Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (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⚠️ Notice: This information collection may be referencing outdated material.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 Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan Attachment VII_ PDP Survey_508.pdf Form
Attachment II_ PDP prenotification letter_lp_9.16.2019 508.pdf PDP prenotification letter IC Document
Attachment IV_wave 1 cover letter_7.30.19 508.pdf Wave 1 cover letter IC Document
Attachment V_wave 2 cover letter_lp_9.23.2019 508.pdf Wave 2 cover letter IC Document
Attachment IX_redacted plan report example_09.20.2019 508.pdf Plan report example IC Document
PDP Disenrollment Survey crosswalk_OMB__508FINAL.pdf PDP Disenrollment Survey crosswalk IC Document
Attachment X_memo on year-to-year variability_508_FINAL.pdf memo on year-to-year variability IC Document

Information Collection (IC) Details

IC Title:	Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version	Agency IC Tracking Number:	CM-CPC

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 Prescriptopn Drug Plan	Attachment VII_ PDP Survey_508.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,446	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,446	-4,222	11,668
Annual IC Time Burden (Hours)	1,340	-994	2,334
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
PDP prenotification letter	Attachment II_ PDP prenotification letter_lp_9.16.2019 508.pdf	03/23/2020
Wave 1 cover letter	Attachment IV_wave 1 cover letter_7.30.19 508.pdf	03/23/2020
Wave 2 cover letter	Attachment V_wave 2 cover letter_lp_9.23.2019 508.pdf	03/23/2020
Plan report example	Attachment IX_redacted plan report example_09.20.2019 508.pdf	03/23/2020
PDP Disenrollment Survey crosswalk	PDP Disenrollment Survey crosswalk_OMB__508FINAL.pdf	03/23/2020
memo on year-to-year variability	Attachment X_memo on year-to-year variability_508_FINAL.pdf	03/23/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.