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Annual Report and Recordkeeping Requirements
Medical Loss Ratio (MLR) Report for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP) (CMS-10476)
OMB: 0938-1232
IC ID: 209359
OMB.report
HHS/CMS
OMB 0938-1232
ICR 201711-0938-013
IC 209359
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1232 can be found here:
2023-05-30 - Revision of a currently approved collection
2022-01-12 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
508_CMS-10476_Attachment_C_MLR_Report_Instructions.pdf
Instruction
CMS-10476 MLR Data Form
508_CMS-10476_Attachment_B_MLR_Data_Form.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Annual Report and Recordkeeping Requirements
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Instruction
508_CMS-10476_Attachment_C_MLR_Report_Instructions.pdf
Yes
No
Printable Only
Form
CMS-10476
MLR Data Form
508_CMS-10476_Attachment_B_MLR_Data_Form.pdf
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
587
Number of Respondents for Small Entity:
25
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
587
0
-29
0
0
616
Annual IC Time Burden (Hours)
21,158
0
-7,822
0
0
28,980
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.