Mailing Mater Associated with Medicare HOS (English and Spanish)

WAVE: PRE-NOTIFICATION POSTCARD 2013
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 2013
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 Medicare members get highquality care. One of the ways we can do this is to ask you about the care you receive and your
health.
We are conducting a survey of people with Medicare. The survey is called the Medicare Health
Outcomes Survey. We selected your name at random from the people in your health plan who
have Medicare. We would appreciate your taking the time to fill out the survey and returning it to
us in the postage-paid envelope.
Your answers will have no effect on your Medicare benefits. Your participation is voluntary, but
we hope that you will take the survey.
Your answers to the survey will give us important information about your health plan’s ability to
give you the care you need. We will contact you in two years and ask you to complete the
survey again. We will compare your answers from both surveys, to determine if the care you
receive is helping you stay as healthy as possible. After we complete our study, we will share
your responses with your health plan, which may use the information to improve the quality of
care it provides to you and to other Medicare members. Survey results are included in the
Medicare Health Plan Compare tool on www.medicare.gov to help members and their families
compare Medicare plans.
[SURVEY VENDOR NAME] is a survey research organization that is working with us to carry
out this survey. If you have any problems completing the survey, or if you have other questions
about it, please call [SURVEY VENDOR NAME] toll free at [800-number] or e-mail [SURVEY
VENDOR NAME] at [e-mail address].
Thank you for your help!
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures
ESPANOL AL OTRO LADO

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING – SIDE B 2013
PROTOCOL: BASELINE, (SIDE A - ENGLISH PRIMARY BASELINE, ENGLISH 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 2013
PROTOCOL: BASELINE
MAILING MATERIALS TRACKING NUMBER: 4
[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 Medicare members get highquality care. One of the ways we can do this is to ask you about the care you receive and your
health.
We recently mailed the Medicare Health Outcomes Survey to you, but we have not received
your response. We are enclosing another copy of the survey. Please complete it and return it to
us in the enclosed postage-paid envelope.
Your answers will have no effect on your Medicare benefits. Your participation is voluntary, but
we hope that you will take the survey.
Your answers will give us important information about your health plan’s ability to give you the
care you need. We will contact you in two years and ask you to complete the survey again. We
will compare your answers from both surveys, to determine if the care you receive is helping
you stay as healthy as possible. After we complete our study, we will share your responses with
your health plan, which may use the information to improve the quality of care it provides to you
and to other Medicare members.
[SURVEY VENDOR NAME] is a survey research organization that is working with us to carry
out this survey. If you have any problems completing the survey, or if you have other questions
about it, please call [SURVEY VENDOR NAME] toll free at [800-number] or e-mail [SURVEY
VENDOR NAME] at [e-mail address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer
Enclosures

WAVE: PRE-NOTIFICATION POSTCARD 2013
PROTOCOL: SPANISH PRIMARY BASELINE, SPANISH FOLLOW-UP
MAILING MATERIALS TRACKING NUMBER: 5
[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 días.
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 2013
PROTOCOL: SPANISH PRIMARY BASELINE, SPANISH FOLLOW-UP
MAILING MATERIALS TRACKING NUMBER: 6
[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: PRE-NOTIFICATION POSTCARD 2013
PROTOCOL: FOLLOW-UP—NO PROXY AT BASELINE, FOLLOW-UP—PROXY AT
BASELINE

MAILING MATERIALS TRACKING NUMBER: 7
[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 2013. 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 2013
PROTOCOL: FOLLOW-UP—NO PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 8
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago, you completed the Medicare Health Outcomes Survey for the Centers for
Medicare & Medicaid Services (CMS). At that time, we said that we would like you to complete
the survey again in 2013, and we are now writing to ask for your continued help. Will you please
take the time to fill out the enclosed survey and return it to us in the enclosed postage-paid
envelope?
After the study is complete, your responses will be shared with your health plan, which may use
the information to improve the quality of care it provides to Medicare members. Your responses
to this follow-up survey will also help us determine if the care you receive is helping you stay 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 if you have other questions about it,
please call [SURVEY VENDOR NAME] toll free at [800-Number] or e-mail [SURVEY VENDOR
NAME] at [e-mail address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR SECOND QUESTIONNAIRE MAILING 2013
PROTOCOL: FOLLOW-UP—NO-PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 9
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago, you completed the Medicare Health Outcomes Survey for the Centers for
Medicare & Medicaid Services (CMS). At that time, we said that we would like you to complete
the survey again in 2013. Recently, we wrote to ask for your help, but we have not received
your response. We are enclosing another copy of the survey, and we would appreciate your
taking the time to complete it. Please return it to us in the enclosed postage-paid envelope.
After the study is complete, your responses will be shared with your health plan, which may use
the information to improve the quality of care it provides to Medicare members. Your responses
to this follow-up survey will also help us determine if the care you receive is helping you stay 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 if you have other questions about it,
please call [SURVEY VENDOR NAME] toll free at [800-number] or e-mail [SURVEY VENDOR
NAME] at [e-mail address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING 2013
PROTOCOL: FOLLOW-UP—PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 10
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago, you completed the Medicare Health Outcomes Survey for the Centers for
Medicare & Medicaid Services (CMS). At that time, we said we would like you to complete the
survey again in 2013. We are now writing to ask for your continued help. Will you please take
the time to fill out the enclosed survey and return it to us in the enclosed postage-paid
envelope?
Two years ago, someone completed this survey for you. This person’s name is [SURVEY
VENDOR INSERTS APPROPRIATE INFORMATION]. If you cannot complete the survey at
this time, please ask the same person to complete the survey about you again. If that
person cannot help you, please ask another person who knows about your health to
complete the survey about you.
After the study is complete, your responses will be shared with your health plan, which may use
the information to improve the quality of care it provides to Medicare members. Your responses
to this follow-up survey will also help us determine if the care you receive is helping you stay 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 if you have other questions about it,
please call [SURVEY VENDOR NAME] toll free at [800-number] or e-mail [SURVEY VENDOR
NAME] at [e-mail address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR SECOND QUESTIONNAIRE MAILING 2013
PROTOCOL: FOLLOW-UP—PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 11
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago, you completed the Medicare Health Outcomes Survey for the Centers for
Medicare & Medicaid Services (CMS). At that time, we said that we would like you to complete
the survey again in 2013. Recently, we wrote to ask for your help, but we have not received
your response. We are enclosing another copy of the survey, and we would appreciate your
taking the time to complete it. Please return it to us in the enclosed postage-paid envelope.
Two years ago, someone completed this survey for you. This person’s name is [SURVEY
VENDOR INSERTS APPROPRIATE INFORMATION]. If you cannot complete the survey at
this time, please ask the same person to complete the survey about you again. If that
person cannot help you, please ask another person who knows about your health to
complete the survey about you.
After the study is complete, your responses will be shared with your health plan, which may use
the information to improve the quality of care it provides to Medicare members. Your responses
to this follow-up survey will also help us determine if the care you receive is helping you stay 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 if you have other questions about it,
please call [SURVEY VENDOR NAME] toll free at [800-number] or e-mail [SURVEY VENDOR
NAME] at [e-mail address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures