_3_4 Instruction	Modified
192764	Public Maintenance of Records Year 2_3_4 Instruction	Modified
192763	Public Fraud and Abuse Procedures Years 2_3_4 Form	Modified
192762	Private Fraud and Abuse Procedures Years 2_3_4 Instruction	Modified
192761	Fraud and Abuse Procedures (Public) - Year 1	Removed
192760	Fraud and Abuse Procedures (Private) - Year 1	Removed
192759	Private Written Agreement Year 2_3_4 Instruction	Modified
192758	Public Written Agreement Year 2_3_4 Instruction	Modified
192757	Written Agreements (Private ) - Year 1	Removed
192756	Written Agreements (Public) - Year 1	Removed
192755	Early Retiree Reinsurance Program - Private Application Form	Removed
192754	Early Retiree Reinsurance Program - Public Application Form	Removed

ICR Details

OMB Control No: 0938-1087	ICR Reference No: 201106-0938-023
Status: Historical Active	Previous ICR Reference No: 201012-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Early Retiree Reinsurance Program
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: 09/30/2011
	Date Received in OIRA: 06/29/2011
Terms of Clearance: In accordance with 5 CFR 1320, the information is approved for three years. However, within 30 days, CMS must submit an ICR revision with a supporting statement that fully describes, for each information collection, the burden that will be imposed over the three years requested, the number of respondents,the frequency of responses, and an annual average burden for the collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved	09/30/2011
Responses	18,872	0	71,518
Time Burden (Hours)	579,704	0	2,008,359
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.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1102 Name of Law: Patient Protection and Affordable Care Act
   US Code: 42 USC 18002 Name of Law: Reinsurance for Early Retirees
  

Citations for New Statutory Requirements: None

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80817	12/23/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 37813	06/28/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 24

IC Title	Form No.	Form Name
Public Written Agreement Year 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Private Written Agreement Year 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Private Fraud and Abuse Procedures Years 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Public Fraud and Abuse Procedures Years 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Public Maintenance of Records Year 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Private Maintenance of Records Year 2_3_4
Public Data Inaccuracies Years 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Public CHOW Years 2_3_4	CMS-10321	ERRP Collection Instrument
Private CHOW Years 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Private Data Inaccuracies Years 2_3_4	CMS-10321	ERRP Collection Instrument
Written Agreements (Public) - Year 1
Early Retiree Reinsurance Program - Private Application	CMS-10321	Deliberative Document
Early Retiree Reinsurance Program - Public Application	CMS-10321	Deliberative Document
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 4	CMS-10321	Revised ERRP Collection Instrument
Fraud and Abuse Procedures (Public) - Year 1
Public Application Update Year 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Private Application Update Year 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Fraud and Abuse Procedures (Private) - Year 1
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 3	CMS-10321	Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Private), for Program Year 4	CMS-10321	Revised ERRP Collection Instrument
Reimbursement Requests (Public)
Reimbursement Requests (Private)
Early Retiree Reinsurance Program Appeals (Public), for Program Year 4	CMS-10321	Revised ERRP Collection Instrument
Written Agreements (Private ) - Year 1
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 2	CMS-10321	Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Reopening Requests (Pub lic), for Program Years 2, 3, 4	CMS-10321	Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Reopening Requests (Private), for Program Years 2, 3, 4	CMS-10321	Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Private), for Program Years 2 and 3	CMS-10321	Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3	CMS-10321	Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 2	CMS-10321	Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 4	CMS-10321	Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Public), for Program Years 2 and 3	CMS-10321	Revised ERRP Collection Instrument

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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	18,872	71,518	0	-56,252	3,606	0
Annual Time Burden (Hours)	579,704	2,008,359	0	-1,590,040	161,385	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: In this revision, CMS removes the burden associated with the application and year one requirements, because those phases are complete.

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Annual Cost to Federal Government: $30,000,000

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]? 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? 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: 06/29/2011

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