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

ICR 202205-0938-003

OMB: 0938-1378

Federal Form Document

ICR Details
0938-1378 202205-0938-003
Received in OIRA 202008-0938-002
HHS/CMS CM-CPC
Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)
Revision of a currently approved collection   No
Regular 05/09/2022
  Requested Previously Approved
36 Months From Approved 07/31/2023
32,215,990 23,614,183
8,594,910 7,707,864
0 0

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.

US Code: 42 USC 1395w-101 Name of Law: Part D Eligible Individuals and Prescription Drug Benefit
   US Code: 42 USC 1395w–21 Name of Law: Part C- Medicare + Choice Program: Eligibility, Election and Enrollment
   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
  
None

Not associated with rulemaking

  87 FR 1752 01/12/2022
87 FR 26759 05/05/2022
Yes

  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 32,215,990 23,614,183 0 0 8,601,807 0
Annual Time Burden (Hours) 8,594,910 7,707,864 0 0 887,046 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Burden has increased due to an increase in MA/MA-PDP/stand-alone PDP sponsors and enrollments processed. Burden has also increased due to to the expanded enrollment options for individuals with ESRD, we estimated an aggregate annual increase of 19,647 hours for ESRD beneficiaries to enroll in MA plans per year in 2021 through 2023. For the contracting standards for dual eligible special needs plan (D-SNP) look-alikes, we estimated an aggregate annual enrollee burden increase of 218 hours. For the Medical Loss Ratio (MLR) deductible factor for MA Medical Savings Account (MSA) contracts, we estimated an aggregate annual increase of 922 hours for a beneficiary to complete an enrollment form.

$0
No
    Yes
    Yes
No
No
No
No
Stephan McKenzie 410 786-1943 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/09/2022


© 2022 OMB.report | Privacy Policy