Information Collection

Medicare Disenrollee Survey - MA

IC 207675 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.