Information Collection

Notice of Rebate to Enrollees

IC 201983 under ICR 201707-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Notice of Rebate to Enrollees	Form and Instruction
CMS-10418 MLR Notice 1 - Individual Market to Subscribers MLR Notice 1 Individual Market - to Subscribers.pdf	Form and Instruction
CMS-10418 MLR Notice 2 Group Markets - Rebate to Policyholder MLR Notice 2 Group Markets - Rebate to Policyholder.pdf	Form and Instruction
CMS-10418 MLR Notice 3 - Group Markets - Rebate to Subscribers MLR Notice 3 Group Markets - Rebate to Subscribers.pdf	Form and Instruction
CMS-10418 MLR Notice Instructions MLR Notice Instructions (2).pdf	Form and Instruction

IC Title:

Notice of Rebate to Enrollees

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10418	MLR Notice 1 - Individual Market to Subscribers	MLR Notice 1 Individual Market - to Subscribers.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10418	MLR Notice 2 Group Markets - Rebate to Policyholder	MLR Notice 2 Group Markets - Rebate to Policyholder.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10418	MLR Notice 3 - Group Markets - Rebate to Subscribers	MLR Notice 3 Group Markets - Rebate to Subscribers.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10418	MLR Notice Instructions	MLR Notice Instructions (2).pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 41

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	640,912	-218,848	859,760
Annual IC Time Burden (Hours)	16,023	-5,471	21,494
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.