OMB SUPPORTING STATEMENT FOR REVISED MEDICARE CAHPS SURVEYS
Table of Contents
Introduction 1
A Justification 2
A.1 Circumstances that make information collection necessary 2
A.2 Purposes and use of information 2
A.3 Use of improved information technology 3
A.4 Efforts to identify duplication 3
A.5 Effects on small businesses 3
A..6 Consequences of Less Frequent Collection 3
A.7 Consequences of not collecting information 3
A.8 Consultation with parties outside of CMS 3
A.9 Payment or gift to respondents 3
A.10 Confidentiality provision 3
A.11 Inclusion of sensitive questions 4
A.12 Estimate of respondent burden 4
A.13 Estimate of cost to respondents 4
A.14 Estimate of cost to Federal government 4
A.15 Changes in Annual Burden 4
A16. Publication and Tabulation Dates 4
A17. Expiration Date 4
A18. Certification Statement 4
B. Collection of Information Employing Statistical Methods 5
B.1 Respondent universe and sample 5
B.2 Information collection procedures 5
B.3 Methods to maximize response rates 5
B.4 Tests of procedures or methods 6
B.5 Statistical and questionnaire design consultants 6
Attachment 1 Pre-notification Letter 7
Attachment 2 MA/ PD Draft Survey Questionnaire 9
Attachment 2 FFS/ PDP Draft Survey Questionnaire 31
SUPPORTING STATEMENT
Medicare MA, FFS and PDP Surveys
Introduction
The Centers for Medicare & Medicaid Services (CMS) requests a three year clearance from the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 for the Medicare CAHPS survey. CMS in February 2007, received emergency approval to use a revised survey instrument, to field the survey the 2007 survey. However, CMS plans to continue fielding the CAHPS survey annually and therefore requires continued clearance.
Based on requirements in the 1997 Balanced Budget Act and 2003 Medicare Prescription Drug Improvement and Modernization Act (MMA), the Centers for Medicare & Medicaid Services (CMS) has collected information on consumer health services experiences of people with Medicare coverage enrolled in Medicare Advantage health plans through annual implementation of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey (MA-CAHPS) since 1998. This request for approval takes the OMB control number is 0938 0732.
Specifically, the MMA under Sec. 1860D-4 (Information to Facilitate Enrollment) requires CMS to conduct consumer satisfaction surveys regarding the prescription drug plan or the MA prescription drug plan pursuant to section 1860D-4(d) and report the results to Part D eligible individuals at least 30 days prior to the enrollment period. This request for approval is to ensure that CMS is able to continue conducting the Medicare CAHPS surveys annually for the purpose of publicly reporting the data for the open enrollment period each Fall. Additionally, CMS will provide health and prescription drug plans with a report that provide an overview of a contract’s performance on summary measures and compares performance to that of other health plans in the state and region and is benchmarked against FFS results in the state, region and nationally.
OMB approved MA CAHPS control number is 0938 0732) and FFS CAHPS (OMB control number is 0938-0796). CBC will combine and streamline the clearance packages together under the 0938 0732 number.
A. JUSTIFICATION
A.1 Circumstances that make information collection necessary
The collection and reporting of MA and FFS satisfaction information was originally mandated by the Balance Budget Act of 1997. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides a requirement to collect and report satisfaction information about the new prescription drug plans. Specifically, the MMA under Sec. 1860D-4 (Information to Facilitate Enrollment) requires CMS to conduct consumer satisfaction surveys regarding the prescription drug plan or the MA prescription drug plan pursuant to section 1860D-4(d) and report the results to Part D eligible individuals at least 30 days prior to the enrollment period.
A.2 Purposes and use of information
The collection of CAHPS measures, in addition to the Health Outcome Survey and the HEDIS surveys, is necessary to hold health and prescription drug plans accountable for the quality of care and services they are delivering. This requirement will allow CMS to obtain information for the proper oversight of the program. It is critical to CMS’s mission that we collect and disseminate information that will help beneficiaries choose among plans, contribute to improved quality of care through identification of quality improvement opportunities, and assist CMS in carrying out its responsibilities.
Information Users
The primary purpose of the CAHPS survey is to provide information to Medicare beneficiaries to help them make more informed choices among health and prescription drug plans.
