Information Collection

Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version

IC 194737 under ICR 202304-0938-020 · 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⚠️ Notice: This information collection may be referencing outdated material.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, Stand Alone Prescription Drug Plan (PDP) Version	Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan Attachment V_Survey_PDP_508Compliant_v2.pdf	Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan Attachment V_Survey_PDP_508Compliant_v2.pdf	Form
Attachment I_Prenote_508Compliant.pdf PDP prenotification letter	IC Document
Attachment I_Prenote_508Compliant.pdf PDP prenotification letter	IC Document
Attachment II_Wave1_Cover_Letter_508Compliant.pdf Wave 1 cover letter	IC Document
Attachment II_Wave1_Cover_Letter_508Compliant.pdf Wave 1 cover letter	IC Document
Attachment III_Wave2_Cover_Letter_508Compliant.pdf Wave 2 cover letter	IC Document
Attachment III_Wave2_Cover_Letter_508Compliant.pdf Wave 2 cover letter	IC Document
PDP Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf PDP Disenrollment Survey crosswalk	IC Document
PDP Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf PDP Disenrollment Survey crosswalk	IC Document
Attachment VII_Year-to-Year Variability_02.08.2023_508Compliant.pdf memo on year-to-year variability	IC Document
Attachment VII_Year-to-Year Variability_02.08.2023_508Compliant.pdf memo on year-to-year variability	IC Document

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:

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 Prescriptopn Drug Plan	Attachment V_Survey_PDP_508Compliant_v2.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,750

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	3,750	-3,696	7,446
Annual IC Time Burden (Hours)	675	-665	1,340
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PDP prenotification letter	Attachment I_Prenote_508Compliant.pdf	04/26/2023
Wave 1 cover letter	Attachment II_Wave1_Cover_Letter_508Compliant.pdf	04/26/2023
Wave 2 cover letter	Attachment III_Wave2_Cover_Letter_508Compliant.pdf	04/26/2023
PDP Disenrollment Survey crosswalk	PDP Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf	04/26/2023
memo on year-to-year variability	Attachment VII_Year-to-Year Variability_02.08.2023_508Compliant.pdf	04/26/2023

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