OMB control number

Implementation of the Medicare Prescription Drug Plan (PDP) and Medicare Advantage (MA) Plan Disenrollment Reasons Survey (CMS-10316)

OMB 0938-1113 · HHS/CMS.

OMB 0938-1113

This information collection will survey disenrollees from Medicare Prescription Drug Plans (PDPs) and Medicare Advantage Prescription Drug Plans (MA-PDs). The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides a requirement to collect and report performance data for Part D prescription drug plans. Specifically, the MMA under Sec. 1860D-4 (Beneficiary Protections for Qualified Prescription Drug Coverage) requires CMS to conduct consumer satisfaction surveys regarding PDPs and MA-PDs - pursuant to section 1860D-4(d). This data collection complements the satisfaction data collected through the Medicare CAHPS Survey by providing dissatisfaction data in the form of reasons for disenrollment from PDPs and MA-PDs.

The latest form for Implementation of the Medicare Prescription Drug Plan (PDP) and Medicare Advantage (MA) Plan Disenrollment Reasons Survey (CMS-10316) expires 2027-11-30 and is listed under ICR 202407-0938-010.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form CMS-10316 MA-PD Survey_Vietnamese	Form
Form CMS-10316 MA-Only Survey_Vietnamese	Form
Form CMS-10316 MA-Only Survey_Traditional Chinese	Form
Form CMS-10316 MA-PD Survey_Traditional Chinese	Form
Form CMS-10316 MAPD_Spanish	Form
Form CMS-10316 MA Only_Spanish	Form
Form CMS-10316 MA Only Survey	Form
Form CMS-10316 MA PD Survey	Form
Form CMS-10316 Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Vietnamese)	Form
Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Chinese)	Form
Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Spanish)	Form
Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan	Form
Form CMS-10316 Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version	Form
Supporting statement A_disenrollment survey_.docx	Supporting Statement A
Supporting statement B_disenrollment survey.docx	Supporting Statement B
Response to Public Comments_May 2024_final_clean.docx	Supplementary Document
PDP Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf	Supplementary Document
MA-Only Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf	Supplementary Document
MA_PD Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf	Supplementary Document
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)	Form
Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version	Form
Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version	Form
Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version	Form
Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version	Form
Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version	Form

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202407-0938-010	Revision of a currently approved collection	2024-07-25
202304-0938-020	Revision of a currently approved collection	2023-05-01	Approved without change
202003-0938-016	Revision of a currently approved collection	2020-03-24	Approved with change
201607-0938-007	Revision of a currently approved collection	2016-07-14	Approved with change
201307-0938-003	Revision of a currently approved collection	2013-07-09	Approved without change
201009-0938-015	New collection (Request for a new OMB Control Number)	2010-09-28	Approved without change

OMB Details

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

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
Form	Name	Electronic access	Type
Form CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan	Fillable Printable	Form
Form CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan (Vietnamese)	Fillable Printable	Form
Form CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan (Chinese)	Fillable Printable	Form
Form CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan (Spanish)	Fillable Printable	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.