Additional purposes of CAHPS include:
Providing data to health and prescription drug plans on their own performance, relative to others, that will help them identify problems and improve the quality of care and service they provide to beneficiaries (all beneficiary-specific information is protected by the Privacy Act and, consequently, is not provided to the plans);
Providing information to CMS that can be used to help monitor the quality of care and relative performance of health and prescription drug plans;
Providing data for the Government Performance and Results Act (GPRA) requirements.
A.3 Use of improved information technology
There are no barriers or obstacles that prohibit the use of improved technology for this information collection activity. The CAHPS survey is sent to beneficiaries by an independent contractor, and is collected and aggregated electronically. Beneficiaries complete a mail survey. The surveys are scanned into an electronic database. The telephone follow-up of beneficiaries is conducted using Computer Assisted Telephone Interviewing (CATI).
A.4 Efforts to identify duplication
The health plan section of the survey that CMS is conducting is the same survey that is required by the National Committee on Quality Assurance (NCQA) for accreditation of health plans; thus, there is no duplication of effort. Besides CAHPS there is no standard satisfaction survey for health plans.
A.5 Effects on small businesses
Survey respondents are Medicare Advantage, FFS or PDP plan enrollees. The survey instruments and procedures for completing the instruments are designed to minimize burden on all respondents and will not have a significant impact on small businesses or other small entities.
A.6 Consequences of Less Frequent Collection
The Medicare CAHPS survey is conducted annually. CMS provides up-to-date information to Medicare beneficiaries each year prior to open enrollment to help them make more informed health plan choices. Additionally, the information is being used by CMS for monitoring of plans, for CMS’s Government Performance and Results Act requirements, and for internal quality improvement activities of the health and prescription drug plans. Given the uses of the data, it is important that CMS has current information from beneficiaries about their experiences in their plans.
A.7 Consequences of not collecting information
CMS will not have sufficient data on beneficiaries’ access, satisfaction and ratings of their Medicare health and prescription drug plans to monitor plan performance. Additionally, CMS will not meet its legislative requirements to collect and report this information to the public.
A.8 Consultation with parties outside CMS
Provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice if applicable.
A.9 Payment or gift to respondents
Respondents will not receive any payments.
A.10 Confidentiality provision
Individuals and organizations contacted will be assured of the confidentiality of their replies under 42 U.S.C. 1306, 20 CFR 401 and 422, 5 U.S.C.552 (Freedom of Information Act), 5 U.S.C.552a (Privacy Act of 1974), and OMB Circular No.A-130. In instances where respondent identity is needed, the information collection will fully comply with all respects of the Privacy Act.
A.11 Inclusion of sensitive questions
No questions of a sensitive nature are included in the survey.
A.12 Estimate of respondent burden
Testing has shown that the average time to complete the CAHPS survey is 20 minutes. Thus, the total survey burden upon the beneficiary is .33 hours x 660,000 respondents for 217,800 hours. Previously, the Medicare MA and FFS CAHPS surveys had a total of 198,000 hours approved by OMB. This revised request is seeking 19,800 additional hours to account for the growth in the numbers of MA and stand-alone PDP plans.
A.13 Estimate of cost to respondents
Costs to respondents will be limited to their time to provide the requested information.
A.14 Estimate of cost to Federal government
The total cost for data collection, analysis and associated reports is $8.7 million.
A.15 Changes in Annual Burden
This request is seeking 19,800 additional hours approved because of the expected growth in the numbers of MA and Stand Alone PDP plans. 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 (i.e. Private Fee For Service), we will split the organizations into multiple sampling units to enable reporting at these smaller geographic levels. We estimate that we will have up to 1,100 sampling units annually.
A16. Publication and Tabulation Dates
A 60-day Federal Register notice was published March 23, 2007.
The CAHPS survey results will be disseminated through tools on www.medicare.gov – Medicare Prescription Drug Plan Finder and Medicare Options Compare -- that contain comparative information on prescription drug and health plans, respectively. The information will also be made available to the public through “print on demand” (i.e., beneficiaries can request a hardcopy of this information from 1-800-MEDICAR(E). The Medicare & You Handbook also contains some limited CAHPS information and instructions about how to request information on additional measures.
Both prescription drug and health plans will receive plan-specific reports that contain detailed plan-specific and area-specific tabulations to use for internal quality improvement. No person-specific information is provided to the plans.
