CMS-10408 ERRP Survey

Sample Survey
For Reference
Purposes Only
PRA Disclosure Statement
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Baltimore, Maryland 21244-1850. Form Number: CMS-10408

Sample Survey – For Reference Purposes Only
1. Plan Sponsor Information
Read me first: Some questions include links to additional details or instructions to assist with
your response. Download sample survey.

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? (You may copy
and paste this 10-digit number from the survey email).

3. As of the day you are completing this survey, 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. Additional
details or instructions for Question 3 regarding the definition of early retiree.

4. As of the day you are completing this survey, how many early retirees does the
plan represented in the ERRP application referenced in this survey cover?
Please include early retirees and spouses, surviving spouses, and dependents of early retirees.
Additional details or instructions for Question 4 regarding the definition of early retiree.

2. Use of ERRP Reimbursements Already Received
5. If your organization received ERRP funding in calendar year (CY) 2010 for the
ERRP application referenced in this survey, against which plan year’s costs did your
organization apply (spend), or against which plan year’s costs does your
organization intend to apply (spend), this funding?
(If your organization did not receive any ERRP reimbursement in CY 2010, skip to Question 6.)
For each listed plan year, select from the drop-down box the percentage of funds received in
CY2010 that were or will be applied against costs for that plan year. Adding up the responses
for all plan years should total 100%. Additional details or instructions for Question 5 regarding
whether an organization received ERRP funding in CY 2010; the definition of plan year; how to
round partial percentages; how to respond if the percentage is between 0% and 1%; and how
to respond if, for a given plan year, your organization did not apply ERRP funds at all.
Plan Year 2010
Plan Year 2011
Plan Year 2012
Plan Year 2013
Plan Year 2014
Plan Year 2015

6. If your organization received ERRP funding in calendar year (CY) 2011 for the
ERRP application referenced in this survey, against which plan year’s costs did your
organization apply (spend), or against which plan year’s costs does your
organization intend to apply (spend), this funding?
(If your organization did not receive any ERRP reimbursement in CY 2011, skip to Question 7.)
For each listed plan year, select from the drop-down box the percentage of funds received in
CY2011 that were or will be applied against costs for that plan year. Adding up the responses
for all plan years should total 100%. Additional details or instructions for Question 6 regarding
whether an organization received ERRP funding in CY 2011; the definition of plan year; how to
round partial percentages; how to respond if the percentage is between 0% and 1%; and how
to respond if, for a given plan year, your organization did not apply ERRP funds at all.
Plan Year 2011
Plan Year 2012
Plan Year 2013
Plan Year 2014
Plan Year 2015

7. If your organization received ERRP funding in calendar year (CY) 2012 for the
ERRP application referenced in this survey, against which plan year’s costs did your
organization apply (spend), or against which plan year’s costs does your
organization intend to apply (spend), this funding?
(If your organization did not receive any ERRP reimbursement in CY 2012, skip to Question 8).
For each listed plan year, select from the drop-down box the percentage of funds received in CY
2012 that were or will be applied against costs for that plan year. Adding up the responses for
all plan years should total 100%. Additional details or instructions for Question 7 regarding
whether an organization received ERRP funding in CY 2012; the definition of plan year; how to
round partial percentages; how to respond if the percentage is between 0% and 1%; and how
to respond if, for a given plan year, your organization did not apply ERRP funds at all.
Plan Year 2012
Plan Year 2013
Plan Year 2014
Plan Year 2015

8. Please characterize how your organization has applied (spent) ERRP
reimbursements that your organization has already received for the ERRP
application referenced in this survey:
Spent all the reimbursements
Spent some but not all of the reimbursements
Spent none of the reimbursements yet

9. For each applicable plan year for which your organization or plan participants
experienced reductions, or offsets of increases, to costs, due to your organization
applying (spending) ERRP funds, select from the drop-down box the appropriate
percentages for how the funds were used to affect costs. For each listed use of funds
for which neither your organization nor plan participants experienced such offsets or reductions
in a listed plan year due to ERRP funds, please select “N/A”. Additional details or instructions for
Question 9 regarding how to calculate the percentages and round partial percentages.
PY2010

PY2011

PY2012

PY2013

a. To offset increases to
sponsor’s health benefit claim
costs (self-insured plan)
b. To offset increases to
sponsor’s health benefit premium
costs (fully insured plan)
c. To reduce, or offset increases
to, premium costs paid by
individual plan participants (selfinsured or fully-insured plan)
d. To reduce, or offset increases
to, individual plan participants’
overall deductibles

