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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1113 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10316 Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan Attachment V_Survey_PDP_508Compliant_v2.pdf Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan Attachment V_Survey_PDP_508Compliant_v2.pdf Form
Attachment I_Prenote_508Compliant.pdf PDP prenotification letter IC Document
Attachment I_Prenote_508Compliant.pdf PDP prenotification letter IC Document
Attachment II_Wave1_Cover_Letter_508Compliant.pdf Wave 1 cover letter IC Document
Attachment II_Wave1_Cover_Letter_508Compliant.pdf Wave 1 cover letter IC Document
Attachment III_Wave2_Cover_Letter_508Compliant.pdf Wave 2 cover letter IC Document
Attachment III_Wave2_Cover_Letter_508Compliant.pdf Wave 2 cover letter IC Document
PDP Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf PDP Disenrollment Survey crosswalk IC Document
PDP Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf PDP Disenrollment Survey crosswalk IC Document
Attachment VII_Year-to-Year Variability_02.08.2023_508Compliant.pdf memo on year-to-year variability IC Document
Attachment VII_Year-to-Year Variability_02.08.2023_508Compliant.pdf memo on year-to-year variability IC Document

Information Collection (IC) Details

IC Title:	Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version	Agency IC Tracking Number:	CM-CPC

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.156

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan	Attachment V_Survey_PDP_508Compliant_v2.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,750	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,750	-3,696	7,446
Annual IC Time Burden (Hours)	675	-665	1,340
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
PDP prenotification letter	Attachment I_Prenote_508Compliant.pdf	04/26/2023
Wave 1 cover letter	Attachment II_Wave1_Cover_Letter_508Compliant.pdf	04/26/2023
Wave 2 cover letter	Attachment III_Wave2_Cover_Letter_508Compliant.pdf	04/26/2023
PDP Disenrollment Survey crosswalk	PDP Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf	04/26/2023
memo on year-to-year variability	Attachment VII_Year-to-Year Variability_02.08.2023_508Compliant.pdf	04/26/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.