A17. Expiration Date
No exemption is being requested.
A18. Certification Statement
Explain each exception to the certification statement identified in Item 19, "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.: Not applicable.
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). The Medicare CAHPS survey will also be conducted among a sample of persons enrolled in the Original Medicare plan for purposes of allowing comparisons of measures obtained from all surveys. For the 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 January each year. Beneficiaries who have been continuously enrolled for 6 months or longer and who are not institutionalized are included in the sampling frame. A random sample of 600 eligible beneficiaries per reporting unit is selected. For health and prescription drug plans, reporting units are defined as the contract organization. For Original Medicare enrollees the reporting unit is defined at the state or territorial level. 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 of changing enrollment patterns and the need to employ the most recent information available, sampling experts from RAND, Harvard, and Westat will prepare the final sample design based on the current CMS enrollment databases available each year just prior to sample draw. 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 annually by January. 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 the current survey, 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 are splitting the organizations into multiple sampling units. With the current growth in the number of plans we estimate there will be up to 1,100 sampling units annually.
Demographic and geographic information on non-respondents is obtained from the sample frame at the time the sample is drawn and used in developing weights for preparing survey results that reflect the full Medicare population. Weighting is done on a stratified basis at the plan and geographic area level to further assure that the measures prepared from the survey result reflect the Medicare population. As noted above, case-mix adjusted methods are employed for comparing performance between plans, but non-adjusted measures are also available for use in quality improvement efforts at the plan and Medicare program levels.
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.
The CAHPS survey has developed a data collection protocol that uses a pre-notification letter alerting sample members that a survey will be mailed to them shortly, a first mailing of the full questionnaire booklet, followed by a reminder postcard and a second mailing to those who do not respond to the earlier questionnaire. For those who also do not respond to the second mailing of the questionnaire, CAHPS employs a telephone follow-up through which it offers sample members the opportunity to complete the survey by phone. This system has resulted in response rates of between 70-80% on average over the past nine years of national data collection in Medicare CAHPS.
Additionally, 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.
Analysis of the Medicare CAHPS survey will be conducted using methodologies and programs developed by the Agency for Healthcare Research and Quality and the CAHPS Consortium and used by other CAHPS surveyors including the National Committee for Quality Assurance. These analytic programs are documented in the CAHPS Health Plan Survey and Reporting Kit and include a set of SAS files which comprise the CAHPS Analysis Program known as the CAHPS macro. The macro allows users to analyze and statistically adjust the survey data in order to make valid comparisons of performance across health plans.
The programs prepare several measures of health plan experiences in two broad categories, 1. enrollee ratings of their plan and health care services received and 2. reports of specific experiences regarding getting needed care, getting care quickly, patient-doctor communication, helpfulness of physician office staff, and getting information from a plan’s customer service. The CAHPS macro is updated occasionally to address new survey questions and issues and is being updated to address data collected in the 2006 Medicare CAHPS, including data on enrollee experiences in Medicare prescription drug plans (PDPs), both Medicare Advantage PDs and Stand Alone PDPs.
The CAHPS data analysis programs use multivariate analysis to control for differences in plan enrollments according to specific enrollee characteristics that have been empirically found to affect enrollees’ perceptions of their care and plan experiences, but for which the plan has no control, such as age, education, health status, and whether or not a spouse or family member assisted the enrollee in completing the survey questionnaire. This set of analysis has been documented in a series of Case-Mix Adjustment reports that present reasons why specific enrollee characteristics are used in the adjustment process and why other factors are not. For example, prior analyses of many CAHPS survey data files show that age and health status affect enrollees’ perceptions of their plan and care experiences in systematic ways. By adjusting for these effects, the CAHPS measures produced from the CAHPS macro present measures that control for differences in the proportions of enrollees in each plan having these characteristics.
The results of these analyses are final measures that might have been obtained from plans that had the same proportions of enrollees according to each of the case-mix adjustment factors.
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
Version:
Document: CAHPS Adult Commercial Core Survey
Flesch-Kinkaid Grade Level: 6.6
Medicare Advantage
Prescription Drug Plan Survey
Dear Medicare Beneficiary:
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 that 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 and your Medicare health plan.
