OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 207675 under ICR 202407-0938-010 · OMB 0938-1113.

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Information Collection (IC) Details

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Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only) 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 MA PD Survey Attachment IV MA-PD Survey_.docx No   Fillable Printable
Form CMS-10316 MA Only Survey Attachment VI MA-Only Survey_.docx No   Fillable Printable
Form CMS-10316 MA Only_Spanish 2025_MA Only_508 compliant_Spanish_06-26-2024.pdf No   Fillable Printable
Form CMS-10316 MAPD_Spanish 2025_MAPD_508 compliant_Spanish_06-26-2024.pdf No   Fillable Printable
Form CMS-10316 MA-PD Survey_Traditional Chinese 2025 MA-PD Survey_508compliant_Traditional Chinese_06-18-25.pdf No   Fillable Printable
Form CMS-10316 MA-Only Survey_Traditional Chinese 2025 MA-Only Survey_508compliant_Traditional Chinese_06-18-25.pdf No   Fillable Printable
Form CMS-10316 MA-Only Survey_Vietnamese 2025 MA-Only Survey_Vietnamese_06-19-2025_508compliant.pdf No   Fillable Printable
Form CMS-10316 MA-PD Survey_Vietnamese 2025 MA-PD Survey_Vietnamese_06-19-2025_508compliant.pdf No   Fillable Printable

Health Health Care Services

 

32,045 0
   
Individuals or Households
 
   0 %

  Approved 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 32,045 0 3,045 0 0 29,000
Annual IC Time Burden (Hours) 6,089 0 -291 0 0 6,380
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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
MA_PD Disenrollment Survey crosswalk MA_PD Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf 07/12/2024
MA-ONLY Disenrollment Survey crosswalk MA-Only Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf 07/12/2024
Pre-Notification Letter Attachment I_Prenote_clean_12.15.2023_.docx 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
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_Traditional Chinese Wave2_Cover_Letter_clean_508compliant - Traditional Chinese_06-18-25.pdf 07/12/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.