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)

⚠️ Notice: This information collection may be referencing outdated material.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

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

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

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	11,668	-8,123	19,791
Annual IC Time Burden (Hours)	2,334	-2,416	4,750
Annual IC Cost Burden (Dollars)	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.