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pdfATTACHMENT 1: Wave 1 Cover Letter
Dear Medicare Beneficiary:
As a person with Medicare, you deserve to get the highest quality medical care when you need it, as well
as access to prescription medicines. The Centers for Medicare & Medicaid Services (CMS), is the
federal agency that administers the Medicare program. It is our responsibility is to ensure that you get
high quality care and coverage for prescriptions at a reasonable price. One of the ways we can fulfill
this responsibility is to find out directly from you about your experience with your (Medicare health
plan/prescription drug plan).
CMS is conducting a survey of people who have disenrolled from their (Medicare health
plan/prescription drug plan) to learn more about the reasons why beneficiaries leave or switch (health
plans/prescription drug plans). Your name was selected at random by CMS from among all
disenrollees from (Medicare Advantage plans with prescription coverage/Medicare Part D prescription
drug plans). We would greatly appreciate it if you would take the time, about 18 minutes, to fill out this
questionnaire. Please answer the survey for the plan named in the survey booklet. The accuracy of the
results depends on getting answers from you and other people with Medicare who have been selected for
this survey. This is your opportunity to help us serve you better.
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 CSS
Research, 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
CMS to learn where and how (Medicare Advantage plans with prescription coverage/Medicare Part D
prescription drug plans) need to do better.
If you have any questions about the survey or would like to find out how to complete the survey by
phone, please don’t hesitate to call Jeff Burkeen with CSS Research toll-free at 1-XXX-XXX-XXXX,
Monday through Friday, between 9:00 a.m. and midnight Eastern time.
Thank you for your help with this important survey.
Sincerely,
Walter Stone
Privacy Officer
ATTACHMENT 2: Wave 2 Cover Letter
Dear Medicare Beneficiary:
As a person with Medicare, you deserve to get the highest quality medical care when you need it, as well
as access to prescription medicines. The Centers for Medicare & Medicaid Services (CMS), is the
federal agency that administers the Medicare program. It is our responsibility is to ensure that you get
high quality care and coverage for prescriptions at a reasonable price. One of the ways we can fulfill this
responsibility is to find out directly from you about your experience with your (Medicare health
plan/prescription drug plan).
CMS is conducting a survey of people who have disenrolled from their (Medicare health
plan/prescription drug plan) to learn more about the reasons why beneficiaries leave or switch (health
plans/prescription drug plans). Your name was selected at random by CMS from among all
disenrollees from (Medicare Advantage plans with prescription coverage/Medicare Part D prescription
drug plans). We would greatly appreciate it if you would take the time, about 18 minutes, to fill out this
questionnaire. Please answer the survey for the plan named in the survey booklet. The accuracy of the
results depends on getting answers from you and other people with Medicare who have been selected for
this survey. This is your opportunity to help us serve you better.
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 CSS
Research, 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.
We recently mailed this same survey to you, but we haven’t yet received your completed survey.
Learning the reasons why you left, switched, or were dropped from your (Medicare Advantage plan with
prescription coverage/Medicare Part D prescription drug plan) is very important to us. Your knowledge
and experiences will help CMS to learn where and how (health plans/prescription drug plans) need to do
better. If you have already sent the survey back, thank you for completing the survey. CSS Research is a
survey organization working with CMS on this survey. If you have any problems completing the survey
or have other questions about the survey, please don’t hesitate to call Jeff Burkeen with CSS Research
toll-free at 1-XXX-XXX-XXXX, Monday through Friday, between 9:00 a.m. and midnight Eastern
time.
Thank you for your help with this important survey.
Sincerely,
Walter Stone
Privacy Officer
ATTACHMENT 3: PDP Disenrollee Survey
OMB No. XXXX-XXXX
Exp. Date XX/XX/2011
Medicare Disenrollee Survey
Version: Stand Alone Prescription Drug Plan
(OMB Version)
Language: English
Last Updated: August 3, 2010
(This survey contains 73 effective items – numbered 1 through 68 -- and is estimated to require 16
minutes to complete, assuming a rate of 4.5 items per minute.)
