CMS-10321 ERRP Application

OMB Approval 0938-1087

ERRP
Early Retiree Reinsurance Program
Information Collection

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 0938-1087. 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 C426-05, Baltimore, Maryland 21244-1850.

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OMB Approval 0938-1087

Application

Please note that if any information in this Application changes or if the sponsor discovers
that any information is incorrect, the sponsor is required to promptly report the change or
inaccuracy.
Send, using the U.S. Postal Service, a hardcopy of the signed original ERRP Application (i.e.
not a photocopy) and Attachments (if any) to:
HHS ERRP Application Center
4700 Corridor Place
Suite D
Beltsville, MD 20705

An asterisk (*) identifies a required field.

PART I: Plan Sponsor and Key Personnel Information
A. Plan Sponsor Information
1) *Organization’s Name (Must correspond with the information associated with the Federal Employer
Tax Identification Number (EIN): ________________________________________________________________
2) *Type of Organization (Check the one category that best describes your organization):
____ Government
____ Union
____ Religious
____ Commercial
____ Non-profit
3) *Organization’s Employer Identification Number (EIN): ______________________
4) *Organization’s Telephone Number: ______ ext.__________
5) Organization’s FAX Number _______________________

6) *Organization’s Address (must be the address associated with the EIN provided above):
* Street Line 1: ___________________________________
Street Line 2: ____________________________________
*City: ______________________
*State/US Territory: _________________________
*Zip Code: ____________________________

7) Organization’s Website Address:___________________________________________________
B. Authorized Representative Information

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1) *First Name: _______________ Middle Initial (optional): _____ *Last Name: ______________
2) *Job Title: ______________________________________

3) *Email Address: _______________________________________________
4) *Telephone Number: _____________________ext__________
5) FAX Number:__________________

6) *Employer Name: ______________________________________________
7) * Authorized Representative Business Address:

* Street Line 1: ___________________________________
Street Line 2: ____________________________________
*City: ______________________
*State/US Territory: _________________________
*Zip Code: ____________________________
C. Account Manager Information

1) *First Name: _______________ Middle Initial (optional): _____ *Last Name: ______________
2) *Job Title: ______________________________________

3) *Email Address: _______________________________________________
4) *Telephone Number: _____________________ext__________
5) FAX Number:__________________

6) Employer Name: ________________________________________

7) Account Manager Business Address:

Street Line 1: ___________________________________
Street Line 2: ____________________________________
City: ______________________
State/US Territory: _________________________
Zip Code: ____________________________

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PART II: Plan Information
A. Plan Information
1) *Plan Name:

2) *Plan Year Cycle: Start Month/Day:__________ End Month/Day: ____________
B. Benefit Option(s) Provided Under this Plan

This section of the application has been removed.

C. *Programs and Procedures for Chronic and High-Cost Conditions
A sponsor cannot participate in the Early Retiree Reinsurance Program unless, as of the date of its
application for the program is submitted, its employment-based plan has in place programs and
procedures that have generated or have the potential to generate cost savings with respect to plan
participants with chronic and high cost conditions. The program regulations define “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. Please identify at least two chronic and high cost
conditions for which the employment-based plan has such programs and procedures in place, and
summarize those programs and procedures, including how it was determined that the identified
conditions satisfy the $15,000 threshold. Also, please identify the nature of each such program (e.g.,
disease management, case management, wellness program, etc.) If necessary to provide a complete
response, the sponsor may submit additional pages as an attachment to the application. Please
reference such attachment in this space.

D. *Estimated Amount of Early Retiree Reinsurance Program Reimbursements
Please estimate the projected amount of proceeds you expect to receive under the Early Retiree
Reinsurance Program for the plan identified in this application, for each of the first two plan year cycles
identified in this application. If you wish, you may provide a range of expected program proceeds that
includes: (1) a low-end estimate of expected program proceeds, (2) an estimate that represents your
most likely amount of program proceeds, and (3) a high-end estimate of expected program proceeds.
For purposes of this estimate only, please assume for each of those plan year cycles that there will be
sufficient program funds to cover all claims submitted by the Plan Sponsor that comply with program
requirements, although this might not be the case. If necessary to provide a complete response, the
sponsor may submit additional pages as an attachment to the application. Please reference such
attachment in this space.
First Plan Year Cycle

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Low Estimate (optional): ________________
*Most Likely Estimate: ___________________
High Estimate (optional): _________________
Second Plan Year Cycle
Low Estimate (optional): ________________
*Most Likely Estimate: ___________________
High Estimate (optional): _________________

E. *Intended Use of Early Retiree Reinsurance Program Reimbursements

1. Please summarize how your organization will use the reimbursement under the Early Retiree
Reinsurance Program (ERRP) by checking the appropriate box that appears next to (a), (b) or (c):

(a) To reduce health benefit or health benefit premium costs for the sponsor of the employmentbased plan (i.e., to offset increases in such costs);

(b) To reduce, or offset increases in, premium contributions, copayments, deductibles, coinsurance,
or other out-of-pocket costs (or combination of these) for plan participants; or

(c)To reduce or offset increases for a combination of any of these costs (whether reducing or
offsetting increases in sponsor costs or reducing, or offsetting increases in, plan participants’ costs).
For assistance with answering this question, you may wish to view the program regulations and
Common Questions at www.errp.gov for information on permissible uses of ERRP reimbursement.

2. If the sponsor indicated in the above question that it intends to use any of the reimbursement under
the ERRP to reduce the sponsor’s health benefit or health benefit premium costs (i.e., the sponsor
checked either (a) or (c) above), the ERRP regulation requires a sponsor to maintain its level of
contribution toward the plan, solely as a way of ensuring that the sponsor does not violate the statutory
prohibition on using program funds as general revenue. Therefore, if the sponsor checked either (a) or
(c) above, the sponsor must attest to the following by checking the box below:

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PART III. Plan Sponsor Agreement
1.

