# Agency Information Collection Activities: Submission for OMB Review; Comment Request
**AGENCY:**
Centers for Medicare & Medicaid Services, Health and Human Services (HHS).
**ACTION:**
Notice.
**SUMMARY:**
The Centers for Medicare & Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (PRA), federal agencies are required to publish notice in the *Federal Register* concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, and to allow a second opportunity for public comment on the notice. Interested persons are invited to send comments regarding the burden estimate or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden.
**DATES:**
Comments on the collection(s) of information must be received by the OMB desk officer by January 15, 2026.
**ADDRESSES:**
Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to *www.reginfo.gov/public/do/PRAMain.* Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function.
To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, please access the CMS PRA website by copying and pasting the following web address into your web browser: *https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.*
**FOR FURTHER INFORMATION CONTACT:**
William Parham at (410) 786-4669.
**SUPPLEMENTARY INFORMATION:**
Under the Paperwork Reduction Act of 1995 (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 (44 U.S.C. 3506(c)(2)(A)) requires federal agencies to publish a 30-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 that summarizes the following proposed collection(s) of information for public comment.
1. *Type of Information Collection Request:* Revision with change 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:* Revision of a currently approved collection; *Title of Information Collection:* Annual Notice of Change and Evidence of Coverage for Applicable Integrated Plans in States that Require Integrated Materials; *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.
This information collection maintains standardized EOC and ANOC models for Dual Eligible Special Needs Plan (D-SNP) applicable integrated plans (AIPs), as defined at § 422.561, in certain States that chose to require that plans issue an integrated EOC and ANOC that covers the Medicare and Medicaid benefits. The models reflect revisions to the D-SNP models under CMS-10260 to include information on Medicaid benefits that State Medicaid agencies can customize. *Form Number:* CMS-10824 (OMB control number: 0938-1444); *Frequency:* Yearly; *Affected Public:* Private Sector, Business or other for profits; *Number of Respondents:* 109; *Total Annual Responses:* 109; *Total Annual Hours:* 1,308. (For policy questions regarding this collection contact Julie Jones at 312-353-9850 or *[email protected].* )
William N. Parham, III,
Director, Division of Information Collections and Regulatory Impacts, Office of Strategic Operations and Regulatory Affairs.