Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction	Unchanged	Repair queued
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	Form and Instruction	Unchanged	Repair queued
Form CMS-10718 Election Process (MA organization)	Form and Instruction	Unchanged	Repair queued
Form CMS-10718 Election Process (Beneficiaries)	Form and Instruction	Modified	Repair queued
CMS-10718_Supporting Statement_A (CMS-4190-F version 6).docx	Supporting Statement A	Uploaded 2020-08-18	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
242684	Part D Communication Requirements, Review and Distribution of Marketing Materials		Unchanged
242683	Medicare Advantage Communication Requirements Review and Distribution of Marketing Materials		Unchanged
240724	Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction	Unchanged
240723	Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	Form and Instruction	Unchanged
240722	Election Process (MA organization)	Form and Instruction	Unchanged
240302	Election Process (Beneficiaries)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1378	ICR Reference No: 202008-0938-002
Status: Received in OIRA	Previous ICR Reference No: 202003-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/18/2020

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2023
Responses	23,611,418	23,551,767
Time Burden (Hours)	7,706,944	7,687,080
Cost Burden (Dollars)	0	0

---

Abstract: As established by Section 1851 of the Act, and implementing regulations at §§ 422.50 and 422.60, an MA-eligible individual who meets the eligibility requirements for enrollment into an MA plan may enroll during the enrollment periods specified in §422.62, by completing an enrollment form with the MA organization or enrolling through other mechanisms that the Centers for Medicare & Medicaid Services (CMS) determines are appropriate. In addition, the authority for requiring this data collection for PDP enrollment is section 1860D-1 of the Act, and implementing regulations at §§ 423.30 and 423.32, a Part D-eligible individual who wishes to enroll in a Medicare Prescription Drug Plan (PDP) may enroll during the enrollment periods specified in §423.38, by completing an enrollment form with the PDP, or enrolling through other mechanisms CMS determines are appropriate. We are proposing changes to the current, standard (“long”) model enrollment form which will yield a beneficiary-focused model form to simplify the enrollment process.

---

Authorizing Statute(s): US Code: 42 USC 1395w–21 Name of Law: Part C- Medicare + Choice Program: Eligibility, Election and Enrollment
   US Code: 42 USC 1395w-101 Name of Law: Part D Eligible Individuals and Prescription Drug Benefit
   PL: Pub.L. 105 - 33 4001 Name of Law: Balanced Budget Act of 1997
   PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT97	Final or interim final rulemaking	85 FR 33796	06/02/2020

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 9002	02/18/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 33796	06/02/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Advantage Communication Requirements Review and Distribution of Marketing Materials
Part D Communication Requirements, Review and Distribution of Marketing Materials
Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	CMS-10718	Enrollment Form
Election Process (Beneficiaries)	CMS-10718	Enrollment Form
Election Process (MA organization)	CMS-10718	Enrollment Form
Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	CMS-10718	Enrollment Form

---

ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	23,611,418	23,551,767	0	59,651	0	0
Annual Time Burden (Hours)	7,706,944	7,687,080	0	19,864	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We are updating this collection of information request to account for changes to the number of Medicare-eligible beneficiaries estimated to make a valid enrollment request for calendar year (CY) 2021 through 2023 as set out in CMS-4190-F (RIN 0938-AT97) to include the MA Plan Options for End Stage Renal Disease (ESRD) Beneficiaries (§§422.50, 422.52, and 422.110) and the Contracting Standards for Dually-Eligible Special Needs Plan (D-SNP) Look-Alikes (§ 422.514). The ESRD provision adds 19,647 hours of burden while the D-SNP look-alike provision adds 218 hours for a total of 19,865 hours and $510,911.

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/18/2020

---