Early Retiree Reinsurance Program: Survey of Plan Sponsors

Forms and Documents

Document Name	Status
Form CMS-10408 Survey of Plan Sponsors (Private Entities) Form	New
Form CMS-10408 Survey of Plan Sponsors (Public Entities) Form	New
CMS-10408_ERRP_Survey_Email_to_Sponsors_11_17_11_FINAL.docx Supplementary Document	2011-11-28
CMS-10408.Public Comment 11_17_11.docx Supplementary Document	2011-11-17
CMS-10408 ERRP Survey of Plan Sponsors_Supporting Statement Part B_11-17-11_FINAL.docx Supporting Statement B	2011-11-17
CMS-10408.Emergency_Justification - (11-10-11).doc Supplementary Document	2011-11-10
CMS-10408 REVISED _ Supporting Statement Part A (11-17-11).docx Supporting Statement A	2011-11-17

IC Document Collections

IC ID	Document Title	Status
200146	Survey of Plan Sponsors (Private Entities) Form	New
200145	Survey of Plan Sponsors (Public Entities) Form	New

ICR Details

OMB Control No: 0938-1150	ICR Reference No: 201111-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Early Retiree Reinsurance Program: Survey of Plan Sponsors
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 11/18/2011
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/01/2011
	Date Received in OIRA: 11/10/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2012	6 Months From Approved
Responses	2,076	0	0
Time Burden (Hours)	22,836	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This is a survey of plan sponsors participating in the Early Retiree Reinsurance Program (ERRP) about how and when plan sponsors have used, or intend to use, ERRP funds.

Emergency Justfication: Please see the attached emergency justification.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1102(c)(4) Name of Law: Reinsurance for early retirees.
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1102(c)(4) Name of Law: Reinsurance for early retirees

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Survey of Plan Sponsors (Public Entities)	CMS-10408	Final Survey
Survey of Plan Sponsors (Private Entities)	CMS-10408	Final Survey

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,076	0	0	2,076	0	0
Annual Time Burden (Hours)	22,836	0	0	22,836	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $18,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/10/2011

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