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 Enrollment Form	Form and Instruction	Modified	Available
Form CMS-10718 Eligibility and Enrollment (Part D Sponsors)	Form and Instruction	Modified	Repair queued
Form CMS-10718 Enrollment Form	Form and Instruction	Modified	Available
Form CMS-10718 Eligibility and Enrollment (Beneficiaries)	Form and Instruction	Modified	Repair queued
Form CMS-10718 Enrollment Form	Form and Instruction	Modified	Available
Form CMS-10718 Election Process (MA Organizations)	Form and Instruction	Modified	Repair queued
Form CMS-10718 Enrollment Form	Form and Instruction	Modified	Repair queued
Form CMS-10718 MA Election Process (Beneficiaries)	Form and Instruction	Modified	Repair queued
CMS-10718_Supporting Statement_A_(CMS-4201-P_version_7).docx	Supporting Statement A	Uploaded 2023-01-25	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 (Part D Sponsors)	Form and Instruction	Modified	Enrollment Form
240724	Eligibility and Enrollment (Part D Sponsors)	Form and Instruction	Modified
240723	Eligibility and Enrollment (Beneficiaries)	Form and Instruction	Modified	Enrollment Form
240723	Eligibility and Enrollment (Beneficiaries)	Form and Instruction	Modified
240722	Election Process (MA Organizations)	Form and Instruction	Modified	Enrollment Form
240722	Election Process (MA Organizations)	Form and Instruction	Modified
240302	MA Election Process (Beneficiaries)	Form and Instruction	Modified	Enrollment Form
240302	MA Election Process (Beneficiaries)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1378	ICR Reference No: 202301-0938-013
Status: Historical Inactive	Previous ICR Reference No: 202205-0938-003
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
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 04/26/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/25/2023
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2024	36 Months From Approved	07/31/2024
Responses	34,026,743	0	34,026,743
Time Burden (Hours)	8,884,761	0	8,884,761
Cost Burden (Dollars)	0	0	0

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Abstract: This 2022 iteration proposes the to update certain reqirements and burden estimates based on our December 27, 2022 (87 FR 79452) proposed rule (CMS-4201-P; RIN 0938-AU96). See section 15 of this Supporting Statement for the net (+/-) changes. See section 12 for the results of the changes. Overall, this iteration increases our burden estimates by 49,559,296 responses (225,906 associated with CMS-4201-P + 49,333,390 non-rule corrections) and 9,795 hours (3,840 associated with CMS-4201-P + 5,955 non-rule corrections). Included is our Model Individual Enrollment Request Form to Enroll in a Medicare Advantage Plan (Part C) or Medicare Prescription Drug Plan (Part D). We are not proposing any changes to that form. The MA and Part D enrollment form needed to be in use for the 2023 Medicare Advantage Open Enrollment Period (MA-OEP) which begins January 1, 2023. CMS announced the release of the approved form on July 5, 2022 to allow plans and third-party vendors at least 6 calendar months to implement systems changes.

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Authorizing Statute(s): 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
   US Code: 42 USC 1395w-101 Name of Law: Part D Eligible Individuals and Prescription Drug Benefit
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU96	Proposed rulemaking	87 FR 79452	12/27/2022

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 79452	12/27/2022
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This 2022 iteration proposes the to update certain reqirements and burden estimates based on our December 27, 2022 (87 FR 79452) proposed rule (CMS-4201-P; RIN 0938-AU96). See section 15 of this Supporting Statement for the net (+/-) changes. See section 12 for the results of the changes. Overall, this iteration increases our burden estimates by 49,559,296 responses (225,906 associated with CMS-4201-P + 49,333,390 non-rule corrections) and 9,795 hours (3,840 associated with CMS-4201-P + 5,955 non-rule corrections).

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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

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Common Form ICR:  No

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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: 01/25/2023

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