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

Forms and Documents

Document Name	Status
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction	New
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction	New
Form CMS-10718 Election Process (MA organization) Form and Instruction	New
Form CMS-10718 Election Process (Beneficiaries) Form and Instruction	New
CMS Response to Public Comments for CMS 10718_30 day PRA.docx Supplementary Document	2020-04-20
CMS-10718_Supporting Statement_Part CD Enroll - Clean 07142020.docx Supporting Statement A	2020-07-15
CMS Response to Public Comments (CMS-10718)_MA PDP FORM_DEEP rev.xlsx Supplementary Document	2020-03-05
CY 2021 MA PDP Enrollment Form- CMS 10718 Crosswalk Final rev.pdf Supplementary Document	2020-04-20

IC Document Collections

IC ID	Document Title	Status
242684	Part D Communication Requirements, Review and Distribution of Marketing Materials	New
242683	Medicare Advantage Communication Requirements Review and Distribution of Marketing Materials	New
240724	Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction	New
240723	Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction	New
240722	Election Process (MA organization) Form and Instruction	New
240302	Election Process (Beneficiaries) Form and Instruction	New

ICR Details

OMB Control No: 0938-1378	ICR Reference No: 202003-0938-002
Status: Active	Previous ICR Reference No:
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: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/17/2020
	Date Received in OIRA: 03/16/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved
Responses	23,551,767	0	0
Time Burden (Hours)	7,687,080	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
   US Code: 42 USC 1395w-101 Name of Law: Part D Eligible Individuals and Prescription Drug Benefit
   PL: Pub.L. 105 - 33 4001 Name of Law: Balanced Budget Act of 1997
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 63655	11/18/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 13163	03/06/2020
Did the Agency receive public comments on this ICR? Yes

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

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

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ICR Summary of Burden

	Total Approved	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	23,551,767	0	0	23,551,767	0	0
Annual Time Burden (Hours)	7,687,080	0	0	7,687,080	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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 is a new information collection.

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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: 03/16/2020

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