Attachment5a

WAVE: PRE-NOTIFICATION POSTCARD 2010
PROTOCOL: BASELINE
MAILING MATERIALS TRACKING NUMBER: 1
[CMS Logo]
MEDICARE HEALTH OUTCOMES SURVEY

Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare,
is conducting a survey to find out more about the care that is provided to people with Medicare.
This survey is called the “Medicare Health Outcomes Survey.” Your name was selected at
random from your health plan. In a few days, you will receive a questionnaire in the mail. We
would greatly appreciate your taking the time to complete the form.
Please look for the Medicare Health Outcomes Survey in the mail in a few days. Thank you for
helping with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

En un esfuerzo por enterarnos más sobre la calidad de la asistencia que se brinda a los
beneficiarios del programa Medicare, la CMS está llevando a cabo una encuesta de los
beneficiarios. Si desea recibir la Encuesta de Medicare Sobre la Salud en español sírvase
llamar gratuitamente a [1-800 number].

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING – SIDE A 2010
PROTOCOL: BASELINE, (SIDE B - SPANISH PRIMARY BASELINE, SPANISH FOLLOWUP)
MAILING MATERIALS TRACKING NUMBER: 2
[CMS Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS) is the Federal agency that administers
the Medicare program. Our responsibility is to make sure that you get high quality care. One of
the ways we can fulfill that responsibility is to find out directly from you about how the care you
are currently receiving under the Medicare program affects your health.
CMS is conducting a survey of people with Medicare called the Medicare Health Outcomes
Survey. Your name was selected at random by CMS from among the people in your health plan
with Medicare. We would greatly appreciate your taking the time to fill out this questionnaire. A
postage-paid return envelope is enclosed.
Your answers to the survey will provide information about the state of your health. You will be
contacted two years from now and asked to complete the survey again. Your answers to the two
surveys will be compared to determine if the care you receive is keeping you as healthy as
possible. After the study is completed, your responses will be shared with your health plan. Your
plan will use this information to improve the quality of care.
Learning about the state of your health is very important to us. While your participation is
voluntary, we hope that you will take the time to answer the questionnaire. Your answers will
have no effect on your Medicare benefits.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this
survey. If you have any problems completing the survey or have other questions about it, please
don’t hesitate to call [SURVEY VENDOR NAME toll free] at [1-800-Number] or e-mail [SURVEY
VENDOR NAME] at [email address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures
ESPANOL AL OTRO LADO

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING – SIDE B 2010
PROTOCOL: BASELINE, (SIDE A - SPANISH PRIMARY BASELINE, SPANISH FOLLOWUP)
MAILING MATERIALS TRACKING NUMBER: 3
[CMS Letterhead]
Estimado beneficiario del programa Medicare:
Los Centros de Servicios de Medicare y Medicaid (CMS por sus siglas en inglés) es la agencia
federal que administra el programa Medicare. Nuestra responsabilidad es garantizar que usted
reciba cuidado médico de alta calidad. Una de las maneras en que podemos cumplir con esa
responsabilidad es enterarnos directamente por usted cómo afecta su salud el cuidado médico
que está recibiendo actualmente en el programa Medicare.
CMS esta realizando una encuesta a las personas con Medicare llamada Encuesta de
Medicare Sobre la Salud. Su nombre ha sido seleccionado al azar por CMS, de entre las
personas con Medicare en su plan de salud. Le agradeceríamos que dedique unos minutos
para completar este cuestionario. Para su comodidad, le adjuntamos un sobre que no necesita
estampilla de correo.
Sus respuestas a la encuesta proporcionarán información sobre el estado de su salud. Dentro
de dos años nos pondremos en contacto con usted para pedirle que complete la encuesta
nuevamente. Sus respuestas a las dos encuestas se compararán para determinar si el cuidado
médico que usted recibe lo mantiene tan sano como sea posible. Después de que se termine el
estudio, sus respuestas serán compartidas con su plan de salud. Su plan usará esta
información para mejorar la calidad de los servicios que ofrece.
Es muy importante para nosotros enterarnos sobre su salud. Aunque su participación es
voluntaria, esperamos que no deje pasar la ocasión de responder al cuestionario. Sus
respuestas no afectarán los beneficios que recibe de Medicare.
[SURVEY VENDOR NAME] es una compañía que realiza estudios que trabaja con Medicare
para llevar a cabo esta encuesta. Si tiene algún problema para completar el cuestionario o tiene
preguntas sobre el mismo, por favor llame gratuitamente a [SURVEY VENDOR NAME] a [1800-Number] o escribir por correo electrónico a [SURVEY VENDOR NAME] a [e-mail address].
Gracias por ayudar con esta encuesta importante.
Atentamente,

