Medical Loss Ratio Annual Reports, MLR Notices, and Recordkeeping Requirements

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10418 Notice_#3_Group_Markets_Rebate_to_Subscribers	Form	New	Repair queued
Form CMS-10418 Notice_#2_Group_Markets_Rebate_to_Policyholder	Form	New	Available
Form CMS-10418 Notice_#1_to_Subscribers_in_Individual_Market	Form	New	Repair queued
Form CMS-10418 .MLR_Annual_Form	Form	New	Available
508CMS-10418_Crosswalk_for_Changes_to_MLR_Reporting_Form_and_Notices_.pdf	Supplementary Document	Uploaded 2012-04-16	Available
2012 0326 Responses to Comments for OMB FINAL-508.pdf	Supplementary Document	Uploaded 2012-04-16	Available
CMS-10418SupportingStatementOMBrevisionsSH (5-10-12@104pm)-1.docx	Supporting Statement A	Uploaded 2012-05-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201985	Retention of Records		New
201983	Notice of Rebate to Enrollees	Form	New	Notice_#3_Group_Markets_Rebate_to_Subscribers
201983	Notice of Rebate to Enrollees	Form	New	Notice_#2_Group_Markets_Rebate_to_Policyholder
201983	Notice of Rebate to Enrollees	Form	New	Notice_#1_to_Subscribers_in_Individual_Market
201983	Notice of Rebate to Enrollees	Instruction	New
201982	Disbursement of Rebate Checks		New
201981	Annual MLR Report	Form	New	.MLR_Annual_Form
201981	Annual MLR Report	Instruction	New

ICR Details

OMB Control No: 0938-1164	ICR Reference No: 201204-0938-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medical Loss Ratio Annual Reports, MLR Notices, and Recordkeeping Requirements
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/11/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/17/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2015	36 Months From Approved
Responses	9,936,664	0	0
Time Burden (Hours)	479,928	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This request includes the Medical Loss Ratio Annual Reports, MLR Notices, and Recordkeeping Requirements set out in Part 158 to Title 45 of the Code of Federal Regulations.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2718 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2718 Name of Law: Public Health Service Act

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 78265	12/16/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 20023	04/03/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Annual MLR Report	CMS-10418	.MLR_Annual_Form
Disbursement of Rebate Checks
Notice of Rebate to Enrollees	CMS-10418, CMS-10418, CMS-10418	Notice_#1_to_Subscribers_in_Individual_Market ,   Notice_#2_Group_Markets_Rebate_to_Policyholder ,   Notice_#3_Group_Markets_Rebate_to_Subscribers
Retention of Records

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ICR Summary of Burden

table that charts list 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	9,936,664	0	9,936,664	0	0	0
Annual Time Burden (Hours)	479,928	0	479,928	0	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.

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Annual Cost to Federal Government: $75,888

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 04/17/2012

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