CMS is conducting a survey of people in Medicare health plans to learn more about the health care services you receive. Your name was selected at random by CMS from among the enrollees in your health plan. We would greatly appreciate it if you would take the time, about 20 minutes, to fill out this questionnaire. 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. Your Medicare health plan is named on the back cover of this booklet.
All information you provide will be held in confidence and is protected by the Privacy Act. The information you provide will not be shared with anyone other than authorized persons at CMS and Wilkerson & Associates, the survey research organization assisting us in this survey. You do not have to participate in this survey. Your help is voluntary, and your decision to participate or not to participate will not affect your Medicare benefits in any way. However, your knowledge and experiences will help other people with Medicare make more informed choices about their health plan, so we hope you will choose to help us.
If you have any questions about the survey or would like to find out how to complete the survey by phone, please call Chris Allen with Wilkerson & Associates toll-free at 1-866-406-1110, Monday through Friday, between 9:00 a.m. and midnight Eastern time.
Thank you in advance for your participation.
Sincerely,
Walter Stone
Privacy Officer
MEDICARE SURVEY INSTRUCTIONS
This survey asks about you and the health care you received in the last six months. Answer each question thinking about yourself. Please take the time to complete this survey. Your answers are very important to us.
Please return the survey with your answers in the enclosed postage-paid envelope to Wilkerson & Associates.
Answer all the questions by putting an “X” in the box to the left of your answer,
like this:
Yes
Be sure to read all the answer choices given before marking your answer.
You are sometimes told not to answer some questions in this survey. When this
happens you will see an arrow with a note that tells you what question to answer
next, like this: [ → If No, Go to Question 3 ]. See the examples below:
EXAMPLE
1. Do you wear a hearing aid now?
Yes
No → If No, Go to Question 3
2. How long have you been wearing a hearing aid?
Less than one year
1 to 3 years
More than 3 years
I don’t wear a hearing aid
3. In the last 6 months, did you have any headaches?
Yes
No
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0732. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
YOUR HEALTH PLAN
1. Our records show that you are now covered by the health plan named on the back cover of this survey. Please look at the health plan name on the back cover. Is that right?
Yes → If Yes, Go to Question 3
No
2. What is the name of your health plan? (Please print)
__________________________________________________________________
YOUR HEALTH CARE IN THE LAST 6 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 6 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?
Yes
No → If No, Go to Question 5
4. In the last 6 months, when you needed care right away, how often did you get care as soon as you thought you needed?
Never
Sometimes
Usually
Always
5. In the last 6 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?
Yes
No → If No, Go to Question 7
6. In the last 6 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?
Never
Sometimes
Usually
Always
7. In the last 6 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
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 6 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?
Yes
No → If No, Go to Question 16
10. In the last 6 months, how many times did you visit your personal doctor to get care for yourself?
None → If None, Go to Question 16
1
2
3
4
5 to 9
10 or more
11. In the last 6 months, how often did your personal doctor explain things in a way that was easy to understand?
Never
Sometimes
Usually
Always
12. In the last 6 months, how often did your personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
13. In the last 6 months, how often did your personal doctor show respect for what you had to say?
Never
Sometimes
Usually
Always
14. In the last 6 months, how often did your personal doctor spend enough time with you?
Never
Sometimes
Usually
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 6 months, did you try to make any appointments to see a specialist?
Yes
No → If No, Go to Question 20
17. In the last 6 months, how often was it easy to get appointments with specialists?
Never
Sometimes
Usually
Always
18. How many specialists have you seen in the last 6 months?
None → If None, Go to Question 20
1 specialist
2
3
4
5 or more specialists
19. We want to know your rating of the specialist you saw most often in the last 6 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 6 months, did you try to get any kind of care, tests, or treatment through your health plan?
Yes
No → If No, Go to Question 22
21. In the last 6 months, how often was it easy to get the care, tests, or treatment you thought you needed through your health plan?
Never
Sometimes
Usually
Always
22. In the last 6 months, did your health plan give you any forms to fill out?
Yes
No → If No, Go to Question 24
23. In the last 6 months, how often were the forms from your health plan easy to fill out?
Never
Sometimes
Usually
Always
24. 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 your health plan decides not to provide or pay for health care services or stops providing health care services.
