Form CMS-R-246 Medicare Advantage Prescription Drug Plan Survey

Draft Version: Do Not Distribute

B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

B.1 Respondent universe and sample

CMS is requiring all Medicare MA, MA-PD and free-standing PDP plans that have had a contract effective for at least one year (defined in this start-up year as effective on or before Jan 1, 2006 to participate in an independent third party administration of this survey (hereinafter referred to as Medicare CAHPS). For the 2007 national Medicare CAHPS survey, the names and addresses of sampled beneficiaries shall be obtained from the Medicare Beneficiary Database (MBD) files on or shortly after November each year. Beneficiaries who have been continuously enrolled for 6 months and who are not institutionalized are included in the sampling frame. A random sample of 600 eligible beneficiaries per reporting unit is selected. If there are less than 600 eligible beneficiaries in an organization, all of the beneficiaries are selected

The survey will be conducted through use of a randomized sample of Medicare enrollees in all 50 states, the District of Columbia, the US Virgin Islands, and Puerto Rico. Because the sample design is dependent on the most recent information available from CMS enrollment databases, sampling experts from RAND, Harvard, and Westat are currently in the process of preparing the sample design for the 2006 survey. Current plans are for 600 enrollees to be drawn from each of the MA, MA-PD, and Stand-alone PDPs, as well as sufficient numbers of additional enrollees in Original Medicare to produce state-level estimates. The sampling plan will be finalized by November 2006. A data collection plan has also been developed and tested to assure sufficient survey response to provide for statistically significant CAHPS measurements in all Medicare health and prescription drug plans and in all states.

The response universe for this survey has grown considerably. The MMA legislation has increased the size and scope of the Medicare CAHPS surveys. For 2007, the number of plans to be included in the survey has grown from 208 in the 2005 MA survey, to now include 509 MA-PD plans and 81 freestanding PDPs. For plans that cover large geographic areas or have national coverage (ie Private Fee For Service), we will be splitting the organizations into multiple sampling units. We estimate that we have up to 1,000 sampling units.

B.2 Information collection procedures

The administration of the survey consists of a pre-notification letter signed by the CMS Privacy Officer sent out prior to the first questionnaire mailing, the first questionnaire mailing, a postcard reminder, and a second mailing. We conduct telephone follow-up of non-respondents.

B.3 Methods to maximize response rates

For the first round of Medicare CAHPS, we achieved a 74 percent response rate. From the first round of the survey, we learned that it would be helpful to lengthen the data collection period to get the most out of the first two mailings and to increase the period of time for telephone follow-up. For the fifth and sixth rounds of the survey, we achieved an 82 percent and 83 percent response rate, respectively.

A variety of efforts have been made to maximize our response rate. First, extensive testing of the individualized questions and their order within the survey, ensures that beneficiaries easily comprehend the questions and can answer with minimum effort. Second, the method of administration chosen pre-notification letter, two mailouts and a reminder postcard, and telephone followup of non-respondents – is a multi-pronged, comprehensive strategy that avoids the weaknesses of reliance upon mail or telephone contact alone.

B.4 Tests of procedures or methods

Not applicable. No tests of new procedures or methods are performed.

B.5 Statistical and questionnaire design consultants

We are receiving ongoing input from statisticians to develop, design, conduct, and analyze the information collected from this survey. This statistical expertise will be available from RAND and Harvard Medical School.

Marc N. Elliot, Ph.D.

RAND

1776 Main Street

Santa Monica, CA 90401-3208

Tel: 310-393-0411

Alan Zaslavsky, Ph.D.

Associate Professor of Statistics

Harvard University, Department of Health Care Policy, Harvard Medical School

ATTACHMENT A

Pre-Notification Letter and Thank You Reminder Postcard

MAIL SURVEY LETTERS – COVER LETTER MAILED WITH FIRST SURVEY

Dear {Mr./Ms.} LAST NAME:

As a person with Medicare, you deserve to get the highest quality medical care when you need it, from doctors that you trust. The Centers for Medicare & Medicaid Services (CMS) is the Federal Agency that administers the Medicare program and our responsibility is to ensure that you get high quality care at a reasonable price. One of the ways we can fulfill that responsibility is to find out directly from you about the care you are currently receiving under the Medicare program.

