View Information Collection Request (ICR) Package
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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:
202301-0938-013
Status:
Historical Inactive
Previous ICR Reference No:
202205-0938-003
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:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Comment filed on proposed rule and continue
Conclusion Date:
04/26/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/25/2023
Terms of Clearance:
In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
07/31/2024
36 Months From Approved
07/31/2024
Responses
34,026,743
0
34,026,743
Time Burden (Hours)
8,884,761
0
8,884,761
Cost Burden (Dollars)
0
0
0
Abstract:
This 2022 iteration proposes the to update certain reqirements and burden estimates based on our December 27, 2022 (87 FR 79452) proposed rule (CMS-4201-P; RIN 0938-AU96). See section 15 of this Supporting Statement for the net (+/-) changes. See section 12 for the results of the changes. Overall, this iteration increases our burden estimates by 49,559,296 responses (225,906 associated with CMS-4201-P + 49,333,390 non-rule corrections) and 9,795 hours (3,840 associated with CMS-4201-P + 5,955 non-rule corrections). Included is our Model Individual Enrollment Request Form to Enroll in a Medicare Advantage Plan (Part C) or Medicare Prescription Drug Plan (Part D). We are not proposing any changes to that form. The MA and Part D enrollment form needed to be in use for the 2023 Medicare Advantage Open Enrollment Period (MA-OEP) which begins January 1, 2023. CMS announced the release of the approved form on July 5, 2022 to allow plans and third-party vendors at least 6 calendar months to implement systems changes.
Authorizing Statute(s):
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
PL:
Pub.L. 108 - 173 101
Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
US Code:
42 USC 1395w-101
Name of Law: Part D Eligible Individuals and Prescription Drug Benefit
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
0938-AU96
Proposed rulemaking
87 FR 79452
12/27/2022
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
87 FR 79452
12/27/2022
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
6
IC Title
Form No.
Form Name
Election Process (MA Organizations)
CMS-10718
Enrollment Form
Eligibility and Enrollment (Beneficiaries)
CMS-10718
Enrollment Form
Eligibility and Enrollment (Part D Sponsors)
CMS-10718
Enrollment Form
MA Election Process (Beneficiaries)
CMS-10718
Enrollment Form
Medicare Advantage Communication Requirements Review and Distribution of Marketing Materials
Part D Communication Requirements, Review and Distribution of Marketing Materials
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 2022 iteration proposes the to update certain reqirements and burden estimates based on our December 27, 2022 (87 FR 79452) proposed rule (CMS-4201-P; RIN 0938-AU96). See section 15 of this Supporting Statement for the net (+/-) changes. See section 12 for the results of the changes. Overall, this iteration increases our burden estimates by 49,559,296 responses (225,906 associated with CMS-4201-P + 49,333,390 non-rule corrections) and 9,795 hours (3,840 associated with CMS-4201-P + 5,955 non-rule corrections).
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:
Mitch Bryman 410 786-5258 Mitch.Bryman@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:
01/25/2023
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