Information Collection

Medicare Advantage Surveys

IC 8404 under ICR 201505-0938-006 · OMB 0938-0732.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0732 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-246 Medicare Advantage Surveys	Form and Instruction
CMS-R-246 Medicare Advantage Prescription Drug Survey MA-PD Survey.pdf	Form and Instruction
CMS-R-246 Medicare Advantage Plan Survey MA-only Survey.pdf	Form and Instruction
MA-PD survey crosswalk.pdf Crosswalk - MA PD Survey	IC Document
MA-only survey crosswalk.pdf Crosswalk - MA Survey	IC Document

IC Title:

Medicare Advantage Surveys

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 417.472 42 CFR 422.152 42 CFR 422.156

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-R-246	Medicare Advantage Prescription Drug Survey	MA-PD Survey.pdf		No		Fillable Printable
Form and Instruction	CMS-R-246	Medicare Advantage Plan Survey	MA-only Survey.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Privacy Act of 1974: HPMS # 09-70-4004

FR Citation: 63 FR 43187

Number of Respondents: 427,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	427,200	427,200
Annual IC Time Burden (Hours)	170,880	170,880
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - MA PD Survey	MA-PD survey crosswalk.pdf	06/03/2015
Crosswalk - MA Survey	MA-only survey crosswalk.pdf	06/03/2015

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