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 XX 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.
Insert Vendor Instructions for Survey Completion Here
YOUR FORMER PRESCRIPTION DRUG PLAN
We are sending you this survey because we believe you recently left, switched or were dropped by a
prescription drug plan.
1.
Our records show that you used to belong to [PLAN NAME], but no longer belong to that plan. Is
that right?
1
2
2.
Did you move outside of the area where [PLAN NAME] was available?
1
2
3.
2
Yes If Yes, Please stop and return this survey
No
Did you recently leave, switch, or were you dropped by a prescription drug plan?
1
2
5.
Yes If Yes, Please stop and return this survey
No If No, If No, go to #6
Do you still belong to [PLAN NAME]?
1
4.
Yes
No If No, If No, go to #3
Yes
No If No, Please stop and return this survey
What is the name of the prescription drug plan you recently left, switched or were dropped by?
Please print:___________________________________
Please think of this plan as you answer
the questions in this survey.
GETTING INFORMATION OR HELP FROM YOUR FORMER PRESCRIPTION DRUG
PLAN
These questions ask about your experience with your former prescription drug plan.
6.
Customer service is information you get from staff about what is covered and how to use the plan.
Did you ever try to get information or help from [PLAN NAME]’s customer service?
1
2
7.
Yes
No If No, go to #8
How often did the plan’s customer service give you the information or help you needed?
1
2
3
4
5
8.
Did you ever try to get information from the plan about which prescription medicines were
covered?
1
2
9.
Never
Sometimes
Usually
Always
I did not try to get information or help from the plan’s customer service
Yes
No If No, go to #10
How often did the plan give you all the information you needed about which prescription
medicines were covered?
1
Never
Sometimes
3
Usually
4
Always
I did not try to get information about which prescription medicines were covered
2
10.
Did you ever try to get information from the plan about how much you would have to pay for a
prescription medicine?
1
2
11.
Yes
No If No, go to #12
How often did the plan give you all the information you needed about how much you would have
to pay for a prescription medicine?
1
2
3
4
5
Never
Sometimes
Usually
Always
I did not try to get information about how much I would have to pay for a prescription
medicine
12.
Did you ever need written information from the plan in a language other than English?
1
2
13.
Yes
No If No, go to #14
How often did the plan give you written information in a language other than English?
1
2
3
4
5
Never
Sometimes
Usually
Always
I did not need written information in a language other than English
GETTING THE PRESCRIPTION MEDICINES YOU NEEDED
FROM YOUR FORMER PRESCRIPTION DRUG PLAN
14.
Did a doctor ever prescribe a medicine for you that the plan did not cover?
1
2
15.
How often was it easy to use the plan to get the medicines your doctor prescribed?
1
2
3
4
5
16.
Yes
No
Never
Sometimes
Usually
Always
I did not use the plan to get any prescription medicines
Did you ever use the plan to fill a prescription at a local pharmacy?
1
2
Yes
No If No, go to #18
17.
How often was it easy to use the plan to fill a prescription at a local pharmacy?
1
2
3
4
5
18.
Did you ever use the plan to fill any prescriptions by mail?
1
2
19.
Yes
No If No, go to #20
How often was it easy to use the plan to fill prescriptions by mail?
1
2
3
4
5
20.
Never
Sometimes
Usually
Always
I did not use the plan to fill a prescription at a local pharmacy
Never
Sometimes
Usually
Always
I did not use the plan to fill a prescription by mail
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 the plan?
0 Worst prescription drug plan possible
1
2
3
4
5
6
7
8
9
10 Best prescription drug plan possible
REASONS YOU LEFT YOUR FORMER PRESCRIPTION DRUG PLAN
People leave, switch or drop a prescription drug plan for different reasons. These questions are about
reasons you may have had for leaving, switching or dropping [PLAN NAME]. In this survey we use the
words “did you leave” to ask about why you left dropped or switched from your former prescription
drug plan.
