Form CMS-R-246 Medicare FFS Survey

OMB #0938-0732

2012 Original Medicare FFS
Health Plan Proposed 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 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.

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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.
CMS is conducting a survey of people with Medicare to learn more about the care and
services you receive. Your name was selected at random by CMS from among Medicare
enrollees. 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 serve you better.
If you changed your Medicare plan for 2011 please answer the questions in the survey
thinking about your experiences in the last six months of 2010. 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 Thoroughbred
Research Group, 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, 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 don’t hesitate to call Chris Allen with Thoroughbred Research
Group 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
CMS Privacy Officer

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YOUR HEALTH INSURANCE COVERAGE
Our records show that you are now in Medicare, the health insurance program for people 65
years old or older or persons with certain disabilities.
Please answer the following questions in this survey as fully as possible regardless of whether
you consider yourself in 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
Any 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
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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 10
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
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9. 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
10. 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 12
11. In the last 6 months, how often was it easy to get the medical equipment you needed
through Medicare?
Never
Sometimes
Usually
Always
YOUR PERSONAL DOCTOR
12. 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

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13. 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
14. 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
15. In the last 6 months, how often did your personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
16. In the last 6 months, how often did your personal doctor show respect for what you had
to say?
Never
Sometimes
Usually
Always
17. In the last 6 months, how often did your personal doctor spend enough time with you?
Never
Sometimes
Usually
Always

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18. 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
19. 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
20. 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 23
21. 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 23
Sometimes
Usually
Always

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22. 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
23. In the last 12 months, did you take any prescription medicine?
Yes
No  If No, go to Question 25
24. 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
25. In the last 6 months, did you see your personal doctor for a specific illness or for any
health conditions?
Yes
No → If No, Go to Question 28

26. In the last 6 months, how often did your personal doctor give you easy to understand
instructions about what to do to take care of this illness or health condition?
Never
Sometimes
Usually
Always
27. In the last 6 months, how often did your personal doctor ask you to describe how you
were going to follow these instructions?
Never
Sometimes
Usually
Always

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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
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

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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.
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
MEDICARE EXPERIENCE
The next questions ask about your experience with Medicare.
38. 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 40
39. 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
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40. In the last 6 months, did you try to get information or help from Medicare’s customer
service?
Yes
No → If No, Go to Question 43
41. In the last 6 months, how often did Medicare’s customer service give you the information
or help you needed?
Never
Sometimes
Usually
Always
42. In the last 6 months, how often did Medicare’s customer service staff treat you with
courtesy and respect?
Never
Sometimes
Usually
Always
43. In the last 6 months, did Medicare 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 Medicare 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 Medicare?
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 Medicare decides not to provide or pay for health care
services or stops providing health care services.
46. Was there ever a time when you believed you needed care or services that Medicare
decided not to give you?
Yes
No → If No, Go to Question 53
47. Have you ever asked anyone at Medicare 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

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48. When you spoke to Medicare 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
49. In the last 6 months, have you called or written Medicare 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 Medicare handled your
complaint?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied
51. How long did it take for Medicare 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

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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
Very good
Good
Fair
Poor
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
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Sometimes
Usually
Always
My doctor did not prescribe any
medicines for me in the last 6 months.

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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 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.
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

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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 the 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
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
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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
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

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75. Because of a health or physical problem are you unable to do or have any difficulty doing
the following activities? (Please mark one response for each activity.)
I am unable
to do this
activity

Yes,
I have
difficulty

No,
I do not
have difficulty

a. Bathing
b. Dressing
c. Eating
d. Getting in or out of chairs
e. Walking
f. Using the toilet
76. 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

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