(149.40) - Updating Data in the Application

OMB Approval # 0938-1087

ERRP
Early Retiree Reinsurance Program
Plan Sponsor Instructions

U.S. Department of Health and Human Services
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 INSERT NUMBER. The time required to complete this information collection is estimated to
average 337 hours for a sponsor’s first year in the program, and 292 hours for subsequent years, 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.

OMB Approval # 0938-1087

Early Retiree Reinsurance Program (ERRP) Plan Sponsor Instructions for Completing an
Application
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Overview
The Early Retiree Reinsurance Program (ERRP) was established by section 1102 of the Patient
Protection and Affordable Care Act (the Affordable Care Act), P.L. 111-148, enacted on March
23, 2010, and codified at 42 U.S.C. 18002. The Congress appropriated funding of $5 billion for
the temporary program. Section 1102(a)(1) requires the Secretary to establish this temporary
program not later than 90 days after enactment of the statute, which is June 21, 2010. The
program ends no later than January 1, 2014. The program provides reimbursement to
participating employment-based plans for a portion of the cost of health benefits for early retirees
and their spouses, surviving spouses and dependents. The Secretary will reimburse plans for
certain claims between $15,000 and $90,000 (with those amounts being indexed for plan years
starting on or after October 1, 2011). The purpose of the reimbursement is to make health
benefits more affordable for plan participants and sponsors so that health benefits are accessible
to more Americans than they would otherwise be without this program.
The program addresses the recent erosion in the number of employers providing health benefits
to early retirees. People in the early retiree age group often face difficulties obtaining insurance
in the individual market because of advanced age or chronic conditions that make coverage
unaffordable and inaccessible. The program provides needed financial help for employmentbased plans to continue to provide valuable coverage to plan participants, and provides financial
relief to plan participants.
The program provides reimbursement to participating sponsors of employment-based plans for a
portion of the costs of providing health benefits to early retirees (and eligible spouses, surviving
spouses, and dependents of such retirees). The program regulation at 45 C.F.R. Part 149 defines
the term “sponsor”, “employment-based plan”, “health benefits,” and “early retiree,” as well as
many other important terms that are relevant to the program. The regulation also sets forth the
requirements of the program, including the requirements discussed in these instructions.
This document provides general instructions with respect to completing a program application
(see ERRP regulation at 45 C.F.R. §149.40). Please note that if any information in the
Application changes or if the sponsor discovers that any information is incorrect, the sponsor is
required to promptly report the change or inaccuracy.
It is critical for program applicants and participants to read the regulation, and the “Common
Questions” and other policy guidance on the ERRP website, at www.errp.gov, in order to fully
understand which organizations qualify for the program, how to apply for the program, what
costs are eligible for reimbursement under the program, how to submit a request for
reimbursement under the program, and sponsors’ obligations under the program.

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Application Information
General Instructions for Completing and Submitting the ERRP
Application
The ERRP application has been designed by the U.S. Department of Health & Human Services
(HHS) to assist in the efficient administration of the ERRP in compliance with Federal
regulatory requirements at 45 C.F.R. Part 149.
The following is an overview of the application process:
1. The Account Manager or Authorized Representative completes ALL parts of the application,
including the Plan Sponsor Agreement which must be signed by the Applicant’s Authorized
Representative.
2. The completed application and attachments are mailed to HHS’ ERRP Application Center,
4700 Corridor Place, Suite D, Beltsville, MD 20705, using the U.S. Postal Service.
3. Applicants will be notified about the status of their application, or will be contacted for further
information.
An applicant must submit an application for each plan for which it will submit a reimbursement
request. The application must be completed in its entirety (and reviewed and approved by HHS)
in order to participate in the ERRP. HHS will certify the sponsor and the plan when the
application is approved. Even if the submitted application satisfies all criteria specified in the
program regulation, it may be denied, depending on the availability of limited ERRP funds.
Complete the items in Parts I throughout. Responses to all items marked with an asterisk (*) are
required. The following are specific instructions for each item that is not self explanatory.

APPLICATION PART I: Plan Sponsor and Key Personnel
Information
A. Plan Sponsor Information
Complete the required information in items 1-7.
Item 1: The Plan Sponsor Organization Name must be the same as that associated with its
Federal Employer Tax Identification Number (EIN).
Item 2: This item is self-selected by the Plan Sponsor. Please choose the one category that best
describes the Plan Sponsor’s type of organization.
Item 6: Organization address must be the address associated with the EIN.

