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

OMB 0938-1378

OMB 0938-1378

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.

The latest form for Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718) expires 2023-07-31 and can be found here.

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Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10718Enrollment Form Fillable PrintableForm and instruction

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