Information Collection

Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)

IC 207675 under ICR 202003-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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, Medicare Advantage (MA-PD and MA-Only)	Form
CMS-10316 MA PD Survey Attachment VI_ MA PD Survey_508.pdf	Form
CMS-10316 MA Only Survey Attachment VIII_ MA Only Survey_508.pdf	Form
Attachment I_ MAPD prenotification letter_lp_9.16.2019 508.pdf MAPD prenotification letter	IC Document
Attachment III_MA Only prenotification letter_lp_9.16.2019 508.pdf MA Only 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
Attachment X_memo on year-to-year variability_508_FINAL.pdf memo on year-to-year variability	IC Document
MA_PD Disenrollment Survey crosswalk_OMB_508FINAL.pdf MA_PD Disenrollment Survey crosswalk	IC Document
MA-ONLY Disenrollment Survey crosswalk_OMB__508FINAL.pdf MA-ONLY Disenrollment Survey crosswalk	IC Document

IC Title:

Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)

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:

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	MA PD Survey	Attachment VI_ MA PD Survey_508.pdf		No		Fillable Printable
Form	CMS-10316	MA Only Survey	Attachment VIII_ MA Only 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: 36,426

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	36,426	13,774	22,652
Annual IC Time Burden (Hours)	8,014	2,804	5,210
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MAPD prenotification letter	Attachment I_ MAPD prenotification letter_lp_9.16.2019 508.pdf	03/23/2020
MA Only prenotification letter	Attachment III_MA Only 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
memo on year-to-year variability	Attachment X_memo on year-to-year variability_508_FINAL.pdf	03/23/2020
MA_PD Disenrollment Survey crosswalk	MA_PD Disenrollment Survey crosswalk_OMB_508FINAL.pdf	03/23/2020
MA-ONLY Disenrollment Survey crosswalk	MA-ONLY Disenrollment Survey crosswalk_OMB__508FINAL.pdf	03/23/2020

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