CMS is conducting a survey of people with Medicare in managed care plans to learn more about the care you receive. This survey is called the “Medicare Satisfaction Survey.” Your name was selected at random by CMS from among the Medicare enrollees in your health plan. We would appreciate it if you would take the time, about 25 minutes, to fill out this questionnaire and then return it in the enclosed postage-paid envelope. The accuracy of the results depends on getting answers from you and other people with Medicare selected for this survey. This is your opportunity to help us, and your health plan, serve you better.

All information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not have to participate in this survey. Your help is voluntary, and your decision to participate or not to participate will have no effect on your Medicare benefits.

We hope that you will take the opportunity to answer the questionnaire and help us to ensure that you get the highest quality care. Your knowledge and experiences could help other people with Medicare make more informed health plan choices.

[VENDOR NAME] is a survey research organization working with us to carry out this survey. If you have any questions about the survey, please feel free to call [CONTACT NAME] of [VENDOR NAME] at 1-800-zzz-zzzz.

Thank you for your help with this important survey.

Sincerely,

Walter D. Stone

Privacy Officer

Centers for Medicare & Medicaid Services

Enclosures

FIRST REMINDER: POSTCARD

Dear Medicare Beneficiary,

We recently sent you a survey about your Medicare health care experiences. If you have returned the survey, thank you for your help. If you have not yet answered the survey, we would appreciate it if you could please fill it out and mail it back in the postage-paid envelope we sent you. We need your information to help Medicare serve you better. All information you provide will be held in confidence by the Centers for Medicare & Medicaid Services and is protected by the Privacy Act. You do not have to participate in this survey. Your help is voluntary, and your decision to participate or not to participate will have no effect on your Medicare benefits.

If you need a copy of the survey, please call {CONTACT NAME} at {INSERT TOLL FREE NUMBER}. All calls to this number are free. Thank you!

ATTACHMENT B:

MA/ PD Draft Survey

Draft Version: 11/28/2005

Document: CAHPS Adult Commercial Core Survey

Flesch-Kinkaid Grade Level: 6.6

Medicare Advantage
Prescription Drug Plan Survey

SAMPLE CONFIRMATION

1. Our records show that you are now in {INSERT HEALTH PLAN NAME}. Is that right?

¹ Yes  If Yes, Go to Question 3

² No

2. What is the name of your health plan? (Please print)

YOUR HEALTH CARE IN THE LAST 3 MONTHS

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

3. In the last 3 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?

¹ Yes

² No  If No, Go to Question 5

4. In the last 3 months, when you needed care right away, how often did you get care as soon as you thought you needed?

¹ Never

² Sometimes

³ Usually

5. In the last 3 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic?

¹ Yes

² No  If No, Go to Question 7 on Next Page

6. In the last 3 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor's office or clinic as soon as you thought you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

7. In the last 3 months, not counting the times you went to an emergency room, how many times did you go to a doctor’s office or clinic to get health care for yourself?

 None  If None, Go to Question 9 on Next Page

 1

 2

 3

 4

 5 to 9

 10 or more

8. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 3 months?

 0 Worst health care possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best health care possible

YOUR PERSONAL DOCTOR

9. A personal doctor is the one you would see if you need a check-up, want advice about a health problem, or get sick or hurt. Do you have a personal doctor?

¹ Yes

² No  If No, Go to Question 16 on Next Page

10. In the last 3 months, how many times did you visit your personal doctor to get care for yourself?

 None  If None, Go to Question 15 on Next Page

 1

 2

 3

 4

 5 to 9

 10 or more

11. In the last 3 months, how often did your personal doctor explain things in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

12. In the last 3 months, how often did your personal doctor listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

13. In the last 3 months, how often did your personal doctor show respect for what you had to say?

¹ Never

² Sometimes

³ Usually

⁴ Always

14. In the last 3 months, how often did your personal doctor spend enough time with you?

¹ Never

² Sometimes

³ Usually

⁴ Always

15. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your personal doctor?

 0 Worst personal doctor possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best personal doctor possible

GETTING HEALTH CARE FROM SPECIALISTS

When you answer the next questions, do not include dental visits or care you got when you stayed overnight in a hospital.

16. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 3 months, did you try to make any appointments to see a specialist?