21.
Did you leave the plan because you found out that someone had signed you up for the plan without
your permission?
1
2
22.
Did you leave the plan because you were accidentally taken off the plan (or because of some other
paperwork or clerical error)?
1
2
23.
Yes
No
Yes
No
A premium is the amount that you pay to have prescription medicine coverage from a prescription
drug plan. Some prescription drug plans charge a premium to people on Medicare who are
enrolled in that prescription drug plan.
Did you leave the plan because the monthly premium for prescription medicine coverage went up?
1
2
24.
Did you leave the plan because you stopped paying the monthly premium for the plan?
1
2
25.
Yes
No
Yes
No If No, go to #26
Why did you stop paying the monthly premium for the plan?
1
2
3
I stopped paying the monthly premium because I could not afford it
I stopped paying the monthly premium because I was unhappy with the plan
I stopped paying the monthly premium for some other reason
26.
A formulary is the list of prescription medicines covered by a prescription drug plan. Did you
leave the plan because of a change in the formulary?
1
2
27.
Did you leave the plan because you hit the temporary limit (also called the “coverage gap” or
“donut hole”) when you had to pay all of the costs of your prescription medicines up to a yearly
limit?
1
2
28.
2
2
2
Yes
No
Did you leave the plan because the plan refused to pay for a medicine your doctor prescribed?
1
2
32.
Yes
No
Did you leave the plan because a change in your personal finances meant you could no longer
afford the plan?
1
31.
Yes
No
Did you leave the plan because you found a prescription drug plan that costs less?
1
30.
Yes
No
Did you leave the plan because the dollar amount you had to pay each time you filled or refilled a
prescription went up?
1
29.
Yes
No
Yes
No
Did you leave the plan because you had problems getting the medicines your doctor prescribed?
1
2
Yes
No
33.
Did you leave the plan because it was difficult to get brand name medicines?
1
2
34.
Did you leave the plan because you were frustrated by the plan’s approval process for medicines
your doctor prescribed that were not on their formulary?
1
2
35.
2
2
2
Yes
No
Did you leave the plan because you could not get the information or help you needed from the
plan?
1
2
39.
Yes
No
Did you leave the plan because you were unhappy with how the plan handled a question or
complaint?
1
38.
Yes
No
Did you leave the plan because it was hard to get information from the plan -- like which
prescription medicines were covered or how much a specific medicine would cost?
1
37.
Yes
No
Did you leave the plan because you did not know whom to contact when you had a problem filling
or refilling a prescription?
1
36.
Yes
No
Yes
No
Did you leave the plan because their customer service staff did not treat you with courtesy and
respect?
1
2
Yes
No
OTHER REASONS FOR LEAVING YOUR
FORMER PRESCRIPTION DRUG PLAN
40.
Did you leave [PLAN NAME] because it wasn’t what you expected?
1
2
41.
Did you leave the plan because a doctor or pharmacist told you that another plan had better
benefits or coverage for prescription medicines?
1
2
42.
2
2
Yes
No
Did you leave the plan because you found another plan that better met your prescription needs?
1
2
45.
Yes
No
Did you leave the plan because you saw a commercial or advertisement for a prescription drug
plan you thought you would like better?
1
44.
Yes
No
Did you leave the plan because a family member or friend told you that another prescription drug
plan was a better plan?
1
43.
Yes
No
Yes
No
Did you leave the plan because you take very few prescription medicines and don’t need a
prescription drug plan?
1
2
Yes
No
46.
What was the one most important reason you left [PLAN NAME]?
Please print:________________________________________________________
__________________________________________________________________
__________________________________________________________________
YOUR EXPERIENCE WITH INSURANCE AGENTS,
BROKERS, OR PLAN REPRESENTATIVES
47.
