CMS-10427 Appendix A 10 24 12

APPENDIX A

Advance MAILING to pace enrollees

EXHIBIT A.1

ADVANCE LETTER TO PACE ENROLLEES

CMS LETTERHEAD

NAME

ADDRESS 1

ADDRESS 2

CITY, STATE, ZIP

Dear NAME:

I am writing to ask for your help with an important new study, The Study of the Program of All-Inclusive Care for the Elderly (PACE), sponsored by the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). The PACE program you are enrolled with is called [PROGRAM NAME]. The study will help us to better understand how the medical and other services provided by the PACE program, [PROGRAM NAME], are helping you. Your name was randomly selected from a list of people receiving healthcare services through a PACE program in Pennsylvania.

CMS has hired Mathematica Policy Research, a private national research firm to conduct this study. Mathematica will call you to ask you to participate in a short telephone survey. Your participation is very important. Your responses will help us understand how the PACE program works and how it might be improved.

We assure you that all information collected through the survey will be confidential and will not be reported in any way that identifies you personally.

Your participation in the survey will not affect your eligibility for the healthcare services you currently receive, either now or in the future. We are collecting this information for research purposes only.

If you are unable to respond because of a health problem, a family member or friend who is familiar with your condition and use of healthcare services can respond on your behalf.

Please help us by responding to the interview when the telephone interviewer calls. The enclosed brochure provides more information about the survey. If you have any questions, or wish to set up a time for the telephone interview, please call Nancy Duda at Mathematica. The toll-free number is 1-888-xxx-xxxx.

Thank you for your help.

Sincerely,

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-XXXX. The time required to complete this information collection is estimated to average 33 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.

eXHIBIT a.2

Information Brochure for pace enrollee

	Am I required by the government to participate? Your participation is entirely voluntary. You may refuse to answer any question during the interview. However, your participation is necessary to make your voice heard about the PACE program. Your responses represent others like you and you cannot be replaced. Your participation will not affect any PACE services you may receive now or apply for in the future. Nor will it affect your eligibility for any other benefits or services. Why should I participate? The information you provide will help the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and the Congress make decisions about medical and long-term care services for persons aged 55 and over. Your experiences with PACE services are vital to understanding how the program works and how it might be improved.	For further information or to schedule an interview, please call toll-free: xxxxxxxxx 1-888-xxxx Study of the PACE Program 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- XXX. The time required to complete this information collection is estimated to average 33 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, Baltimore, Maryland 21244-1850		FACTS ABOUT THE Study of the PACE Program Sponsored by the Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services Conducted by Mathematica Policy Research
Why is this survey being done? The Study of the PACE Program will collect information from persons who are using medical and other services provided by PACE. The Centers for Medicare & Medicaid Services sponsor this survey to broaden their understanding how frail and disabled persons get along day to day and how the PACE healthcare services are helping them. Why was I chosen for this study? You were selected for this study if you enrolled in PACE. The information you provide is essential to obtain an accurate picture of peoples’ experiences using PACE and other healthcare services.			If I never used the services at the PACE Program, should I respond to this survey? Yes. Even if you never received PACE medical services or long-term care services, we need your information in order to better understand how the PACE program is working. Will my answers be confidential? Yes, the Mathematica Policy Research representative who will interview you has signed a confidentiality statement that prohibits him or her from disclosing survey information to anyone other than authorized Mathematica staff. No information that could identify you or your family will be released to anyone outside the Mathematica project staff. The answers from all respondents will be summarized in such a way that no individual can be identified.		How long will the interview take? The interview will probably take about half an hour. If you are unable to respond because of a health problem, a family or friend who is familiar with your care can respond on your behalf. Remember, we can schedule the interview any time that is convenient for you. What kind of questions will I be asked? The topics include: Use of healthcare services Health problems and functioning Use of PACE caregivers Satisfaction Individual characteristics