Early Retiree Reinsurance Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10321 ERRP Prima Facie Evidence Cover Sheet	Form	New	Available
Form CMS-10321 ERRP Application	Form	New	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
Form CMS-10321 Revised ERRP Collection Instrument	Form	Removed	Available
0938-1087Revised_CrosswalkofChanges[1][1].doc	Justification for No Material/Nonsubstantive Change	Uploaded 2012-02-08	Available
RevisionstoPRAPackage200938-1087Overview[1].docx	Supplementary Document	Uploaded 2011-10-31	Available
0938-1087Revised_SummaryBurdenEstimates[1].docx	Supplementary Document	Uploaded 2011-10-31	Available
0938-1087Revised_CrosswalkofChanges[1].doc	Supplementary Document	Uploaded 2011-10-31	Available
0938-1087.Revised_Supporting_Statement.doc	Supporting Statement A	Uploaded 2011-10-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201229	(149.700) - Reporting Change of Ownership		New
201228	(149.610) - Requesting Reopenings	Instruction	New
201227	(149.600) - Reporting Previous Data Inaccuracies	Instruction	New
201226	(149.500 & 149.510) - Requesting Appeals	Instruction	New
201225	(149.350) Maintenance of Records		New
201224	(149.335) - Documentation of Actual Medical Claims Involved	Form	New	ERRP Prima Facie Evidence Cover Sheet
201224	(149.335) - Documentation of Actual Medical Claims Involved	Instruction	New
201223	(149.40) - Updating Data in the Application	Form	New	ERRP Application
201223	(149.40) - Updating Data in the Application	Instruction	New
201222	(149.35(b)(3)) - Procedures to Protect Against Fraud, etc.		New
201221	(149.35(b)(2)) - Written Agreement with Issuer or Plan		New
199567	Early Retiree Reinsurance Program Reopening Requests (Pub lic), for Program Years 2, 3, 4	Form	Removed	Revised ERRP Collection Instrument
199567	Early Retiree Reinsurance Program Reopening Requests (Pub lic), for Program Years 2, 3, 4	Instruction	Removed
199566	Early Retiree Reinsurance Program Appeals (Public), for Program Year 4	Form	Removed	Revised ERRP Collection Instrument
199566	Early Retiree Reinsurance Program Appeals (Public), for Program Year 4	Instruction	Removed
199565	Early Retiree Reinsurance Program Reopening Requests (Private), for Program Years 2, 3, 4	Form	Removed	Revised ERRP Collection Instrument
199565	Early Retiree Reinsurance Program Reopening Requests (Private), for Program Years 2, 3, 4	Instruction	Removed
199564	Early Retiree Reinsurance Program Appeals (Public), for Program Years 2 and 3	Form	Removed	Revised ERRP Collection Instrument
199564	Early Retiree Reinsurance Program Appeals (Public), for Program Years 2 and 3	Instruction	Removed
199563	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 4	Form	Removed	Revised ERRP Collection Instrument
199563	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 4	Instruction	Removed
199562	Early Retiree Reinsurance Program Appeals (Private), for Program Year 4	Form	Removed	Revised ERRP Collection Instrument
199562	Early Retiree Reinsurance Program Appeals (Private), for Program Year 4	Instruction	Removed
199561	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 3	Form	Removed	Revised ERRP Collection Instrument
199561	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 3	Instruction	Removed
199560	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 2	Form	Removed	Revised ERRP Collection Instrument
199560	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 2	Instruction	Removed
199558	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 4	Form	Removed	Revised ERRP Collection Instrument
199558	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 4	Instruction	Removed
199556	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3	Form	Removed	Revised ERRP Collection Instrument
199556	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3	Instruction	Removed
199543	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 2	Form	Removed	Revised ERRP Collection Instrument
199543	Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 2	Instruction	Removed
199541	Early Retiree Reinsurance Program Appeals (Private), for Program Years 2 and 3	Form	Removed	Revised ERRP Collection Instrument
199541	Early Retiree Reinsurance Program Appeals (Private), for Program Years 2 and 3	Instruction	Removed
198340	Private Application Update Year 2_3_4	Form	Removed	Revised ERRP Collection Instrument
198340	Private Application Update Year 2_3_4	Instruction	Removed
198339	Public Application Update Year 2_3_4	Form	Removed	Revised ERRP Collection Instrument
198339	Public Application Update Year 2_3_4	Instruction	Removed
192771	Private Data Inaccuracies Years 2_3_4	Form	Removed	ERRP Collection Instrument
192771	Private Data Inaccuracies Years 2_3_4	Instruction	Removed
192768	Private CHOW Years 2_3_4	Form	Removed	Revised ERRP Collection Instrument
192768	Private CHOW Years 2_3_4	Instruction	Removed
192767	Public CHOW Years 2_3_4	Form	Removed	ERRP Collection Instrument
192767	Public CHOW Years 2_3_4	Instruction	Removed
192766	Public Data Inaccuracies Years 2_3_4	Form	Removed	Revised ERRP Collection Instrument
192766	Public Data Inaccuracies Years 2_3_4	Instruction	Removed
192765	Private Maintenance of Records Year 2_3_4	Instruction	Removed
192764	Public Maintenance of Records Year 2_3_4	Form	Removed	Revised ERRP Collection Instrument
192764	Public Maintenance of Records Year 2_3_4	Instruction	Removed
192763	Public Fraud and Abuse Procedures Years 2_3_4	Form	Removed	Revised ERRP Collection Instrument
192763	Public Fraud and Abuse Procedures Years 2_3_4	Instruction	Removed
192762	Private Fraud and Abuse Procedures Years 2_3_4	Form	Removed	Revised ERRP Collection Instrument
192762	Private Fraud and Abuse Procedures Years 2_3_4	Instruction	Removed
192759	Private Written Agreement Year 2_3_4	Form	Removed	Revised ERRP Collection Instrument
192759	Private Written Agreement Year 2_3_4	Instruction	Removed
192758	Public Written Agreement Year 2_3_4	Form	Removed	Revised ERRP Collection Instrument
192758	Public Written Agreement Year 2_3_4	Instruction	Removed