2.

3.

4.

5.

Compliance: In order to receive program reimbursement(s), Plan Sponsor agrees to comply with
all of the terms and conditions of Section 1102 of the Patient Protection Act (P.L. 111-148) and 45
C.F.R .Part 149 and in other guidance issued by the Secretary of the U.S. Department of Health &
Human Services (the Secretary), including, but not limited to, the conditions for submission of data
for obtaining reimbursement and the record retention requirements.

Reimbursement-Related and Other Representations Made by Designees: Plan Sponsor may be
given the opportunity to identify one or more Designees (i.e., individuals the Sponsor will authorize
to perform certain functions on behalf of the Sponsor related to the Early Retiree Reinsurance
Program, such as individual(s) who will be involved in making program reimbursement requests).
Plan Sponsor affirms that all individuals that will be identified as Designees will have first been
given authority by the Plan Sponsor to perform those respective functions on behalf of the Plan
Sponsor. Plan Sponsor understands that it is bound by any representations such individuals make
with respect to the Sponsor’s involvement in the Early Retiree Reinsurance Program, including but
not limited to the Sponsor’s reimbursement under, the program.
Written Agreement: Plan Sponsor affirms that, prior to submitting a Reimbursement Request, it
has executed a written agreement with its health insurance issuer(s), employment-based plan, and
other entities participating in the administration of the plan, regarding disclosure of information,
data, documents, and records to HHS, and the issuer, plan, and other entity participating in the
administration of the plan agrees to disclose to HHS, on behalf of the Plan Sponsor, at a time and in
a manner specified by the HHS Secretary in guidance, the information, data, documents, and
records necessary for the Plan Sponsor to comply with the requirements of the Early Retiree
Reinsurance Program, as specified in 45 C.F.R. 149.35.

Use of Records: Plan Sponsor understands and agrees that the Secretary may use data and
information collected under the Early Retiree Reinsurance Program only for the purposes of, and to
the extent necessary in, carrying out Section 1102 of the Patient Protection Act (P.L. 111-148) and
45 C.F.R. Part 149 including, but not limited to, determining reimbursements and reimbursementrelated oversight and program integrity activities, or as otherwise allowed by law. Nothing in this
section limits the U.S. Department of Health & Human Services’ Office of the Inspector General’s
authority to fulfill the Inspector General’s responsibilities in accordance with applicable Federal
law.
Obtaining Federal Funds: Plan Sponsor acknowledges that the information furnished in its Plan
Sponsor application is being provided to obtain Federal funds. Plan Sponsor affirms that it requires
all subcontractors, including plan administrators, to acknowledge that information provided in
connection with a subcontract is used for purposes of obtaining Federal funds. Plan Sponsor
acknowledges that reimbursement of program funds is conditioned on the submission of accurate
information. Plan Sponsor agrees that it will not knowingly present or cause to be presented a false
or fraudulent claim. Plan Sponsor acknowledges that any excess reimbursement made to the Plan
Sponsor under the Early Retiree Reinsurance Program, or any debt that arises from such excess
reimbursement, may be recovered by the Secretary. Plan Sponsor will promptly update any
changes to the information submitted in its Plan Sponsor application. If Plan Sponsor becomes
aware that information in this application is not (or is no longer) true, accurate and complete, Plan

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Sponsor agrees to notify the Secretary promptly of this fact.
6.

7.

8.

9.

Data Security: Plan Sponsor agrees to establish and implement proper safeguards against
unauthorized use and disclosure of the data exchanged under this Plan Sponsor application. Plan
Sponsor recognizes that the use and disclosure of protected health information (PHI) is governed
by the Health Insurance Portability and Accountability Act (HIPAA) and accompanying regulations.
Plan Sponsor affirms that its employment-based plan(s) has established and implemented
appropriate safeguards in compliance with 45 C.F.R. Parts 160 and 164 (HIPAA administrative
simplification, privacy and security rule) in order to prevent unauthorized use or disclosure of such
information. Sponsor also agrees that if it participates in the administration of the plan(s), then it
has also established and implemented appropriate safeguards in regard to PHI. Any and all Plan
Sponsor personnel interacting with PHI shall be advised of: (1) the confidential nature of the
information; (2) safeguards required to protect the information; and (3) the administrative, civil
and criminal penalties for noncompliance contained in applicable Federal laws.

Depository Information: Plan Sponsor hereby authorizes the Secretary to initiate reimbursement,
credit entries and other adjustments, including offsets and requests for reimbursement, in
accordance with the provisions of Section 1102 of the Patient Protection Act (P.L. 111-148) and 45
C.F.R Part 149 and applicable provisions of 45 C.F.R. Part 30, to the account at the financial
institution (hereinafter the “Depository”) identified by the Plan Sponsor. Plan Sponsor agrees to
immediately pay back any excess reimbursement or debt upon notification from the Secretary of
the excess reimbursement or debt. Plan Sponsor agrees to promptly update any changes in its
Depository information.
Policies and Procedures to Detect Fraud, Waste and Abuse. The Plan Sponsor attests that, as of
the date this Application is submitted, has in place policies and procedures to detect and reduce
fraud, waste, and abuse related to the Early Retiree Reinsurance Program. The Plan Sponsor will
produce the policies and procedures, and necessary information, records and data, upon request by
the Secretary, to substantiate existence of the policies and procedures and their effectiveness, as
specified in 45 C.F.R. Part 149.
Change of Ownership: The Plan Sponsor shall provide written notice to the Secretary at least 60
days prior to a change in ownership, as defined in 45 C.F.R, 149.700. When a change of ownership
results in a transfer of the liability for health benefits costs, this Plan Sponsor Agreement is
automatically assigned to the new owner, who shall be subject to the terms and conditions of this
Plan Sponsor Agreement.
Signature of Plan Sponsor Authorized Representative

