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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 202512-0938-014 · OMB 0938-1378 · Received in OIRA

Forms and Documents
Document
Name
Status
Form and Instruction
 Modified
Form and Instruction
 Modified
Form and Instruction
 Modified
Form and Instruction
 Modified
Supporting Statement A
2025-12-16
Supplementary Document
2025-12-11
IC Document Collections
IC ID
Document
Title
Status
270344
Modified
242684
Modified
242683
Modified
240724 Modified
240723 Modified
240722 Modified
240302 Modified
ICR Details
0938-1378 202512-0938-014
Received in OIRA 202505-0938-017
HHS/CMS CM-CPC
Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)
Extension without change of a currently approved collection   No
Regular 12/16/2025
  Requested Previously Approved
36 Months From Approved 12/31/2026
49,153,959 39,858,503
12,240,174 9,916,605
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.
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
Not associated with rulemaking
  90 FR 45939 09/24/2025
90 FR 58248 12/16/2025
Yes
  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 49,153,959 39,858,503 0 582,028 8,713,428 0
Annual Time Burden (Hours) 12,240,174 9,916,605 0 174,608 2,148,961 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
Burden has increased due to updating this collection of information request to account for changes to administrative and cost estimates resulting from updated enrollment data and wage estimates.
$462
No
    Yes
    Yes
No
No
No
No
Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov
  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.
12/16/2025