DMMA Mail Survey Cover7-24

D epartment of Health & Human Services

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop N2-04-27C3-19-07

Baltimore, Maryland 21244-1850

C MS PRIVACY OFFICER

Month day, 2008

Mr./Ms. First and Last Name

Title

Company Name

Address

City, State, Zip code

Dear Mr./Ms. Last Name:

The Centers for Medicare & Medicaid Services (CMS) is conducting an evaluation of care and disease management programs provided by Medicare Advantage plans. As part of this evaluation, Mathematica Policy Research, Inc. (MPR) is conducting a survey of all Medicare Advantage plans operating in 2008. The survey is designed to learn about the availability of care and disease management programs and some of their key features.

You have received this questionnaire because you were named as the contact person for MA CONTRACTOR NAME which holds a Medicare Advantage contract covering COVERAGE AREA. The contract number is CONTRACT NUMBER; this contract covers the following plans: PLAN ID NUMBERS. Please only report on this MA contract and its associated plans when you complete the enclosed questionnaire.

Your participation in this survey is voluntary, but vital to CMS’s understanding of care and disease management programs. Please complete the enclosed questionnaire and return it in the self-addressed, stamped envelope by [DATE]. Individual responses to this survey will be kept private to the fullest extent permitted by law.Individual responses to this survey will be kept confidential. Answers from all responding contract holders will be tabulated and provided to CMS in aggregate form. Responses will not be linked to individual contracts or persons.

Please take the time to complete the enclosed questionnaire. If you have questions about CMS’s evaluation, please feel free to call the evaluation’s CMS project officer, Noemi Rudolph, at (410) 786-6662. For specific questions about the questionnaire, please call Todd Ensor, MPR’s Survey Director at (609) 275-2326. We look forward to learning about your program.

Sincerely,

[NAME]

CMS Project Officer

Enclosure: Survey Questionnaire

MPR DOCUMENTATION:

/home/ec2-user/sec/disk/omb/icr/200805-0938-006/doc/7978301

(RECEIVED—12/17/07) 12/17/2007 12:40 PM

Lynne reviewed format for Todd Ensor

DMMA – 6387-201