Form CMS-10408 ERRP Survey of Plan Sponsors

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 0938-XXXX.. 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.

OMB Control Number: 0938-XXXX
Form Number: CMS-10408

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 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]
4. 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, and spouses, surviving spouses, and dependents. [Enter number]
II. Use of ERRP Reimbursements
5. Against which plan year’s costs did your organization apply, or against which plan year’s
costs does your organization plan to apply, any ERRP funding received in calendar year 2010?
(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 CY 2010, 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. Against which plan year’s costs did your organization apply, or against which plan year’s
costs does your organization plan to apply, any ERRP funding received in calendar year 2011?
(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 CY
2011, skip to question 7.
a. 2011 [Enter percentage]
b. 2012 [Enter percentage]
c. 2013 [Enter percentage]
d. 2014 [Enter percentage]

OMB Control Number: 0938-XXXX
Form Number: CMS-10408

7. How has your organization used ERRP reimbursements received in calendar years 2010
and/or 2011? (Select all that apply) If your organization hasn’t yet used ERRP reimbursements,
skip to question 12.
a. Offset increases to sponsor’s health benefit claim costs (self-insured plan)
b. Offset increases to sponsor’s health benefit premium cost (fully insured plan)
c. Reduce, or offset increases to, premium costs paid by individual plan participants.
d. Reduce, or offset increases to, individual plan participants’ overall deductibles
e. 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”. ]
2010
2011
2012
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”. ]
2010
2011
2012
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”]
2010
2011
2012
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]
2010
2011
2012

OMB Control Number: 0938-XXXX
Form Number: CMS-10408

12. How is your organization planning to use ERRP reimbursements received in calendar years
2010 and/or 2011? (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).
a. Offset increases to sponsor’s health benefit claim costs (self-insured plan)
b. Offset increases to sponsor’s health benefit premium cost (fully insured plan)
c. Reduce, or offset increases to, premium costs paid by individual plan participants.
d. Reduce, or offset increases to, individual plan participants’ overall deductibles
e. 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 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”. ]
2011
2012
2013
2014
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 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”.]
2011
2012
2013
2014
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”]
2011
2012
2013
2014

OMB Control Number: 0938-XXXX
Form Number: CMS-10408

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”;]
2011
2012
2013
2014
17. ERRP requires plan sponsors participating in ERRP to have 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. Which conditions do these programs
target and how much cost savings do you estimate that your organization has saved or will save
as a result of these programs and procedures, for the most recently completed plan year from
which data is available? [Enter condition list, enter dollar amount, enter plan year]

III. Future Benefit Changes and Impact of ERRP

18. Before ERRP, how likely was your organization to terminate early retiree coverage?
a. Not likely
b. Somewhat likely
c. Very likely

19. Has ERRP affected your organization’s decisions about making premium and/or cost
sharing changes to your plan in the future?
a. Not at all
b. Somewhat
c. Moderately
d. Significantly
20. Has ERRP deferred a decision to terminate coverage for early retirees? If yes, by how
many plan years?
a. Yes, by one plan year
b. Yes, by two plan years or more
b. No

OMB Control Number: 0938-XXXX
Form Number: CMS-10408