Information Collection

Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316)

IC 194738 under ICR 201009-0938-015 · OMB 0938-1113.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1113 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10316 Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316)	Form and Instruction
CMS-10316 Medicare Disenrollee Survey (Stand Alone PDP and MAPD) Attachments 1 2 3 and 4_revised09 01 10.pdf	Form and Instruction

IC Title:

Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.156

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10316	Medicare Disenrollee Survey (Stand Alone PDP and MAPD)	Attachments 1 2 3 and 4_revised09 01 10.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	18,000	18,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.