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B. Authorized Representative Information
An Authorized Representative is an individual with legal authority to sign and bind a sponsor to
the terms of a contract or agreement. Examples of the Authorized Representative include the
Sponsor’s general partner, CFO, CEO, President, Human Resource Director, or an individual
who holds a position of similar status and authority within the Plan Sponsor’s organization. Only
one individual at a time can serve in the role of Authorized Representative. For multi-employer
plans, the Authorized Representative does not have to be an employee of the Plan Sponsor, but
may be a member of the jointly appointed board of trustees, which includes both labor and
management trustees. Furthermore, the Authorized Representative cannot be the same person as
the Account Manager. An Authorized Representative of the requesting Plan Sponsor must sign
the Plan Sponsor Agreement in the completed application and certify that the information
contained in the application is true and accurate to the best of the Authorized Representative’s
knowledge and belief.
Complete the required information in Items 1-7 for the Authorized Representative Information.

C. Account Manager Information
The Account Manager is generally the individual who coordinates the application process for the
Plan Sponsor, and is the Sponsor’s primary contact with HHS with respect to the application. An
Account Manager may be an employee of the Plan Sponsor, or a non-employee, such as a
consultant, with whom the Plan Sponsor has an arrangement to assist with the application
process. There can be only one Account Manager per ERRP application at a time. Furthermore,
the Authorized Representative cannot be the same person as the Account Manager.
Complete the required information in Items 1-7 for the Account Manager Information.

APPLICATION PART II: Plan Information
A. Plan Information
Complete the required information in Items 1-2 for the employment-based plan for which you
expect to be requesting ERRP reimbursements.
Item 2: For ERRP purposes, your plan year cycle start (MM/DD) and end (MM/DD) are
determined as follows: The plan year is the year that is designated as the plan year in the plan
document of an employment-based plan, except that if the plan document does not designate a
plan year, if the plan year is not a 12-month plan year, or if there is no plan document, the plan
year is: (1) the deductible or limit year used under the plan; (2) the policy year, if the plan does
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not impose deductibles or limits on a 12-month basis: (3) the sponsor’s taxable year, if the plan
does not impose deductibles or limits on a 12-month basis, and either the plan is not insured or
the insurance policy is not renewed on a 12-month basis, or (4) the calendar year, in any other
case. (See the program regulation at 45 C.F.R. §149.2).

B. Benefit Option(s) Provided Under this Plan
This section of the application appeared in previous versions, but has been removed. There is
nothing to complete in this section.

C. Programs and Procedures for Chronic and High-Cost Conditions
In completing this item, please follow the instructions in the application. Please be aware that the
ERRP regulation defines “chronic and high-cost condition” as a condition for which $15,000 or
more in health benefit claims are likely to be incurred during a plan year by one plan participant.
(See the ERRP regulation at 45 C.F.R. §149.2). Therefore, you should make clear in your
summary that the conditions for which you have programs and procedures in place, have resulted
in $15,000 or more in health benefit claims, or likely would result in such amount of claims,
absent the programs and procedures, for one plan participant, during a plan year. You should
also identify at least two chronic and high-cost conditions for which you have programs and
procedures in place that have resulted in $15,000 or more in health benefit claims, or likely
would result in such amount of claims, absent the programs and procedures, for one plan
participant, during a plan year. You should also identify the nature of each such program (e.g.
disease management, case management, wellness program, etc.)

D. Estimated Amount of Early Retiree Reinsurance Program
Reimbursements
In completing this item, please follow the instructions in the application.

E. Intended Use of Early Retiree Reinsurance Program Reimbursements
In completing this item, please be aware that the ERRP regulation specifies that the sponsor must
use the proceeds under this program for the following purposes: (1) To reduce the sponsor’s
health benefit premiums or health benefit costs, or (2) To reduce health benefit premium
contributions, copayments, deductibles, coinsurance, or other out-of-pocket costs, or any
combination of these costs, for plan participants, or (3) To reduce any combination of the costs in
(1) and (2). Proceeds under this program must not be used as general revenue for the sponsor.
(See the ERRP regulation at 45 C.F.R. §149.200). In completing this item, please follow the
instructions in the application. Check the box or boxes that apply.

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APPLICATION PART III: Plan Sponsor Agreement
The Authorized Representative of the Plan Sponsor must read the Plan Sponsor Agreement, and
if the terms are accepted, must indicate acceptance by providing his or her signature. A stamped
signature is not permitted.