Different kinds of people sell health insurance. Insurance may be sold by independent insurance
agents or brokers who don’t work for the health plan OR by plan representatives who work
directly for the plan.
Did an insurance agent, broker, or plan representative ever call you without your asking them to, to
tell you about insurance for prescription medicines?
1
2
48.
Did an insurance agent, broker, or plan representative ever visit your home without your asking
them to, to tell you about insurance for prescription medicines?
1
2
49.
Yes
No
Did you decide to leave [PLAN NAME] because of information you got from an insurance agent,
broker, or plan representative?
1
2
50.
Yes
No
Yes
No
Did an insurance agent, broker, or plan representative give you any information that was not
correct?
1
2
Yes
No If No, go to #52
51.
What kind of information was not correct?
1
2
3
4
5
What the plan covered
What the plan would cost you
Which pharmacies were covered by the plan
Some other information
Please print:______________________________________________
I did not get any information that was not correct
ABOUT YOU
52.
In general, how would you rate your overall health?
1
2
3
4
5
53.
In general, how would you rate your overall mental health?
1
2
3
4
5
54.
Excellent
Very good
Good
Fair
Poor
In the last 12 months, how many different prescription medicines did you fill or have refilled?
1
2
3
4
55.
Excellent
Very good
Good
Fair
Poor
None
1 to 2 medicines
3 to 5 medicines
6 or more medicines
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
2
Yes
No If No, go to #57
56.
Is this a condition or problem that has lasted for at least 3 months?
1
2
57.
Do you now need or take medicine prescribed by a doctor?
1
2
58.
Yes
No If No, go to #59
Is this to treat a condition that has lasted for at least 3 months?
1
2
59.
Yes
No
Yes
No
Has a doctor ever told you that you had any of the following conditions?
Yes
a. A heart attack?
b. Angina or coronary heart disease?
c. A stroke?
d. Cancer, other than skin cancer?
e. Emphysema, asthma, or COPD (chronic obstructive
pulmonary disease)?
f. Any kind of diabetes or high blood sugar?
60.
What is your age?
1
2
3
4
5
6
7
8
9
61.
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 79
80 to 84
85 or older
Are you male or female?
1
2
Male
Female
No
1
2
1
2
1
2
1
2
1
2
1
2
62.
What is the highest grade or level of school that you have completed?
1
2
3
4
5
6
63.
Are you of Hispanic or Latino origin or descent?
1
2
64.
Yes, Hispanic or Latino
No, not Hispanic or Latino
What is your race? Please mark one or more.
1
2
3
4
5
65.
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
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
What language do you mainly speak at home?
1
Chinese
English
3
Russian
4
Spanish
5
Vietnamese
6
Some other language
Please print:________________________________________________
2
66.
Did someone help you complete this survey?
1
2
Yes
No If No, Go to #68
67.
How did that person help you? Please mark one or more.
1
Read the questions to me
Entered 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:________________________________________________
2
68.
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
2
Yes
No
THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage paid envelope to:
(Insert Vendor Address Here)
ATTACHMENT 4: MA-PD Disenrollee Survey
OMB No. XXXX-XXXX
Exp. Date XX/XX/2011
Medicare Disenrollee Survey
Version: Medicare Advantage with Prescription
Drug Coverage (OMB Version)
Language: English
Last Updated: August 3, 2010
(This survey contains 81 effective items – numbered 1 through 78 -- and is estimated to require 18
minutes to complete, assuming a rate of 4.5 items per minute.)
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 XX 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.
Insert Vendor Instructions for Survey Completion Here
YOUR FORMER HEALTH PLAN
We are sending you this survey because we believe you recently left, switched or were
dropped by a health plan.
1.
Our records show that you used to belong to [PLAN NAME], but no longer belong
to that plan. Is that right?
1
2
2.
Did you move outside of the area where [PLAN NAME] was available?
1
2
3.
2
Yes If Yes, Please stop and return this survey
No
Did you recently leave, switch, or were you dropped by a health plan?
