Form CMS-10408 Final Survey

Early Retiree Reinsurance Program: Survey of Plan Sponsors

CMS_Sample_Survey

Survey of Plan Sponsors (Private Entities)

OMB: 0938-1150

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1150 can be found here:

2013-01-25 - Reinstatement with change of a previously approved collection

Document [pdf]

Download: pdf | pdf

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Sample Survey
For Reference
Purposes Only

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PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-XXXX. The time required to complete this information collection is
estimated to average 11 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850. FN: CMS-10408

2. What is the Application ID number assigned by the ERRP Center?

1. What is the name of the Plan Sponsor listed on your ERRP application?

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Sample Survey – For Reference Purposes Only

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3. How many participants does the plan represented in the ERRP application
referenced in this survey, cover? Please include ALL participants such as active
employees, early retirees, other retirees (for example, those over age 65), and
spouses, surviving spouses, and dependents.

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4. How many participants in the plan represented in the ERRP application
referenced in this survey, are “early retirees”, as defined in the ERRP statute,
regulations, and other guidance? Please include spouses, surviving spouses, and
dependents of early retirees. Additional details or instructions for Question 4.

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5. If your organization received ERRP funding in 2010, against which plan year’s
costs did your organization apply, or against which plan year’s costs does your
organization intend to apply, this funding? Select all that apply; dates below indicate
plan years. For each listed plan year, indicate the percentage of funds received in CY2010 that
were or will be applied in that plan year. If your organization did not receive any ERRP
reimbursement in CY2010, skip to Question 6. Additional details or instructions for Question 5
regarding definition of plan year.

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2010 (e.g. 10.5%)
2011 (e.g. 10.5%)

2012 (e.g. 10.5%)

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2013 (e.g. 10.5%)
2014 (e.g. 10.5%)

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6. If your organization received ERRP funding in 2011, against which plan year’s
costs did your organization apply, or against which plan year’s costs does your
organization intend to apply, this funding? Select all that apply; dates below indicate
plan years. For each listed plan year, indicate the percentage of funds received in CY2011 that
were or will be applied in that plan year. If your organization did not receive any ERRP
reimbursement in 2011, skip to Question 7. Additional details or instructions for Question 6
regarding definition of plan year.

2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

2013 (e.g. 10.5%)

2014 (e.g. 10.5%)

Spent all the reimbursements

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7. Please characterize how your organization has applied (spent) ERRP
reimbursements received in CY2010 and/or CY2011:
Spent some but not all of the reimbursements
Spent none of the reimbursements yet

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8. How has your organization used ERRP reimbursements received in CY2010
and/or CY2011? Select all that apply. Additional details or instructions for Question 8. Please
answer all questions on this page. If any of questions 9-12 are not applicable, please enter
“n/a” in the first response box for that question.
a. To offset increases to sponsor's health benefit claim costs (self-insured plan)

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b. To offset increases to sponsor's health benefit premium cost (fully insured plan)
c. To reduce, or offset increases to, premium costs paid by individual plan participants

d. To reduce, or offset increases to, individual plan participants' overall deductibles

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e. To reduce, or offset increases to, individual plan participants' copayments, coinsurance,
or other out-of-pocket health benefit costs

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9. If you selected (a) in Question 8, by how much have you been able to offset
increases to your organization’s health benefit claim costs (self-insured plan)
because of ERRP? Enter the percentage of the total dollar cost increase that you have offset,
for each plan year for which you have applied ERRP reimbursement. For any plan year for
which you did not use the funds in the manner stated in 8(a), enter "n/a".
2010 (e.g. 10.5%)

2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

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10. If you selected (b) in Question 8, by how much have you been able to offset
increases to your organization’s health benefit premium costs (fully insured plan)
because of ERRP? Enter the percentage of the total dollar cost increase that you have offset,
for each plan year for which you have applied ERRP reimbursement. For any plan year for
which you did not use the funds in the manner stated in 8(b), enter "n/a".

2010 (e.g. 10.5%)

2011 (e.g. 10.5%)

2012 (e.g. 10.5%)

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11. If you selected (c) in Question 8, by how much have you been able to reduce or
offset increases to premium costs paid by individual plan participants because of
ERRP? Enter the implemented reduction in the dollar amount that individual plan participants
pay or will pay in premium costs as a percentage of what the dollar amount would otherwise
be, for each plan year for which you have applied ERRP reimbursement. For any plan year for
which you did not use the funds in the manner stated in 8(c), enter "n/a". Additional details or
instructions for Question 11.
2010 (e.g. 10.5%)
2011 (e.g. 10.5%)

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2012 (e.g. 10.5%)

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2011 (e.g. 10.5%)

2010 (e.g. 10.5%)

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12. If you selected (d) in Question 8, by how much have you been able to reduce or
offset increases to individual plan participants’ overall deductibles because of
ERRP? Enter the implemented reduction in the dollar amount for individual plan participants’
overall deductibles as a percentage of what the dollar amount would otherwise be, for each
plan year for which you have applied ERRP reimbursement. For any plan year for which you did
not use the funds in the manner stated in 8(d), enter "n/a". Additional details or instructions
for Question 12.

