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Sample Survey
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For Reference
Purposes Only
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The following are the questions that appear in the online survey. The
associated instructions for each question are listed at the end of
all the questions in this sample. This document is for reference
purposes only; survey responses must be submitted to CMS through
the online survey.
PRA Disclosure Statement
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 0938-1150.
The time required to complete this information collection is estimated to average 11 hours per response, including the
time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. 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. Form Number: CMS-10408
OMB Approval 0938-1150
Sample Survey – For Reference Purposes Only
Plan Sponsor Information
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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).
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1. What is the name of the Plan Sponsor listed on your ERRP application?
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Read me first: Some questions include links to additional details or instructions to assist with your response. Download
sample survey [link will redirect to specific page on PWS].
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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.
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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.
Form #CMS-10408
Page 2
OMB Approval 0938-1150
Use of ERRP Reimbursements Already Received
0%
Plan Year 2012
0%
Plan Year 2013
0%
Plan Year 2014
0%
Plan Year 2015
0%
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Plan Year 2011
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0%
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Plan Year 2010
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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 CY 2010 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.
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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 CY 2011 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.
0%
Plan Year 2012
0%
Plan Year 2013
0%
Plan Year 2014
0%
Plan Year 2015
0%
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Plan Year 2011
Form #CMS-10408
Page 3
OMB Approval 0938-1150
0%
Plan Year 2013
0%
Plan Year 2014
0%
Plan Year 2015
0%
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Plan Year 2012
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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.
Spent all the reimbursements
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Spent none of the reimbursements yet
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Spent some but not all of the reimbursements
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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:
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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.
PY 2010
PY 2011
PY 2012
PY 2013
N/A
N/A
N/A
N/A
b. To offset increases to sponsor’s health benefit premium
costs (fully insured plan)
N/A
N/A
N/A
N/A
c. To reduce, or offset increases to, premium costs paid by
individual plan participants (self-insured or fully-insured plan)
N/A
N/A
N/A
N/A
d. To reduce, or offset increases to, individual plan
participants’ overall deductibles
N/A
N/A
N/A
N/A
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a. To offset increases to sponsor’s health benefit claim costs
(self-insured plan)
Form #CMS-10408
Page 4
OMB Approval 0938-1150
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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.”
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Yes or No
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Plan Year 2010
Plan Year 2011
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Plan Year 2012
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Plan Year 2013
Form #CMS-10408
Page 5
OMB Approval 0938-1150
Future Use of ERRP Reimbursements Already Received
PY 2010
PY 2011
PY 2012
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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 2013
PY 2014
PY 2015
N/A
N/A
N/A
N/A
N/A
N/A
b. To offset increases to sponsor’s health
benefit premium costs (fully insured plan)
N/A
N/A
N/A
N/A
N/A
N/A
c. To reduce, or offset increases to,
premium costs paid by individual plan
participants (self-insured or fully-insured
plan)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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N/A
N/A
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d. To reduce, or offset increases to,
individual plan participants’ overall
deductibles
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a. To offset increases to sponsor’s health
benefit claim costs (self-insured plan)
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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, 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
Plan Year 2011
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Plan Year 2012
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Plan Year 2013
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Plan Year 2014
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Plan Year 2015
Form #CMS-10408
Page 6
OMB Approval 0938-1150
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.
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Please click "Submit Survey" to submit your responses.
Form #CMS-10408
Page 7
OMB Approval 0938-1150
Instructions for Completing Early Retiree
Reinsurance Program Survey of Plan Sponsors
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Instructions for Questions 3 and 4
Return to Question 4
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Return to Question 3
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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.
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Instructions for Question 5, 6 and 7
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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.
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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 0.5-0.9 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 6
Return to Question 7
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Return to Question 5
Form #CMS-10408
Page 8
OMB Approval 0938-1150
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
Form #CMS-10408
Page 9
OMB Approval 0938-1150
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
Form #CMS-10408
Page 10
| File Type | application/pdf |
| File Title | Sample Survey 2012 for Reference Purposes Only |
| Subject | Sample Survey 2012 for Reference Purposes Only |
| Author | HHS/CMS/CCIIO |
| File Modified | 2012-09-11 |
| File Created | 2012-09-06 |