Information Collection

Annual Reporting and Recordkeeping Requirements

IC 209359 under ICR 202001-0938-011 · OMB 0938-1232.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1232 can be found here:

Documents and Forms

Document Name Document Type
508_CMS-10476_Attachment_C_MLR_Report_Instructions.pdf.pdf Instruction
CMS-10476 MLR Data Form 508_CMS-10476_Attachment_B_MLR_Data_Form.pdf.pdf www.cms.gov/files/zip/cy2018-mlr-workbook-and-instructionszip. Form
508_CMS-10476_Attachment_C_Instructions Crosswalk.pdf.pdf Crosswalk: Instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Reporting 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.pdf		Yes	No	Printable Only
Form	CMS-10476	MLR Data Form	508_CMS-10476_Attachment_B_MLR_Data_Form.pdf.pdf	https://www.cms.gov/files/zip/cy2018-mlr-workbook-and-instructionszip.	Yes	Yes	Fillable Printable

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	587	0	587
Annual IC Time Burden (Hours)	21,159	1	21,158
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk: Instructions	508_CMS-10476_Attachment_C_Instructions Crosswalk.pdf.pdf	03/05/2020

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