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Access to ERRP Secure Website
Part I- User Registration Information
Authorized Representatives, Account Managers and Designees must complete required items in
1 through 12 in order to be able to access the Secure Website and be able to perform the tasks
allowed for each type of website user. Item 2 requires Authorized Representatives, Account
Managers and Designees to read and accept the User Agreement and Privacy Policy that will
appear.

Part II-Designee Invitation
The Authorized Representative and/or Account Manager can designate other individuals to
perform tasks within the Secure Website. While an Authorized Representative can designate
individuals to perform certain tasks within the Secure Website, there are certain tasks that only
an Authorized Representative can perform. For example, only an Authorized Representative can
make the affirmation that appears in Part I.F. in “Reimbursement Request Information.”

Part III- Login Warning
Authorized Representatives, Account Managers and Designees must read and accept this
agreement, by clicking “I Accept”, otherwise access to the Secure Website will not be allowed.
Or Authorized Representatives, Account Managers and Designees click “Decline”, in which case
access will not be allowed.

Part IV- User Agreement and Privacy Policy
Authorized Representatives, Account Managers and Designees must read and accept the terms of
the User Agreement and Privacy Policy, by clicking “I Accept”, otherwise access to the Secure
Website will not be allowed. Or Authorized Representatives, Account Managers and Designees
click “I decline”, in which case access will not be allowed.

Reimbursement Request Information
General Instructions for Providing Reimbursement Request
Information

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To submit an ERRP reimbursement request, a sponsor must initiate a reimbursement request, and
then submit a list of early retirees for whom it is requesting reimbursement. The sponsor will
then receive a response to its early retiree list from HHS, indicating which of the individuals on
the early retiree list are actually early retirees under the ERRP, and for what period of time. The
sponsor will submit summary-level claims data and well as detailed claims data, which
document actual costs of the health benefits being submitted for reimbursement. The list of early
retirees and the documentation of actual costs of the health benefits being submitted for
reimbursement can each be submitted in one of several ways. The sponsor must specify which
way it wishes to submit each type of data, as will be discussed below.

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REIMBURSEMENT REQUEST INFORMATION
PART I: Reimbursement Request Setup Information
A. Early Retiree List: Submission Information
A sponsor must identify, for each plan year, how it will be sending its Early Retiree List, and
how it will receive HHS’ response to the submission. To do so, a sponsor must complete Item 1.
Items 2-4 must be completed if sending data using the mainframe-to-mainframe method. If a
sponsor chooses this method, it must work with HHS to establish mainframe communications
protocols.

B. Submit Detailed Claims Data: Submission Information.
A sponsor must identify, for each plan year, how it will be sending its documentation of actual
costs for health benefits. To do so, a sponsor must complete Item 1.
Items 2-4, as applicable, must be completed if sending data using the mainframe-to-mainframe
method of delivery. If a sponsor chooses the mainframe to mainframe method, it must work with
HHS to establish mainframe communications protocols.

C. Assign Reimbursement-Related Privilege to Account
Manager
An Authorized Representative may assign certain privileges to an Account Manager. While an
Authorized Representative can designate individuals to perform certain tasks within the Secure
Website, there are certain tasks only an Authorized Representative can perform. For example,
only an Authorized Representative can make the affirmation that appears in Part I.F. in
“Reimbursement Request Information.”

D.

Banking Information

An Authorized Representative, Account Manager, or Designee with appropriate privileges must
complete the information in this section.

E.

Affirmation by Authorized Representative

The Authorized Representative must read the Affirmation and click to affirm that he or she will
comply with the terms of the affirmation.

REIMBURSEMENT REQUEST INFORMATION PART II:
Reimbursement Request Information
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A. Initiate Reimbursement Request
An individual with the appropriate privileges must select a sponsor, an application and plan year
when initiating a reimbursement request. This is because an individual may have authority to
request reimbursement for more than one sponsor, application and/or plan year. Once the
request has been initiated, HHS will assign the Reimbursement Request Number, and all
documents a sponsor sends HHS related to that reimbursement request, must reference that
number.

B. Submit List of Early Retirees and Process Response Files
A sponsor must electronically submit an early retiree list, of all individuals for whom the sponsor
has submitted cost data for the plan year, with each Reimbursement Request. The list must
include all such members and the subscriber through whom the member has coverage, even if the
sponsor has not submitted costs for the subscriber. The form and content of the list will vary,
depending upon the method of delivery. The plan sponsor must also be able to process HHS’s
response to the early retiree list, which will be either in a Mainframe Layout or Secure Website
Layout. See the Information Collection Document for the file layouts, one of which a sponsor
must be able to process.

