Notice of Rebate to Enrollees

Medical Loss Ratio Annual Reports, MLR Notices, and Recordkeeping Requirements (CMS-10418)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10418 Notice of Rebate to Enrollees Form
MLR Notice Instructions Optional-A-B.pdf Instruction
CMS-10418 MLR Notice 1 - Individual Market to Subscribers MLR Notice 1 Individual Market - to Subscribers Optional-A.docx Form
CMS-10418 MLR Notice 2 Group Markets - Rebate to Policyholder MLR Notice 2 Group Markets - Rebate to Policyholder.pdf Form
CMS-10418 MLR Notice 3 - Group Markets - Rebate to Subscribers MLR Notice 3 Group Markets - Rebate to Subscribers.pdf Form
CMS-10418 MLR Notice Individual Market to Subscribers Optional B MLR Notice 1 Individual Market - to Subscribers Optional-B.pdf Form

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10418	MLR Notice 1 - Individual Market to Subscribers	MLR Notice 1 Individual Market - to Subscribers Optional-A.docx	Yes	Yes	Fillable Printable
Form	CMS-10418	MLR Notice 2 Group Markets - Rebate to Policyholder	MLR Notice 2 Group Markets - Rebate to Policyholder.pdf	Yes	Yes	Fillable Printable
Form	CMS-10418	MLR Notice 3 - Group Markets - Rebate to Subscribers	MLR Notice 3 Group Markets - Rebate to Subscribers.pdf	Yes	Yes	Fillable Printable
Instruction			MLR Notice Instructions Optional-A-B.pdf	Yes	Yes	Paper Only
Form	CMS-10418	MLR Notice Individual Market to Subscribers Optional B	MLR Notice 1 Individual Market - to Subscribers Optional-B.pdf	Yes	Yes	Fillable Printable

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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	640,912	0	640,912
Annual IC Time Burden (Hours)	16,848	825	16,023
Annual IC Cost Burden (Dollars)	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.