OMB
.report
Search
Medicare Disenrollment Survey - Stand Alone PDP Version
Implementation of the Medicare Prescription Drug Plan (PDP) and Medicare Advantage (MA) Plan Disenrollment Reasons Survey (CMS-10316)
OMB: 0938-1113
IC ID: 194737
OMB.report
HHS/CMS
OMB 0938-1113
ICR 201607-0938-007
IC 194737
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1113 can be found here:
2024-07-25 - Revision of a currently approved collection
2023-05-01 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form CMS-10316
Medicare Disenrollment Survey - Stand Alone PDP Version
Form
CMS-10316 Medicare Disenrollee Survey: Prescription Drug Plan
Attachment VII Stand Alone PDP Survey revised 02-06-2017.pdf
Form
Attachment II PDP Prenotification Letter.pdf
PDP - PRE NOTIFICATION LETTER
IC Document
Attachment IV Wave 1 Cover Letter.pdf
Wave 1 - SURVEY COVER LETTER
IC Document
PDP Crosswalk 508.pdf
PDP Crosswalk
IC Document
Attachment V Wave 2 Cover Letter.pdf
Wave 2 - SURVEY COVER LETTER
IC Document
Attachment IX Plan Report Sample.pdf
Plan Report Sample
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Medicare Disenrollment Survey - Stand Alone PDP Version
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
42 CFR 423.156
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10316
Medicare Disenrollee Survey: Prescription Drug Plan
Attachment VII Stand Alone PDP Survey revised 02-06-2017.pdf
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
11,668
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
11,668
0
-8,123
0
0
19,791
Annual IC Time Burden (Hours)
2,334
0
-2,416
0
0
4,750
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
PDP - PRE NOTIFICATION LETTER
Attachment II PDP Prenotification Letter.pdf
07/13/2016
Wave 1 - SURVEY COVER LETTER
Attachment IV Wave 1 Cover Letter.pdf
07/13/2016
PDP Crosswalk
PDP Crosswalk 508.pdf
07/13/2016
Wave 2 - SURVEY COVER LETTER
Attachment V Wave 2 Cover Letter.pdf
07/13/2016
Plan Report Sample
Attachment IX Plan Report Sample.pdf
04/21/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.