Medicare Prescription Drug Plan (PDP) and Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10316 Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316)	Form and Instruction	New	Available
Form CMS-10316 Medicare Prescription Drug Plan (PDP) Disenrollment Reasons Survey - (CMS-10316)	Form and Instruction	New	Available
SUPPORTING STATEMENT B.pdf	Supporting Statement B	Uploaded 2010-09-22	Available
Response_to_Public_Comments_09_02_10.pdf	Supplementary Document	Uploaded 2010-09-22	Available
Supporting Statement TOC.doc	Supplementary Document	Uploaded 2010-09-22	Available
Medicare Disenrollee Stand Alone PDP Crosswalk w response options.pdf	Supplementary Document	Uploaded 2010-09-22	Available
Medicare Disenrollee MA Crosswalk w response options.pdf	Supplementary Document	Uploaded 2010-09-22	Available
SUPPORTING STATEMENT A.doc	Supporting Statement A	Uploaded 2010-09-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
194738	Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316)	Form and Instruction	New
194737	Medicare Prescription Drug Plan (PDP) Disenrollment Reasons Survey - (CMS-10316)	Form and Instruction	New

ICR Details

OMB Control No: 0938-1113	ICR Reference No: 201009-0938-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Prescription Drug Plan (PDP) and Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey
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 without change	Conclusion Date: 11/19/2010
	Date Received in OIRA: 09/28/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2013	36 Months From Approved
Responses	120,000	0	0
Time Burden (Hours)	34,800	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection will survey disenrollees from Medicare Prescription Drug Plans (PDPs) and Medicare Advantage Prescription Drug Plans (MA-PDs). The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides a requirement to collect and report performance data for Part D prescription drug plans. Specifically, the MMA under Sec. 1860D-4 (Beneficiary Protections for Qualified Prescription Drug Coverage) requires CMS to conduct consumer satisfaction surveys regarding PDPs and MA-PDs - pursuant to section 1860D-4(d). This data collection complements the satisfaction data collected through the Medicare CAHPS Survey by providing dissatisfaction data in the form of reasons for disenrollment from PDPs and MA-PDs.

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Authorizing Statute(s): Statute at Large: 1 Stat. 1860 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 21295	04/23/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 57035	09/17/2010
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Prescription Drug Plan (PDP) Disenrollment Reasons Survey - (CMS-10316)	CMS-10316	Medicare Disenrollee Survey (Stand Alone PDP and MAPD)
Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316)	CMS-10316	Medicare Disenrollee Survey (Stand Alone PDP and MAPD)

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ICR Summary of Burden

table that charts list 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	120,000	0	0	120,000	0	0
Annual Time Burden (Hours)	34,800	0	0	34,800	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: CMS is implementing the disenrollment reasons survey to complement the information collected as part of the Medicare CAHPS survey that fulfills the MMA requirements specified in MMA section 1860D-4(d). Disenrollment is the ultimate measure of beneficiary dissatisfaction.

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Annual Cost to Federal Government: $2,462,540

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

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Common Form ICR:  No

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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: 09/28/2010

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