Crosswalk of Revisions

Information Collection 0938-1087 (revised, submitted to OMB on DATE)

Crosswalk of Changes Between Existing Collection Instrument,
and Revised Collection Instrument
NOTE: All page numbers refer to pages in the “clean” Information Collection Instrument
submitted with this revised PRA package.

General Changes Made Throughout Document


The Information Collection Instrument has been heavily revised for purposes of
making it 508 compliant.



All previous statutory cites to the Public Law number for the Affordable Care Act
(P.L. 111-148), are now immediately followed by the United States Code cite (42
U.S.C. §18002).

Specific Changes Made to the Document
Reimbursement Request Information
Part I. B (pages 13-14)
This paragraph B. has been retitled “Submit Claim List(s).” It formerly was titled
“Submit Detailed Data List(s).” (This change of terms was made globally throughout the
document).
Part II. E (page 21)
This paragraph E has been retitled “Submit Claim List(s)”. It formerly was titled “Submit
Detailed Claims Data List(s).”
Part II. E. (pages 21-91)
The previously submitted version of the Information Collection Instrument had listed all
the data elements necessary for ERRP plan sponsors to include in a Claim List. This
version of the document instead includes the actual required claims layout format for
each type of claim (i.e., institutional, professional, prescription drug). Each data element
that is relevant to that specific type of claim, is included in the layout for that specific
type of claim. The data elements included, are the same data elements that had been listed
in the previous version of the Information Collection Instrument, with three exceptions.
The “Claim Type” and” Type of Service” data elements have been eliminated, as they
duplicate the information that can be gleaned the “Record Type” data element. One new
data element has been added. That new data element is Cost Adjustment (i.e., price

concessions), to be reported at the individual early retiree level. A sponsor must include
this data element with respect to each individual for which the sponsor is submitting
claims data, to the extent any Cost Adjustments apply to the costs submitted for that
individual. We estimate the burden of providing this information to be nominal. This is
because the previous version of the Information Collection Instrument required sponsors
to provide this Cost Adjustment data on an aggregate basis for all such individuals, which
required the sponsor to first determine the amount of Cost Adjustments for each
individual, before summing the amounts. We believe that most of the burden associated
with reporting the amounts on an individual basis, is the burden of first determining the
amounts for each such individual. That burden existed, and was already accounted for, in
the previous PRA submission, as part of the burden associated with submitting a
reimbursement request.

Part II.F (page 92)
This paragraph has been retitled “Submit Prima Facie Evidence of Early Retiree
Payment.” It formerly was titled “Submit Evidence of Early Retiree Payment.” This
language change makes the title consistent with the applicable regulatory provision (45
CFR 149.335(b)).
Part II.F lists the data elements that must appear on each piece of prima facie evidence, to
demonstrate that an early retiree actually paid his or her share of a claim. It lists the same
four data elements as in the previously submitted Information Collection Instrument, but
clarifies that if the provider of services is an individual, as opposed to an entity, the
individual must be named. It also adds a fifth data element – a description of the health
benefit item or service for which the sponsor seeks reimbursement. There is no additional
burden to the plan sponsor for providing this data, because the receipt itself (i.e., the
piece of prima facie evidence) will already include that information.
Part II. F also lists the data elements that must appear on the Cover Sheet that
accompanies prima facie evidence. All the data elements listed in the previously
submitted Information Collection Instrument are listed here, except for the first and last
name of the individual who paid the costs. (This information is not necessary for the plan
sponsor to submit, as it can be identified through other information provided by the
sponsor).
Part II, F also lists data elements that must appear on the Cover Sheet, that were not
included in the previously submitted Information Collection Instrument. These data
elements are: Plan Sponsor Name, Plan Year End Date, Today’s Date, Contact Name,
Contact Phone Number, and the following information related to the Summary Cost Data
for that reimbursement request: Reimbursement Request Number, Current Cost Paid by
Early Retiree, Old Cost Paid by Early Retiree, Net Cost Paid by Early Retiree,
Reimbursement Request Date, and Reimbursement Request Total.

A copy of the Cover Sheet, with separate detailed instructions for its completion, is being
submitted with this PRA package. The burden associated with reading those detailed
instructions and completing the Cover Sheet, was accounted for in the previous PRA
submission under the burden hours for submitting a reimbursement request. The change
to the data elements that must be submitted as part of a submission of prima facie
evidence, as described in the immediately preceding three paragraphs, reduce burden
nominally. This is because, as described above, a sponsor no longer must provide the first
name and last name of every individual who paid costs, for each record of Prima Facie
Evidence on the Cover Sheet. Although there are additional data elements that a sponsor
must provide on the Cover Sheet that were not required in the previously submitted
Information Collection Instrument, these additional data elements must be provided only
once on the Cover Sheet, as opposed to providing the first and last name of each person
for whom prima facie evidence is being submitted, a burden which has been eliminated in
this Information Collection Instrument. Also, we believe that only a small fraction of plan
sponsors will be subject to these prima facie evidence requirements, as they only apply to
plan sponsors that submit costs paid by early retirees (as opposed to cost paid by the
plan). Thus far in the program, only a small percentage of sponsors have submitted such
costs.
Reopening Information (page 94)
We have added this section, which sets forth the data elements a sponsor must submit
when submitting a request for a reopening. These data elements are discussed in the
guidance document entitled Explanation of the Processes for Reporting Early Retiree and
Claims Data Inaccuracies, and for Reopening, which is submitted as part of this PRA
package. A plan sponsor has a right to request a reopening pursuant to the ERRP
regulations at 45 CFR 149.610. The burden associated with requesting a reopening is the
time and effort necessary for a sponsor to read the applicable guidance and draft and
submit a reopening request, including supporting documentation. The submission of an
ERRP reopening request is similar to the submission of an ERRP appeal under 45 CFR
149.500. Therefore, while this requirement under section 149.610 is subject to the PRA,
we believe the associated burden is exempt under 5 CFR 1320.4. In this case, the
information associated with a reopening request would be collected subsequent to an
administrative action, that is, a reimbursement determination.