I, the undersigned Authorized Representative of Plan Sponsor, declare that I have legal authority to
sign and bind the Plan Sponsor to the terms of this Plan Sponsor Agreement, and I have or will
provide evidence of such authority. I declare that I have examined this Plan Sponsor Application
and Plan Sponsor Agreement. My signature legally and financially binds the Plan Sponsor to the
statutes, regulations, and other guidance applicable to the Early Retiree Reinsurance Program
including, but not limited to Section 1102 of the Patient Protection Act (P.L. 111-148) and 45 C.F.R.
Part 149 and applicable provisions of 45 C.F.R. Part 30 and all other applicable statutes and
regulations. I affirm that the information contained in this Plan Sponsor Application and Plan
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Sponsor Agreement is true, accurate and complete to the best of my knowledge and belief, and I
authorize the Secretary to verify this information. I understand that, because program
reimbursement will be made from Federal funds, any false statements, documents, or concealment
of a material fact is subject to prosecution under applicable Federal and/or State law.
*Signature _____________________________________________________________________________________
Only the Authorized Representative specified in Part I.B. can sign this agreement.

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Access to ERRP Secure Website
Part I – User Registration Information
The individual attempting to register in the ERRP Secure Website must either provide or confirm the
accuracy of the following data:
1) *Enter the Pass-phrase (Designee only)

2) *Read and accept the user Agreement and Privacy Policy (located in “Access to ERRP Secure Website”, Part
V of the document.
3) *First Name: _______________ Middle Initial (optional): _____ *Last Name: ______________
4) *Job Title: ______________________________________

5) *Date of birth (Month/Day/Year):________________
6) *Social Security Number: __________________

7) *Email Address: _______________________________________________
8) *Telephone Number: _____________________ext__________
9) FAX Number:__________________

10) *Employer Name: ________________________________________

11) *Business Address of the Registering Individual:
*Street Line 1: ___________________________________
Street Line 2: ____________________________________
*City: ______________________
*State/US Territory: _________________________
*Zip Code: ____________________________
12) *Login Information

*Login ID: _________________
*Password ________________
*Security Question 1: ______
*Answer 1:________
*Security Question 2:__________
*Answer 2:__________

Part II – Designee Invitation

1) *Email Address:_____________
2)*First Name___________ Middle Initial_________ *Last Name
3) *Pass-phrase
4) *Specify actions designee can perform (e.g., report costs, request reimbursement).

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Part III – Login Warning
Registered secure website user must read and agree to the following terms prior to
each login.
UNAUTHORIZED ACCESS TO THIS COMPUTER SYSTEM IS PROHIBITED BY LAW

The ERRP Secure Website is maintained by the U.S. Government and is protected by Federal law. Use of this
computer system without authority or in excess of granted authority, such as access through use of another's
Login ID and/or Password, may be in violation of Federal law, including the False Claims Act, the Computer
Fraud and Abuse Act and other relevant provisions of Federal, civil, and criminal law. Violators are subject to
administrative disciplinary action and civil and criminal penalties including civil monetary penalties.

For site security purposes, HHS' ERRP Center employs software programs to monitor and identify
unauthorized access, unauthorized attempts to upload or change information, or attempts to otherwise cause
damage. In the event of authorized law enforcement investigations, and pursuant to any required legal
process, information from these sources may be used to help identify an individual and may be used for
administrative, criminal, or other adverse action. You may access the ERRP Privacy Policy by clicking on the
link at the bottom of most ERRP Secure Website pages after you log in.
By clicking on "I Accept" you indicate your awareness of, and consent to, the terms and conditions of use
stated in this Login Warning.
Click Decline IMMEDIATELY if you are not authorized to access this system or if you do not agree to the
conditions stated in this warning.
I Accept
Decline

Part IV – User Agreement and Privacy Policy
Registered secure website user must read and agree to the following terms prior to
each login.
THE FOLLOWING DESCRIBES THE TERMS AND CONDITIONS ON WHICH THE EARLY RETIREE
REINSURANCE PROGRAM (ERRP) CENTER OFFERS YOU ACCESS TO THE ERRP CENTER SECURE
WEBSITE.
You must read and accept the terms and conditions contained in this User Agreement expressly set out below and
incorporated by reference before you may access the ERRP Center Secure Website.

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The ERRP Center may amend this User Agreement at any time. Except as stated below, all amended terms shall
automatically be effective 30 days after they are initially posted on the Site. This User Agreement is effective
immediately.

1. Purpose of ERRP Center Secure Website
The U.S. Department of Health & Human Services (HHS) recently published interim final regulations for the Early
Retiree Reinsurance Program (ERRP), which is established in section 1102 of the Patient Protection and Affordable
Care Act (the Affordable Care Act). Section 1102 and its implementing regulations at 45 C.F.R Part 149 contain the
provisions governing the ERRP, which is designed to assist employers and unions with continuing provision of high
quality health benefit coverage to early retirees and their spouses, surviving spouses, and dependents, as well as to
other individuals.

2. Privacy Policy
The U.S. Department of Health & Human Services (HHS) at (http://www.hhs.gov/), of which the ERRP Center Secure
Website is a part, has a clear privacy policy. When you access the ERRP Center Secure Website, we collect the
minimum amount of information about you necessary to manage your ERRP account.
Information Automatically Collected and Stored
When you browse through any website, certain personal information about you can be collected. We automatically
collect and temporarily store the following information about your visit:
•

the name of the domain you use to access the Internet (for example, aol.com, if you are using an American

•

Online account, or stanford.edu, if you are connecting from Stanford University's domain);
the date and time of your visit

•
•

the pages you visited
the address of the web site you came from when you came to visit

