Medicare Disenrollee Survey - MA

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⚠️ Notice: This information collection may be referencing outdated material.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 Disenrollee Survey - MA Form
CMS-10316 Medicare Disenrollee Survey - MA Attachment VIII MA-Only Survey revised 02-06-2017.pdf Form
Attachment III MA-Only Prenotification Letter.pdf MA - PRE NOTIFICATION LETTER IC Document
Attachment IV Wave 1 Cover Letter.pdf Wave 1 - SURVEY COVER LETTER IC Document
MA Only Crosswalk 508 revised.pdf MA Survey 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 Disenrollee Survey - MA	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	Attachment VIII MA-Only 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	15,782	6,870
Annual IC Time Burden (Hours)	5,210	3,767	1,443
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
MA - PRE NOTIFICATION LETTER	Attachment III MA-Only Prenotification Letter.pdf	07/13/2016
Wave 1 - SURVEY COVER LETTER	Attachment IV Wave 1 Cover Letter.pdf	07/13/2016
MA Survey Crosswalk	MA Only 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.