SNP-OMB text 8_23.Supporting Statement A & B

I. SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT
SUBMISSIONS

A. BACKGROUND
As part of the Evaluation of Medicare Advantage Special Needs Plans (SNPs), the Centers
for Medicare & Medicaid Services (CMS) intends to conduct a “Mail Survey of Medicare
Advantage Special Needs Plans” and “Focus Groups with Enrollees in Medicare Advantage
Special Needs Plans.” The survey will collect data on all SNPs operating in 2006. The survey
will be conducted by mail, with a telephone followup to SNPs that do not return the mail
questionnaire. It will gather uniform information that is not available through other CMS sources
such as the Health Plan Management System (HPMS) and SNP applications. Information
obtained through the mail survey includes: plan organization and reasons for offering the SNP;
financial arrangements with providers and structure of the plan’s prescription drug benefit;
approaches to enrolling members; services provided to members with special needs; use of
technology and recordkeeping; and issues related to serving Medicaid beneficiaries. Results will
be combined with other sources of data to produce profiles of the structure and operation of these
plans. The focus groups will collect data on the experiences of Medicare beneficiaries enrolled in
SNPs, such as reasons for enrolling in SNPs and use of special plan services. Focus groups of
approximately 10 beneficiaries each will be conducted at 15 plans as part of a case study of
SNPs. The focus groups will provide the only information to CMS’s evaluation of beneficiary
experiences in SNPs.

B. JUSTIFICATION
1.

Need and Legal Basis

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003
(P.L. 108-173) allows Medicare Advantage (MA) plans to specialize in serving Medicare
beneficiaries who: are dually enrolled in state Medicaid programs, reside in nursing facilities or
similar institutions, or have severe or disabling chronic conditions (Section 231). This legislation
requires the Secretary of the Department of Health and Human Services (DHHS) to submit to
Congress, by the end of 2007, a report that “assesses the impact of specialized MA plans for
special needs individuals on the cost and quality of services provided to enrollees.” This report
will also describe the operation of SNPs and the services they provide, as presented by plan
representatives and as perceived by enrollees.
CMS is developing profiles of all MA SNPs in order to describe the structure and operation
of these plans in 2006. The Mail Survey of Medicare Advantage Special Needs Plans will gather
information about SNPs that is not available from other sources such as applications and plan
benefit materials submitted to CMS. As part of their application process to CMS, SNPs
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submitted applications with basic plan information and plan benefit packages (PBPs) with
detailed information on benefits. However, these materials do not provide information on issues
such as the motivation for becoming a SNP, information on care coordination, use of electronic
medical records and collection of quality measures. In addition, a preliminary review of the
application materials suggests that their completeness varies considerably across plans. Because
site visits and conversations with every SNP plan to collect this information are not feasible
under budget constraints, this brief survey serves as a cost-efficient way to collect uniform,
additional data on SNPs.
CMS’s evaluation will also include more in-depth case studies of about 15 SNPs. As part of
the site visits to these plans, CMS intends to conduct focus groups with beneficiaries about their
experiences, such as their decision to join a SNP, their use of special plan benefits, and their
satisfaction with the plan. The focus groups will provide the only direct information on
beneficiary experiences to the evaluation, since CMS does not plan to conduct a beneficiary
survey of SNP enrollees. Focus groups will allow in-depth discussion of issues not easily elicited
in a survey, and will also allow discussion of topics of importance to SNP enrollees that might
not be anticipated or adequately addressed in a survey. Enrollees’ viewpoints will round out the
plan descriptions, which will also reflect the perspective of plan staff and findings from the
quantitative analysis. Results from the focus groups will be combined with other case study
findings and analysis.

2.