¹ Yes

² No  If No, Go to Question 20 on Next Page

17. In the last 3 months, how often was it easy to get appointments with specialists?

¹ Never

² Sometimes

³ Usually

⁴ Always

18. How many specialists have you seen in the last 3 months?

 None  If None, Go to Question 20

 1 specialist

 2

 3

 4

 5 to 9 specialists

19. We want to know your rating of the specialist you saw most often in the last 3 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?

 0 Worst specialist possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best specialist possible

YOUR HEALTH PLAN

The next questions ask about your experience with your health plan.

20. In the last 3 months, did you try to get any kind of care, tests, or treatment through your health plan?

¹ Yes

² No  If No, Go to Question 22 on Next Page

21. In the last 3 months, how often was it easy to get the care, tests or treatment you thought you needed through your health plan?

¹ Never

² Sometimes

³ Usually

⁴ Always

22. In the last 3 months, did you try to get information or help from your health plan’s customer service?

¹ Yes

² No  If No, Go to Question 25

23. In the last 3 months, how often did your health plan’s customer service give you the information or help you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

24. In the last 3 months, how often did your health plan’s customer service staff treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

25. In the last 3 months, have you called or written [HEALTH PLAN NAME] with a complaint or a problem?

¹ Yes

² No  If No, Go to Question 28 on Next Page

26. How long did it take for [HEALTH PLAN NAME] to resolve your complaint?

¹ Same day

² 2 – 7 days

³ 8 – 14 days

⁴ 15 – 21 days

⁵ More than 21 days

⁶ I am still waiting for it to be settled.

If still waiting, Go to Question 57 on Next Page

⁷ I didn’t have any complaint in the last 3 months.

27. Was your complaint settled to your satisfaction?

¹ Yes

² No

³ I am still waiting for it to be settled.

⁴ I didn’t have any complaint in the last 3 months.

28. In the last 3 months, did your health plan give you any forms to fill out?

¹ Yes

² No  If No, Go to Question 30

29. In the last 3 months, how often were the forms from your health plan easy to fill out?

¹ Never

² Sometimes

³ Usually

⁴ Always

30. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?

 0 Worst health plan possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best health plan possible

YOUR MEDICARE RIGHTS

You have the right to file an appeal if a doctor or [HEALTH PLAN] decides not to provide or pay for health care services or stops providing health care services

31. Was there ever a time when you believed that you needed and should have received health care or services that your doctor decided not to give you?

¹ Yes

² No

³ Don’t know

32. Before today, did you know that you can ask [HEALTH PLAN] to reconsider your doctor’s decision not to provide health care or services?

¹ Yes

² No

33. Does your doctor’s office provide you with any information about what to do if a doctor will not give you the care or service that you believe you need?

¹ Yes

² No

³ Don’t know

34. Was there ever a time when you believed you needed care or services that [HEALTH PLAN NAME] decided not to give you

¹ Yes

² No  If No, Go to Question 40 on Next Page

35. Have you ever asked anyone at [HEALTH PLAN] to reconsider a decision not to provide or pay for health care or services?

¹ Yes

² No  If No, Go to Question 38 on Next Page

³ Don’t know

36. When you spoke to your health plan about the decision not to provide care or services, did they…

Please mark one or more

¹ Tell you that you can file an appeal

² Offer to send you forms that you need to file an appeal

³ Suggest how to resolve your complaint

⁴ Listen to your complaint but did not help resolve it

⁵ Discourage you from taking action

37. Has your doctor ever asked someone at [HEALTH PLAN] to reconsider its decision not to provide or pay for health care or services?

¹ Yes

² No

³ Don’t know

38. Before today, did you know that you could file an appeal in writing to your plan?

¹ Yes

² No  If No, Go to Question 40

39. Did you ever submit an appeal in writing to [HEALTH PLAN] asking them to reconsider a decision not to provide or pay for care or services?

¹ Yes

² No

³ Don’t know

Now, we would like to ask you some questions about your prescription drug plan. This is the prescription drug coverage you get through {INSERT MA HEALTH PLAN NAME}.

