OMB control number

Early Retiree Reinsurance Program

OMB 0938-1087 · HHS/CMS.

OMB 0938-1087

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10321 (149.335) - Documentation of Actual Medical Claims Involved Form
0938-1087Revised_CrosswalkofChanges[1][1].doc Justification for No Material/Nonsubstantive Change
RevisionstoPRAPackage200938-1087Overview[1].docx Supplementary Document
0938-1087Revised_SummaryBurdenEstimates[1].docx Supplementary Document
0938-1087Revised_CrosswalkofChanges[1].doc Supplementary Document
0938-1087.Revised_Supporting_Statement.doc Supporting Statement A
(149.700) - Reporting Change of Ownership
(149.610) - Requesting Reopenings Instruction
(149.600) - Reporting Previous Data Inaccuracies Instruction
(149.500 & 149.510) - Requesting Appeals Instruction
(149.350) Maintenance of Records
(149.335) - Documentation of Actual Medical Claims Involved Form
(149.40) - Updating Data in the Application Instruction
(149.35(b)(3)) - Procedures to Protect Against Fraud, etc.
(149.35(b)(2)) - Written Agreement with Issuer or Plan
Early Retiree Reinsurance Program Reopening Requests (Pub lic), for Program Years 2, 3, 4 Instruction
Early Retiree Reinsurance Program Appeals (Public), for Program Year 4 Instruction
Early Retiree Reinsurance Program Reopening Requests (Private), for Program Years 2, 3, 4 Instruction
Early Retiree Reinsurance Program Appeals (Public), for Program Years 2 and 3 Instruction
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 4 Instruction
Early Retiree Reinsurance Program Appeals (Private), for Program Year 4 Instruction
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 3 Instruction
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 2 Instruction
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 4 Instruction
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3 Instruction
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 2 Instruction
Early Retiree Reinsurance Program Appeals (Private), for Program Years 2 and 3 Instruction
Private Application Update Year 2_3_4 Instruction
Public Application Update Year 2_3_4 Instruction
Private Data Inaccuracies Years 2_3_4 Instruction
Private CHOW Years 2_3_4 Instruction
Public CHOW Years 2_3_4 Instruction
Public Data Inaccuracies Years 2_3_4 Instruction
Private Maintenance of Records Year 2_3_4 Instruction
Public Maintenance of Records Year 2_3_4 Instruction
Public Fraud and Abuse Procedures Years 2_3_4 Instruction
Private Fraud and Abuse Procedures Years 2_3_4 Instruction
Private Written Agreement Year 2_3_4 Instruction
Public Written Agreement Year 2_3_4 Instruction

All Historical Document Collections

201202-0938-004 Approved without change	Revision of a currently approved collection	2012-02-14
201106-0938-023 Approved with change	Revision of a currently approved collection	2011-06-29
201012-0938-015 Approved without change	Revision of a currently approved collection	2010-12-21
201009-0938-016 Approved without change	Revision of a currently approved collection	2010-09-29
201005-0938-012 Approved without change	No material or nonsubstantive change to a currently approved collection	2010-05-26
201004-0938-012 Approved with change	New collection (Request for a new OMB Control Number)	2010-04-29