This information is used for statistical purposes only and to help us make this site more useful to visitors. Unless it is
specifically stated otherwise, no additional information will be collected about you.
Information Collected to Process Reimbursement Requests and Manage Accounts through ERRP Center
Secure Website
When Users of the ERRP Center Secure website register to use the website, we will collect personal information
necessary to validate Users, to process reimbursement requests, and to manage information related to the
application. The authority to collect this information is granted by § section 1102 of the Patient Protection Act and the
ERRP implementing regulations at 45 C.F.R. Part 149. The provision of this information is mandatory for participation
in ERRP, and may include your name, address, telephone and fax numbers, e-mail address, social security number,
Federal Employer Identification Number (FEIN), banking information, certain certifications, or other payment
information. Your e-mail address will be used by the ERRP Center to send you mandatory program and account email notifications. The ERRP Center may also collect a password and password hint for each User accessing the
ERRP Secure Website. We use this information to verify Users' identities in order to prevent unauthorized access to
Plan Sponsors' secure ERRP accounts. ERRP Center staff has role-based access to this information, and use only
the information minimally necessary to accomplish their jobs.
The personal information you provide is encrypted and sent to us using a secure method, in order to assure that your
personal information is securely and safely transmitted. However, no one can give an absolute assurance that
information intended to be maintained as private, whether transmitted via the Internet or otherwise, cannot be

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accessed inappropriately or unlawfully by third parties. We have taken and will continue to take reasonable steps to
ensure the secure and safe transmission of your personal information.
Personally Provided Information
If you are not involved with the submission or management of an ERRP application, or the submission or
management of data related to a reimbursement request on the ERRP Center Secure Website, you do not have to
give us personal information. If you choose to provide us with additional information about yourself through e-mail,
forms, surveys, etc., we will maintain the information as long as needed to respond to your question or to fulfill the
stated purpose of the communication.
Disclosure
HHS does not disclose, give, sell or transfer any personal information about its visitors, unless required for law
enforcement or statute.
Intrusion Detection
This website is maintained by the U.S. Government. It is protected by various provisions of Title 18, U.S. Code.
Violations of Title 18 are subject to criminal prosecution in federal court.
For site security purposes and to ensure that this service remains available to all Users, we employ software
programs to monitor traffic to identify unauthorized attempts to upload or change information, or otherwise cause
damage. In the event of authorized law enforcement investigations, and pursuant to any required legal process,
information from these sources may be used to help identify an individual.

3. Systems of Records
Information originally collected in traditional paper systems can be submitted electronically, i.e., electronic commerce
transactions and information updates about eligibility benefits. Electronically submitted information is maintained and
destroyed pursuant to the Federal Records Act and in some cases may be subject to the Privacy Act. If information
that you submit is to be used in a Privacy Act system of records, there will be a Privacy Act Notice provided.

4. Links
References from this website to any non-governmental entity, product, service or information do not imply
endorsement or recommendation by HHS or any other HHS agency or employees.
We are not responsible for the contents of any "off-site" web pages referenced from this server. We do not endorse
ANY specific products or services provided by public or private organizations. In addition, we do not necessarily
endorse the views expressed by such sites, nor do we warrant the validity of any site's information or its fitness for
any particular purpose.

5. Pop-up Advertisements
When visiting our website, your web browser may produce pop-up advertisements. These advertisements were most
likely produced by other websites you visited or by third party software installed on your computer. HHS does not
endorse or recommend products or services for which you may view a pop-up advertisement on your computer
screen while visiting our site.

6. Outdated Information
Many HHS documents are time sensitive. Department policies change over time. Information in older documents may
be out-dated. You also may wish to review our Privacy Policy, above.

7. Accessibility

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This page provides information for those visitors who use assistive or other devices to access the content on this
website. Please see the Contact Us section at http://errp.gov/contact/default.htm if you have general questions and
comments or have difficulty finding something on this site.
Synopsis of Section 508 Accessibility Requirements
Section 508 requires that individuals with disabilities, who are members of the public seeking information or services
from this website have access to and use of information and data that is comparable to that provided to the public
who are not individuals with disabilities, unless an undue burden would be imposed on us. Section 508 also requires
us to ensure that Federal employees with disabilities have access to and use of information and data that is
comparable to the access to and use of information and data by Federal employees who are not individuals with
disabilities, unless an undue burden would be imposed on us. (To learn more about the regulations governing the
accessibility of Federal electronic information, read the Synopsis of Section 508 Accessibility Requirements at
http://www.section508.gov/index.cfm?FuseAction=Content&ID=11.)

8. Freedom of Information Act (FOIA)
The ERRP Center website is a service of the U.S. Department of Health & Human Services at http://www.hhs.gov/.
Any Freedom of Information Act (FOIA) requests concerning this website should be submitted in accordance with the
Department's FOIA guidelines, which are online at http://www.hhs.gov/foia. Information on making FOIA requests is
available at the Freedom of Information Group page. You also may wish to review our Privacy Policy above.

I accept
I decline

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Reimbursement Request Information
An asterisk (*) identifies a required field.

PART I: Reimbursement Request Setup Information
A. Early Retiree List : Submission Information

Note: The Plan Sponsor must provide the following information for each plan year.
1) * Early Retiree List Submission Method (Choose one):

____ Submission via ERRP Secure Website – Response via the ERRP Website

____ Submission via Plan Sponsor Mainframe to ERRP Data Center Mainframe – Response via ERRP
Data Center Mainframe to Plan sponsor Mainframe

____ Submission via Plan Sponsor Mainframe to ERRP Data Center Mainframe - Response via ERRP
Data Center Mainframe to Plan sponsor Mainframe with a copy of all Early Retiree Response files
sent to the ERRP Secure Website
___ Submission via Vendor Mainframe to ERRP Data Center Mainframe – Response via ERRP Data
Center Mainframe to Vendor Mainframe

___ Submission via Vendor Mainframe to ERRP Data Center Mainframe - Response via ERRP Data
Center Mainframe to Vendor Mainframe with a copy of all Early Retiree Response Files sent to the
ERRP Secure Website

Note: Items 2-4 are required if sending data using the mainframe-to-mainframe method. If a
Plan Sponsor chooses this method, it must work with HHS to establish mainframe
communications protocols.
2)*Mainframe Vendor ID (assigned by HHS): ________________