10. For each applicable plan year listed below, indicate whether or not your
individual plan participants experienced a reduction, or an offset of increases, to
copayments, coinsurance, or other out-of-pocket health benefit costs, due to the
application of (spending of) ERRP funds. Choose “yes” or “no” from the drop-down box,
for each plan year listed. For purposes of this question, benefit-specific deductibles, such as a
prescription drug deductible (as opposed to overall deductibles), are considered a type of “other
out-of-pocket health benefit costs.”
Yes or No
PY
PY
PY
PY

2010
2011
2012
2013

3. Future Use of ERRP Reimbursements Already Received
11. For each applicable plan year listed below, indicate for which plan years your
organization projects that it and/or its plan participants will experience reductions,
or offsets of increases to costs, due to your organization applying (spending) ERRP
funds it has already received but has not yet spent. Select from the drop-down
box the appropriate percentages for how your organization projects the funds will
be used to affect costs. For each listed use of funds for which your organization does not
project that it and/or its plan participants will experience such offsets or reductions in a listed
plan year due to ERRP funds, please select “N/A”. Additional details or instructions for Question
11 regarding how to calculate the percentages and round partial percentages.
PY 2010

PY2011

PY2012

PY2013

PY 2014

PY 2015

a. To offset increases to sponsor’s
health benefit claim costs (self-insured
plan)
b. To offset increases to sponsor’s
health benefit premium costs (fully
insured plan)
c. To reduce, or offset increases to,
premium costs paid by individual plan
participants (self-insured or
fully-insured plan)
d. To reduce, or offset increases to,
individual plan participants’ overall
deductibles

12. For each applicable plan year listed below, indicate whether or not your
organization projects that individual plan participants will experience a reduction,
or an offset of increases, to copayments, coinsurance, or other out-of-pocket health
benefit costs, due to the application of (spending of) ERRP funds. Choose “yes” or
“no” from the drop-down box, for each plan year listed. For purposes of this question, benefitspecific deductibles, such as a prescription drug deductible (as opposed to overall deductibles),
are considered a type of “other out-of-pocket health benefit costs.”
Yes or No
PY
PY
PY
PY
PY

2011
2012
2013
2014
2015

4. Submit Survey Responses
Thank you for completing the survey! If you would like to review or make copies of your
responses, click "Previous" button and print screenshots as needed.

Please click "Submit Survey" to submit your responses.

Instructions for Completing Early Retiree
Reinsurance Program Survey of Plan Sponsors

Instructions for Question 3 and 4
In general, an “early retiree” is a plan participant who is age 55 and older who is enrolled for
health benefits in a certified employment-based plan, who is not eligible for Medicare, and who
is not an active employee of an employer maintaining, or currently contributing to, the
employment-based plan or of any employer that has made substantial contributions to fund
such plan. An “early retiree” also includes the enrolled spouse, surviving spouse, and
dependents of such individuals. The complete ERRP definition of “early retiree” can be found in
the definition section of the ERRP regulations at 45 CFR 149.2. A copy of the regulations can be
found at www.errp.gov. There is additional information on the definition of early retiree in the
set of Common Questions designated "Early Retirees" which are also published on
www.errp.gov.
Return to Question 3

Return to Question 4

Instructions for Question 5, 6 and 7
An organization received ERRP funding in calendar year 2010, 2011, or 2012 if CMS transferred
ERRP funds to the organization’s bank account on any day within that calendar year. All
references to "plan year" in this survey refer to the sponsor's 12-month plan year based on the
cycle provided in the sponsor's ERRP application, which may not necessarily be a calendar year.
For purposes of this survey, a sponsor's 2010, 2011, 2012, 2013, 2014, or 2015 plan year refers
to its plan year that ends in that year, respectively. For example, a sponsor's plan year that
starts on January 1, 2011, and ends on December 31, 2011, would be considered its 2011 plan
year. A sponsor's plan year that starts on July 1, 2011, and ends on June 30, 2012, would be
considered its 2012 plan year.
Since the options provided in the drop-down box are whole numbers, the sponsor may have to
round to the nearest whole number. In general, a sponsor should round down if the sponsor’s
answer contains the 0.1-0.4 fraction of a percent, and round up if the answer contains the 0.50.9 fraction of a percent. If the percentage is greater than 0%, but less than 1%, select 1%.
However, the sponsor should ensure that all the selected numbers add up to 100. For example,
if a sponsor spent 49.5% for PY 2010, the sponsor should round up to 50%. However if the
sponsor also spent 50.5% for PY2011, the sponsor should round down so that the numbers
total 100. Select 0% if ERRP funds were not applied or will not be applied at all in a plan year.

