Information Collection Request

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

ICR 202401-0938-002 · OMB 0938-1378 · Received in OIRA

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Document Name	Status
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction	Modified
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction	Modified
Form CMS-10718 Election Process (MA organization) Form and Instruction	Modified
Form CMS-10718 Election Process (Beneficiaries) Form and Instruction	Modified
CMS-10718_Supporting Statement_A - CY 2025.docx Supporting Statement A	2024-01-11
CMS Response to Public Comments - CMS-10718, OMB 0938-1378.docx Supplementary Document	2024-01-11
CMS 10718- CY 2025 Enrollment Form Crosswalk.pdf Supplementary Document	2024-01-11

IC Document Collections

IC ID	Document Title	Status
242684	Part D Communication Requirements, Review and Distribution of Marketing Materials	Modified
242683	Medicare Advantage Communication Requirements Review and Distribution of Marketing Materials	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
240722	Election Process (MA organization) Form and Instruction	Modified
240302	Election Process (Beneficiaries) Form and Instruction	Modified

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-1378
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202306-0938-006
Agency Tracking No	CM-CPC
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31