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

Agency Information Collection Activities: Proposed Collection; Comment Request

DATES:

Comments must be received by November 24, 2025.

SUPPLEMENTARY INFORMATION:

Contents

This notice sets out a summary of the use and burden associated with the following information collections. More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES ).

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

CMS-10611-Medicare Outpatient Observation Notice (MOON)

CMS-10260-Medicare Advantage and Prescription Drug Program

Under the PRA (44 U.S.C. 3501-3520), federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. The term "collection of information" is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA requires federal agencies to publish a 60-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for approval. To comply with this requirement, CMS is publishing this notice.

Information Collections

1. Type of Information Collection Request: Revision with of a currently approved collection; Title of Information Collection: Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form; Use: The enrollment form is considered a "model" under Medicare regulations at §§ 422.2267 and 423.2267, for purposes of communication and marketing review and approval; therefore, MA and Part D plans are able to modify the language, format, or order of the enrollment form. The model enrollment form includes the minimal amount of information to process the enrollment, located in Section 1 of the MA/PDP enrollment form, and other limited information, in Section 2, that the sponsor is required ( i.e., accessible format preference) or chooses ( i.e., premium payment information) to provide to the beneficiary. The optional data elements, which aids the MA and Part D plan in processing the enrollment, is developed for efficiency for the plan. Plan sponsors can obtain information at the initial point of contact to help streamline the beneficiary's enrollment process. The optional questions include information specific to the plan's business needs that serves to reduce overall burden and allow for timely processing of an enrollment request. All data elements in Section 2 are optional for the beneficiary to complete. Plan enrollment will not be affected if the beneficiary does not complete this additional information. Form Number: CMS-10718 (OMB control number 0938-1378); Frequency: Occasionally; Affected Public: Individuals and Households, Private sector and Business or other for-profits; Number of Respondents: 24,464,437; Number of Responses: 49,917,959; Total Annual Hours: 12,240,174. (For questions regarding this collection, contact: AnhViet Nguyen at (667) 290-9745 or [email protected] ).

2. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Hospital Notice: Medicare Outpatient Observation Notice (MOON); Use: The Medicare Outpatient Observation Notice (MOON), serves as the written notice component of this mandatory notification process. The standardized content of the MOON includes all informational elements required by statute, in language understandable to beneficiaries, and fulfils the regulatory requirements at 42 CFR part 489.20(y).

The MOON is a standardized notice delivered to people entitled to Medicare benefits under Title XVIII of the Act who receive more than 24 hours of observation services, informing them that their hospital stay is outpatient and not inpatient, and the implications of being an outpatient. Form Number: CMS-10611 (OMB control number 0938-1308); Frequency: Annually; Affected Public: Private sector, Business or other for-profits and Not-for-profits institutions; Number of Respondents: 5,817; Number of Responses: 2,073,991; Total Annual Hours: 518,498. (For questions regarding this collection, contact: Katherine Hosna at 410-786-4993 or [email protected] ).

3. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Medicare Advantage and Prescription Drug Program; Use: CMS requires MA organizations and Part D sponsors to use the standardized documents being submitted for OMB approval to satisfy disclosure requirements mandated by section 1851 (d)(3)(A) of the Act and § 422.111 for MA organizations and section 1860D-1(c) of the Act and § 423.128(a)(3) for Part D sponsors.

The regulatory provisions at §§ 422.111(b) and 423.128(b) require MA organizations and Part D sponsors to disclose plan information, including: service area, benefits, access, grievance and appeals procedures, and quality improvement/assurance requirements. MA organizations and sponsors may send the ANOC separately from the EOC but must send the ANOC for enrollee receipt by September 30. The required due date for the EOC is 15 days prior to the start of the AEP. Form Number: CMS-10260 (OMB control number 0938-1051); Frequency: Annually; Affected Public: Private sector and Business or other for-profits; Number of Respondents: 712; Number of Responses: 45,996; Total Annual Hours: 12,316. (For questions regarding this collection, contact: Lauren Yeary at (410) 786-3211 or [email protected] ).