40. In the last 3 months, did you try to get information or help from your prescription drug plan’s customer service?

¹ Yes

² No  If No, Go to Question 43

41. In the last 3 months, how often did your drug plan’s customer service

give you the information or help you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not try to get information or help from customer service

42. In the last 3 months, how often did your drug plan’s customer service treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not try to get information or help from customer service

43. In the last 3 months, did you look for information from your drug plan about which prescription medicines were covered?

¹ Yes

² No  If No, Go to Question 45

44. In the last 3 months, how often was it easy to find information from your plan about which medicines were covered?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not look for information about which medicines were covered

45. In the last 3 months, did you look for information from your drug plan about how much you would have to pay for your prescription medicines?

¹ Yes

² No  If No, Go to Question 47 on Next Page

46. In the last 3 months, how often was it easy to find out from your plan how much you would have to pay for your medicines?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not look for information about how much I would have to pay for medicines

47. In the last 3 months, did you look for information from your plan about which pharmacies accept your prescription drug plan?

¹ Yes

² No  If No, Go to Question 49

48. In the last 3 months, was it easy to find out from your plan which pharmacies accept your prescription drug plan?

¹ Yes

² No

³ I did not look for information about which pharmacies accept my plan

49. In the last 3 months, did you fill a prescription?

¹ Yes

² No  If No, Go to Question 57 on Next Page

50. In the last 3 months, did a doctor prescribe a medicine that your plan did not cover?

¹ Yes

² No  If No, Go to Question 52

51. When this happened, did you or someone else contact your drug plan to ask them to cover the medicine your doctor prescribed?

¹ Yes

² No

³ I did not get a prescription for a medicine that was not covered

52. In the last 3 months, how often was it easy to use your drug plan to get the medicines your doctor prescribed?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not fill any prescriptions since I joined my prescription drug plan

53. In the last 3 months, did you ever use your plan to fill a prescription at a local pharmacy?

¹ Yes

² No  If No, Go to Question 55 on Next Page

54. In the last 3 months, how often was it easy to use your plan to fill a prescription at

a local pharmacy?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not fill a prescription at a local pharmacy

55. In the last 3 months, did you ever use your plan to get any prescriptions by mail?

¹ Yes

² No  If No, Go to Question 57

56. In the last 3 months, how often did you get your prescriptions in the mail when your drug plan said you would?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not get any prescriptions by mail

57. In the last 3 months, did you ever delay or not fill a prescription because you felt that you could not afford it?

¹ Yes

² No

58. Mistakes with prescriptions can include things like the pharmacy giving you the wrong number of pills, giving you medicine that was not the strength ordered by your doctor, or giving you the wrong medicine.

In the last 3 months, did a pharmacy ever make a mistake with one of your prescriptions?

¹ Yes

² No

59. If your drug plan does not cover a prescription medicine that a doctor prescribes for you, you have the right to ask your plan to cover that medicine.

In the last 3 months, did your drug plan give you information about how to ask the plan to cover a medicine?

¹ Yes

² No

³ I don’t know

60. Using any number from 0 to 10, where 0 is the worst prescription drug plan

possible and 10 is the best prescription drug plan possible, what number would you use to rate your prescription drug plan?

 0 Worst prescription drug plan possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

10 Best prescription drug plan possible

61. Would you recommend your prescription drug plan to other people like you?

¹ Definitely yes

² Somewhat yes

³ Somewhat no

⁴ Definitely no

ABOUT YOU

62. In general, how would you rate your overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

The next two questions are about activities you might do during a typical day.

63. Does your health now limit you in doing moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? If so, how much?

¹ Yes, limited a lot

² Yes, limited a little

³ No, not limited at all

64. Does your health now limit you in climbing several flights of stairs? If so, how much?

¹ Yes, limited a lot

² Yes, limited a little

³ No, not limited at all

The next two questions ask about your physical health and your daily activities during the past four weeks.

65. During the past 4 weeks, have you accomplished less than you would like as a result of your physical health?

¹ Yes

² No

66. During the past 4 weeks, were you limited in the kind of work or other regular daily activities you did as a result of your physical health?

¹ Yes

² No

The next two questions ask about problems with your work or other regular daily activities as a result of any emotional problems, such as feeling depressed or anxious.

67. During the past 4 weeks, have you accomplished less than you would like as a result of any emotional problems, such as feeling depressed or anxious?

