Information Collection Request

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

ICR 202504-0938-004 · OMB 0938-1378 · Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1378 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction	Modified	Available
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction	Modified	Repair queued
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	Form and Instruction	Modified	Available
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	Form and Instruction	Modified	Repair queued
Form CMS-10718 Election Process (MA organization)	Form and Instruction	Modified	Repair queued
Form CMS-10718 Election Process (MA organization)	Form and Instruction	Modified	Repair queued
Form CMS-10718 Election Process (Beneficiaries)	Form and Instruction	Modified	Repair queued
Form CMS-10718 Election Process (Beneficiaries)	Form and Instruction	Modified	Repair queued
CMS 10718 - Non-Sub Change Request Memo - February 2025 jms edits v2.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-04	Available
CMS 10718 - Non-Sub Change Request Memo - February 2025 jms edits v2.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-04	Repair queued
CMS-10718_Supporting Statement_A clean v2.docx	Supporting Statement A	Uploaded 2025-04-04	Available
CMS-10718_Supporting Statement_A clean v2.docx	Supporting Statement A	Uploaded 2025-04-04	Repair queued

IC Document Collections

IC ID	Collection	Type	Status
270344	Required Notice for Reinstatements Based on Beneficiary Cancellation of New Enrollment		Unchanged
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	Modified
240724	Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction	Modified
240723	Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	Form and Instruction	Modified
240723	Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	Form and Instruction	Modified
240722	Election Process (MA organization)	Form and Instruction	Modified
240722	Election Process (MA organization)	Form and Instruction	Modified
240302	Election Process (Beneficiaries)	Form and Instruction	Modified
240302	Election Process (Beneficiaries)	Form and Instruction	Modified

ICR Details

Status	Active
Agency/Subagency	HHS/CMS
OMB Control No	0938-1378
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202408-0938-020
Agency Tracking No	CM-CPC
Date Submitted to OIRA	2025-04-07
Requested Expiration Date	1969-12-31