3)*Name of Organization Submitting Early Retiree Data: ___________________________________
4)*Contact Information:

4a)*First Name: ___________ Middle Initial (optional): _____*Last Name: __________________
4b)*Email Address: _____________________________________________________
4c)*Telephone Number: _____________________ext__________
4d) FAX Number: _______________________
4e)* Address:

*Street Line 1: ___________________________________

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Street Line 2: ____________________________________
*City: ______________________
*State/US Territory: _________________________
*Zip Code: ____________________________

B. Submit Detailed Claims Data: Submission Information
Note: The Plan Sponsor must provide the following information for each plan year:
1) *Submit Detailed Claims Data: Submission Method (Choose one):

____ Secure file upload using Hypertext Transfer Protocol Secure (HTTPS) to ERRP Secure Website
____ Plan Sponsor (or Vendor) Mainframe to HHS Mainframe

Note: Items 2-4, as applicable, are required if sending data using the mainframe-to-mainframe
method of delivery. If a Plan Sponsor chooses the mainframe to mainframe method, it must
work with HHS to establish mainframe communications protocols.
2)*Mainframe Vendor ID (assigned by HHS): ________________

3)*Name of Organization Submitting Claims Data: ___________________________________
4)*Contact Information:

4a)*First Name: ___________ Middle Initial (optional): _____*Last Name: __________________
4b)*Email Address: _____________________________________________________
4c)*Telephone Number: _____________________ext__________
4d) FAX Number: _______________________
4e)* Address:

*Street Line 1: ___________________________________
Street Line 2: ____________________________________
*City: ______________________
*State/US Territory: _________________________
*Zip Code: ____________________________

C. Assign Reimbursement-Related Privilege to Account Manager
1) *Specify one of the following privileges for the Account Manager (Choose one)
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_____ Report Costs
_____ Request Reimbursement
_____ View Only

D. Banking Information
Provide the following information:
Account information

1) *Bank Name: ________________________________________________________________________

2) *Account Type (Indicate Checking or Savings): __________________________________

3) *Organization Name Associated with Account: ____________________________________________________
4) *Account Number: ___________________________________________

5) *Bank Routing Number: _____________________________________

Bank Contact Information
1) *First Name: ___________ Middle Initial (optional): _____*Last Name: __________________

2) *Telephone Number: _____________________ext__________

Bank Address

1) *Address:
Street Line 1: ___________________________________
Street Line 2: ____________________________________
City: ______________________
State/US Territory: _________________________
Zip Code: ____________________________

E. Affirmation by Authorized Representative
Prior to the Sponsor’s first reimbursement request for an ERRP application, its Authorized
Representative must agree to the following:

As the Authorized Representative of the plan sponsor identified in this application, I hereby affirm that
the sponsor will make a reasonable, good-faith effort to satisfy the following requirements, and that the
sponsor will be prepared to demonstrate that it has made such a good-faith effort with respect to the
following requirements, upon the request of the U.S. Department of Health & Human Services:
•

Sponsor will use any and all Early Retiree Reinsurance Program (ERRP) reimbursement
proceeds to: (A) Reduce the sponsor’s health benefit premiums or health benefit costs, (B)

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•

•

•
•

Reduce health benefit premium contributions, copayments, deductibles, coinsurance, or other
out of pocket costs, or any combination of these costs, for plan participants, or (C) Reduce any
combination of the costs in (A) or (B).

If sponsor uses any portion of ERRP reimbursement funds to offset increases its own health
benefit premiums or health benefit costs, sponsor will comply with the statutory and regulatory
prohibition against using ERRP reimbursement as general revenue, by maintaining its level of
contribution toward supporting the plan.

Sponsor will provide a notice to all plan participants notifying them that, because the plan is
participating in the Affordable Care Act's Early Retiree Reinsurance Program, the plan may use
the payments to reduce premium contributions, co-payments, deductibles, co-insurance, or
other out-of-pocket costs, and therefore that plan participants may experience such changes in
the terms and conditions of their plan participation. Sponsor will provide this notice, drafted by
the U.S. Department of Health & Human Services (HHS), in a manner specified in HHS guidance.

Sponsor will submit claims only for items and services that Medicare would cover, as specified
in HHS guidance.
Sponsor will not submit claims associated with plan participants who are not U.S. citizens or
lawfully present in the U.S.

*Click here to make the affirmation

HHS Form #CMS-10321

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OMB Approval 0938-1087

PART II: Reimbursement Request Information
A. Initiate Reimbursement Request
An individual with the appropriate privilege must
1)*Select sponsor

2) *Select application
3) *Select plan year

B. Submit List of Early Retirees and Process Response Files
A Plan Sponsor must submit with each Reimbursement Request an electronic cumulative list of Early
Retirees for whom it is seeking or has sought program reimbursement for the plan year. The form and
content of the list will vary, depending on the method of delivery, as follows.

ERRP Mainframe Early Retiree File Processing Layout
Data
Element
HEADER
RECORD
Record Type
Application
ID
Plan Year
Start Date
Create Date
Create Time
Filler
DETAIL
RECORD
Record Type
Subscriber
SSN

Member
Unique
Person ID

Unique

HHS Form #CMS-10321

Size

Alpha /
Numeric

Incoming
Early
Retiree
File

Outgoing
Response &
Notification
Files

Allowable Values
/ Notes

1

A

X*

X

“H”

N

X*

X

CCYYMMDD

10

N

8
6
217

N
N
A/N

1

A

8

X*
X*
X*
X*
X*
X*

X
X
X
X

CCYYMMDD
HHMMSS
Must be spaces

X

“D”

9

N

X

20

A/N

X*

X

1

N

X*

X

The Early Retiree
Beneficiary for
whom you are
seeking
reimbursement
(For the
Subscriber it will
be the same as
Subscriber SSN)
Type of Member