¹ Yes

² No

68. During the past 4 weeks, did you do work or other regular daily activities less carefully than usual as a result of any emotional problems, such as feeling depressed or anxious?

¹ Yes

² No

69. During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework?

¹ Not at all

² A little bit

³ Moderately

⁴ Quite a bit

⁵ Extremely

The next three questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

70. How much of the time, during the past 4 weeks, have you felt calm and peaceful?

¹ All of the time

² Most of the time

³ A good bit of the time

⁴ Some of the time

⁵ A little of the time

⁶ None of the time

71. How much of the time, during the past 4 weeks, did you have a lot of energy?

¹ All of the time

² Most of the time

³ A good bit of the time

⁴ Some of the time

⁵ A little of the time

⁶ None of the time

72. How much of the time, during the past 4 weeks, have you felt downhearted and blue?

¹ All of the time

² Most of the time

³ A good bit of the time

⁴ Some of the time

⁵ A little of the time

⁶ None of the time

73. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

¹ All of the time

² Most of the time

³ A good bit of the time

⁴ Some of the time

⁵ A little of the time

⁶ None of the time

74. In the past 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?

¹ Yes

² No  If No, Go to Question 76 on Next Page

75. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.

¹ Yes

² No

76. Do you now need or take medicine prescribed by a doctor? Do not include birth control.

¹ Yes

² No  If No, Go to Question 78

77. Is this to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause.

¹ Yes

² No

78. Because of any impairment or health problem, do you need the help of other persons with your personal care needs, such as eating, dressing, or getting around the house?

¹ Yes

² No

79. Because of any impairment or health problem, do you need help with your routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

¹ Yes

² No

80. Do you have a physical or medical condition that seriously interferes with your independence, participation in the community, or quality of life?

¹ Yes

² No

81. Did you get a flu shot last year, that is anytime from September to December 2005?

¹ Yes

² No  If No, Go to Question 83

³ Don’t know

82. Did you get that flu shot either through [HEALTH PLAN NAME] or from your personal doctor?

¹ Yes

² No

³ Don’t know

⁴ I didn’t get a flu shot last year.

83. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.

¹ Yes

² No

³ Don’t know

84. Do you now smoke cigarettes every day, some days, or not at all?

¹ Every day

² Some days

³ Not at all  Go to Question 87

⁴ Don’t know  Go to Question 89

85. In the last 3 months, on how many visits were you advised to quit smoking by a doctor or other health provider in your plan?

¹ None

² At least one visit

³ I had no visits in the last 3 months.

86. What is your age?

¹ 18 to 24

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 or older

87. Are you male or female?

¹ Male

² Female

88. What is the highest grade or level of school that you have completed?

¹ 8th grade or less

² Some high school, but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

89. Are you of Hispanic or Latino origin or descent?

¹ Yes, Hispanic or Latino

² No, Not Hispanic or Latino

90. What is your race? Please mark one or more.

¹ White

² Black or African-American

³ Asian

⁴ Native Hawaiian or other Pacific Islander

⁵ American Indian or Alaska Native

91. Did someone help you complete this survey?

¹ Yes

² No  If No, Go to Question 93 on Next Page

92. How did that person help you? Check all that apply.

¹ Read the questions to me

² Wrote down the answers I gave

³ Answered the questions for me

⁴ Translated the questions into my
language

⁵ Helped in some other way (Please print)

__________________________

__________________________

The Medicare program is trying to learn more about your Medicare experience.

93. May we contact you again about your experiences?

 Yes

 No

Appendix C

FFS and PDP CAHPS Draft Questionnaire

Draft Version: 11/28/2005

Document: CAHPS Adult Commercial Core Survey

Flesch-Kinkaid Grade Level: 6.6

Medicare FFS Stand-Alone
Prescription Drug Plan Survey

SAMPLE CONFIRMATION

Our records show that you are now in Medicare, the health insurance program for people 65 years old and older or persons with certain disabilities.

Please answer the questions in this survey as fully as possible regardless of whether or not you consider yourself on Medicare.

1. Some people who have Medicare also have other insurance to help pay for some of the costs of their health care. Do you have any other insurance that pays at least some of the cost of your health care?