Information Users

Information from the Mail Survey of Medicare Advantage Special Needs Plans and Focus
Groups of Enrollees in Medicare Advantage Special Needs Plans will be collected and analyzed
by Mathematica Policy Research, Inc. (MPR), under Contact number 500-00-0033, Task order
13 with CMS, titled “Evaluation of Medicare Advantage Special Needs Plans.”
For the mail survey, questionnaires will be mailed to approximately 200 health plans,
following an introductory letter from CMS. As of January 2006 there were 276 SNP plans in
operation (http://www.cms.hhs.gov/SpecialNeedsPlans). However, a number of these plans were
the same type of SNP product offered by the same company in separate counties. MPR will
identify each unique SNP product offered in each state, and mail a questionnaire to the applicant
contact person at each one. Follow-up phone calls will be made to non-respondents.
The questionnaire is designed to provide more comprehensive information on all SNPs than
is available in existing sources. This includes descriptions of organizational structure, financial
arrangements, services provided to members, use of information technology, and the structure of
plans’ drug benefits. The questionnaire will also show application information that the plan
submitted and will ask respondents to verify this information and fill in any missing information,
as preliminary review of applications has found many incomplete applications. The survey
questionnaire is provided in Appendix A.
Information from the survey of SNPs will be combined with application and plan benefit
data to develop a description of the operation of SNPs and the services they provide in 2006. A
plan profile will be developed for each SNP plan. By developing plan profiles for all SNPs, the

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Evaluation of Medicare Advantage SNPs will begin to answer questions about what makes SNPs
“special” and whether their interventions seem likely to lead to improved care for their members.

CMS and MPR plan to conduct focus groups of approximately 8 to 10 enrollees at 15 case
study sites. Potential focus group participants will be identified through enrollment lists supplied
by the plans. To meet the selection criteria (for example, length of membership in the SNP, type
of chronic condition), we will request that plans include in the enrollee list the date on which
each beneficiary enrolled in the SNP and, for SNPs that serve beneficiaries with more than one
chronic condition, the primary diagnosis. In addition, MPR will also attempt to include the
person who makes health care decisions for the plan member, whether this is the member
himself, a relative, or another unpaid (or paid) caregiver. The focus groups will be held at a local
hotel, community center, or other location that is accessible to participants. An experienced
moderator, assisted by a member of the site visit team, will lead the focus groups.
MPR will mail a letter of invitation and a fact sheet about the focus group to each enrollee
selected for the focus group. The letter will be printed on CMS letterhead and signed by a CMS
official to enhance recruitment participants. It will outline the purpose of the group, how the
information collected will be used, explain how long the session is expected to last, state that
participation is voluntary, explain assurance of confidentiality, offer the $50 incentive payment,
and alert the enrollees that they will receive a follow-up (recruitment) call. Confirmation letters
including the focus group date, time, and address of the location will be sent to those who agree
to participate.
The focus group moderator guide is included in Appendix B. To secure information on
characteristics of SNP enrollees, we will ask focus group participants to complete a short
information form on their background and their experience with the SNP (Appendix C). These
forms will allow us to collect information on, for example, age, ethnicity, and medical history,
that is not easily obtained in a group setting. Participants will be instructed not to include their
name on the form.
Results from the SNP mail survey and focus groups will be summarized and combined with
other findings from the case studies and analysis of CMS administrative data in the Report to
Congress due in late 2007.
3.

Use of Information Technology

Data collection for the SNP survey is achieved through a self-administered mail
questionnaire. Computer-assisted interviewing methods of data collection were not believed to
be appropriate for the scope and content of this effort. Making the survey available on the
internet was also considered but was not cost effective given the sample size and the estimated
level of response expected from the web. We believe that a mail survey will be convenient for
respondents because they may need to check administrative records as they complete the
questionnaire.
Mail survey data will be entered using Viking data entry software on a SUN Ultra
Enterprise 2 workstation. A data entry program specific to the survey instrument will be

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developed and thoroughly tested prior to use. The program will contain study-specific logic and
range and consistency checks to produce high-quality data. Quality control and data entry of
completed questionnaires will continue throughout the eight-week field period, ending about two
weeks following the end of data collection. The data entry program will contain edit
specifications and will flag errors electronically. All errors will be reviewed and resolved during
data cleaning, and all entries will be 100 percent verified.
The focus group sessions will be tape recorded. Audiotapes from each focus group sessions
will then be transcribed professionally. The transcripts will be coded using Atlas.ti software to
facilitate organization of the data by topic and identification of key themes. The resulting Atlas.ti
database will be searchable by code identifying topics and themes.

4.

