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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicare Disenrollee Survey, Medicare Advantage (MA-PD and MA-Only)
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
MA PD Survey
Attachment IV_Survey_MAPD_508Compliant.pdf
No
Fillable Printable
Form
CMS-10316
MA Only Survey
Attachment VI_Survey_MA-Only_508Compliant.pdf
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
29,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
29,000
0
-7,426
0
0
36,426
Annual IC Time Burden (Hours)
6,380
0
-1,634
0
0
8,014
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
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
memo on year-to-year variability
Attachment VII_Year-to-Year Variability_02.08.2023_508Compliant.pdf
04/26/2023
MA_PD Disenrollment Survey crosswalk
MA_PD Disenrollment Survey crosswalk_OMB__1.25.2023_508Compliant.pdf
04/26/2023
MA-ONLY Disenrollment Survey crosswalk
MA-Only Disenrollment Survey crosswalk_OMB_1.25.2023_508Compliant.pdf
04/26/2023
Pre-Notification Letter
Attachment I_Prenote_508Compliant.pdf
04/26/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.