25. Was there ever a time when you believed you needed care or services that your health plan decided not to give you?
Yes
No → If No, Go to Question 28
26. Have you ever asked anyone at your health plan to reconsider a decision not to provide or pay for health care or services?
Yes
No → If No, Go to Question 28
Don’t know → If Don't know, Go to Question 28
27. When you spoke to your health plan about the decision not to provide care or services, did they…
Please mark one or more.
Tell you that you can file an appeal
Offer to send you forms that you need to file an appeal
Suggest how to resolve your complaint
Listen to your complaint but did not help resolve it
Discourage you from taking action
Do none of these things
YOUR PRESCRIPTION DRUG PLAN
Now, we would like to ask you some questions about the prescription drug coverage you get through your health plan.
28. In the last 6 months, did you try to get information or help from your health plan’s customer service about prescription drugs?
Yes
No → If No, Go to Question 31
29. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed about prescription drugs?
Never
Sometimes
Usually
Always
I did not try to get information or help from my health plan’s customer service in the last 6 months.
30. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect?
Never
Sometimes
Usually
Always
I did not try to get information or help from my health plan’s customer service in the last 6 months.
31. In the last 6 months, did you try to get information from your health plan about which prescription medicines were covered?
Yes
No → If No, Go to Question 33
32. In the last 6 months, how often did your health plan give you all the information you needed about which prescription medicines were covered?
Never
Sometimes
Usually
Always
I did not try to get information about which prescription medicines were covered in the last 6 months.
33. In the last 6 months, did you try to get information from your health plan about how much you would have to pay for your prescription medicines?
Yes
No → If No, Go to Question 35
34. In the last 6 months, how often did your health plan give you all the information you needed about how much you would have to pay for your prescription medicine?
Never
Sometimes
Usually
Always
I did not try to get information about how much I would have to pay for prescription medicines in the last 6 months.
35. In the last 6 months, how many different prescription medicines did you fill or have refilled?
None
1 to 2 medicines
3 to 5 medicines
6 or more medicines
36. In the last 6 months, did a doctor prescribe a medicine for you that your health plan did not cover?
Yes
No → If No, Go to Question 38
37. When this happened, did you or someone else contact your health plan to ask them to cover the medicine your doctor prescribed?
Yes
No
All my prescribed medicines were covered.
38. In the last 6 months, how often was it easy to use your health plan to get the medicines your doctor prescribed?
Never
Sometimes
Usually
Always
I did not use my health plan to get any prescription medicines in the last 6 months.
39. In the last 6 months, did you ever use your health plan to fill a prescription at a local pharmacy?
Yes
No → If No, Go to Question 41
40. In the last 6 months, how often was it easy to use your health plan to fill a prescription at a local pharmacy?
Never
Sometimes
Usually
Always
I did not use my health plan to fill a prescription at a local pharmacy in the last 6 months.
41. In the last 6 months, did you ever use your health plan to fill any prescriptions by mail?
Yes
No → If No, Go to Question 43
42. In the last 6 months, how often was it easy to use your health plan to fill a prescription through the mail?
Never
Sometimes
Usually
Always
I did not use my health plan to fill any prescriptions by mail in the last 6 months.
43. If your health 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 6 months, did your health plan give you information about how to ask the health plan to cover a medicine?
Yes
No
Don’t know
44. 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 health plan for coverage of prescription drugs?
0 Worst prescription drug plan possible
1
2
3
4
5
6
7
8
9
10 Best prescription drug plan possible
45. Would you recommend your health plan for coverage of prescription drugs to other people like yourself?
Definitely yes
Somewhat yes
Somewhat no
Definitely no
ABOUT YOU
46. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
47. In general, how would you rate your overall mental health now?
Excellent
Very good
Good
Fair
Poor
The next two questions are about activities you might do during a typical day.
48. 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?
Yes, limited a lot
Yes, limited a little
No, not limited at all
49. Does your health now limit you in climbing several flights of stairs? If so, how much?
Yes, limited a lot
Yes, limited a little
No, not limited at all
The next two questions ask about your physical health and your daily activities during the past 4 weeks.
50. During the past 4 weeks, have you accomplished less than you would like as a result of your physical health?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
51. 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?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
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.
52. 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?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
53. 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?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
54. During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework?
Not at all
A little bit
Moderately
Quite a bit
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.
