Form CMS-R-246 Medicare Advantage Only - Survey

OMB #0938-0732

2012 Medicare Advantage
Only Plan Survey
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 25 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.

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DRAFT COVER LETTER
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 25 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.
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
[VENDOR NAME], 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 [VENDOR NAME] toll-free at 1-XXX XXXX, Monday through Friday, between XX:XX
a.m. and XX:XX p.m.
Thank you in advance for your participation.
Sincerely,

Walter Stone
Privacy Officer

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“Medicare Satisfaction Survey”
2012 Medicare Advantage Plan Survey
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 [Survey Vendor].




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 example 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 25 minutes, 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 C1-25-05, Baltimore, Maryland 21244-1850.

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1.

Our records show that in 2011 your health services were covered by the plan named on the back
page. Is that right?
Yes If Yes, Go to Question 3
No

2.

Please write below the name of the health plan you had in 2011 and complete the rest of the
survey based on the experiences you had with that plan. (Please print)

Your Health Care in the Last 6 Months
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

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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.

Wait time includes time spent in the waiting room and exam room. In the last 6 months, how
often did you see the person you came to see within 15 minutes of your appointment time?
Never
Sometimes
Usually
Always

9.

In the last 6 months, did you phone a doctor’s office or clinic with a medical question after
regular office hours?
Yes
No If No, Go to Question 12

10. In the last 6 months, when you phoned a doctor’s office or clinic after regular office hours,
how often did you get an answer to your medical question as soon as you needed?
Never
Sometimes
Usually
Always

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11. In the last 6 months, when you phoned a doctor’s office or clinic after regular office hours,
how long did it take for someone to call you back?
Less than 1 hour
1 to 3 hours
More than 3 hours but less than 6 hours
More than 6 hours
I did not ask for a return call
I did not get a return call
I was told to go to the Emergency Room
12. 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?
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible
13. In the last 6 months, did you have a health problem for which you needed special medical
equipment, such as a cane, a wheelchair, oxygen equipment, or diabetic supplies and
equipment?
Yes
No If No, Go to Question 15
14. In the last 6 months, how often was it easy to get the medical equipment you needed through
your health plan?
Never
Sometimes
Usually
Always

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Your Personal Doctor
15. 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 33
16. 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 33
1
2
3
4
5 to 9
10 or more
17. 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
18. In the last 6 months, how often did your personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
19. In the last 6 months, how often did your personal doctor show respect for what you had to
say?
Never
Sometimes
Usually
Always

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20. In the last 6 months, how often did your personal doctor spend enough time with you?
Never
Sometimes
Usually
Always
21. 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
22. In the last 6 months, when you visited your personal doctor for a scheduled appointment how
often did he or she have your medical records or other information about your care?
Never
Sometimes
Usually
Always
23. In the last 6 months, did your personal doctor order a blood test, x-ray or other test for you?
Yes
No If No, Go to Question 26
24. In the last 6 months, when your personal doctor ordered a blood test, x-ray or other test for
you, how often did someone from your personal doctor’s office follow up to give you those
results?
Never If Never, Go to Question 26
Sometimes
Usually
Always

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25. In the last 6 months, when your personal doctor ordered a blood test, x-ray or other test for you
how often did you get those results as soon as you needed them?
Never
Sometimes
Usually
Always
26. In the last 12 months, did you take any prescription medicine?
Yes
No  If No, go to Question 28
27. In the last 6 months, how often did you and your personal doctor talk about all the prescription
medicines you were taking?
Never
Sometimes
Usually
Always
28. In the last 6 months, did you get care from more than one kind of health care provider or use
more than one kind of health care service?
Yes
No  If No, go to Question 31
29. In the last 6 months, did you need help from anyone in your personal doctor’s office to manage
your care among these different providers and services?
Yes
No  If No, go to Question 31
30. In the last 6 months, did you get the help you needed from your personal doctor’s office to
manage your care among these different providers and services?
Yes, definitely
Yes, somewhat
No

