Crosswalk of Changes

Appendix II: Crosswalk of Changes
Limited Wraparound Coverage Reporting
(CMS- 10571/OMB control number 0938-NEW)

Section
Edited
Purpose of
this Form
Section I
Section 4,
Part I, line
1(b)

Section 4,
Part I, line
2(a)
Section 5,
Part I, 2.b.
Glossary –
Additional
Benefits
Glossary Full-time
employee

Revision (Changes indicated in red)
Edited to say “…Employee Retirement Income
Security Act of 1974 (ERISA)……”
Edited to say “Fill out one form per Limited
Wraparound Coverage plan.”
Added “Plan Sponsors of plans that are not
subject to ERISA and that do not have plan
identification numbers should create a sequential
number for each Limited Wraparound Coverage
for which the Form is submitted.”
Added “If this plan covers the employees of
multiple employers, enter the name of the Plan
Sponsor.”
Edited to say “Plan Sponsor’s Employer
Identification Number (EIN)”
Edited to day “Examples include, but are not
limited to: …..”

Rationale
Edited for accuracy
Edited for accuracy
Clarification added to
address comment that
non-ERISA plans do not
have plan identification
numbers.
Clarification to address
comment that plan may
cover multiple employers.
Edited for accuracy.
Edited for accuracy.

Edited to say “Full-time employee means (1) for Edited for accuracy.
Limited Wraparound Coverage offered in
connection with Eligible individual health
insurance and/or BHP coverage: an employee
who is reasonably expected to work an average of
at least 30 hours of service per week; and (2) for
Limited Wraparound Coverage offered in
connection with a MSP: an employee who is
employed an average of at least 30 hours of
service per week with an employer who is not in
a limited non-assessment period for certain
employees, as defined in 26 C.F.R. § 54.4980H1(a)(26). See 26 C.F.R. § 54.4980H-1(a)(21).”