Walter Stone
Funcionario de Privacidad
Anexos
ENGLISH ON THE OTHER SIDE

WAVE: LETTER FOR SECOND QUESTIONNAIRE MAILING 2010
PROTOCOL: BASELINE
MAILING MATERIALS TRACKING NUMBER: 4
[CMS Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS) is conducting a survey of people with
Medicare in managed care plans to learn if the care you receive is keeping you as healthy as
possible. Your name was randomly selected from your health plan.
Recently, we mailed the Medicare Health Outcomes Survey to you but have not received your
response. We are enclosing another copy and would greatly appreciate your taking the time to
complete the survey. Please return it in the enclosed postage-paid envelope.
Learning about the state of your health is very important to us. While your participation is
voluntary, we hope you will help us by completing the questionnaire. Your answers will have no
effect on your Medicare benefits.
You will be contacted again two years from now and asked to complete the survey again. Your
answers to the two surveys will be compared to determine if the care you receive is keeping you
as healthy as possible. After the study is completed, your responses will be shared with your
health plan. Your plan will use this information to improve the quality of care.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this
survey. If you have any problems completing the survey or have other questions about the
survey, please don’t hesitate to call [SURVEY VENDOR NAME] toll free at [1-800-Number] or email [SURVEY VENDOR NAME] at [email address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer
Enclosures

WAVE: REMINDER/THANK-YOU POSTCARD 2010
PROTOCOL: BASELINE, FOLLOW-UP—NO PROXY AT BASELINE, FOLLOW-UP—
PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 5
[CMS Logo]
MEDICARE HEALTH OUTCOMES SURVEY
Hello!
About a week ago you received the Medicare Health Outcomes Survey in the mail.
This is a reminder that we would like you to fill out the questionnaire and mail it back in the
postage-paid envelope that came with it. We need your answers. This is your chance to help
your health plan serve you better.
If you have returned the completed questionnaire, thank you!
If you did not get the questionnaire or have misplaced it, please call [SURVEY VENDOR NAME]
toll free at [1-800-Number] or e-mail [SURVEY VENDOR NAME ] at [email address] and we will
mail a questionnaire to you.
THANK YOU!

[SURVEY VENDOR NAME]

WAVE: PRENOTIFICATION POSTCARD 2010
PROTOCOL: SPANISH PRIMARY BASELINE, SPANISH FOLLOW-UP
MAILING MATERIALS TRACKING NUMBER: 6
[CMS Logo]
ENCUESTA DE MEDICARE SOBRE LA SALUD
Estimado beneficiario del programa Medicare:
En un esfuerzo por enterarnos más sobre la calidad de la asistencia que se brinda a los
beneficiarios del programa Medicare, los Centros de Servicios de Medicare y Medicaid (cuya
sigla en inglés es CMS) están llevando a cabo una encuesta de los beneficiarios. Esta encuesta
se llama Encuesta de Medicare Sobre la Salud. Su nombre fue seleccionado al azar de entre
todos los miembros inscritos en su plan de cuidado médico. Agradecemos muchísimo el tiempo
que tome para llenar la encuesta.
Por favor esté pendiente de la Encuesta de Medicare Sobre la Salud que le llegará por correo
en unos dias.
Gracias por ayudar con esta encuesta importante.
Atentamente,

Walter Stone
Funcionario de Privacidad
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs
Medicare, is conducting a survey to find out more about the care that is provided to
people with Medicare. This survey is called the “Medicare Health Outcomes Survey.” If
you would like to receive an English copy of the survey please call toll free at [1-800
number].