55. How much of the time, during the past 4 weeks, have you felt calm and peaceful?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
56. How much of the time, during the past 4 weeks, did you have a lot of energy?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
57. How much of the time, during the past 4 weeks, have you felt downhearted and blue?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
58. 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.)?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
59. In the past 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?
Yes
No → If No, Go to Question 61
60. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
61. Do you now need or take medicine prescribed by a doctor?
Yes
No → If No, Go to Question 63
62. Is this to treat a condition that has lasted for at least 3 months?
Yes
No
63. In the last 6 months, did you ever delay or not fill a prescription because you felt that you could not afford it?
Yes
No
My doctor did not prescribe any medicines for me in the last 6 months
64. 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?
Yes
No
65. 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?
Yes
No
66. Do you have a physical or medical condition that seriously interferes with your independence, participation in the community, or quality of life?
Yes
No
67. Did you get a flu shot last year, that is anytime from September to December 2006?
Yes
No → If No, Go to Question 69
Don’t know → If Don't know, Go to Question 69
68. Did you get that flu shot either through your health plan or from your personal doctor?
Yes
No
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.
Yes
No
Don’t know
70. Do you now smoke cigarettes every day, some days, or not at all?
Every day
Some days
Not at all → If Not at all, Go to Question 72
Don’t know → If Don't know, Go to Question 72
71. In the last 6 months, on how many visits were you advised to quit smoking by a doctor or other health provider in your plan?
None
At least one visit
I had no visits in the last 6 months.
72. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 80
81 to 84
85 or older
73. Are you male or female?
Male
Female
74. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
75. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
76. What is your race? Please mark one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
77. Did someone help you complete this survey?
Yes
No → If No, Go to Question 79
78. How did that person help you? Check all that apply.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
(Please print)
__________________________________________________________________
79. Please check the box that best describes your current living arrangement:
Assisted living facility
Long-term care facility
Personal home or apartment
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.
80. 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
81. 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?
Yes
No
82. Please write your daytime telephone number below.
- -
Area Code
Version:
Document: CAHPS Adult Commercial Core Survey
Flesch-Kinkaid Grade Level: 6.6
Medicare FFS Stand-Alone
Prescription Drug Plan Survey
Dear Medicare Beneficiary:
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 that 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 who are also enrolled in a Medicare prescription drug plan to learn more about the care and services you receive. Your name was selected at random by CMS from among the enrollees in your plan. We would greatly appreciate it if you would take the time, about 20 minutes, to fill out this questionnaire. 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 prescription drug plan, serve you better. Your Medicare prescription drug plan is named on the back cover of this booklet.
All information you provide will be held in confidence and is protected by the Privacy Act. The information you provide will not be shared with anyone other than authorized persons at CMS and Wilkerson & Associates, the survey research organization assisting us in this survey. You do not have to participate in this survey. Your help is voluntary, and your decision to participate or not to participate will not affect your Medicare benefits in any way. However, your knowledge and experiences will help other people with Medicare make more informed choices about their prescription drug plan, so we hope you will choose to help us.
If you have any questions about the survey or would like to find out how to complete the survey by phone, please call Chris Allen with Wilkerson & Associates toll-free at 1-866-406-1110, Monday through Friday, between 9:00 a.m. and midnight Eastern time.
Thank you in advance for your participation.
Sincerely,
Walter Stone
Privacy Officer
MEDICARE SURVEY INSTRUCTIONS
This survey asks about you and the health care you received in the last six months. Answer each question thinking about yourself. Please take the time to complete this survey. Your answers are very important to us.
Please return the survey with your answers in the enclosed postage-paid envelope to Wilkerson & Associates.
Answer all the questions by putting an “X” in the box to the left of your answer,
like this:
Yes
Be sure to read all the answer choices given before marking your answer.
You are sometimes told not to answer some questions in this survey. When this
happens you will see an arrow with a note that tells you what question to answer
next, like this: [ → If No, Go to Question 3 ]. See the examples below:
EXAMPLE
1. Do you wear a hearing aid now?
Yes
No → If No, Go to Question 3
2. How long have you been wearing a hearing aid?
Less than one year
1 to 3 years
More than 3 years
I don’t wear a hearing aid
3. In the last 6 months, did you have any headaches?
Yes
No
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0732. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
YOUR HEALTH INSURANCE COVERAGE
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?
