Crosswalk

Permanent Residence street address (Don’t Page 2 enter a PO Box):
Section 1

IMPORTANT: Read and sign below:
Page 2 • I understand that people with Medicare
Section 1
are generally not covered under Medicare
while out of the country, except for limited
coverage near the U.S. border.

Current Location

Reason for Change

Type of Change

CY 2023 Model
MA/Part D
Enrollment
Request Form

Location on CY
2022 Enrollment
Form

Current CY 2022
MA/Part D
Enrollment Form

CMS-10718 CY 2022 - CY 2023 MEDICARE ADVATAGE AND MEDICARE PRECRIPTION DRUG PLAN ENROLLMENT FORM CROSSWALK

Individuals experiencing homelessness
•
If you want to join a plan but have no
permanent residence, a Post Office Box,
an address of a shelter or clinic, or the
address where you receive mail (e.g.,
social security checks) may be
considered your permanent residence
address.
Permanent Residence street address

Add To advance equity and address barriers to Cover page, page 1 enrollment, CMS added instructions to
Instructions
help individuals experiencing
homelessness, navigate enrollment in an
MA or Part D plan.

In addition to the information collected
on the request, the enrollment
mechanism must include information
indicating that the applicant
acknowledges specific information
regarding their enrollment--

Rev To align with requirements in subPage 2 - Section 1
regulatory guidance, the following bullets
were added: • I understand that I can be
enrolled in only one MA or Part D plan at
a time – and that enrollment in this plan
will automatically end my enrollment in
another MA or Part D plan (exceptions
apply for MA PFFS, MA MSA plans).

Rev There are limited exceptions to entering a Page 2 - Section 1
P.O. Box. A permanent residence address
is required to determine eligibility for a
plan in a defined service area, but for
individuals experiencing homelessness, a
P.O. Box is allowed for MA and/or Part
D enrollment.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Are you Hispanic, Latino/a, or Spanish
origin? Select all that apply.
____ No, not of Hispanic, Latino/a, or
Spanish origin
____Yes,
Mexican, Mexican American, Chicano/a
____ Yes, Puerto Rican
____ Yes, Cuban
____ Yes, another Hispanic, Latino, or
Spanish origin
____ I choose not to answer.
What’s your race? Select all that apply.
0 American Indian or Alaska Native
0 Asian Indian
0 Black or African American0 Chinese
0 Filipino
0 Guamanian or Chamorro0 Japanese
0 Korean
0 Native Hawaiian0 Other Asian
0 Other Pacific Islander
0 Samoan0 Vietnamese
0 White
0 I choose not to answer.

Add Added Ethnicity data based on the 2011 Page 3 - Section 2
HHS Data Standards for person-level data
collection and in accordance with
Executive Order 13985. Collecting and
maintaining demographic data in CMS
enrollment files allows for analyses
stratified by ethnicity to identify needed
improvements in health care, and for
identification of individuals or population
groups that might be the focus of
interventions designed to address health
Add Collecting voluntary self-reported race
Page 3 - Section 3
data based on the 2011 HHS Data
Standards for person-level data collection
and in accordance with Executive Order
13985. Collecting and maintaining
demographic data in CMS enrollment
files allows for analyses stratified by race
to identify needed improvements in health
care, and for identification of individuals
or population groups that might be the
focus of interventions designed to address
health care needs.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.