¹ Yes

² No  If No, Go to Question 3

2. What is the name of your health plan? (Please print)

3. Please mark the box below for each type of health insurance that you have.

¹ Medigap, which may be identified on the front of your policy as "Medicare

Supplemental Insurance"

² Employer, Union, or Retiree Health Coverage (insurance)

³ Veteran's Benefits, also known as VA benefits

⁴ Military Retiree Benefits, also known as Tricare

⁵ Medicaid, also known as State medical assistance, which is for some persons with

limited income and resources

⁶ Other (Please write the name of the other health insurance you currently have

on the line below.)

Write Name of Insurance Here

⁷ I don't have health insurance other than Medicare

YOUR HEALTH CARE IN THE LAST 3 MONTHS

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

4. In the last 3 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?

¹ Yes

² No  If No, Go to Question 6

5. In the last 3 months, when you needed care right away, how often did you get care as soon as you thought you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

6. In the last 3 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic?

¹ Yes

² No  If No, Go to Question 8

7. In the last 3 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor's office or clinic as soon as you thought you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

8. In the last 3 months, not counting the times you went to an emergency room, how many times did you go to a doctor’s office or clinic to get health care for yourself?

 None  If None, Go to Question 10 on Next Page

 1

 2

 3

 4

 5 to 9

 10 or more

9. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 3 months?

 0 Worst health care possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best health care possible

YOUR PERSONAL DOCTOR

10. A personal doctor is the one you would see if you need a check-up, want advice about a health problem, or get sick or hurt. Do you have a personal doctor?

¹ Yes

² No  If No, Go to Question 17 on Page 5

11. In the last 3 months, how many times did you visit your personal doctor to get care for yourself?

 None  If None, Go to Question 17 on Page 5

 1

 2

 3

 4

 5 to 9

 10 or more

12. In the last 3 months, how often did your personal doctor explain things in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

13. In the last 3 months, how often did your personal doctor listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

14. In the last 3 months, how often did your personal doctor show respect for what you had to say?

¹ Never

² Sometimes

³ Usually

⁴ Always

15. In the last 3 months, how often did your personal doctor spend enough time with you?

¹ Never

² Sometimes

³ Usually

⁴ Always

16. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your personal doctor?

 0 Worst personal doctor possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best personal doctor possible

GETTING HEALTH CARE FROM SPECIALISTS

When you answer the next questions, do not include dental visits or care you got when you stayed overnight in a hospital.

17. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 3 months, did you try to make any appointments to see a specialist?

¹ Yes

² No  If No, Go to Question 21 on Next Page

18. In the last 3 months, how often was it easy to get appointments with specialists?

¹ Never

² Sometimes

³ Usually

⁴ Always

19. How many specialists have you seen in the last 3 months?

 None  If None, Go to Question 21

 1 specialist

 2

 3

 4

 5 to 9 specialists

20. We want to know your rating of the specialist you saw most often in the last 3 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?

 0 Worst specialist possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best specialist possible

MEDICARE EXPERIENCE

The next questions ask about your experience with Medicare.

21. In the last 3 months, did you try to get any kind of care, tests, or treatment through Medicare?

¹ Yes

² No  If No, Go to Question 23 on Next Page

22. In the last 3 months, how often was it easy to get the care, tests or treatment you thought you needed through Medicare?

¹ Never

² Sometimes

³ Usually

⁴ Always

23. In the last 3 months, did you try to get information or help from Medicare’s customer service?

¹ Yes

² No  If No, Go to Question 26

24. In the last 3 months, how often did Medicare’s customer service give you the information or help you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

25. In the last 3 months, how often did Medicare’s customer service staff treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

26. In the last 3 months, did Medicare give you any forms to fill out?

¹ Yes

² No  If No, Go to Question 28 on Next Page

27. In the last 3 months, how often were the forms from Medicare easy to fill out?

¹ Never

² Sometimes

³ Usually

⁴ Always

28. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate Medicare?

 0 Worst health plan possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best health plan possible

Now, we would like to ask you some questions about your prescription drug plan. We understand your prescription drug plan is {INSERT PRESCRIPTION DRUG PLAN NAME}.

29. In the last 3 months, did you try to get information or help from {INSERT PRESCRIPTION DRUG PLAN NAME} customer service?

