Information Collection

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

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⚠️ Notice: This information collection may be referencing outdated material.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

2024-07-25 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Form CMS-10316 Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only) Form
CMS-10316 MA PD Survey Attachment IV_Survey_MAPD_508Compliant.pdf Form
CMS-10316 MA PD Survey Attachment IV_Survey_MAPD_508Compliant.pdf Form
CMS-10316 MA Only Survey Attachment VI_Survey_MA-Only_508Compliant.pdf Form
CMS-10316 MA Only Survey Attachment VI_Survey_MA-Only_508Compliant.pdf Form
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
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
MA_PD Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf MA_PD Disenrollment Survey crosswalk IC Document
MA_PD Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf MA_PD Disenrollment Survey crosswalk IC Document
MA-Only Disenrollment Survey crosswalk_OMB_1.25.2023_508Compliant.pdf MA-ONLY Disenrollment Survey crosswalk IC Document
MA-Only Disenrollment Survey crosswalk_OMB_1.25.2023_508Compliant.pdf MA-ONLY Disenrollment Survey crosswalk IC Document
Attachment I_Prenote_508Compliant.pdf Pre-Notification Letter IC Document
Attachment I_Prenote_508Compliant.pdf Pre-Notification Letter IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10316	MA PD Survey	Attachment IV_Survey_MAPD_508Compliant.pdf		No		Fillable Printable
Form	CMS-10316	MA Only Survey	Attachment VI_Survey_MA-Only_508Compliant.pdf		No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 29,000	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	29,000	-7,426	36,426
Annual IC Time Burden (Hours)	6,380	-1,634	8,014
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
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
memo on year-to-year variability	Attachment VII_Year-to-Year Variability_02.08.2023_508Compliant.pdf	04/26/2023
MA_PD Disenrollment Survey crosswalk	MA_PD Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf	04/26/2023
MA-ONLY Disenrollment Survey crosswalk	MA-Only Disenrollment Survey crosswalk_OMB_1.25.2023_508Compliant.pdf	04/26/2023
Pre-Notification Letter	Attachment I_Prenote_508Compliant.pdf	04/26/2023

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