C.

The Sponsor Must Review Response/Notification Files

The sponsor must review the response file from HHS and only submit claims information for
individuals for claims incurred while the individuals qualify as early retiree (and spouses,
surviving spouses and dependents of early retirees).

D.

Submit Summary Cost Data

A Plan Sponsor must submit, with each Reimbursement Request, summary cost data related to
the Reimbursement Request on a cumulative basis. A sponsor must only submit summary data
for items and services for which Medicare would reimburse under Parts A or B, or which may be
covered under a standard Part D plan. Summary Cost Data will include costs paid by plan, costs
paid by early retiree, if any, threshold reduction, and limit reduction.

E. Submit Detailed Claims Data
A sponsor must only submit detailed claims data for items and services for which Medicare
would reimburse under Parts A or B, or which may be covered under a standard Part D plan.
Furthermore, a sponsor must include, when appropriate, the detailed claims information listed in
the Information Collection Document.for professional claims, institutional claims, and pharmacy
claims, as appropriate. For each of these three types of claims, not every field is required.

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For additional information about what a sponsor should enter with respect to Member ID and
Member Group ID, see the Common Questions document at www.errp.gov
“Record Type” means whether the file is a professional, institutional, or prescription claim,
whether it is a header or trailer for subsequent or previous such claims, etc.
“Claim Type” means professional, institutional, or prescription claim.
“Place of Service” means, for example, doctor’s office or hospital, as identified by industry
standard code sets.
“Type of Service” means, for example, medical care, or surgery, as identified by industry
standard code sets.
“Type of bill” means type of facility/bill classification/frequency, as identified by industry
standard code sets.
“ICD Diagnosis Code Qualifier” means whether the ICD code listed is from the 9th or the 10th
edition.
“Rendering Provider ID Qualifier” means whether the Rendering Provider ID listed is a National
Provider Identifier (NPI) or other type of ID.
“Facility Provider ID Qualifier” means whether the Facility Provider ID listed is an NPI or other
type of ID.
“Prescription Service Provider ID Qualifier” means whether the Prescription Service ID listed is
an NPI or other type of ID.
“Prescription Product/Service ID Qualifier” means whether the product or service listed is an
NDC code or other type of code.

F. Submit Evidence of Early Retiree Payment
When required, a sponsor must submit prima facie evidence that the early enrollee paid his or her
portion of the claim, in instances when the sponsor submits ERRP costs for such amounts. This
evidence must be in the form of a receipt. (See ERRP regulation at 45 C.F.R. §149.335(b)).
Each collection of submitted receipts must be accompanied by cover sheet. The data that must be
included in each receipt, and in each cover sheet, is set forth in section F.
F1. The receipt identifier is a unique number assigned by the sponsor to each receipt, and which
corresponds to the identifier provided for that receipt on the cover sheet discussed in F2.
F2. The first day of the plan year to which the receipts apply should be expressed in the format
mm/dd/yy.
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For additional information about what a sponsor should enter with respect to Member ID and
Member Group ID, see the Common Questions document at www.errp.gov. The Member ID,
Member Group ID, and Claim ID on the lists of receipts on the cover sheet must correspond to
such applicable IDs that appear on the Early Retire List and Detailed Claims Data submitted to
HHS.

F.

Authority to View Protected Health Information

An individual sending and/or receiving retiree data and/or claims or summary cost data must
read and agree to the terms the statement relating to the authority to view protected health
information. The individual must accept the terms of the notice by clicking “I accept”. The
individual sending and/or receiving may also click “I Decline”, in which case the individual will
not be able to access certain electronic Protected Health Information.

Appeal Information
The ERRP regulation at 45 CFR 149.500 specifies that a sponsor may appeal directly to the
Secretary within 15 calendar days of receipt of an adverse reimbursement determination. The
request for appeal must specify the findings or issues with which the sponsor disagrees and the
reasons for the disagreements. The request for appeal may include supporting documentary
evidence the sponsor wishes the Secretary to consider. Additional information about the
circumstances under which it would be appropriate to submit an appeal, and how to submit an
appeal, will be published in a guidance document on this topic at www.errp.gov. Consistent with
the regulation and that guidance document, the sponsor must or may include the Items 1-12, as
applicable, when submitting an appeal request.

