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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-1378
ICR Reference No:
202003-0938-002
Status:
Historical 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
Retrieve Notice of Action (NOA)
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
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.
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
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
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
Number of Information Collection (IC) in this ICR:
6
IC Title
Form No.
Form Name
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
Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)
CMS-10718
Enrollment Form
Medicare Advantage Communication Requirements Review and Distribution of Marketing Materials
Part D Communication Requirements, Review and Distribution of Marketing Materials
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.
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
Agency Contact:
Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov
Common Form ICR:
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:
(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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