1
2
5.
Yes If Yes, Please stop and return this survey
No If No, go to #6
Do you still belong to [PLAN NAME]?
1
4.
Yes
No If No, go to #3
Yes
No If No, Please stop and return this survey
What is the name of the health plan you recently left, switched or were dropped by?
Please print:___________________________________
Please think of this plan as you answ
the questions in this survey.
GETTING INFORMATION OR HELP FROM YOUR FORMER HEALTH PLAN
These questions ask about your experience with your former health plan.
6.
Customer service is information you get from staff about what is covered and how
to use the plan. Did you ever try to get information or help from [PLAN NAME]’s
customer service?
1
2
Yes
No If No, go to #8
20
7.
How often did the plan’s customer service give you the information or help you
needed?
1
2
3
4
5
8.
Did you ever try to get information from the plan about which prescription
medicines were covered?
1
2
9.
Never
Sometimes
Usually
Always
I did not try to get information or help from the plan’s customer service
Yes
No If No, go to #10
How often did the plan give you all the information you needed about which
prescription medicines were covered?
1
2
3
4
5
Never
Sometimes
Usually
Always
I did not try to get information about which prescription medicines were
covered
10. Did you ever try to get information from the plan about how much you would have
to pay for a prescription medicine?
1
2
Yes
No If No, go to #12
11. How often did the plan give you all the information you needed about how much
you would have to pay for a prescription medicine?
1
2
3
4
5
Never
Sometimes
Usually
Always
I did not try to get information about how much I would have to pay for a
prescription medicine
21
12. Did you ever need written information from the plan in a language other than
English?
1
2
Yes
No If No, go to #14
13. How often did the plan give you written information in a language other than
English?
1
2
3
4
5
Never
Sometimes
Usually
Always
I did not need written information in a language other than English
GETTING HEALTH CARE AND THE PRESCRIPTION MEDICINES
YOU NEEDED FROM YOUR FORMER HEALTH PLAN
*14. Did you ever try to get any kind of care, tests, or treatment through the plan?
1
2
Yes
No If No, go to #16
*15. How often was it easy to get the care, tests, or treatment you thought you needed
through the plan?
1
2
3
4
Never
Sometimes
Usually
Always
16. Did a doctor ever prescribe a medicine for you that the plan did not cover?
1
2
Yes
No
22
17. How often was it easy to use the plan to get the medicines your doctor prescribed?
1
2
3
4
5
Never
Sometimes
Usually
Always
I did not use the plan to get any prescription medicines
18. Did you ever use the plan to fill a prescription at a local pharmacy?
1
2
Yes
No If No, go to #20
19. How often was it easy to use the plan to fill a prescription at a local pharmacy?
1
2
3
4
5
Never
Sometimes
Usually
Always
I did not use the plan to fill a prescription at a local pharmacy
20. Did you ever use the plan to fill any prescriptions by mail?
1
2
Yes
No If No, go to #22
21. How often was it easy to use the plan to fill prescriptions by mail?
1
2
3
4
5
Never
Sometimes
Usually
Always
I did not use the plan to fill a prescription by mail
23
*22. 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 the plan?
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible
REASONS YOU LEFT YOUR FORMER HEALTH PLAN
People leave, switch or drop a health plan for different reasons. These questions are
about reasons you may have had for leaving, switching or dropping [PLAN NAME]. In
this survey we use the words “did you leave” to ask about why you left, dropped or
switched from your former health plan.
23. Did you leave the plan because you found out that someone had signed you up for
the plan without your permission?
1
2
Yes
No
24. Did you leave the plan because you were accidentally taken off the plan (or because
of some other paperwork or clerical error)?
1
2
Yes
No
24
*25. A premium is the amount that you pay to have health care and prescription
medicine coverage from a health plan. Some health plans charge a premium to
people on Medicare who are enrolled in that health plan.