Duplication of Efforts

The SNP survey will ask health plans only about information they have not already reported
to CMS as part of their applications and plan bid/benefit packages or other submissions. We will
review each of these other sources in detail to ensure nothing is repeated.
The focus groups of SNP participants will provide the only information to the evaluation on
direct beneficiary experiences, since CMS does not plan to conduct a beneficiary survey of SNP
enrollees. The ongoing Consumer Assessment of Health Plans (CAHPS) does collect
information on general satisfaction with a health plan from Medicare Advantage enrollees;
however, we estimate that CAHPS data will not be available in time to meet the deadline for the
Report to Congress for all SNPs in the evaluation timeframe.
5.

Small Businesses

All sections of the questionnaire apply equally to both large and small entities, so
development of a shorter version for small entities was not feasible. The survey was designed to
be of minimal burden to any plan.

6.

Less Frequent Collection

The mail survey and focus groups are both one-time-only data collections. Not conducting
this survey and focus groups would limit CMS’s understanding of the operation and structure of
MA SNPs, and beneficiary experiences in SNPs, and would impair CMS’s ability to provide
Congress with a fully informed report as required in Section 231 of PL 108 - 173.

7.

Special Circumstances

There are no special circumstances that would cause the collection of information to be
inconsistent with 5 CFR 1320.6.

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8.

Federal Register/Outside Consultation

The notice required in 5 CFR 1320.8(d) was published in the Federal Register on May 26,
2006, (vol. 71, no. 102, pp 30410). The notice is attached as Appendix D.
Comments and Responses.
Comments on the proposed mail survey and focus groups were received from one
organization, the National Health Policy Group (NHPG). This organization represents a number
of the SNPs. CMS and its contractor held two discussions with NHPG to review the comments.
This section summarizes the comments and responses to the mail survey and focus groups. A
full copy of their comments is attached as Appendix E.
Mail Survey Administration. NHPG recommended sending the survey questionnaire to the
government relations/programs division and SNP compliance officer, and asking them to direct it
to the person(s) best suited to complete the survey. Using the contact information CMS has on
record for contracts and individual plans, we will attempt to identify these people. We have also
added space at the beginning of the survey for the primary respondent to provide his/her name,
title, telephone number, and e-mail address in case we have questions about a particular
response.
NHPG further recommended that we not send multiple surveys to MA organizations with
multiple contracts for SNPs across the country (for example, United HealthCare). We had
already planned to send only one survey questionnaire to each unique contract (identified by Hnumber) with multiple SNPs of the same type in one state (for example a contract with a dualeligible SNP in each county of a state). We do, however, plan to send questionnaires to each
unique contract number within an organization. Because the survey asks specific questions about
arrangements with states, we feel that responses should be kept separate for contracts in different
states. However, using the contact information, we will determine if the person listed as the
government relations/programs division and SNP compliance officer is the same person across
states.
We plan to contact certain organizations (for example, United HealthCare and Wellcare)
with a large number of plans to determine how best to capture variation across plans and to
ascertain which persons in the corporation will be likely to complete the questionnaires for the
plans. The general goal is to send questionnaires to those entities that represent a range of
practice within the organization, while minimizing response burden for the organization.
NHPG also suggested clarifying the data collection period (CY 2006) and specifying the
response time plans have to return the survey. We have added both these clarifications to the
Instructions section of the questionnaire.
Mail Survey Section A (Organization). NHPG suggested asking about whether a SNP
was an exclusive or disproportionate-share plan, within each of the questions on SNP type (dual,
institutional, and chronic condition) in section A (A2, A6, A10). We expect to obtain this
information from other CMS sources, so will not change the questionnaire in this regard; for
example, we will have this information in the application data verification sheet for plans to
verify.
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NHPG suggested adding categories to the question on enrollment restrictions for dual
eligible plans (A3) to include seniors, adults with disabilities, nursing home certifiable
beneficiaries, and dual subsets. We left this unchanged because such subsetting was approved for
2006 only for demonstrations that were redesignated as SNPs. However, we altered the question
about additional restrictions to have two columns, one for listing enrollment restrictions and the
other for indicating how these restrictions are verified.
Mail Survey Section B (Provider Arrangements). The original questionnaire asked
respondents to indicate the percentage of members expected to receive their care in various
physician practice settings. NHPG felt it would be difficult for SNPs to provide this information
and that responses would not be uniform. We have therefore removed this question from the
survey.
They suggested revising an earlier question that asked plans to specify risk sharing
arrangements with providers as full risk, partial risk or no risk, since the multiplicity of possible
arrangements may not easily fall into these categories. We revised the question on this topic (B2)
which is now open ended and permits plans to describe what types of providers the plan shares
risk with and how the risk is shared. We added questions about financial incentives to improve
care quality other than strict risk sharing (B3 and B4).
NHPG suggested adding a question to the end of section B to ask about the impact Part D
exclusions have on special needs plans beneficiaries. Though we did not add a new question
here, this topic is addressed later in the survey (questions F14-F18) which asks SNPs that have
enrolled members who also have Medicaid if any members have had difficulty filling
prescriptions or getting medications excluded by statute from Medicare Part D, and what effect
these difficulties have had on members.
Mail Survey Section C (Enrollment). NHPG suggested asking participants to rank order
the response categories the question on how the plan primarily identifies members. We agreed
and changed the question (now C3) to reflect this. Per NHPG’s comments, we also split out
response categories in C3 so that plans could rank separately: 1) passively enrolled members
from parent organization’s Medicaid managed care plan or demonstration program; 2) marketing
to members of parent organization’s other plans.
Mail Survey Section D (Services for Members with Special Needs). NHPG suggested
expanding the question about how plans identify members who need the plan’s special services
beyond those offered by traditional Medicare (D1). We expanded the question to have separate
response categories for screening surveys versus comprehensive clinical assessments. We also
specified response categories for assessment activities at enrollment and monitoring over time.
Regarding questions on the use of care coordination, care management and disease
management, NHPG felt the existing question was too open ended and did not specify what was
meant by each category. We revised the question (D2) first to provide working definitions for
“disease management” and “care coordination” allowing response categories for the plan to
check if they provide these two services or a similar service (with space to describe). (We also