Return to Question 5

Return to Question 6

Return to Question 7

Instructions for Question 9
For line a, select the percentage of the total dollar cost increase that you have offset, for each
plan year for which you have applied ERRP reimbursement in this manner. If the percentage is
greater than 0%, but less than 1%, select 1%. If the plan is fully insured, select “N/A” for each
plan year.
For line b, select the percentage of the total dollar cost increase that you have offset, for each
plan year for which you have applied ERRP reimbursement in this manner. If the percentage is
greater than 0%, but less than 1%, select 1%. If the plan is self-insured, select “N/A” for each
plan year.
For line c, select 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 in this
manner. If the percentage is greater than 0%, but less than 1%, select 1%. To the extent that
the impact of ERRP funds varies across plan participants, your answer should reflect a weighted
average. For example, consider a plan with 100 participants. Assume that premium
contributions paid by plan participants remained constant for 30 participants, decreased by 5%
of what they otherwise would be for 30 participants, and decreased by 10% of what they
otherwise would be for the remaining 40 participants. In this case, the weighted average of the
reduction to plan participants’ premium contributions, as a percentage of what they otherwise
would be, would be calculated as follows: [{(0x30) + (.05x30) + (.10x40)} / (30+30+40 =
0.055, which equates to 5.5%. If individual plan participants did not, do not, or will not pay any
premium costs for a given plan year, even absent the use of ERRP funds to reduce such costs,
select “N/A” for each plan year.
For line d, select 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 in this manner. If the percentage is
greater than 0%, but less than 1%, select 1%. The reference to "overall deductibles" refers to
single deductibles that apply across all a plan's benefits, as opposed to deductibles for a
discrete type or category of benefits. However, if a plan has a single deductible that applies
across all a plan's medical benefits, and a separate deductible that applies to prescription drugs,
the reference to "overall deductibles" refers to the single deductible that applies across all the
plan's medical benefits. To the extent that overall deductibles are or will be reduced, or
increases to deductibles are or will be offset, but not for all plan participants, and/or not equally
for all plan participants, your answer should reflect a weighted average. See sample weighted
average calculation in the Instruction for Question 9c. If individual plan participants did not, do
not, or will not be subject to an overall deductible for a given plan year, even absent the use of
ERRP funds to reduce such a deductible, select “N/A” for each plan year. For purposes of this
survey, benefit-specific deductibles, such as a prescription drug deductible (as opposed to

overall deductibles), are considered a type of “other out-of-pocket health benefit costs”
referenced in Question 10.
Return to Question 9

Instructions for Question 11
For line a, select 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 in this manner. If the
percentage is greater than 0%, but less than 1%, select 1%. If the plan is fully insured, select
“N/A” for each plan year.
For line b, select 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 in this manner. If the
percentage is greater than 0%, but less than 1%, select 1%. If the plan is self-insured, select
“N/A” for each plan year.
For line c, select 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 in this manner. If the
percentage is greater than 0%, but less than 1%, select 1%. To the extent that the impact of
ERRP funds varies across plan participants, your answer should reflect a weighted average. For
example, consider a plan with 100 participants. Assume that premium contributions paid by
plan participants are projected to remain constant for 30 participants, are projected to decrease
by 5% of what they otherwise would be for 30 participants, and are projected to decrease by
10% of what they otherwise would be for the remaining 40 participants. In this case, the
weighted average of the reduction to plan participants’ premium contributions, as a percentage
of what they otherwise would be, would be calculated as follows: [{(0x30) + (.05x30) +
(.10x40)} / (30+30+40)] = 0.055, which equates to 5.5%. If individual plan participants did
not, do not, or will not pay any premium costs for a given plan year, even absent the use of
ERRP funds to reduce such costs, select “N/A” for each plan year.
For line d, select 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 in this manner. If the percentage
is greater than 0%, but less than 1%, select 1%. The reference to "overall deductibles" refers
to single deductibles that apply across all a plan's benefits, as opposed to deductibles for a
discrete type or category of benefits. However, if a plan has a single deductible that applies
across all a plan's medical benefits, and a separate deductible that applies to prescription drugs,
the reference to "overall deductibles" refers to the single deductible that applies across all the
plan's medical benefits. To the extent that overall deductibles are projected to be reduced, or
increases to deductibles are projected to be offset, but not for all plan participants, and/or not
equally for all plan participants, your answer should reflect a weighted average. See sample
weighted average calculation in the Instruction for Question 11c. If individual plan participants
did not, do not, or will not be subject to an overall deductible for a given plan year, even absent

the use of ERRP funds to reduce such a deductible, select “N/A” for each plan year. For
purposes of this survey, benefit-specific deductibles, such as a prescription drug deductible (as
opposed to overall deductibles), are considered a type of “other out-of-pocket health benefit
costs” referenced in Question 12.
Return to Question 11