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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10418 Annual MLR Report Form and Instruction
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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10418	MLR Reporting Form	2019-MLR-Reporting-Form-PRA.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10418	MLR Form Instructions	CMS-10418-2019 MLR Form Instructions.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10418 - 2016-Risk-Corridor-Plan-Level-Instructions-x.pdf	Yes	Yes	Paper Only
Form	CMS-10418	Risk Corridors Plan Level Form	CMS-10418 - 2016-Risk-Corridors-Plan-Level-Form-x.xlsx	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 %

	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

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.