Private Company for Disbursement of checks

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⚠️ Notice: This information collection may be referencing outdated material.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 Private Company for Disbursement of checks Form
MLR Notice Instructions Optional-A-B.pdf Instruction
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 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 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 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
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:	Private Company for Disbursement of checks	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: 44	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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,912,240	1,271,328	640,912
Annual IC Time Burden (Hours)	47,807	30,959	16,848
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.