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Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202505-0938-017 · OMB 0938-1378 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
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 Modified Available
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.docx Supporting Statement A Uploaded 2025-05-29 Repair queued
CMS 10718 - Non-Sub Change Request Memo - May 2025.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-05-29 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
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 Unchanged
240723 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction Modified
240722 Election Process (MA organization) Form and Instruction Unchanged
240302 Election Process (Beneficiaries) Form and Instruction Modified
ICR Details
0938-1378 202505-0938-017
Received in OIRA 202504-0938-004
HHS/CMS CM-CPC
Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)
No material or nonsubstantive change to a currently approved collection   No
Regular 06/17/2025
  Requested Previously Approved
12/31/2026 12/31/2026
39,858,503 39,858,503
9,916,605 10,570,530
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.
PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
   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
   US Code: 42 USC 1395w-101 Name of Law: Part D Eligible Individuals and Prescription Drug Benefit
  
None
0938-AU96 Final or interim final rulemaking 89 FR 30448 04/23/2024
  87 FR 79452 12/27/2022
89 FR 30448 04/23/2024
No
  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 39,858,503 39,858,503 0 0 0 0
Annual Time Burden (Hours) 9,916,605 10,570,530 0 0 -653,925 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Due to the removal of fields related to sexual orientation, gender identity, race, and ethnicity from the MA and Part D enrollment form, we project a 2 minute (or 10%) reduction in time to complete the enrollment form. Using the reduced time that it takes for an individual to complete an enrollment form (18 minutes or 0.3 hr). These changes were made during the last PRA approval and the updated form resulted in a total of 653,925 hours saved annually,
$452
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.
06/17/2025