6

note that for simplicity we use the term “care coordination” to refer to case management and care
management as well.)
A series of follow-on questions (D3-D17) then ask plans to provide more information on
these services. NHPG suggested differentiating between what type of health professional
provides disease management and care coordination services, and suggested adding a matrix
chart for plans to specify, for each function, components, percent receiving, FTEs, and
accountable health professional type. They also suggested the question about primary
responsibilities ask plans to differentiate these responsibilities by staff/health professional type
and in relation to which function (disease management versus care coordination). In response we
developed separate sets of questions concerning disease management and care coordination with
the goal of allowing plans to describe separately staff who provide these two types of
management, the proportion of members receiving management, and the focus of management
activities. (Questions D4 through D9 pertain to disease management and D11 through D17 to
care coordination.) They also suggested adding an option in the care coordination duties of
“serving as a liaison to family members”, which we added to D16 and D17. NHPG felt that the
definition of disease management is sufficiently narrow that the survey did not have to ask about
specific disease manager functions, as compared with case managers who typically perform a
wider range of functions. Therefore, we did not add a question on primary responsibilities for the
DM series of questions, but do include it under the care management section (D16 and D17).
After discussion, NHPG agreed that completing the suggested matrix (rather than answer a set of
questions) would be excessively cumbersome for plans.
NHPG also suggested including examples of how plans meet the special needs of members.
We added questions (D18 and D19) on goods and services offered to members with special
needs in addition to disease management and care coordination, which lists the number of
response categories, such as medical transportation, wound care, alcohol or drug abuse services,
fall clinics, and medication management. Question D19 asks plans to choose the three services
from D18 that were most frequently used in 2006.
Mail Survey Section E (Use of Technology). In response to NHPG comments about
provider access to member medical records, we added two questions. The first (E3) asks if the
plan’s clinical staff have access to the electronic patient record; the second (E4) asks whether
members’ primary or specialty physicians have access to electronic patient record. Question E5
then asks if clinical staff and/or providers have remote access to electronic records. We also
added a question (E6) about how plans without electronic patient records track and monitor
members health services receipt.
NHPG suggested adding additional response categories to the question about process of care
data that the plan collects. We added two new categories to E13: 1) number and type of contacts
received from SNP clinical staff (such as care coordinators or disease managers) and 2)
medication reviews conducted and errors identified. Plans can also specify other process
measures collected in an open-ended category. In response to the comment to provide more
specificity on outcomes data collected (E15), we added and revised some response categories as
suggested by their medical director panel.

