Information Collection

Medicare Disenrollee Survey - MA-PD

IC 194738 under ICR 201607-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10316 Medicare Disenrollee Survey - MA-PD Form
CMS-10316 Medicare Disenrollee Survey - MA PD Attachment VI MA-PD Survey revised 02-06-2017.pdf Form
Attachment I MA-PD Prenotification Letter .pdf MA-PDP - PRE NOTIFICATION LETTER IC Document
Attachment IV Wave 1 Cover Letter.pdf Wave 1 - SURVEY COVER LETTER IC Document
MAPD Crosswalk 508 revised.pdf Crosswalk - MA PD 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 Disenrollee Survey - MA-PD	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 - MA PD	Attachment VI MA-PD 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: 22,652	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	22,652	-39,179	61,831
Annual IC Time Burden (Hours)	5,210	-11,484	16,694
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
MA-PDP - PRE NOTIFICATION LETTER	Attachment I MA-PD Prenotification Letter .pdf	07/13/2016
Wave 1 - SURVEY COVER LETTER	Attachment IV Wave 1 Cover Letter.pdf	07/13/2016
Crosswalk - MA PD	MAPD Crosswalk 508 revised.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.