Private Company for Disbursement of checks

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

Documents and Forms

Document Name Document Type
Form CMS-10418 Private Company for Disbursement of checks Form
2022 MLR Form Instructions.pdf Instruction
2022 MLR Form Instructions.pdf Instruction
CMS-10418 MLR Notice 1 - Individual Market to Subscribers MLR Notice 1 Individual Market- Rebate to Subsribers.pdf Form
CMS-10418 MLR Notice 1 - Individual Market to Subscribers MLR Notice 1 Individual Market- Rebate to Subsribers.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 2 Group Markets - Rebate to Policyholder CMS-10418 - MLR-Notice-2-Group-Markets-Rebate-to-Policyholderf.docx 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- Rebate to Subsribers.pdf	Yes	Yes	Fillable Printable
Form	CMS-10418	MLR Notice 2 Group Markets - Rebate to Policyholder	CMS-10418 - MLR-Notice-2-Group-Markets-Rebate-to-Policyholderf.docx	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			2022 MLR Form Instructions.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: 62	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	994,046	-918,194	1,912,240
Annual IC Time Burden (Hours)	24,851	-22,956	47,807
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.