Implementation of the Medicare Prescription Drug Plan (PDP) and Medicare

Forms and Documents

Document Name	Status
Form CMS-10316 Medicare Disenrollee Survey - MA (CMS-10316) Form	New
Form CMS-10316 Medicare Disenrollee Survey - MA-PD (CMS-10316) Form	Modified
Form CMS-10316 Medicare Disenrollment Survey - Stand Alone PDP Version (CMS-10316) Form	Modified
CMS-10316 - Supporting Statement part B.docx Supporting Statement B	2013-07-08
Revisions Disenrollment - Response to Comments to OMB (4)_062813.docx Supplementary Document	2013-07-08
Attachment 2 - SURVEY COVER LETTERS.docx Supplementary Document	2013-07-08
Attachment 1 - PRE NOTIFICATION LETTERS.docx Supplementary Document	2013-07-08
Crosswalk - MA PD.xlsx Supplementary Document	2013-07-08
Attachment 2 - SURVEY COVER LETTERS.docx Supplementary Document	2013-07-08
Attachment 1 - PRE NOTIFICATION LETTERS.docx Supplementary Document	2013-07-08
Crosswalk - PDP.xlsx Supplementary Document	2013-07-08
Attachment 2 - SURVEY COVER LETTERS.docx Supplementary Document	2013-07-08
Attachment 1 - PRE NOTIFICATION LETTERS.docx Supplementary Document	2013-07-08
CMS-10316 - Supporting Statement part A [rev 7-8-2013].docx Supporting Statement A	2013-07-08

IC Document Collections

IC ID	Document Title	Status
207675	Medicare Disenrollee Survey - MA (CMS-10316) Form	New
194738	Medicare Disenrollee Survey - MA-PD (CMS-10316) Form	Modified
194737	Medicare Disenrollment Survey - Stand Alone PDP Version (CMS-10316) Form	Modified

ICR Details

OMB Control No: 0938-1113	ICR Reference No: 201307-0938-003
Status: Historical Active	Previous ICR Reference No: 201009-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: 19956
Title: Implementation of the Medicare Prescription Drug Plan (PDP) and Medicare
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/24/2013
	Date Received in OIRA: 07/09/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2016	36 Months From Approved	11/30/2013
Responses	88,492	0	120,000
Time Burden (Hours)	22,887	0	34,800
Cost Burden (Dollars)	0	0	0

---

Abstract: 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.

---

Authorizing Statute(s): Statute at Large: 1 Stat. 1860 Name of Statute: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 23566	04/19/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 40482	07/05/2013
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Medicare Disenrollee Survey - MA-PD (CMS-10316)	CMS-10316	Medicare Disenrollee Survey - MA PD
Medicare Disenrollee Survey - MA (CMS-10316)	CMS-10316	Medicare Disenrollee Survey - MA
Medicare Disenrollment Survey - Stand Alone PDP Version (CMS-10316)	CMS-10316	Medicare Disenrollee Survey: Prescription Drug Plan

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	88,492	120,000	0	-31,508	0	0
Annual Time Burden (Hours)	22,887	34,800	0	-11,913	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Implementation of the survey for 2012 through 2014 will differ from the earlier large-scale field test, which excluded the small number of MA only plans. The MA only plan survey has been added to this ICR. In addition to adding the MA only survey, the number of responses for the PDP survey has decreased from 60,000 to 19,791 and the hours have decreased from 16,800 to 4,750 hr. While the MA-PD survey has a slight increase in the number of responses from 60,000 to 61,831, the response time decreased from .3 hr to .27 hr and a number of hours has decreased from 18,000 to 16,694 hr. Overall, this ICR reduces the number of respondents from 120,000 to 88,492 and reduces the burden hours from 34,800 to 22,887 hr.

---

Annual Cost to Federal Government: $2,462,540

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/09/2013

---