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

ICR 202304-0938-020

OMB: 0938-1113

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10316 Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only) Form	Modified
Form CMS-10316 Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version Form	Modified
supporting statement A_disenrollment reasons survey_.docx Supporting Statement A	2023-04-28
CMS-10316_supporting statement B_disenrollment reasons survey_.docx Supporting Statement B	2023-04-26
PDP Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf Supplementary Document	2023-04-26
MA-Only Disenrollment Survey crosswalk_OMB_1.25.2023_508Compliant.pdf Supplementary Document	2023-04-26
MA_PD Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf Supplementary Document	2023-04-26

IC Document Collections

IC ID	Document Title	Status
207675	Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only) Form	Modified
194737	Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version Form	Modified