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2012 (e.g. 10.5%)

b. To offset increases to sponsor's health benefit premium cost (fully insured plan)

a. To offset increases to sponsor's health benefit claim costs (self-insured plan)

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13. How is your organization planning to use ERRP reimbursements received in
CY2010 and/or CY2011? Select all that apply. Additional details and instructions for
Question 13. Please answer all questions on this page. If any of questions 14-17 are not
applicable, please enter “n/a” in the first response box for that question.

c. To reduce, or offset increases to, premium costs paid by individual plan participants
d. To reduce, or offset increases to, individual plan participants' overall deductibles

e. To reduce, or offset increases to, individual plan participants' copayments, coinsurance,
or other out-of-pocket health benefit costs

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14. If you selected (a) in Question 13, by how much do you project to offset
increases to your organization’s health benefit claim costs (self-insured plan)
because of ERRP? Enter the percentage of the total dollar cost increase that you project to
offset, for each plan year for which you intend to apply ERRP reimbursement. For any plan year
for which you do not intend to use the funds in the manner stated in 13(a), enter "n/a". For
any plan year for which you intend to use the funds in the manner stated in 13(a), but can’t
project the offset in increases to your organization’s health benefit claim costs, enter
"unknown".

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2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

2013 (e.g. 10.5%)

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2014 (e.g. 10.5%)

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15. If you selected (b) in Question 13, by how much do you project to offset
increases to your organization’s health benefit premium costs (fully insured plan)
because of ERRP? Enter the percentage of the total dollar cost increase that you project to
offset, for each plan year for which you intend to apply ERRP reimbursement. For any plan year
for which you do not intend to use the funds in the manner stated in 13(b), enter "n/a". For
any plan year for which you intend to use the funds in the manner stated in 13(b), but can’t
project the offset in increases to your organization’s health premium costs, enter "unknown".

2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

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2013 (e.g. 10.5%)
2014 (e.g. 10.5%)

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16. If you selected (c) in Question 13, by how much do you project to reduce or
offset increases to premium costs paid by individual plan participants because of
ERRP? Enter the projected reduction in the dollar amount that individual plan participants will
pay in premium costs as a percentage of what the dollar amount would otherwise be, for each
plan year for which you intend to apply ERRP reimbursement. For any plan year for which you
do not intend to use the funds in the manner stated in 13(c), enter "n/a". For any plan year for
which you intend to use the funds in the manner stated in 13(c), but can’t project the reduction
or offset in increases to premium costs paid by individual plan participants, enter "unknown".
Additional details or instructions for Question 16.

2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

2013 (e.g. 10.5%)

2014 (e.g. 10.5%)

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17. If you selected (d) in Question 13, by how much do you project to reduce or
offset increases to individual plan participants’ overall deductibles because of
ERRP? Enter the projected reduction in the dollar amount for individual plan participants’
overall deductibles as a percentage of what the dollar amount would otherwise be, for each
plan year for which you intend to apply ERRP reimbursement. For any plan year for which you
do not intend to use the funds in the manner stated in 13(d), enter "n/a". For any plan year for
which you intend to use the funds in the manner stated in 13(d), but can’t project the reduction
or offset in increases to individual plan participants’ overall deductibles, enter "unknown".
Additional details or instructions for Question 17.

2011 (e.g. 10.5%)

2013 (e.g. 10.5%)

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2014 (e.g. 10.5%)

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2012 (e.g. 10.5%)

Thank you for completing the survey! If you would like to review or make copies of your
responses, click "Previous" button and print screenshots as needed.

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Please click "Submit Survey" to submit your responses.

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Instructions for Completing Early Retiree
Reinsurance Program Survey of Plan Sponsors
Instructions for Question 4

The ERRP definition of "early retiree" can be found in the definition section of the ERRP
regulations at 45 CFR 149.2. A copy of the regulations can be found at www.errp.gov. There is
additional information on the definition of early retiree in the set of Common Questions
designated "Early Retirees" which are also published on www.errp.gov.

Return to Question 4

Instructions for Question 5 and 6

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All references to "plan year" in this survey refer to the sponsor's 12-month plan year based on
the cycle provided in the sponsor's ERRP application, which may not necessarily reflect a
calendar year. For purposes of this survey, a sponsor's 2010, 2011, 2012, 2013, or 2014 plan
year refers to its plan year that ends in that year. For example, a sponsor's plan year that starts
on January 1, 2011, and ends on December 31, 2011, would be considered its 2011 plan year.
A sponsor's plan year that starts on July 1, 2011, and ends on June 30, 2012, would be
considered its 2012 plan year.
Return to Question 6

Return to Question 5

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Instructions for Question 8 and 13

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The reference to "overall deductibles" refers to single deductibles that apply across all a plan's
benefits, as opposed to deductibles for a discrete type or category of benefits. However, if a
plan has a single deductible that applies across all a plan's medical benefits, and a separate
deductible that applies to prescription drugs, the reference to "overall deductibles" refers to the
single deductible that applies across all the plan's medical benefits.
Return to Question 13

Return to Question 8

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Instructions for Question 11 and 16
To the extent that the impact of ERRP funds varies across plan participants, your answer should
reflect a weighted average. For example, consider a plan with 100 participants. Assume that
premium contributions paid by plan participants remained constant for 30 participants,
increased by 5% for 30 participants and increased by 10% for the remaining 40 participants. In
this case, the weighted average of the premium increase would be calculated as follows:
[{(0x30) + (.05x30) + (.10x40)} / (30+30+40)]= 5.5%.
Return to Question 11

Return to Question 16

Instructions for Question 12 and 17

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Return to Question 17

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Return to Question 12

To the extent that overall deductibles are or will be reduced, or increases to deductibles are or
will be offset, but not for all plan participants, and/or not equally for all plan participants, your
answer should reflect a weighted average. See sample weighted average calculation in the
Instruction for Questions 11 and 16.

File Type	application/pdf
File Modified	2011-12-01
File Created	2011-11-30