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Mail Survey Section F (Serving Medicaid Beneficiaries). NHPG commented that the
survey sections for Dual Eligible SNPs (originally F and G) should not be asked only of dual
eligible SNPs, since other types of SNPs are also likely to enroll dual eligibles. As a result, we
have decided ask all SNPs with any Medicaid-eligible members to complete this section, now
combined into one (F). We have deleted the question about special needs of members, since a
question on special services used by enrollees is already asked of all SNPs in section D. In
response to comments and discussion with NHPG about the questions on contracts with
Medicaid (originally section G), we now ask questions about whether the plan has any type of
contract with Medicaid, the nature of plan contracts with Medicaid and whether those contracts
include capitated payment for any services (F2 through F10). NHPG was particularly interested
in the extent to which SNPs controlled all aspects of Medicaid service provision as this was a
necessary factor for increased integration and coordination of Medicaid and Medicare services.
This concern gave rise to question F8.
Focus Group Protocol. All of NHPG’s comments concerning the focus group protocol
were accepted and incorporated into the Moderator Guide.
MPR has provided input to CMS for the study. Senior technical staff from MPR who have
furnished assistance are:
Robert Schmitz
Jennifer Schore
Todd Ensor
9.

(617) 301-8976
(609) 275-2380
(609) 275-2326

Payment/Gifts to Respondents

There are no plans for payment of any kind to respondents to the mail survey. However,
some type of incentive is often provided to encourage participation in focus groups, especially
for individuals with limited income such as Medicaid enrollees. We plan to provide focus group
participants with an incentive to compensate them for their time and to offset transportation
expenses incurred by them or by an accompanying caregiver. Because some focus group
participants will have chronic medical conditions it may be considerably more difficult to recruit
group participants. We believe, therefore, that $50 is sufficiently generous to encourage
participation in the focus groups.

10. Confidentiality
We will make no assurance of confidentiality to respondents of the mail survey. Because
this is an “establishment” survey, the questions asked will refer to the health plans and not to
individuals. The survey will also not ask any questions of a proprietary or sensitive nature to the
operation of the health plan, such as profit margins or other competitive information.
We will make the following pledge to focus group respondents: “All information identifying
individual focus-group participants will remain confidential to the extent allowed by law”. CMS
does not invoke any statutory or other legal authority in making this pledge. Responses will not
be linked to individual programs or person-level data. These assurances will be made clear in an
advance letter to recruit potential focus group respondents and stated in the beginning of the
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focus group. Also, focus group participants will be instructed not to write their names on the
short information form that will be distributed at the group meeting. Staff who will conduct the
focus groups have signed formal pledges of confidentiality as a term of employment with MPR.
11. Sensitive Questions
There are no questions of a sensitive nature in the mail survey of health plans. The focus
groups will ask about topics that might be considered sensitive, such as use of special services
offered by the SNPs and satisfaction with plan services. Participants will also be asked to fill out
information forms that will allow us to collect information on, for example, age, ethnicity, and
medical history, that is not easily obtained in a group setting. However, participants will be
instructed not to put their names on these forms. Respondents will be assured of the
confidentiality of their identities as described in question 10.
12. Burden Estimates (Hours and Wages)
Table B.1 presents estimates of respondent burden. Because this is a one-time data collection effort, “annual time” is merely the time taken to provide information once.

TABLE B.1
RESPONSE BURDEN
Number of
Respondents
200

Responses per
Respondent
1

Hours per
Response
0.75

Total Response
Burden (Hours)
150

Focus Groups

150

1

1.5

225

Total

350

1

NA

375

Data Collection
Mail Survey

The mail survey questionnaire will typically be completed by the person identified by the
SNP compliance officer as most suitable for completing the questionnaire. It appears this will
typically be someone at the Vice President, Manager or Director of Medicare products level.
Using an approximate wage of $34/hr for this position, the estimated cost to each respondent is
0.75 hrs (45 minutes) x $34/hr, or $25.50.1 This estimate of 45 minutes is based on pretests with
nine SNP plans.

1

This wage estimate of $34 comes from the Bureau of Labor Statistics National Compensation Survey wage for
“Managers, medicine and health (private industry)”, from http://www.bls.gov/ncs/ocs/sp/ncbl0727.pdf, accessed
4/3/06.

