CMS-10408 REVISED ERRP Survey of Plan Sponsors 11-17-11

ERRP

Early Retiree Reinsurance Program: Survey of Plan Sponsors

Centers for Medicare & Medicaid 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 -----------.. The time required to complete this information collection is estimated to average 11 hours, including the time to review instructions, search existing data resources, gather the data needed, and complete the survey. 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.

Survey of ERRP Plan Sponsors

I. Plan Sponsor Information

1. What is the name of the plan sponsor listed on your ERRP application? [Enter text]

2. What is the Application ID number assigned by the ERRP Center? [Enter text]

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

4. How many participants in the plan, represented in the ERRP application referenced in this survey, are “early retirees”, as defined in the ERRP statute, regulations, and other guidance? Please include spouses, surviving spouses, and dependents of early retirees. [Enter number]

II. Use of ERRP Reimbursements Already Received

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

a. 2010 [Enter percentage]

b. 2011 [Enter percentage]

c. 2012 [Enter percentage]

d. 2013 [Enter percentage]

e. 2014 [Enter percentage]

6. If your organization received ERRP funding in 2011, against which plan year’s costs did your organization apply, or against which plan year’s costs does your organization intend to apply this funding? (Select all that apply; dates below indicate plan years). For each

listed plan year, indicate the percentage of funds received in CY 2011 that were or will be applied in that plan year. If your organization did not receive any ERRP reimbursement in 2011, skip to question 7.

a. 2011 [Enter percentage]

b. 2012 [Enter percentage]

c. 2013 [Enter percentage]

d. 2014 [Enter percentage]

7. How has your organization used ERRP reimbursements received in CY2010 and/or CY2011? (Select all that apply) If your organization hasn’t yet used ERRP reimbursements, skip to question 12.

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

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

3. To reduce, or offset increases to, premium costs paid by individual plan participants.

4. To reduce, or offset increases to, individual plan participants’ overall deductibles

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

8. If you selected (a) in question 7, by how much have you been able to offset increases to your organization’s health benefit claim costs because of ERRP? [Enter the percentage of the total dollar cost increase that you have offset, for each plan year for which you have applied ERRP reimbursement. For any plan year for which you did not use the funds in the manner stated in 7(a), enter “n/a”.]

a. 2010 [Enter percentage]

b. 2011 [Enter percentage]

c. 2012 [Enter percentage]

9. If you selected (b) in question 7, by how much have you been able to offset increases to your organization’s health premium costs because of ERRP? [Enter the percentage of the total dollar cost increase that you have offset, for each plan year for which you have applied ERRP reimbursement. For any plan year for which you did not use the funds in this manner stated in 7(b), enter “n/a”.]

a. 2010 [Enter percentage]

b. 2011 [Enter percentage]

c. 2012 [Enter percentage]

10. If you selected (c) in question 7, by how much have you been able to reduce or offset increases to premium costs paid by individual plan participants’ because of ERRP? [Enter the implemented reduction in the dollar amount that individual plan participants pay or will pay in premium costs as a percentage of what the dollar amount would otherwise be, for each plan year for which you have applied ERRP reimbursement. For any plan year for which you did not use the funds in the manner stated in 7(c), enter “n/a”.]

a. 2010 [Enter percentage]

b. 2011 [Enter percentage]

c. 2012 [Enter percentage]

11. If you selected (d) in question 7, by how much have you been able to reduce or offset increases to individual plan participants’ overall deductibles because of ERRP? [Enter the implemented reduction in the dollar amount for individual plan participants’ overall deductibles as a percentage of what the dollar amount would otherwise be, for each plan year for which you have applied ERRP reimbursement. For any plan year for which you did not use the funds in the manner stated in 7(d), enter “n/a”.]

a. 2010 [Enter percentage]

b. 2011 [Enter percentage]

c. 2012 [Enter percentage]

III. Future Use of ERRP Reimbursements

12. How is your organization planning to use ERRP reimbursements received in CY2010 and/or CY2011? (Select all that apply).If your organization has already used all its ERRP reimbursements, and does not expect to receive any more, skip to question 17).

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

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

3. To reduce, or offset increases to, premium costs paid by individual plan participants.

4. To reduce, or offset increases to, individual plan participants’ overall deductibles

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

13. If you selected (a) in question 12, by how much do you project to offset increases to your organization’s health benefit claim costs because of ERRP? [Enter the percentage of the total dollar cost increase that you would project to offset, for each plan year for which you intend to apply ERRP reimbursement. For any plan year for which you do not intend to use the funds in the manner stated in 12(a), enter “n/a”. For any plan year for which you intend to use the funds in the manner stated in 12(a), but can’t project the offset in increases to your organization’s health benefit claim costs, enter “unknown”.]

a. 2011 [Enter percentage]

b. 2012 [Enter percentage]

c. 2013 [Enter percentage]

d. 2014 [Enter percentage]

14. If you selected (b) in question 12, by how much do you project to offset increases to your organization’s health premium costs because of ERRP? [Enter the percentage of the total dollar cost increase that you would project to offset, for each plan year for which you intend to apply ERRP reimbursement. For any plan year for which you do not intend to use the funds in the manner stated in 12(b), enter “n/a”. For any plan year for which you intend to use the funds in the manner stated in 12(b), but can’t project the offset in increases to your organization’s health premium costs, enter “unknown”.]

a. 2011 [Enter percentage]

b. 2012 [Enter percentage]

c. 2013 [Enter percentage]

d. 2014 [Enter percentage]

15. If you selected (c) in question 12, by how much do you project to reduce or offset increases to premium costs paid by individual plan participants’ because of ERRP? [Enter the projected reduction in the dollar amount that individual plan participants will pay in premium costs as a percentage of what the dollar amount would otherwise be, for each plan year for which you intend to apply ERRP reimbursement. For any plan year for which you do not intend to use the funds in the manner stated in 12(c), enter “n/a”. For any plan year for which you intend to use the funds in the manner stated in 12(c), but can’t project the reduction or offset in increases to premium costs paid by individual plan participants, enter “unknown.”]

a. 2011 [Enter percentage]

b. 2012 [Enter percentage]

c. 2013 [Enter percentage]

d. 2014 [Enter percentage]

16. If you selected (d) in question 12, by how much do you project to reduce or offset increases to individual plan participants’ overall deductibles because of ERRP? [Enter the projected reduction in the dollar amount for individual plan participants’ overall deductibles as a percentage of what the dollar amount would otherwise be, for each plan year for which you intend to apply ERRP reimbursement. For any plan year for which you do not intend to use the funds in the manner stated in 12(d), enter “n/a”. For any plan year for which you intend to use the funds in the manner stated in 12(d), but can’t project the reduction or offset in increases to individual plan participants’ overall deductibles, enter “unknown”.]

a. 2011 [Enter percentage]

b. 2012 [Enter percentage]

c. 2013 [Enter percentage]

d. 2014 [Enter percentage]

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