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OMB Approval 0938-1087

Person ID
Type

Member
First Name
Member
Middle
Initial
Member Last
Name
Member
Date of Birth

30

A

X*

X

40

A

X*

X

N

X*

01

A

X

X

Not Required

X

CCYYMMDD

08

N

02

N

X*

X

30

A/N

X*

X

08

N

X*

X

Member
Coverage
Termination
Date

08

N

X*

X

Member
Coverage
Termination
Reason

1

N

X*

X

70

A/N

X*

02

N

X

02

N

X

Member
Gender
Member
Relationship
to Early
Retiree
Member ID
Member
Group ID
Member
Coverage
Effective
Date

Filler
Reason Code
1
Reason Code
2
Reason Code
3

HHS Form #CMS-10321

01

20

02

A/N

N

X*

X*

UPI:
1=SSN
2=Alien ID
3=I-94 ID
4=Other Federal
ID

X

X

X

0 = Unknown,
1 = Male,
2 = Female
01 = Self,
02 = Spouse,
03 = Dependent

See accompanying
instructions
See
accompanying
instructions
Date coverage
begins for the
Member
CCYYMMDD
Date coverage
ends for the
Member
CCYYMMDD
(Blank if not
terminated)
1 = Death,
2 = Other
(Needed for
spouse/dependent
coverage
continuation
determination)
Must be spaces
Reason for full or
partial denial of
ERRP eligibility.
Reason for full or
partial denial of
ERRP eligibility.
Reason for full or
partial denial of
ERRP eligibility.

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OMB Approval 0938-1087

Reason Code
4
ERRP
Effective
Date
ERRP
Termination
Date
Filler
TRAILER
RECORD
Record Type
Application
ID
Plan Year
Start Date
Create Date
Create Time
Record
Count
Filler

Reason for full or
partial denial of
ERRP eligibility.
ERRP Center
calculated
eligibility start
date. CCYYMMDD
ERRP Center
calculated
eligibility end
date. CCYYMMDD

02

N

X

08

N

X

08

N

X

46

A/N

X

1

A

X*

X

“T”

N

X*

X

CCYYMMDD

10

N

8
6

N
N

8

X*
X*
X*

Must be spaces

X
X
X

7

N

X*

X

210

A/N

X*

X

CCYYMMDD
HHMMSS
Record count
corresponds to
number of Detail
records only (not
Header/Trailer)
Must be spaces

ERRP Secure Website Early Retiree File Processing Layout
Data Element
Application ID
Plan Year Start
Date
Subscriber SSN

Member Unique
Person ID

Unique Person
ID Type

HHS Form #CMS-10321

N

Incoming
Early
Retiree
File
X*

Outgoing
Response &
Notification
Files
X

N

X*

X

Max
Size

Alpha /
Numeric

10
9

8

N

X*

X

20

A/N

X*

X

1

N

X*

X

Allowable Values
/ Notes

CCYYMMDD

The Early Retiree
Beneficiary for
whom you are
seeking
reimbursement
(For the
Subscriber it will
be the same as
Subscriber SSN)
Type of Member
UPI:
1=SSN
2=Alien ID
3=I-94 ID
Page 20

OMB Approval 0938-1087

Member First
Name
Member Middle
Initial
Member Last
Name
Member Date of
Birth
Member Gender
Member
Relationship to
Early Retiree
Member ID

30

A

X*

X

40

A

X*

X

N

X*

01

A

X

X

Not Required

X

CCYYMMDD

08

N

02

N

X*

X

A/N

X*

X

01

X*

X

30

A/N

08

N

X*

X

Member
Coverage
Termination
Date

08

N

X*

X

Member
Coverage
Termination
Reason

1

N

X*

X

Reason Code 1

02

N

X

Reason Code 2

02

N

X

Reason Code 3

02

N

X

Reason Code 4

02

N

X

08

N

X

Member Group
ID
Member
Coverage
Effective Date

ERRP Effective
Date
ERRP

HHS Form #CMS-10321

20

08

N

X*

4=Other Federal
ID

X

X

0 = Unknown,
1 = Male,
2 = Female
01 = Self,
02 = Spouse,
03 = Dependant
See accompanying
instructions
See accompanying
instructions
Date coverage
begins for the
Member
CCYYMMDD
Date coverage
ends for the
Member
CCYYMMDD
(Blank if not
terminated)
1 = Death,
2 = Other
(Needed for
spouse/dependent
coverage
continuation
determination)
Reason for full or
partial denial of
ERRP eligibility.
Reason for full or
partial denial of
ERRP eligibility.
Reason for full or
partial denial of
coverage.
Reason for full or
partial denial of
ERRP eligibility.
ERRP Center
calculated
eligibility start
date. CCYYMMDD
ERRP Center

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OMB Approval 0938-1087

Termination
Date

C. Sponsor Must Review Response Files

calculated
eligibility end
date. CCYYMMDD

After submitting an Early Retiree List, a Plan Sponsor will receive from the ERRP Center a response file
specifying which individuals on the Early Retiree List are approved or rejected for the purpose of
submitting cost/claims data and requesting reimbursement. If an individual is approved, the response
file will include the dates within the plan year for which the sponsor can submit cost/claims data and
request reimbursement. Also, the response file, for records that are either rejected or approved only for
a portion of the time period requested, will specify the reason(s) for the rejection or partial approval.
See the column labeled “Outgoing Response & Notification Files” in both tables in Part II.B. to identify
the data elements returned to the Plan Sponsor in the response file.

D. Submit Summary Cost Data

A Plan Sponsor must submit with each Reimbursement Request (via data entry in the ERRP Secure
Website) the following summary cost data related to the Reimbursement Request, on a cumulative
basis. The data must correlate to the actual cost data specified inE. that is submitted for the same
reimbursement request:
1.

2.

3.

4.

5.