¹ Yes

² No  If No, Go to Question 32 on Next Page

30. In the last 3 months, how often did your drug plan’s customer service give you the information or help you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not try to get information or help from customer service

31. In the last 3 months, how often did your drug plan’s customer service staff treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not try to get information or help from customer service

32. In the last 3 months, did you look for information from {INSERT PRESCRIPTION DRUG PLAN NAME} about which prescription medicines were covered?

¹ Yes

² No  If No, Go to Question 34

33. In the last 3 months, how often was it easy to find information from your plan about which medicines were covered?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not look for information about which medicines were covered

34. In the last 3 months, did you look for information from {INSERT PRESCRIPTION DRUG PLAN NAME} about how much you would have to pay for your prescription medicines?

¹ Yes

² No  If No, Go to Question 36

35. In the last 3 months, how often was it easy to find out from your plan how much you would have to pay for your medicines?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not look for information about how much I would have to pay for medicines

36. In the last 3 months, did you look for information from your plan about which pharmacies accept {INSERT PRESCRIPTION DRUG PLAN NAME}?

¹ Yes

² No  If No, Go to Question 38 on Next Page

37. In the last 3 months, was it easy to find out from your plan which pharmacies accept your prescription drug plan?

¹ Yes

² No

³ I did not look for information about which pharmacies accept my plan

38. In the last 3 months, did you fill a prescription?

¹ Yes

² No  If No, Go to Question 46 on Page 11

39. In the last 3 months, did a doctor prescribe a medicine that {INSERT PRESCRIPTION DRUG PLAN NAME} did not cover?

¹ Yes

² No  If No, Go to Question 41

40. When this happened, did you or someone else contact your drug plan to ask them to cover the medicine your doctor prescribed?

¹ Yes

² No

³ I did not get a prescription for a medicine that was not covered

41. In the last 3 months, how often was it easy to use your drug plan to get the medicines your doctor prescribed?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not fill any prescriptions since I joined my prescription drug plan

42. In the last 3 months, did you ever use your plan to fill a prescription at a local pharmacy?

¹ Yes

² No  If No, Go to Question 44 on Next Page

43. In the last 3 months, how often was it easy to use your plan to fill a prescription at

a local pharmacy?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not fill a prescription at a local pharmacy

44. In the last 3 months, did you ever use {INSERT PRESCRIPTION DRUG PLAN NAME} to get any prescriptions by mail?

¹ Yes

² No  If No, Go to Question 46

45. In the last 3 months, how often did you get your prescriptions in the mail when your drug plan said you would?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ I did not get any prescriptions by mail

46. In the last 3 months, did you ever delay or not fill a prescription because you felt that you could not afford it?

¹ Yes

² No

47. Mistakes with prescriptions can include things like the pharmacy giving you the wrong number of pills, giving you medicine that was not the strength ordered by your doctor, or giving you the wrong medicine.

In the last 3 months, did a pharmacy ever make a mistake with one of your prescriptions?

¹ Yes

² No

48. If your drug plan does not cover a prescription medicine that a doctor prescribes for you, you have the right to ask your plan to cover that medicine.

In the last 3 months, did {INSERT PRESCRIPTION DRUG PLAN NAME} give you information about how to ask the plan to cover a medicine?

¹ Yes

² No

³ I don’t know

49. Using any number from 0 to 10, where 0 is the worst prescription drug plan possible and 10 is the best prescription drug plan possible, what number would you use to rate {INSERT PRESCRIPTION DRUG PLAN NAME}?

 0 Worst prescription drug plan possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

10 Best prescription drug plan possible

50. Would you recommend your prescription drug plan to other people like you?

¹ Definitely yes

² Somewhat yes

³ Somewhat no

⁴ Definitely no

ABOUT YOU

51. In general, how would you rate your overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

52. In general, how would you rate your overall mental health now?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

The next two questions are about activities you might do during a typical day.

53. Does your health now limit you in doing moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? If so, how much?

¹ Yes, limited a lot

² Yes, limited a little

³ No, not limited at all

54. Does your health now limit you in climbing several flights of stairs? If so, how much?

¹ Yes, limited a lot

² Yes, limited a little

³ No, not limited at all

The next two questions ask about your physical health and your daily activities during the past four weeks.

