Early Retiree Reinsurance Program: Survey of Plan Sponsors

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10408 ERRP Survey	Form and Instruction	New	Available
Form CMS-10408 Revised_Survey_Screenshots	Form and Instruction	New	Available
Form CMS-10408 Final Survey	Form	Modified	Available
Form CMS-10408 REVISED ERRP Survey of Plan Sponsors 11-17-11	Form	Modified	Available
Form CMS-10408 ERRP Survey of Plan Sponsors	Form	Modified	Available
Form CMS-10408 Final Survey	Form	Modified	Available
Form CMS-10408 REVISED ERRP Survey of Plan Sponsors 11-17-11	Form	Modified	Available
Form CMS-10408 ERRP Survey of Plan Sponsors	Form	Modified	Available
CMS-10408_Supporting_Statement_Part_B_FINAL.docx	Supporting Statement B	Uploaded 2013-01-25	Available
CMS-10408_ERRP_Survey_Crosswalk_of_Changes_FINAL.pdf	Supplementary Document	Uploaded 2013-01-25	Available
CMS-10408_Subsequent_Email_Clean_Sponsor_Previously_Responded_FINAL.pdf	Supplementary Document	Uploaded 2013-01-25	Available
CMS-10408_Subsequent_Email_Clean_Sponsor_Did_Not_Previously_Respond_FINAL.pdf	Supplementary Document	Uploaded 2013-01-25	Available
CMS-10408 SupportingStatement_A_FINAL (Reinstatement).docx	Supporting Statement A	Uploaded 2013-01-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205535	Survey of Plan Sponsors	Form and Instruction	New	ERRP Survey
205535	Survey of Plan Sponsors	Form and Instruction	New	Revised_Survey_Screenshots
200146	Survey of Plan Sponsors (Private Entities)	Form	Modified	Final Survey
200146	Survey of Plan Sponsors (Private Entities)	Form	Modified	REVISED ERRP Survey of Plan Sponsors 11-17-11
200146	Survey of Plan Sponsors (Private Entities)	Instruction	Modified
200146	Survey of Plan Sponsors (Private Entities)	Form	Modified	ERRP Survey of Plan Sponsors
200145	Survey of Plan Sponsors (Public Entities)	Form	Modified	Final Survey
200145	Survey of Plan Sponsors (Public Entities)	Form	Modified	REVISED ERRP Survey of Plan Sponsors 11-17-11
200145	Survey of Plan Sponsors (Public Entities)	Instruction	Modified
200145	Survey of Plan Sponsors (Public Entities)	Form	Modified	ERRP Survey of Plan Sponsors

ICR Details

OMB Control No: 0938-1150	ICR Reference No: 201301-0938-008
Status: Historical Active	Previous ICR Reference No: 201111-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: 18617
Title: Early Retiree Reinsurance Program: Survey of Plan Sponsors
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/07/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/25/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	36 Months From Approved
Responses	3,003	0	0
Time Burden (Hours)	33,033	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: As part of the Secretary's monitoring efforts, the Secretary intends to direct plan sponsors that have received ERRP funds to respond to this survey in order to obtain information about the ERRP program, including how and when plan sponsors have used, or intend to use, ERRP funds.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1102(c)(4) 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:
	77 FR 59615	09/28/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 2480	01/11/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Survey of Plan Sponsors	CMS-10408, CMS-10408	ERRP Survey ,   Revised_Survey_Screenshots
Survey of Plan Sponsors (Private Entities)	CMS-10408, CMS-10408, CMS-10408	ERRP Survey of Plan Sponsors ,   REVISED ERRP Survey of Plan Sponsors 11-17-11 ,   Final Survey
Survey of Plan Sponsors (Public Entities)	CMS-10408, CMS-10408, CMS-10408	ERRP Survey of Plan Sponsors ,   REVISED ERRP Survey of Plan Sponsors 11-17-11 ,   Final Survey

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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	3,003	0	0	3,003	0	0
Annual Time Burden (Hours)	33,033	0	0	33,033	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The universe of sponsors that will be directed to respond, is much smaller, which accounts for much of the reduction in burden.

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Annual Cost to Federal Government: $30,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 01/25/2013

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