Information Collection

Annual MLR Report

IC 201981 under ICR 202011-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10418 MLR Reporting Form Annual MLR Report	Form and Instruction
Form CMS-10418 MLR Form Instructions Annual MLR Report	Form and Instruction
Form CMS-10418 Risk Corridors Plan Level Form Annual MLR Report	Form
CMS-10418 - 2016-Risk-Corridor-Plan-Level-Instructions-x.pdf	Instruction
CMS-10418 - 2016-Risk-Corridor-Plan-Level-Instructions-x.pdf	Instruction
CMS-10418 MLR Reporting Form 2019-MLR-Reporting-Form-PRA.xlsx	Form and Instruction
CMS-10418 MLR Reporting Form 2019-MLR-Reporting-Form-PRA.xlsx	Form and Instruction
CMS-10418 MLR Form Instructions CMS-10418-2019 MLR Form Instructions.pdf	Form and Instruction
CMS-10418 MLR Form Instructions CMS-10418-2019 MLR Form Instructions.pdf	Form and Instruction
CMS-10418 Risk Corridors Plan Level Form CMS-10418 - 2016-Risk-Corridors-Plan-Level-Form-x.xlsx	Form
CMS-10418 Risk Corridors Plan Level Form CMS-10418 - 2016-Risk-Corridors-Plan-Level-Form-x.xlsx	Form

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10418	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10418	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Paper Only
Form	CMS-10418	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 494

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,897	-545	2,442
Annual IC Time Burden (Hours)	119,401	-31,636	151,037
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.

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