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)

OMB: 0938-1113

IC ID: 194737

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 V_Survey_PDP_508Compliant_v2.pdf Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Spanish) 2025_PDP_508 compliant_Spanish_06-26-2024.pdf Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Chinese) 2025 PDP Survey_508_compliant_Traditional Chinese_06-18-25.pdf Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Vietnamese) 2025 PDP Survey_Vietnamese_06-19-2025_508compliant.pdf Form
Attachment I_Prenote_clean_12.15.2023_.docx PDP prenotification letter IC Document
Attachment II_Wave1_Cover_Letter_clean_12.15.2023_.docx Wave 1 cover letter IC Document
Attachment III_Wave2_Cover_Letter_clean.docx Wave 2 cover letter IC Document
Attachment VII_Year-to-Year Variability of Disenrollment Reason Scores_.docx Memo on year-to-year variability IC Document
Prenote_508 compliant_Traditional Chinese_06-30-24.pdf Prenote_Traditional Chinese IC Document
Wave1_Cover_Letter_508 compliant_Traditional Chinese_06-30-24.pdf Wave1_Cover_Letter_Traditional Chinese IC Document
Wave2_Cover_Letter_clean_508compliant - Traditional Chinese_06-18-25.pdf Wave2_Cover_Letter_clean - Traditional Chinese IC Document
PDP Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf PDP Disenrollment Survey Crosswalk_ IC Document
2025 Prenote_Vietnamese_07.01.2025_508compliant.pdf Prenote_Vietnamese IC Document
2025 Wave1_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf Wave1_Cover_Letter_Vietnamese IC Document
2025_Wave2_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf Wave2_Cover_Letter_Vietnamese IC Document