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.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10316 Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only) | 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, Stand Alone Prescription Drug Plan (PDP) Version |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | 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
| 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.