Form CMS-10308 Parts C and D Complaint Closure Beneficiary Survey

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop XX-XX-XX
Baltimore, Maryland XXXXX-XXX

Parts C and D Complaint Closure Beneficiary Survey
[DATE]

Dear Medicare Beneficiary:
You deserve the highest quality care from your health plan. The Centers for Medicare & Medicaid
Services (CMS) is the federal agency that administers the Medicare program. One of the ways we
ensure quality care is to ask about the service you are currently receiving from your Medicare health
plan and/or Prescription Drug Plan.
You are being contacted to complete a survey about a complaint that you – or someone on your
behalf – made against your [PLAN NAME] health plan and/or your Prescription Drug Plan on
[DATE]. Your complaint was closed on [DATE] by your Medicare health plan. You will be asked
about your complaint and how satisfied you are with the way your complaint was handled. Your
opinions are very important to us. The information you provide will help improve the way Medicare
plans handle complaints in the future. This is your opportunity to help us, and your health plan
and/or prescription drug plan, serve you better.
Your cooperation in filling out this brief 5-10 minute survey is greatly appreciated. All the
information you provide is confidential and is protected by the Privacy Act. Your information will
not be shared with anyone other than authorized persons at CMS and IMPAQ International, LLC,
the independent contractor assisting with this survey. Your participation is voluntary and your
decision to participate, or not to participate, will not affect your Medicare benefits in any way.

Instructions:
Please read the questions on the back of this page and mark each answer that best describes your
opinion. After completing the survey, please place it in the postage-paid envelope provided with
this letter and mail it to IMPAQ International, attn: “Complaints Resolution Survey,” 10420 Little
Patuxent Pkwy, Ste 300, Columbia, MD 21044.
If you have any questions about the survey or would like to complete the survey by phone, please
call [NAME] with IMPAQ International toll-free at [NUMBER], between [TIME] and [TIME].
Thank you, your opinions are valued and your participation is appreciated.
Sincerely,
Signatory

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 XXXX-XXXX. The time required to complete this information
collection is estimated to average 10 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.

Q1. According to our records, the complaint you filed about [COMPLAINT CATEGORY] was recently
closed by the plan. Was the complaint settled?
Yes
No
I Don’t Know
Q2. Thinking about the aspects of the complaints process, regardless of whether you agree or disagree with
the final outcome, please indicate how satisfied you are with each of the following:
Very
Satisfied
Length of the complaint process

Courtesy of the plan representative

Time your plan took to contact you

Amount of time spent handling your complaint

Awareness of the complaints process

Explanation of the final outcome


Satisfied

Dissatisfied















Very
Dissatisfied







I Don’t
Know/NA







Q3. During the complaint process, did you experience any of the following? Mark a response for each line.
I Don’t
Know/NA
Delay in receiving care or medications



Unable to obtain medications



Extreme stress or anxiety



Health complications



Loss of health insurance coverage



Need to use an out-of-plan provider



Financial hardship



Missed an opportunity to see a doctor or undergo a medical procedure



Other (specify) ___________________________________________________________________________
Yes

Q4.

No

What was the final outcome or decision regarding your complaint? ____________________________
__________________________________________________________________________________

Q5. How satisfied are you with the final outcome of your complaint?
Very Satisfied

 Satisfied

 Dissatisfied

Very Dissatisfied

 NA

Q6. Whether you agree or disagree with the final outcome, how would you rate your overall satisfaction
with the way your complaint was handled by the plan?
Very Satisfied

 Satisfied

 Dissatisfied

Very Dissatisfied

 NA

Q7. Based on your recent experience, how satisfied are you with [Plan name]?
Very Satisfied

 Satisfied

 Dissatisfied

Very Dissatisfied

 NA

 Unlikely

Very Unlikely

 NA

The Beneficiary

 Someone Else

Q8. How likely are you to stay with this plan?
Very Likely
Q9.

Are you…?

 Likely

Q10. Do you have any suggestions or comments about how your plan could handle complaints better?
__________________________________________________________________________________