This premium that the health plan charges is separate from the premium that people
on Medicare pay for Medicare Part B. Medicare Part B premiums are usually
deducted each month from a person’s Social Security check.
Did you leave the plan because the monthly premium for health care and
prescription medicine coverage went up?
1
2
Yes
No
26. Did you leave the plan because you stopped paying the monthly premium for the
plan?
1
2
Yes
No If No, go to #28
27. Why did you stop paying the monthly premium for the plan?
1
2
3
I stopped paying the monthly premium because I could not afford it
I stopped paying the monthly premium because I was unhappy with the plan
I stopped paying the monthly premium for some other reason
*28. A formulary is the list of prescription medicines covered by a health plan. Did you
leave the plan because of a change in the formulary?
1
2
Yes
No
29. Did you leave the plan because you hit the temporary limit (also called the
“coverage gap” or “donut hole”) when you had to pay all of the costs of your
prescription medicines up to a yearly limit?
1
2
Yes
No
30. Did you leave the plan because the dollar amount you had to pay each time you
filled or refilled a prescription went up?
1
2
Yes
No
25
*31. Did you leave the plan because the dollar amount you had to pay each time you
visited a doctor went up?
1
2
Yes
No
*32. Did you leave the plan because you found a health plan that costs less?
1
2
Yes
No
33. Did you leave the plan because a change in your personal finances meant you could
no longer afford the plan?
1
2
Yes
No
34. Did you leave the plan because the plan refused to pay for a medicine your doctor
prescribed?
1
2
Yes
No
35. Did you leave the plan because you had problems getting the medicines your doctor
prescribed?
1
2
Yes
No
36. Did you leave the plan because it was difficult to get brand name medicines?
1
2
Yes
No
37. Did you leave the plan because you were frustrated by the plan’s approval process
for medicines your doctor prescribed that were not on their formulary?
1
2
Yes
No
26
38. Did you leave the plan because you did not know whom to contact when you had a
problem filling or refilling a prescription?
1
2
Yes
No
39. Did you leave the plan because it was hard to get information from the plan -- like
which prescription medicines were covered or how much a specific medicine would
cost?
1
2
Yes
No
*40. Did you leave the plan because you were frustrated by the plan’s approval process
for care, tests, or treatment?
1
2
Yes
No
*41. Did you leave the plan because you had problems getting the care, tests or treatment
you needed?
1
2
Yes
No
*42. Claims are sent to a health plan for payment. You may send in the claims yourself,
or doctors, hospitals, or others may do this for you. Did you leave the plan because
you had problems getting the plan to pay a claim?
1
2
Yes
No
*43. Did you leave the plan because the doctors or other health care providers you
wanted to see did not belong to the plan?
1
2
Yes
No
*44. Did you leave the plan because clinics or hospitals you wanted to go to for care
were not covered by the plan?
1
2
Yes
No
27
*45. Did you leave the plan because it was hard to get information from the plan -- like
which health care services were covered or how much a specific test or treatment
would cost?
1
2
Yes
No
46. Did you leave the plan because you were unhappy with how the plan handled a
question or complaint?
1
2
Yes
No
47. Did you leave the plan because you could not get the information or help you
needed from the plan?
1
2
Yes
No
48. Did you leave the plan because their customer service staff did not treat you with
courtesy and respect?
1
2
Yes
No
OTHER REASONS FOR LEAVING YOUR FORMER HEALTH PLAN
49. Did you leave [PLAN NAME] because it wasn’t what you expected?
1
2
Yes
No
50. Did you leave the plan because a doctor or pharmacist told you that another plan
had better benefits or coverage for prescription medicines?
1
2
Yes
No
28
*51. Did you leave the plan because a family member or friend told you that another
health plan was a better plan?
1
2
Yes
No
*52. Did you leave the plan because you saw a commercial or advertisement for a health
plan you thought you would like better?
1
2
Yes
No
53. Did you leave the plan because you found another plan that better met your
prescription needs?