WAVE: LETTER FOR SECOND QUESTIONNAIRE MAILING 2010
PROTOCOL: SPANISH PRIMARY BASELINE, SPANISH FOLLOW-UP
MAILING MATERIALS TRACKING NUMBER: 8 7
[CMS Letterhead]

Estimado beneficiario del programa Medicare:
Los Centros de Servicios de Medicare y Medicaid (CMS por sus siglas en inglés) están llevando
a cabo una encuesta de personas con Medicare inscritas en planes de salud administrados.
Esta encuesta tiene el propósito de averiguar si el cuidado médico que usted recibe lo mantiene
tan sano como sea posible. Su nombre ha sido seleccionado al azar de entre todos los
miembros inscritos en su plan de cuidado médico.
Recientemente le enviamos por correo la Encuesta de Medicare Sobre la Salud, pero no hemos
recibido su respuesta. Adjunto le enviamos otra copia y le agradeceremos mucho que dedique
unos minutos para completarla. Luego que termine, enviar la encuesta en el sobre que se
adjunta que no necesita estampilla de correo.
Es muy importante para nosotros enterarnos sobre su salud. Aunque su participación es
voluntaria, esperamos que no deje pasar la ocasión de responder al cuestionario. Sus
respuestas no afectarán los beneficios que recibe de Medicare.
Dentro de dos años nos pondremos en contacto con usted para pedirle que complete la
encuesta nuevamente. Sus respuestas a las dos encuestas se compararán para determinar si
el cuidado médico que usted recibe lo mantiene tan sano como sea posible. Después de que se
termine el estudio, sus respuestas serán compartidas con su plan de salud. Su plan usará esta
información para mejorar la calidad del cuidado que ofrece.
[VENDOR NAME] es una compañía que realiza estudios que trabaja con Medicare para llevar
a cabo esta encuesta. Si tiene algún problema para completar el cuestionario o tiene otras
preguntas sobre el mismo, por favor llame gratuitamente a [SURVEY VENDOR NAME] a [1800-Number] o escribir por correo electrónico a [SURVEY VENDOR NAME] a [e-mail address].
Gracias por ayudar con esta encuesta importante.
Atentamente,

Walter Stone
Funcionario de Privacidad

Anexos

WAVE: REMINDER/THANK YOU POSTCARD 2010
PROTOCOL: SPANISH PRIMARY BASELINE, SPANISH FOLLOW-UP
MAILING MATERIALS TRACKING NUMBER: 9 8
[CMS Logo]
ENCUESTA DE MEDICARE SOBRE LA SALUD
¡Hola!
Hace aproximadamente una semana, usted recibió la Encuesta de Medicare Sobre la Salud por
correo.
Esta nota es para recordarle que le agradeceríamos se tome la molestia de responder a la
encuesta y enviarla en el sobre que se adjunta que no necesita estampilla de correo .
Necesitamos sus respuestas. Esta es su oportunidad de ayudar a que su plan de salud le sirva
mejor.
Si ya ha devuelto el cuestionario, le quedamos agradecidos.
Si no ha recibido el cuestionario o se le ha perdido, llame gratuitamente a [SURVEY VENDOR
NAME] a [1-800-Number] o escriba por correo electrónico a [SURVEY VENDOR NAME] a [email address] y se lo enviaremos por correo.
¡MUCHAS GRACIAS!

[SURVEY VENDOR NAME]

WAVE: PRENOTIFICATION POSTCARD 2010
PROTOCOL: FOLLOW-UP—NO PROXY AT BASELINE, FOLLOW-UP—PROXY AT
BASELINE
MAILING MATERIALS TRACKING NUMBER: 10 9
[CMS Logo]
MEDICARE HEALTH OUTCOMES SURVEY

Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said that
we would like you to complete the survey again in the year 2010. In a few days, you will receive
a questionnaire in the mail. We would greatly appreciate your taking the time to complete the
form.
The Centers for Medicare & Medicaid Services (CMS) conducts this survey to find out more
about the care that is provided to people with Medicare. Your answers can help your health plan
to improve the quality of care.
Please look for the Medicare Health Outcomes Survey in the mail in a few days. Thank you for
your continued help in this important study.
Sincerely,

