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

Information Collection (IC) Details

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Medicare Disenrollment Survey - Stand Alone PDP Version
 
No Modified
 
Voluntary
 
42 CFR 423.156

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

Health Health Care Services

 

11,668 0
   
Individuals or Households
 
   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

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.

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