* Cost Paid by Plan - User enterable text field. This represents the aggregated actual costs for
health benefits paid by the plan and incurred for Early Retirees
* Cost Paid by Early Retiree - User enterable text field. This represents the aggregated actual
costs for health benefits paid by approved Early Retirees
* Threshold Reduction - User enterable text field. This field represents the aggregated cost
threshold reduction amount for all approved Early Retirees with costs for health benefits
reported for the planyear. The Plan Sponsor’s data aggregator shall be responsible for
calculating and inputting the threshold reductions.
* Limit Reduction - User enterable text field. This field represents the aggregated cost limit
reduction amount for all approved Early Retirees with costs for health benefits reported for the
plan year. The Plan Sponsor’s data aggregator shall be responsible for calculating and inputting
the limit reductions.

E. Submit Detailed Claims Data
A Plan Sponsor must submit with each Reimbursement Request the following data:
1)
2)
3)
4)

*Reimbursement Request Number (assigned by HHS)
*Vendor ID (if applicable)
*Plan Sponsor ID (assigned by HHS)
*Application ID (assigned by HHS)

For each item or service for which the Plan Sponsor is seeking program reimbursement, a Plan Sponsor
must submit each of the following data elements when appropriate (all data elements are not required
for each claim type, e.g. institutional, professional, and pharmacy):
HHS Form #CMS-10321

Page 22

OMB Approval 0938-1087

Field Name

Definition

Record Type

Code value used to identify the record format

Plan Year Start Date

The starting date of the Plan Sponsor’s plan year

Application ID

Create Date

Create Time

Member First Name
Member Middle Initial
Member Last Name

Member Date of Birth
Member Gender
Member ID

Member Group ID
Claim Number
Claim Line Item Number
Claim Type

Plan Paid Date

Derived Claim Indicator
Cost Paid By Early Retiree

HHS Form #CMS-10321

10 digit identifier assigned to the Plan Sponsor’s ERRP
application
The date the file is created

The time of day the file is created

First name of the member associated with a given
claim

Middle Initial of the member associated with a given
claim

Last name of the member associated with a given claim
Date of birth for the Member (Subscriber, Spouse, or
Dependant)associated with a given claim

Gender for the Member associated with a given claim
The Plan’s unique identification number for the
Member associated with a given claim

The Plan’s group number for the Member associated
with a given claim
Unique ID of a given claim that is assigned by the
claim processing system

Line Number identifying the Service line associated
within a claim assigned by the claim processing system
Code value used to designate type of claim
Date claim system adjudicated the claim

Code value indicating whether a given claim was paid
as a fee for service claim or paid under a capitated
arrangement

The aggregated actual costs for health benefits paid by
approved Early Retiree for a given claim
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OMB Approval 0938-1087

From Date of Service

Service Begin Date

Place of Service

Code value used to identify the location/facility where
the service was rendered

To Date of Service

Type of Service
Procedure Code
Procedure Code Modifier1
Procedure Code Modifier2
Procedure Code Modifier3
Procedure Code Modifier4
ICD Diagnosis Code Qualifier
Principal Diagnosis Code
Other Diagnosis Code2
Other Diagnosis Code3
Other Diagnosis Code4
Other Diagnosis Code5
Other Diagnosis Code6
Quantity Qualifier

HHS Form #CMS-10321

Service End Date

Code value used to designate the classification of
service or benefits
Code value used to designate the specific health
interventions taken by medical professionals
(HCPCS/CPT)

Code value used to provide further information about
the service being performed (HCPCS/CPT)
Code value used to provide further information about
the service being performed (HCPCS/CPT)

Code value used to provide further information about
the service being performed (HCPCS/CPT)
Code value used to provide further information about
the service being performed (HCPCS/CPT)
Code value used to identify which version of ICD is
being utilized
Primary diagnosis associated with the Member’s
(patient) condition

Other diagnosis code associated with the Member’s
(patient) condition
Other diagnosis code associated with the Member’s
(patient) condition

Other diagnosis code associated with the Member’s
(patient) condition
Other diagnosis code associated with the Member’s
(patient) condition
Other diagnosis code associated with the Member’s
(patient) condition

Code value used to identify the type of measurement
used in the Unit Quantity field.

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OMB Approval 0938-1087

Unit Quantity

Quantity of services/product delivered

Rendering Provider ID Qualifier

Code value used to identify the type of Provider ID
reported in the Rendering Provider ID field.

Item Plan Paid Amount

Rendering Provider ID
Service Location Zip Code
Type of Bill
Facility Provider ID Qualifier
Facility Provider ID
Admission Date

Principal ICD Procedure Code
Other ICD Procedure Code2
Other ICD Procedure Code3
Other ICD Procedure Code4
Other ICD Procedure Code5
Other ICD Procedure Code6
Revenue Code
Prescription Service Provider ID
Qualifier
Prescription Service Provider ID
Prescription Filled Date
HHS Form #CMS-10321

Dollar amount paid by the plan for this claim item

ID of the Provider/Supplier rendering the services to
the Member (patient).
US Zip Code of the location where the service was
rendered.

Code value which identifies the specific type of bill for
institutional claims.
Code value that defines the type of Provider ID
reported in the Facility Provider ID field.

ID of the Facility where service were provided for
institutional claims.
Date admitted to facility for institutional claims.

Principal procedure performed within an institutional
setting
Other procedures performed within an institutional
setting
Other procedures performed within an institutional
setting

Other procedures performed within an institutional
setting
Other procedures performed within an institutional
setting
Other procedures performed within an institutional
setting
Code value that identifies the specific cost center
related to the service for institutional claims.