ICR Details

OMB Control No: 0938-1087	ICR Reference No: 201202-0938-004
Status: Historical Active	Previous ICR Reference No: 201106-0938-023
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 without change	Conclusion Date: 03/23/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/14/2012
Terms of Clearance: OMB notes compliance with the previous terms of clearance.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	09/30/2014	09/30/2014
Responses	14,086	0	18,872
Time Burden (Hours)	283,211	0	579,704
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection request covers the recordkeeping and reporting requirements associated with the Early Retiree Reinsurance Program.

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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: 9

table that charts list of burden

IC Title	Form No.	Form Name
(149.335) - Documentation of Actual Medical Claims Involved	CMS-10321	ERRP Prima Facie Evidence Cover Sheet
(149.35(b)(2)) - Written Agreement with Issuer or Plan
(149.35(b)(3)) - Procedures to Protect Against Fraud, etc.
(149.350) Maintenance of Records
(149.40) - Updating Data in the Application	CMS-10321	ERRP Application
(149.500 & 149.510) - Requesting Appeals
(149.600) - Reporting Previous Data Inaccuracies
(149.610) - Requesting Reopenings
(149.700) - Reporting Change of Ownership
Early Retiree Reinsurance Program Appeals (Private), for Program Year 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 Appeals (Public), for 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
Early Retiree Reinsurance Program Reopening Requests (Private), for Program Years 2, 3, 4	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 Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 2	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) (Private) Program Year 4	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 3	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
Private Application Update Year 2_3_4	CMS-10321	Revised 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
Private Fraud and Abuse Procedures Years 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Private Maintenance of Records Year 2_3_4
Private Written Agreement Year 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Public Application Update Year 2_3_4	CMS-10321	Revised ERRP Collection Instrument
Public CHOW Years 2_3_4	CMS-10321	ERRP Collection Instrument
Public Data Inaccuracies 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
Public Written Agreement Year 2_3_4	CMS-10321	Revised ERRP Collection Instrument

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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	14,086	18,872	0	-18,872	14,086	0
Annual Time Burden (Hours)	283,211	579,704	0	-579,704	283,211	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: This revision makes technical changes to the approved ICR to clarify the various information collections associated with this approval. The agency also took the opportunity to update the respondent and burden hour estimates based on most recent experience.

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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: 02/08/2012

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