CMS-10408 Final Survey

[PDF] CMS ERRP Survey 2011-11-28
1. Plan Sponsor Information

Important: Some questions include links to additional details or instructions to assist with your response. 

1. What is the name of the Plan Sponsor listed on your ERRP application?

2. What is the Application ID number assigned by the ERRP Center?

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.

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.
 Additional details or instructions for Question 4.

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[PDF] CMS ERRP Survey 2011-11-28
2. 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 CY2010 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. Additional details or instructions for Question 5 regarding
definition of plan year.
2010 (e.g. 10.5%)
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)
2013 (e.g. 10.5%)
2014 (e.g. 10.5%)

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 CY2011 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. Additional details or instructions for Question 6 regarding
definition of plan year.
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)
2013 (e.g. 10.5%)
2014 (e.g. 10.5%)

7. Please characterize how your organization has applied (spent) ERRP reimbursements
received in CY2010 and/or CY2011:
j Spent all the reimbursements
k
l
m
n

j Spent some but not all of the reimbursements
k
l
m
n
j Spent none of the reimbursements yet
k
l
m
n

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[PDF] CMS ERRP Survey 2011-11-28
3. Use of ERRP Reimbursements Already Received

8. How has your organization used ERRP reimbursements received in CY2010 and/or
CY2011?  Select all that apply. Additional details or instructions for Question 8. Please
answer all questions on this page. If any of questions 9­12 are not applicable, please enter
“n/a” in the first response box for that question.
c a. To offset increases to sponsor's health benefit claim costs (self­insured plan)
d
e
f
g

c b. To offset increases to sponsor's health benefit premium cost (fully insured plan)
d
e
f
g

c c. To reduce, or offset increases to, premium costs paid by individual plan participants
d
e
f
g
c d. To reduce, or offset increases to, individual plan participants' overall deductibles
d
e
f
g

c e. To reduce, or offset increases to, individual plan participants' copayments, coinsurance, or other out­of­pocket health benefit costs
d
e
f
g

9. If you selected (a) in Question 8, by how much have you been able to offset increases to
your organization’s health benefit claim costs (self­insured plan) 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 8(a), enter "n/a".
2010 (e.g. 10.5%)
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

10. If you selected (b) in Question 8, by how much have you been able to offset increases
to your organization’s health benefit premium costs (fully insured plan) 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 8(b), enter "n/a".
2010 (e.g. 10.5%)
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

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[PDF] CMS ERRP Survey 2011-11-28
11. If you selected (c) in Question 8, 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 8(c), enter "n/a".  Additional
details or instructions for Question 11.
2010 (e.g. 10.5%)
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

12. If you selected (d) in Question 8, 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 8(d), enter "n/a".  Additional details or
instructions for Question 12.
2010 (e.g. 10.5%)
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)

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[PDF] CMS ERRP Survey 2011-11-28
4. Future Use of ERRP Reimbursements Already Received

13. How is your organization planning to use ERRP reimbursements received in CY2010
and/or CY2011?  Select all that apply.  Additional details and instructions for Question 13.
Please answer all questions on this page. If any of questions 14­17 are not applicable,
please enter “n/a” in the first response box for that question.
c a. To offset increases to sponsor's health benefit claim costs (self­insured plan)
d
e
f
g

c b. To offset increases to sponsor's health benefit premium cost (fully insured plan)
d
e
f
g

c c. To reduce, or offset increases to, premium costs paid by individual plan participants
d
e
f
g
c d. To reduce, or offset increases to, individual plan participants' overall deductibles
d
e
f
g

c e. To reduce, or offset increases to, individual plan participants' copayments, coinsurance, or other out­of­pocket health benefit costs
d
e
f
g

14. If you selected (a) in Question 13, by how much do you project to offset increases to
your organization’s health benefit claim costs (self­insured plan) 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 13(a), enter "n/a". For any plan year for
which you intend to use the funds in the manner stated in 13(a), but can’t project the offset
in increases to your organization’s health benefit claim costs, enter "unknown".
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)
2013 (e.g. 10.5%)
2014 (e.g. 10.5%)

15. If you selected (b) in Question 13, by how much do you project to offset increases to
your organization’s health benefit premium costs (fully insured plan) 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 13(b), enter "n/a". For any plan
year for which you intend to use the funds in the manner stated in 13(b), but can’t project
the offset in increases to your organization’s health premium costs, enter "unknown".
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)
2013 (e.g. 10.5%)
2014 (e.g. 10.5%)

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[PDF] CMS ERRP Survey 2011-11-28
16. If you selected (c) in Question 13, 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 13(c), enter "n/a". For any plan
year for which you intend to use the funds in the manner stated in 13(c), but can’t project
the reduction or offset in increases to premium costs paid by individual plan participants,
enter "unknown".  Additional details or instructions for Question 16.
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)
2013 (e.g. 10.5%)
2014 (e.g. 10.5%)

17. If you selected (d) in Question 13, 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 13(d), enter "n/a". For any plan year
for which you intend to use the funds in the manner stated in 13(d), but can’t project the
reduction or offset in increases to individual plan participants’ overall deductibles, enter
"unknown".  Additional details or instructions for Question 17.
2011 (e.g. 10.5%)
2012 (e.g. 10.5%)
2013 (e.g. 10.5%)
2014 (e.g. 10.5%)

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[PDF] CMS ERRP Survey 2011-11-28
5. Submit Survey Responses

Thank you for completing the survey! Please click "Done" to submit your responses. 

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