Yes
No → If No, Go to Question 3
2. Please mark the box below for each type of health insurance that you have.
Medigap, which may be identified on the front of your policy as “Medicare Supplemental Insurance”
Employer, Union, or Retiree Health Coverage (insurance)
Veteran’s Benefits, also known as VA benefits
Military Retiree Benefits, also known as Tricare
Medicaid, also known as State medical assistance, which is for some persons with limited income and resources
A Medicare Prescription Drug Plan
Other (Please write the name of the other health insurance you currently have on the line below.)
____________________________________________________________
I don’t have health insurance other than Medicare.
YOUR HEALTH CARE IN THE LAST 6 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 6 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?
Yes
No → If No, Go to Question 5
4. In the last 6 months, when you needed care right away, how often did you get care as soon as you thought you needed?
Never
Sometimes
Usually
Always
5. In the last 6 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?
Yes
No → If No, Go to Question 7
6. In the last 6 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?
Never
Sometimes
Usually
Always
7. In the last 6 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
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 6 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?
Yes
No → If No, Go to Question 16
10. In the last 6 months, how many times did you visit your personal doctor to get care for yourself?
None → If None, Go to Question 16
1
2
3
4
5 to 9
10 or more
11. In the last 6 months, how often did your personal doctor explain things in a way that was easy to understand?
Never
Sometimes
Usually
Always
12. In the last 6 months, how often did your personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
13. In the last 6 months, how often did your personal doctor show respect for what you had to say?
Never
Sometimes
Usually
Always
14. In the last 6 months, how often did your personal doctor spend enough time with you?
Never
Sometimes
Usually
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 6 months, did you try to make any appointments to see a specialist?
Yes
No → If No, Go to Question 20
17. In the last 6 months, how often was it easy to get appointments with specialists?
Never
Sometimes
Usually
Always
18. How many specialists have you seen in the last 6 months?
None → If None, Go to Question 20
1 specialist
2
3
4
5 or more specialists
19. We want to know your rating of the specialist you saw most often in the last 6 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.
20. In the last 6 months, did you try to get any kind of care, tests, or treatment through Medicare?
Yes
No → If No, Go to Question 22
21. In the last 6 months, how often was it easy to get the care, tests, or treatment you thought you needed through Medicare?
Never
Sometimes
Usually
Always
22. In the last 6 months, did Medicare give you any forms to fill out?
Yes
No → If No, Go to Question 24
23. In the last 6 months, how often were the forms from Medicare easy to fill out?
Never
Sometimes
Usually
Always
24. 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
MEDICARE PRESCRIPTION DRUG PLAN EXPERIENCES
Now, we would like to ask you some questions about your prescription drug plan. Your prescription drug plan is the plan named on the back cover of this booklet.
25. In the last 6 months, did you try to get information or help from your drug plan’s customer service?
Yes
No → If No, Go to Question 28
26. In the last 6 months, how often did your drug plan’s customer service give you the information or help you needed?
Never
Sometimes
Usually
Always
I did not try to get information or help from my drug plan’s customer service in the last 6 months.
27. In the last 6 months, how often did your drug plan’s customer service staff treat you with courtesy and respect?
Never
Sometimes
Usually
Always
I did not try to get information or help from my drug plan’s customer service in the last 6 months.
28. In the last 6 months, did you try to get information from your drug plan about which prescription medicines were covered?
Yes
No → If No, Go to Question 30
29. In the last 6 months, how often did your drug plan give you all the information you needed about which prescription medicines were covered?
Never
Sometimes
Usually
Always
I did not try to get information about which prescription medicines were covered in the last 6 months.
30. In the last 6 months, did you try to get information from your drug plan about how much you would have to pay for your prescription medicines?
Yes
No → If No, Go to Question 32
31. In the last 6 months, how often did your drug plan give you all the information you needed about how much you would have to pay for your prescription medicine?
Never
Sometimes
Usually
Always
I did not try to get information about how much I would have to pay for prescription medicines in the last 6 months.
32. In the last 6 months, how many different prescription medicines did you fill or have refilled?
None
1 to 2 medicines
3 to 5 medicines
6 or more medicines
33. In the last 6 months, did a doctor prescribe a medicine for you that your drug plan did not cover?
Yes
No → If No, Go to Question 35
34. When this happened, did you or someone else contact your drug plan to ask them to cover the medicine your doctor prescribed?