1
2
Yes
No
*54. Did you leave the plan because another plan offered better benefits or coverage for
some types of care, treatment, or services?
1
2
Yes
No
*55. Did you leave the plan because your doctor or another health care provider or
someone from the plan told you that you could get better care or treatment
elsewhere?
1
2
Yes
No
56. What was the one most important reason you left [PLAN NAME]?
Please print:________________________________________________________
__________________________________________________________________
__________________________________________________________________
29
YOUR EXPERIENCE WITH INSURANCE AGENTS,
BROKERS OR PLAN REPRESENTATIVES
57. Different kinds of people sell health insurance. Insurance may be sold by
independent insurance agents or brokers who don’t work for the health plan OR by
plan representatives who work directly for the plan.
Did an insurance agent, broker, or plan representative ever call you without your
asking them to, to tell you about insurance for health care or prescription
medicines?
1
2
Yes
No
58. Did an insurance agent, broker, or plan representative ever visit your home without
your asking them to, to tell you about insurance for health care or prescription
medicines?
1
2
Yes
No
59. Did you decide to leave [PLAN NAME] because of information you got from an
insurance agent, broker, or plan representative?
1
2
Yes
No
60. Did an insurance agent, broker, or plan representative give you any information that
was not correct?
1
2
Yes
No If No, go to #62
61. What kind of information was not correct?
1
2
3
4
5
6
What the plan covered
What the plan would cost you
Which doctors belong to the plan
Which pharmacies are covered by the plan
Which hospitals are covered by the plan
Some other information
Please print:______________________________________________
30
7
I did not get any information that was not correct
ABOUT YOU
62. In general, how would you rate your overall health?
1
2
3
4
5
Excellent
Very good
Good
Fair
Poor
63. In general, how would you rate your overall mental health?
1
2
3
4
5
Excellent
Very good
Good
Fair
Poor
64. In the last 12 months, how many different prescription medicines did you fill or
have refilled?
1
2
3
4
None
1 to 2 medicines
3 to 5 medicines
6 or more medicines
65. 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
2
Yes
No If No, go to #67
66. Is this a condition or problem that has lasted for at least 3 months?
1
2
Yes
No
67. Do you now need or take medicine prescribed by a doctor?
31
1
2
Yes
No If No, go to #69
68. Is this to treat a condition that has lasted for at least 3 months?
1
2
Yes
No
69. Has a doctor ever told you that you had any of the following conditions?
Yes
a. A heart attack?
b. Angina or coronary heart disease?
c. A stroke?
d. Cancer, other than skin cancer?
e. Emphysema, asthma, or COPD (chronic obstructive
pulmonary disease)?
f. Any kind of diabetes or high blood sugar?
2
1
2
1
2
1
2
1
2
1
2
70. What is your age?
1
2
3
4
5
6
7
8
9
71
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 79
80 to 84
85 or older
Are you male or female?
1
2
Male
Female
72. What is the highest grade or level of school that you have completed?
32
No
1
1
2
3
4
5
6
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
73. Are you of Hispanic or Latino origin or descent?
1
2
Yes, Hispanic or Latino
No, not Hispanic or Latino
74. What is your race? Please mark one or more.
1
2
3
4
5
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
75. What language do you mainly speak at home?
1
Chinese
English
3
Russian
4
Spanish
5
Vietnamese
6
Some other language
Please print:________________________________________________
2
76. Did someone help you complete this survey?
1
2
Yes
No If No, Go to #78
77. How did that person help you? Please mark one or more.
1
Read the questions to me
Entered 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:________________________________________________
2
33
78. 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
2
Yes
No
THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage paid envelope to:
(Insert Vendor Address Here)
34
| File Type | application/pdf |
| File Title | ATTACHMENT 1: Wave 1 Cover Letter |
| Author | CMS |
| File Modified | 2010-09-02 |
| File Created | 2010-09-02 |