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For the focus groups conducted at the 15 plans chosen for site visits, 18 enrollees from each
plan will be recruited, to achieve a group size of 8 to 10. Focus groups will last 90 minutes.
Focus group respondents will incur no monetary costs for participating in the focus groups. (The
cost of traveling to the session will be compensated through respondent payments, described in
question 9 above.)

13. Capital Costs
There are no direct costs to respondents other than their time to participate in the study.

14. Cost to the Federal Government
The estimated cost of the SNP mail survey of SNP plans to the Federal Government is
$78,600 over a period of four months (December 2006-March 2007). This estimate is based on
contractor’s costs for conducting and tabulating mail survey results including labor, other direct
costs for computer, telephone, postage, reproduction, fax, printing, and survey facilities, and
indirect costs for fringe benefits, general and administrative costs, and fee.
The estimated cost of the focus groups of SNP enrollees to the Federal Government is
$92,730 over a period of three months (January 2007-March 2007). This estimate includes
contractor’s costs for planning and conducting the focus groups, including labor, other direct
costs for computer, telephone, postage, fax, survey facilities, incentive payments, and rental of
focus group facilities, and indirect costs for fringe benefits, general and administrative costs, and
fee. It also includes logistics for each focus group (room, setup, recording, incentives), airfare for
survey researcher, and meals/lodging for each focus group.

15. Changes to Burden
This is a new data collection.

16. Publication/Tabulation Dates
The analysis of the survey of SNP plans will consist of simple crosstabulations of results
within SNP types. Responses to open-ended questions about problems with the program will be
studied to identify common themes and thus isolate possible improvements in the design of the
program. We will also develop an individual profile for each SNP, combining data from the
survey with application and plan benefits data available from CMS. These findings will be
combined with the summary of the focus groups, other site visit findings, analysis of
administrative data in the Report to Congress due in late 2007.

a.

Project Schedule
OMB approval for mail survey and focus groups
10

mid November 2006

Mail survey:
Mail out advance letters and telephone plans
Mail questionnaire
Follow-up phone calls to nonrespondent plans
Data file complete
Tabulation/analysis complete
Submit final survey report

late November 2006
early December 2006
mid January 2007
January 2007
February 2007
March 2007

Focus groups:
Finalize site visit locations and times
Conduct focus groups/site visits
Transcribe and analyze results
Submit final focus group report

December 06-January 07
January-March 2007
March-May 2007
June 2007

17. Expiration Date
The OMB expiration date will be displayed on the mail survey questionnaire, the fact sheet,
the focus group protocol, and on any advance material sent to respondents for the survey or the
focus group.

18. Certification Statement
The data collection will conform to all provisions of the Paperwork Reduction Act.

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C. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS
Rather than employing statistical sampling of SNPs for the mail survey, CMS intends to
conduct a survey of the entire population of plans operating in 2006, the evaluation period. Only
about 200 such plans are operating in 2006,2 and they vary widely in the types of beneficiaries
served (dual eligibles, institutionalized beneficiaries, and those with chronic illnesses). Plans
also vary in other respects, for example, the use of so-called passive enrollment and the specific
arrangements made with state Medicaid agencies. In consequence, there is no effective means of
stratifying a sample of SNPs that would not require all or nearly all SNPs within those strata to
be surveyed. CMS has therefore chosen to survey the entire population of SNPs. We will also
not employ any statistical sampling of SNP enrollees for the focus groups. Although our ability
to generalize from focus group responses will therefore be limited, the responses can both inform
the evaluation and provide valuable input to SNPs. Focus groups will be conducted with
beneficiaries from each type of SNP.
1. Potential respondent universe and any sampling or other respondent technique to be
used
The universe of SNPs for the mail survey is approximately 200 as of April 2006. This is
based on CMS’s final list of approved SNPs in 2006. Contact information for SNPs will come
from CMS’s contract and plan contact databases maintained in the Health Plan Management
System. We plan to survey all SNPs and so will not sample from this population. For each of
the 15 focus groups, we plan to identify 18 beneficiaries from each SNP for which a focus group
will be conducted, to achieve a group size of 8 to 10 enrollees. The sampling frame for focus
groups will come from will come from lists of enrollees and contact information from SNP
plans, which will provide the most up-to-date information on all SNP enrollees. The enrollees
chosen for recruitment will not be a representative sample of SNP enrollees; however, they will
be chosen based on time enrolled in the plan (at least six months if possible) and on additional
criteria within SNP types. For example, for chronic care SNPs that target beneficiaries with
several different diagnoses or disabling conditions, we will attempt to include members with
each targeted condition.
2. Procedures for the collection of information
CMS wishes to estimate the proportion of SNPs using certain approaches to enrollment
(such as the proportion using passive enrollment) to within +/-0.025 with 95% confidence for a
proportion near 0.50. For a population of 200, the necessary sample to achieve this precision,
employing the finite population correction, is 177. Because this number is so close to the total
population size and because there will be some nonresponse in any event, CMS has decided to
survey the entire population of 200 SNPs. Therefore, no statistical sampling will be used for the
mail survey of plans or for the focus groups. This is a one-time data collection and will not be
repeated.

