Information Collection

Annual Reporting and Recordkeeping Requirements

IC 209359 under ICR 202305-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10476 MLR Report Workbook Annual Reporting and Recordkeeping Requirements	Form
Attachment C-CY 2023 MLR Reporting Instructions_final.docx	Instruction
Attachment C-CY 2023 MLR Reporting Instructions_final.docx	Instruction
CMS-10476 MLR Report Workbook Attachment B - CY2023 MLR Report Workbook_clean.pdf www.cms.gov/files/zip/cy2018-mlr-workbook-and-instructionszip	Form
CMS-10476 MLR Report Workbook Attachment B - CY2023 MLR Report Workbook_clean.pdf www.cms.gov/files/zip/cy2018-mlr-workbook-and-instructionszip	Form
Attachment B - CY2023 MLR Report Workbook_redline.docx Track Change: MLR Report Workbook	IC Document
Attachment C-CY 2023 MLR Reporting Instructions_redline.docx Track Change: MLR Report Filing Instructions	IC Document
Attachment C-CY 2023 MLR Reporting Instructions_redline (version 2).docx Track Change: MLR Report Filing Instructions	IC Document
Attachment B - CY2023 MLR Report Workbook_redline (version 2).docx Track Change: MLR Report Workbook	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					Yes	No	Printable Only
Form	CMS-10476			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: 601

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	601	0	14	587
Annual IC Time Burden (Hours)	36,748	15,084	505	21,159
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change: MLR Report Filing Instructions		09/26/2023
Track Change: MLR Report Workbook		09/26/2023

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

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