Reporting Data Inaccuracies
The ERRP regulation at 45 C.F.R. §149.600 acknowledges that claims data submitted for
reimbursement may change after a sponsor has submitted data for reimbursement. Because
sponsors are obligated to provide accurate data, the regulations state that HHS is establishing a
process, separate from the appeals process, that will give sponsors the ability to update HHS on
any data inaccuracies and will allow HHS to reopen and revise reimbursement as necessary,
based on the updated data. The process HHS expects to establish, is that the sponsor must
submit a reimbursement request that includes an accurate Early Retiree List, accurate summary
claims data, accurate detailed claims data, and accurate evidence of payment by early retirees (if
applicable), no later than during the calendar quarter after a sponsor knows or should know of
such data inaccuracies. Consistent with that process, sponsors must report data inaccuracies by
reporting the data required to be submitted in a reimbursement request, in a form and manner specified in
Reimbursement Request Information, Part II. The reimbursement request could be reimbursement request
solely for the purpose of reporting data inaccuracies, or data inaccuracies could be reported as part of a

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broader reimbursement request in which the sponsor seeks additional reimbursement from that received
for prior reimbursement requests.

Reporting Change of Ownership
The ERRP regulation at 45 C.F.R. 149.700 requires a sponsor to provide the Secretary with
advance notice of any change of ownership of the sponsor. The regulation defines a change of
ownership as any of the following:
(1) The removal, addition, or substitution of a partner, unless the partners expressly agree
otherwise as permitted by applicable state law.
(2) Transfer of all or substantially all of the assets of the sponsor to another party.
(3) The merger of the sponsor's corporation into another corporation or the consolidation
of the sponsor's organization with one or more other corporations, resulting in a new
corporate body.
(4) Transfer of corporate stock or the merger of another corporation into the sponsor's
corporation, with the sponsor surviving, does not ordinarily constitute change of
ownership.
A sponsor that has a sponsor agreement in effect and is considering or negotiating a change in
ownership must notify the Secretary at least 60 days before the anticipated effective date of the
change.
The type and detail of information that must be provided with respect to a change of ownership
will vary, based on the corporate structure of the plan sponsor and the details of the change of
ownership.

Other Information to be Produced Upon Request
The ERRP regulation requires sponsors to develop and submit several types of documentation or
information that HHS does not collect from them as a matter of course, but that the sponsor must
provide such documentation or information upon request. This documentation and information
includes the following:
42 U.S.C. 18002 requires the Secretary to establish procedures to protect against fraud, waste
and abuse. In order to implement this provision, the Secretary will, for example, check the
exclusions lists developed by the HHS’ Office of the Inspector General and the U.S. General
Services Administration before allowing an entity to participate, or play a role, in the program,
and will take other steps such as verifying the identities of the early retirees for whom claims are
being submitted. To aid the Secretary in detecting and reducing fraud, waste and abuse, we are
requiring that sponsors ensure that there are policies and procedures in place to detect and reduce
fraud, waste and abuse. While the policies and procedures may be maintained by the sponsor’s
health insurance issuer or group health plan or any and all other entities participating in the
administration of the plan, the sponsor will have to attest that these policies and procedures are in
place in the application. The sponsor must comply with requests from the Secretary to produce
the policies and procedures and any documents or data to substantiate the implementation, and
the effectiveness, of the procedures.

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The ERRP regulation at 45 C.F.R. §149.40 requires a sponsor to make an assurance to the
Secretary that the sponsor has a written agreement with its health insurance issuer (as defined in
45 CFR 160.103) or employment-based plan, as applicable, regarding disclosure of information
to the Secretary, and the health insurance issuer or employment-based plan must disclose to the
Secretary, on behalf of the sponsor, at a time and in a manner specified by the Secretary in
guidance, information, data, documents, and records necessary for the sponsor to comply with
the requirements of the program. This requirement is in place to give deference to the HIPAA
privacy regulations, which would prohibit a group health plan or health insurance issuer from
submitting protected health information (PHI), such as the type that must be submitted to the
Secretary in order to make reimbursements under the ERRP, to a sponsor. It is necessary that
these agreements also be in place with other entities participating in the administration of the
plan.
Finally, the ERRP regulation at 45 C.F.R. §149.350 states that the sponsor (or a subcontractor, as
applicable) must maintain and furnish to the Secretary, upon request, certain records. The
records must be maintained for 6 years after the expiration of the plan year in which the costs
were incurred, or longer if otherwise required by law. The records that must be retained are: (1)
All documentation, data, and other information related to the regulation, (2) Any other records
specified by the Secretary. Although a subcontractor can produce the documents, the sponsor is
ultimately responsible for ensuring that the records are maintained and provided according to this
subpart.

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