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
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
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.
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)
CMS-10718_Supporting Statement_A.docx
Required Notice for Reinstatements Based on Beneficiary Cancellation of New Enrollment