55. During the past 4 weeks, have you accomplished less than you would like as a result of your physical health?

¹ Yes

² No

56. During the past 4 weeks, were you limited in the kind of work or other regular daily activities you did as a result of your physical health?

¹ Yes

² No

The next two questions ask about problems with your work or other regular daily activities as a result of any emotional problems, such as feeling depressed or anxious.

57. During the past 4 weeks, have you accomplished less than you would like as a result of any emotional problems, such as feeling depressed or anxious?

¹ Yes

² No

58. During the past 4 weeks, did you do work or other regular daily activities less carefully than usual as a result of any emotional problems, such as feeling depressed or anxious?

¹ Yes

² No

59. During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework?

¹ Not at all

² A little bit

³ Moderately

⁴ Quite a bit

⁵ Extremely

The next three questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

60. How much of the time, during the past 4 weeks, have you felt calm and peaceful?

¹ All of the time

² Most of the time

³ A good bit of the time

⁴ Some of the time

⁵ A little of the time

⁶ None of the time

61. How much of the time, during the past 4 weeks, did you have a lot of energy?

¹ All of the time

² Most of the time

³ A good bit of the time

⁴ Some of the time

⁵ A little of the time

⁶ None of the time

62. How much of the time, during the past 4 weeks, have you felt downhearted and blue?

¹ All of the time

² Most of the time

³ A good bit of the time

⁴ Some of the time

⁵ A little of the time

⁶ None of the time

63. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

¹ All of the time

² Most of the time

³ A good bit of the time

⁴ Some of the time

⁵ A little of the time

⁶ None of the time

64. In the past 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?

¹ Yes

² No  If No, Go to Question 66

65. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.

¹ Yes

² No

66. Do you now need or take medicine prescribed by a doctor? Do not include birth control.

¹ Yes

² No  If No, Go to Question 68

67. Is this to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause.

¹ Yes

² No

68. Did you get a flu shot last year, that is anytime from September to December 2005?

¹ Yes

² No

³ Don’t know

69. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.

¹ Yes

² No

³ Don’t know

70. Do you now smoke cigarettes every day, some days, or not at all?

¹ Every day

² Some days

³ Not at all  Go to Question 72

⁴ Don’t know  Go to Question 72

71. In the last 3 months, on how many visits were you advised to quit smoking by a doctor or other health provider in your plan?

¹ None

² At least one visit

³ I had no visits in the last 3 months.

72. What is your age?

¹ 18 to 24

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 or older

73 . Are you male or female?

¹ Male

² Female

74. What is the highest grade or level of school that you have completed?

¹ 8th grade or less

² Some high school, but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

75. Are you of Hispanic or Latino origin or descent?

¹ Yes, Hispanic or Latino

² No, Not Hispanic or Latino

76. What is your race? Please mark one or more.

¹ White

² Black or African-American

³ Asian

⁴ Native Hawaiian or other Pacific Islander

⁵ American Indian or Alaska Native

77. Did someone help you complete this survey?

¹ Yes

² No  If No, Go to Question 79 on Next Page

78. How did that person help you? Check all that apply.

¹ Read the questions to me

² Wrote down the answers I gave

³ Answered the questions for me

⁴ Translated the questions into my
language

⁵ Helped in some other way (Please print)

__________________________

__________________________

79. Please check the box that best describes your current living arrangement:

¹ Assisted living facility

² Long-term care facility

³ Personal home or apartment

⁴ Other, specify below

__________________________

__________________________

Earlier in the survey you were asked to indicate whether you have any limitations in your activities. We are now going to ask a few additional questions in this area.

81. Because of a health or physical problem do you have any difficulty doing the following activities? (Please mark one response for each activity.)

I am unable Yes, No,

to do this I have I do not

activity difficulty have difficulty

a. Bathing

b. Dressing

c. Eating

d. Getting in or out of chairs

e. Walking

f. Using the toilet

82. The Medicare Program is trying to learn more about the health care or services provided to people with Medicare. May we contact you again about the health care services that you received?

¹ Yes

² No

THANK YOU FOR COMPLETING THIS SURVEY.

Please return your completed survey in the postage paid envelope to:

Medicare Satisfaction Survey

44