2

There are currently 276 approved SNPs in 2006, but many of these are the same plan offering the same
coverage in distinct counties.

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3. Methods to maximize response rates
A number of steps will be taken to increase response rates in the mail survey of SNPs. First,
CMS will inform provider groups, such as the National Health Policy Group (SNP Alliance), of
the importance of the survey. The cover letter that will accompany survey mailings will be
personally addressed, will be written on CMS letterhead, will include contact information and
the signature of the CMS Project Officer, and a toll-free number at which to reach the
Mathematica Survey Director. The letter will describe the evaluation and the purpose of the mail
survey, and will provide instructions and a timeline for responding to the survey. The letter will
also indicate that the survey is voluntary and will give the estimated time to complete the survey.
Reminder postcards and follow-up telephone calls by trained interviewers (during which plans
can complete the survey) extend our strategy for maximizing response rates. We will send one
questionnaire by mail and will place a follow-up call if the plan has not responded in four weeks.
The questionnaire is relatively short and has as few open-ended response categories as possible.
There are clear instructions on the first page. We considered making the survey available on the
web but concluded that the response might be lower for this modality; we believe that a mail
survey will be convenient for respondents because they may need to check administrative
records as they complete the questionnaire.
To increase participation in the focus groups, the contractor will mail a letter of invitation
and a fact sheet about the focus group to each enrollee selected for the focus group. The letter
will be printed on CMS letterhead and signed by a CMS official and will outline the purpose of
the group, explain how we intend to ensure confidentiality, offer the $50 incentive payment, and
alert the enrollees that they will receive a follow-up (recruitment) call. Trained interviewers will
place recruitment calls. Recruits will be sent a confirmation letters including the focus group
date, time, and address of the location, and will also receive a reminder call the day before their
group is scheduled to meet. Based on past experience, approximately 18 beneficiaries will be
recruited to achieve the desired group size of 8 to 10 persons.
The response rate for the mail survey will be calculated as the completion rate – the number
of SNPs that complete the questionnaire (either by returning the mail questionnaire or by
telephone) divided by the total number of SNP that were mailed surveys (all unique SNPs).
Because we know the universe of approved, unique SNPs, the denominator of the response rate
does not include ineligible plans or plans whose eligibility is unknown.
4. Tests of Procedures or Methods
A total of nine SNPs were selected to pretest the survey instrument. The plans will were
selected to represent a mix that varies in size and population served. The pretest identified some
items that were burdensome or difficult to respond to, and these items were removed or revised
accordingly. An average response time estimate from the pretests was 45 minutes, which is
figured in our response burden estimate in section B.12 above.

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5. Individuals involved in design
The following individuals have contributed to the design of the mail survey and focus groups:
Dr. Robert Schmitz, a MPR senior fellow and study project director (617-301-8976), Dr. Angela
Merrill, a senior researcher at MPR (617-301-8977), Ms. Jennifer Schore, also a senior
researcher at MPR (609-275-2380), and Ms. Julita Milliner-Waddell, a survey researcher at
MPR, (609) 275-2206. Mr. James Hawthorne (410-786-6689), Project Officer, Office of
Research, Demonstrations, and Information, is supervising the study for the government.

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