Information Collection

Annual MLR Report

IC 201981 under ICR 201504-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10418 Annual MLR Report	Form and Instruction
CMS-10418 MLR Reporting Form 2014_MLR_Reporting_Form_4-03-2015.xlsx	Form and Instruction
CMS-10418 MLR Form Instructions 2014 MLR Form Instructions 4-02-2015.pdf	Form and Instruction

IC Title:

Annual MLR Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10418	MLR Reporting Form	2014_MLR_Reporting_Form_4-03-2015.xlsx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10418	MLR Form Instructions	2014 MLR Form Instructions 4-02-2015.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 522

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,394	0	3,394
Annual IC Time Burden (Hours)	212,361	-4,074	216,435
Annual IC Cost Burden (Dollars)	0	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.