Form CMS-R-246 Stand Alone PDP Survey

OMB #0938-0732

2012 Medicare Stand Alone
Prescription Drug 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 15 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 15 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 Prescription Drug 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 examples 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 15 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.

56

1.

Our records show that in 2011 your prescriptions were covered by the Medicare
prescription drug 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 Medicare prescription drug plan you had in 2011
and complete the rest of the survey based on the experiences you had with that plan.
(Please print)
___________________________

3.

You contact customer service to get information about what is covered and how to
use a drug plan. In the last 6 months, did you try to get information or help about
prescription drugs from your prescription drug plan’s customer service?
Yes
No If No, Go to Question 6

4.

In the last 6 months, how often did your prescription drug plan’s customer service give
you the information or help you needed about prescription drugs?
Never
Sometimes
Usually
Always
I did not try to get information or help from my prescription drug plan’s customer
service in the last 6 months.

5.

In the last 6 months, how often did your prescription drug plan’s customer service
staff treat you with courtesy and respect when you tried to get information or help
about prescription drugs?
Never
Sometimes
Usually
Always
I did not try to get information or help from my prescription drug plan’s customer
service in the last 6 months

6.

In the last 6 months, did you try to get information from your prescription drug plan
about which prescription medicines were covered?
Yes
No If No, Go to Question 8

7.

In the last 6 months, how often did your prescription drug plan’s customer service give
you all the information you needed about which prescription medicines were
covered?
Never
Sometimes
Usually
Always
I did not try to get information or help from my prescription drug plan’s customer
service in the last 6 months

8.

In the last 6 months, did you try to get information from your prescription drug plan
about how much you would have to pay for your prescription medicines?
Yes
No If No, Go to Question 10

9.

In the last 6 months, how often did your prescription drug plan’s customer service give
you all the information you needed about how much you would have to pay for your
prescription medicine?
Never
Sometimes
Usually
Always
I did not try to get information or help from my prescription drug plan’s customer
service in the last 6 months

10. In the last 6 months, how many different prescription medicines did you fill or have
refilled?
None
1 to 2 medicines
3 to 5 medicines
6 or more medicines

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11. In the last 6 months, did a doctor prescribe a medicine for you that your prescription
drug plan did not cover?
Yes
No If No, Go to Question 17
12. When this happened, did you contact your prescription drug plan to ask them to cover
the medicine your doctor prescribed?
Yes
No If No, Go to Question 17
All my prescribed medicines are covered Go to Question 17
13. When you contacted your prescription drug plan about the decision not to cover a
prescription medicine 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 the above
All my prescribed medicines were covered
14. Thinking about the complaint process, regardless of whether you agree or disagree
with the final outcome, how satisfied are you with how your plan handled your
complaint?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied
15. How long did it take for your 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
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16. Was your complaint or problem settled to your satisfaction?
Yes
No
I am still waiting for it to be settled
17. In the last 6 months, how often was it easy to use your prescription drug plan to get
the medicines your doctor prescribed?
Never
Sometimes
Usually
Always
I did not use my prescription drug plan to get any medicines in the last 6 months
18. In the last 6 months, did you ever use your prescription drug plan to fill a prescription
at your local pharmacy?
Yes
No If No, Go to Question 20

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19. In the last 6 months, how often was it easy to use your prescription drug plan to fill a
prescription at your local pharmacy?
Never
Sometimes
Usually
Always
I did not use my prescription drug plan to fill a prescription at my local pharmacy in
the last 6 months
20. In the last 6 months, did you ever use your prescription drug plan to fill a prescription
by mail?
Yes
No If No, Go to Question 22
I am not sure if my drug plan offers prescriptions by mail Go to Question 22
21. In the last 6 months, how often was it easy to use your prescription drug plan to fill a
prescription by mail?
Never
Sometimes
Usually
Always
I did not use my prescription drug plan to fill a prescription by mail in the last 6
months
I am not sure if my drug plan offers prescriptions by mail
22. 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
your prescription drug plan?
0 Worst prescription drug plan possible
1
2
3
4
5
6
7
8
9
10 Best prescription drug plan possible

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23. Would you recommend your prescription drug plan for coverage of prescription drugs
to other people like yourself?
Definitely yes
Somewhat yes
Somewhat no
Definitely no

About You
24. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
25. In general, how would you rate your overall mental health?
Excellent
Very good
Good
Fair
Poor
26. 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 28
27. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
28. Do you now need or take medicine prescribed by a doctor?
Yes
No If No, Go to Question 30

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29. Is this to treat a condition that has lasted for at least 3 months?
Yes
No
30. 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
31. 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?
32. Have you had a flu shot since September 1, 2010?
Yes
No
Don’t know
33. 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

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34. 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 36
Don’t know If Don’t know, Go to Question 36
35. 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
36. 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
37. Are you male or female?
Male
Female
38. 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

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39. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
40. 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
41. Did someone help you complete this survey?
Yes
No If No, Go to Question 43
42. 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
43. Do you live alone?
Yes, I live alone
No, I live with others
44. 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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Thank you.
Contract Name: ____________________

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

[SURVEY VENDOR ADDRESS]

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