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31. How satisfied are you with the help you received from your personal doctor’s office to
manage your care in the last 6 months?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied
32. After visit notes sum up what was talked about on a visit to a doctor’s office. After visit notes
may be available on paper, on a website or by e-mail. In the last 6 months, did anyone in your
personal doctor’s office offer you after visit notes?
Yes
No

Getting Health Care From Specialists
33. 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 38
34. In the last 6 months, how often was it easy to get appointments with specialists?
Never
Sometimes
Usually
Always
35. How many specialists have you seen in the last 6 months?
None If None, Go to Question 38
1 specialist
2
3
4
5 or more specialists

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36. 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
37. In the last 6 months, how often did your personal doctor seem informed and up-to-date
about the care you got from specialists?
Never
Sometimes
Usually
Always
I do not have a personal doctor
I did not visit my personal doctor in the last 6 months

Your Health Plan
38. 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 40
39. 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

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40. In the last 6 months, did you try to get information or help from your health plan’s customer
service?
Yes
No If No, Go to Question 43
41. In the last 6 months, how often did your health plan’s customer service give you the
information or help you needed?
Never
Sometimes
Usually
Always
42. 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
43. In the last 6 months, did your health plan give you any forms to fill out?
Yes
No If No, Go to Question 45
44. In the last 6 months, how often were the forms from your health plan easy to fill out?
Never
Sometimes
Usually
Always

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45. 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
46. In the last 6 months, was there 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 49
47. In the last 6 months, 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 49
Don’t know If Don’t know, Go to Question 49
48. 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 in order to file an appeal
Suggest how to resolve your complaint
Listen to your complaint but did not help to resolve it
Discourage you from taking action
Do none of these things

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49. In the last 6 months, have you called or written your health plan with a complaint or
problem?
Yes
No If No, Go to Question 53
50. Thinking about the complaint process, regardless of whether you agree or disagree with the
final outcome, how satisfied are you with how your health plan handled your complaint?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied
51. How long did it take for your health plan to settle your complaint?
Same day
1 week
2 weeks
3 weeks
4 or more weeks
I am still waiting for it to be settled
52. Was your complaint or problem settled to your satisfaction?
Yes
No
I am still waiting for it to be settled

About You
53. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
54. In general, how would you rate your overall mental health?
Excellent
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Very good
Good
Fair
Poor

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55. 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 57
56. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
57. Do you now need or take medicine prescribed by a doctor?
Yes
No If No, Go to Question 59
58. Is this to treat a condition that has lasted for at least 3 months?
Yes
No
59. In the last 6 months, how often was it easy to get the medicines your doctor prescribed?
Never
Sometimes
Usually
Always
My doctor did not prescribe any medicines for me in the last 6 months.
60. Do you have insurance that pays part or all of the cost of your prescription medicines?
Yes
No
Don’t know
61. In the last 6 months, did you delay or not fill a prescription because you felt you could not
afford it?
Yes
No
My doctor did not prescribe any medicines for me in the last 6 months

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62. Has a doctor ever told you that you had any of the following conditions?
Yes No
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?
63. Have you had a flu shot since September 1, 2010?
Yes
No
Don’t know
64. 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 a flu shot. It is also called the pneumococcal vaccine.
Yes
No
Don’t know
65. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?
Every day
Some days
Not at all If Not at all, Go to Question 67
Don’t know If Don’t know, Go to Question 67

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66. In the last 6 months, how often were you advised to quit smoking or using tobacco by a
doctor or other health provider?
Never
Sometimes
Usually
Always
I had no visits in the last 6 months
67. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 or older
68. Are you male or female?
Male
Female
69. 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
70. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino

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71. 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
72. Did someone help you complete this survey?
Yes
No If No, Go to Question 74
73. How did that person help you? Please mark one or more.
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
74. Do you live alone?
Yes, I live alone
No, I live with others
75. 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
Thank you.

Please return the completed survey in the postage-paid envelope.

[SURVEY VENDOR ADDRESS]

Contract Name:_____________________
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