Yes
No
All my prescribed medicines were covered.
35. In the last 6 months, how often was it easy to use your drug plan to get the medicines your doctor prescribed?
Never
Sometimes
Usually
Always
I did not use my drug plan to get any prescriptions in the last 6 months.
36. In the last 6 months, did you ever use your drug plan to fill a prescription at a local pharmacy?
Yes
No → If No, Go to Question 38
37. In the last 6 months, how often was it easy to use your drug plan to fill a prescription at a local pharmacy?
Never
Sometimes
Usually
Always
I did not use my drug plan to fill a prescription at a local pharmacy in the last 6 months.
38. In the last 6 months, did you ever use your drug plan to fill any prescriptions by mail?
Yes
No → If No, Go to Question 40
39. In the last 6 months, how often was it easy to use your drug plan to fill prescriptions by mail?
Never
Sometimes
Usually
Always
I did not use my drug plan to fill a prescription by mail in the last 6 months.
40. 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 6 months, did your drug plan give you information about how to ask the drug plan to cover a medicine?
Yes
No
Don’t know
41. 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 drug plan?
0 Worst prescription drug plan possible
1
2
3
4
5
6
7
8
9
10 Best prescription drug plan possible
42. Would you recommend your prescription drug plan to other people like yourself?
Definitely yes
Somewhat yes
Somewhat no
Definitely no
ABOUT YOU
43. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
44. In general, how would you rate your overall mental health now?
Excellent
Very good
Good
Fair
Poor
The next two questions are about activities you might do during a typical day.
45. 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?
Yes, limited a lot
Yes, limited a little
No, not limited at all
46. Does your health now limit you in climbing several flights of stairs? If so, how much?
Yes, limited a lot
Yes, limited a little
No, not limited at all
The next two questions ask about your physical health and your daily activities during the past 4 weeks.
47. During the past 4 weeks, have you accomplished less than you would like as a result of your physical health?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
48. 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?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
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.
49. 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?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
50. 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?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
51. During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework?
Not at all
A little bit
Moderately
Quite a bit
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.
52. How much of the time, during the past 4 weeks, have you felt calm and peaceful?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
53. How much of the time, during the past 4 weeks, did you have a lot of energy?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
54. How much of the time, during the past 4 weeks, have you felt downhearted and blue?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
55. 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.)?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
56. In the past 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?
Yes
No → If No, Go to Question 58
57. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
58. Do you now need or take medicine prescribed by a doctor?
Yes
No → If No, Go to Question 60
59. Is this to treat a condition that has lasted for at least 3 months?
Yes
No
60. In the last 6 months, did you ever delay or not fill a prescription because you felt that you could not afford it?
Yes
No
My doctor did not prescribe any medicines for me in the last 6 months.
61. 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?
Yes
No
62. 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?
Yes
No
63. Do you have a physical or medical condition that seriously interferes with your independence, participation in the community, or quality of life?
Yes
No
64. Did you get a flu shot last year, that is anytime from September to December 2006?
Yes
No
Don’t know
65. 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.
Yes
No
Don’t know
66. Do you now smoke cigarettes every day, some days, or not at all?
Every day
Some days
Not at all → If Not at all, Go to Question 68
Don’t know → If Don't know, Go to Question 70
67. In the last 6 months, on how many visits were you advised to quit smoking by a doctor or other health provider in your plan?
None
At least one visit
I had no visits in the last 6 months.
68. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 80
81 to 84
85 or older
69. Are you male or female?
Male
Female
70. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
71. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
72. What is your race? Please mark one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
73. Did someone help you complete this survey?
Yes
No → If No, Go to Question 75
74. How did that person help you? Check all that apply.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
(Please print)
75. Please check the box that best describes your current living arrangement:
Assisted living facility
Long-term care facility
Personal home or apartment
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.
76. 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
77. 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?
Yes
No
78. Please write your daytime telephone number below.
- -
Area Code
| File Type | application/msword |
| File Title | OMB SUPPORTING STATEMENT FOR REVISED MEDICARE CAHPS SURVEYS |
| File Modified | 2007-06-12 |
| File Created | 2007-03-08 |