Code value that defines the type of Service Provider ID
reported in the Prescription Service Provider ID field
ID of the Pharmacy or Supplier for prescription claims
Date Prescription was filled for prescription claims

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OMB Approval 0938-1087

Prescription Product/Service ID
Qualifier
Prescription Product/Service ID
Prescription Product/Service ID
Modifier1
Prescription Product/Service ID
Modifier2
Prescription Product/Service ID
Modifier3
Prescription Product/Service ID
Modifier4
Prescription Product/Service ID
Modifier5
Prescription Product/Service ID
Modifier6
Prescription Product/Service ID
Modifier7
Prescription Product/Service ID
Modifier8
Prescription Product/Service ID
Modifier9

Prescription Product/Service ID
Modifier10
Prescription Unit of Measure

Prescription Quantity Dispensed
Prescriber Provider ID Qualifier
Prescriber ID

HHS Form #CMS-10321

Code value that defines the type of Product/Service ID
reported in the Product/Service ID field on
prescription claims
Code value used to identify the product delivered

Code value used to provided further information about
the service being performed
Code value used to provide further information about
the service being performed
Code value used to provide further information about
the service being performed
Code value used to provide further information about
the service being performed
Code value used to provide further information about
the service being performed

Code value used to provide further information about
the service being performed
Code value used to provide further information about
the service being performed

Code value used to provide further information about
the service being performed for prescription claims
Code value used to provide further information about
the service being performed for prescription claims
Code value used to provide further information about
the service being performed for prescription claims

Code value specifies the type of Quantity Reported for
prescription claims
Quantity of services/products delivered for
prescription claims

Code value that defines the type of Prescriber Provider
ID reported in the Prescriber Provider ID field for
prescription claims
ID of the Prescriber for prescription claims

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OMB Approval 0938-1087

Total Number of Unique Early Retirees

Sum of the unique Early Retirees within the claim file

Total Number of Claim records

Sum of unique claim records within the claim file

Total Cost paid by Plan

Aggregated actual costs for health benefits paid by the
plan and incurred for Early Retirees for claims
included in the claim file

Included in Claim File

Total Number of Claim Service Line
Records

Total Cost paid by Early Retiree
Total Cost Adjustment

Sum of unique claim service line records within the
claim file

Aggregated actual costs for health benefits paid by
approved Early Retirees for claims included in the
claim file

Post point-of-sales concessions and rebates that were
not included in the Costs Paid by Plan Sponsor for
claims included in the claim file

F. Submit Evidence of Early Retiree Payment
When required, a Plan Sponsor must submit an Early Retiree Paid Claims Receipt or other evidence of
payment for each item or service for which it is seeking program reimbursement for amounts that the
Early Retiree paid. The evidence must correlate to the summary cost data specified in D.: The following
must be submitted:
1. Actual or copies of receipts, that each includes the following information:
Receipt identifier;

Amount paid by the individual;

Date paid;

Identity of entity paid:
2, Cover sheet that includes the following information:
Number of pages to follow:

Application ID to which the receipts apply;

First day of the Plan Year to which the receipts apply;
HHS Form #CMS-10321

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OMB Approval 0938-1087

A list of receipts, by receipt identifier;

Next to each receipt identifier: The individual’s first and last name, the amount paid by the individual,
the applicable Member ID for the individual, the applicable Member Group ID, and the Claim ID.

G. *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 following statement:
NOTE: Your privileges permit you to access certain Electronic Protected Health Information (e-PHI)
associated with this ERRP application. E-PHI is subject to protection under the federal privacy and
security regulations established at 45 CFR Parts 160 and 164 and promulgated pursuant to the Health
Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicable statutes and
regulations, and is intended for the access and use by individuals only as authorized by the Plan
Sponsor. Disclosure of this e-PHI to any other party, unless authorized by the Plan Sponsor or required
to do so by law, is prohibited.

By clicking on the "I Accept" button below, you hereby acknowledge that you are authorized by the Plan
Sponsor to access or use e-PHI associated with this ERRP application, and that you will do so in
accordance with applicable statutes and regulations. Clicking the "Cancel" button will allow you to
navigate away from this page, and you will not be permitted to access the Plan Sponsor’s Retiree
Response files.
I Accept

I Decline

HHS Form #CMS-10321

Page 28

OMB Approval 0938-1087

Appeal Information
An asterisk (*) identifies a required field.

A Plan Sponsor must submit the following information if it wishes to appeal a reimbursement
determination:

1)
2)
3)
4)

*Plan Sponsor ID (assigned by HHS)
*Application ID (assigned by HHS)
*Copy of the Determination being appealed
*The findings or issues with which the sponsor disagrees, and the reason(s) for disagreement
with the determination
5) *The items and/or services at issue
6) *The amount of reimbursement at issue
7) *The individuals to whom the items and/or services at issue, were provided
8) Supporting documentary evidence
9) Will additional supporting documentary evidence be submitted?
10) Estimated date by which any additional supporting documentary evidence will be submitted
11) Request for extended due date for submitting any additional documentary evidence
12) Additional supporting documentary evidence

Reporting Data Inaccuracies
1) To report data inaccuracies, a Plan Sponsor must submit a new reimbursement request,
reflecting an accurate Early Retiree List, accurate Summary Cost Data, accurate Detailed Claims
Data, and accurate Evidence of Early Retiree Payment (if applicable), in a form and manner
specified in Reimbursement Request Information, Part II.

Reporting Change of Ownership
An asterisk (*) identifies a required field.

A Plan Sponsor must report the following information when reporting a Change of Ownership:
*Information necessary for HHS to understand the transaction and structure of the ownership
change.

HHS Form #CMS-10321

Page 29

OMB Approval 0938-1087

Other Information to be Produced Upon Request
1) *Fraud, Waste, and Abuse (FWA) Policies and Procedures related to the ERRP
2) *Data demonstrating the effectiveness of the FWA Policies and Procedures
3) *Written agreement with its health insurance issuer (as defined in 45 CFR Section 160.103),
group health plan, or other entities participating in the administration of the plan regarding
disclosure of information to HHS
4) *Any other documentation or data necessary for the Secretary to effectively administer the
ERRP.

HHS Form #CMS-10321

Page 30