Walter Stone
CMS Privacy Officer

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING 2010
PROTOCOL: FOLLOW-UP—NO-PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 1110
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said that
we would like you to complete the survey again in the year 2010. Therefore, we are writing to
ask for your continued help. We would greatly appreciate your taking the time to fill out the
enclosed questionnaire. A postage-paid return envelope is enclosed.
After the study is completed, your responses will be shared with your health plan. Your plan will
use this information to improve the quality of care. Your responses to this follow-up survey will
also help the Centers for Medicare & Medicaid Services (CMS) to determine if the care you
receive is keeping you as healthy as possible.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this
survey. If you have any problems completing the survey or have other questions about it, please
don’t hesitate to call [SURVEY VENDOR NAME] toll free at [1-800-Number] or e-mail [SURVEY
VENDOR NAME] at [email address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR SECOND QUESTIONNAIRE MAILING 2010
PROTOCOL: FOLLOW-UP—NO-PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 1211
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said that
we would like you to complete the survey again in the year 2010. Recently we wrote to ask for
your continued help but have not received your response. We would greatly appreciate your
taking the time to fill out the enclosed questionnaire. A postage-paid return envelope is
enclosed.
After the study is completed, your responses will be shared with your health plan. Your plan will
use this information to improve the quality of care. Your responses to this follow-up survey will
also help the Centers for Medicare & Medicaid Services (CMS) to determine if the care you
receive is keeping you as healthy as possible.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this
survey. If you have any problems completing the survey or have other questions about it, please
don’t hesitate to call [SURVEY VENDOR NAME] toll free at [1-800-Number] or e-mail [SURVEY
VENDOR NAME] at [email address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING 2010
PROTOCOL: FOLLOW-UP—PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 1312
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said we
would like you to complete the survey again in the year 2010. Therefore, we are writing to ask
for your continued help. We would greatly appreciate your taking the time to fill out the enclosed
questionnaire. A postage-paid return envelope is enclosed.
Two years ago someone completed this survey for you. This person’s name is printed
[SURVEY VENDOR INSERTS APPROPRIATE INFORMATION]. If you are unable to
complete the survey at this time, please ask the same person to complete the survey
about you again. If that person is not able to help you, please ask another person who
knows about your health to complete the survey about you.
After the study is completed, your responses will be shared with your health plan. Your plan will
use this information to improve the quality of care. Your responses to this follow-up survey will
also help the Centers for Medicare & Medicaid Services (CMS) to determine if the care you
receive is keeping you as healthy as possible.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this
survey. If you have any problems completing the survey or have other questions about it, please
don’t hesitate to call [SURVEY VENDOR NAME] toll free at [1-800-Number] or e-mail [SURVEY
VENDOR NAME] at [email address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR SECOND QUESTIONNAIRE MAILING 2009
PROTOCOL: FOLLOW-UP—PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 1413
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said that
we would like you to complete the survey again in the year 2010. Recently we wrote to ask for
your continued help but have not received your response. We would greatly appreciate your
taking the time to fill out the enclosed questionnaire. A postage-paid return envelope is
enclosed.
Two years ago someone completed this survey for you. This person’s name is printed
[VENDOR INSERTS APPROPRIATE INFORMATION]. If you are unable to complete the
survey at this time, please ask the same person to complete the survey about you again.
If that person is not able to help you, please ask another person who knows about your
health to complete the survey about you.
After the study is completed, your responses will be shared with your health plan. Your plan will
use this information to improve the quality of care. Your responses to this follow-up survey will
also help the Centers for Medicare & Medicaid Services (CMS) to determine if the care you
receive is keeping you as healthy as possible.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this
survey. If you have any problems completing the survey or have other questions about it, please
don’t hesitate to call [SURVEY VENDOR NAME] toll free at [1-800-Number] or e-mail [SURVEY
VENDOR NAME] at [email address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures