Information Collection

GenIC #87 (New): Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template

IC 276013 under ICR 202409-0938-028 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #87 Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template GenIC #87 (New): Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template	Form and Instruction
CMS-10398 #87 Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporti MLR Plan to State ReportingTemplate_FINAL.pdf	Form and Instruction
GenIC 87 - Generic Supporting Statement (2025 version 10).docx Generic Supporting Statement	IC Document

IC Title:

GenIC #87 (New): Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Mandatory

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
Form and Instruction	CMS-10398 #87				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	470	470
Annual IC Time Burden (Hours)	2,350	2,350
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		06/30/2025

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

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