Information Collection

Notice of Rebate to Enrollees

IC 201983 under ICR 201204-0938-004 · OMB 0938-1164.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1164 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
508CMS-10418_MLR_Rebate_Notice_Instructions.pdf	Instruction
2012 0510 MLR Rebate Notice Instructions FINAL.docx	Instruction
2012 0510 Guidance re Rebate Notices FINAL.docx	Instruction
CMS-10418 Notice_#1_to_Subscribers_in_Individual_Market 508CMS-10418_Notice_#1_to_Subscribers_in_Individual_Market.pdf	Form
CMS-10418 Notice_#2_Group_Markets_Rebate_to_Policyholder 508CMS-10418_Notice_#2_Group_Markets_Rebate_to_Policyholder.pdf	Form
CMS-10418 Notice_#3_Group_Markets_Rebate_to_Subscribers 508CMS-10418_Notice_#3_Group_Markets_Rebate_to_Subscribers.pdf	Form

IC Title:

Notice of Rebate to Enrollees

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 158

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			2012 0510 MLR Rebate Notice Instructions FINAL.docx	Yes	No	Fillable Fileable
Instruction			2012 0510 Guidance re Rebate Notices FINAL.docx	Yes	No	Fillable Fileable
Form	CMS-10418	Notice_#1_to_Subscribers_in_Individual_Market	508CMS-10418_Notice_#1_to_Subscribers_in_Individual_Market.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10418	Notice_#2_Group_Markets_Rebate_to_Policyholder	508CMS-10418_Notice_#2_Group_Markets_Rebate_to_Policyholder.pdf	Yes	No	Fillable Fileable
Form	CMS-10418	Notice_#3_Group_Markets_Rebate_to_Subscribers	508CMS-10418_Notice_#3_Group_Markets_Rebate_to_Subscribers.pdf	Yes	No	Fillable Fileable
Instruction			508CMS-10418_MLR_Rebate_Notice_Instructions.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 177

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	7,205,139	7,205,139
Annual IC Time Burden (Hours)	58,897	58,897
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.