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

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Information Collection (IC) Details

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Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version CM-CPC
 
No Modified
 
Voluntary
 
42 CFR 423.156

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
Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Spanish) 2025_PDP_508 compliant_Spanish_06-26-2024.pdf No   Fillable Printable
Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Chinese) 2025 PDP Survey_508_compliant_Traditional Chinese_06-18-25.pdf No   Fillable Printable
Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Vietnamese) 2025 PDP Survey_Vietnamese_06-19-2025_508compliant.pdf No   Fillable Printable

Health Health Care Services

 

4,005 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,005 0 255 0 0 3,750
Annual IC Time Burden (Hours) 641 0 -34 0 0 675
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
PDP prenotification letter Attachment I_Prenote_clean_12.15.2023_.docx 07/12/2024
Wave 1 cover letter Attachment II_Wave1_Cover_Letter_clean_12.15.2023_.docx 07/12/2024
Wave 2 cover letter Attachment III_Wave2_Cover_Letter_clean.docx 07/12/2024
Memo on year-to-year variability Attachment VII_Year-to-Year Variability of Disenrollment Reason Scores_.docx 07/12/2024
Prenote_Traditional Chinese Prenote_508 compliant_Traditional Chinese_06-30-24.pdf 07/12/2024
Wave1_Cover_Letter_Traditional Chinese Wave1_Cover_Letter_508 compliant_Traditional Chinese_06-30-24.pdf 07/12/2024
Wave2_Cover_Letter_clean - Traditional Chinese Wave2_Cover_Letter_clean_508compliant - Traditional Chinese_06-18-25.pdf 07/12/2024
PDP Disenrollment Survey Crosswalk_ PDP Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf 07/12/2024
Prenote_Vietnamese 2025 Prenote_Vietnamese_07.01.2025_508compliant.pdf 07/12/2024
Wave1_Cover_Letter_Vietnamese 2025 Wave1_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf 07/12/2024
Wave2_Cover_Letter_Vietnamese 2025_Wave2_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf 07/12/2024
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