Form CMS-10445 Initial Call Form

OMB No.: XXXX-XXXX

Expiration Date: XX/XX/20XX

MPR Reference No.:

MPR ID Number: | | | | | | | | |

Medicare Advantage Contract Number: | | | | | |

Evaluation of the Quality Bonus Payment Demonstration

Initial Call Form

Draft

June 1, 2012

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 XXXX-XXXX. The time required to complete this information collection is estimated to average 10 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, N2-14-26, Baltimore, MD  21244-1850.

Hello, my name is [INTERVIEWER’S FULL NAME]. I am calling from Mathematica Policy Research on behalf of the Centers for Medicare & Medicaid Services. May I please speak to [PERSON LISTED ON CONTACT SHEET] of [CONTRACTOR ORGANIZATION NAME]?

REASON FOR THE CALL

We recently sent [you/PERSON] a letter describing the survey we are conducting as part of a CMS evaluation of the Quality Bonus Payment Demonstration. I would like to ask [you/him/her] a few questions about the plans operating under this Medicare Advantage contract. I would also like your help in identifying the person at your organization to whom our survey questionnaire should be sent.

Q1. According to information provided by CMS, this contract includes [NUMBER OF PLANS] health plans. Is that correct?

Number of Plans under this contract will be fed in to this form from HPMS

YES (GO TO Q3) 1

NO 0

Q2. How many health plans operate under this MA contract?

| | | Health Plans

Q3. INTERVIEWER: CHECK QUESTION Q2. IS THERE MORE THAN ONE PLAN?

YES 1

NO (GO TO Q6) 0

Q4. Do quality improvement activities differ in any meaningful way across plans under this contract?

YES 1

NO (GO TO Q6) 0

Q5. What are two or three main ways they differ?

Q6. We would like to send you a questionnaire which asks you to describe the quality improvement programs of this contract. The survey takes about 25 minutes to complete.

Individual responses to this survey will be kept confidential. Answers from all responding contract holders will be tabulated and provided to CMS in aggregate form only. Individual responses will not be linked to individual contracts, plans, or respondents.

To whom should the questionnaire be sent?

INTERVIEWER: IF THE PERSON TO WHOM YOU ARE SPEAKING WANTS THE QUESTIONNAIRE SENT TO HIM OR HER, VERIFY (AND CORRECT) ADDRESS AND OTHER CONTACT INFORMATION ON THE CONTACT SHEET.

ASK WHETHER THE PERSON WOULD LIKE TO HAVE THE DOCUMENT SENT VIA EMAIL AND IF SO, GET THE PERSON’S EMAIL ADDRESS.

IF THE QUESTIONNAIRE IS TO BE SENT TO ANOTHER PERSON, RECORD THE NAME AND MAILING INFORMATION UNDER Q7. ASK WHETHER THAT PERSON SHOULD ALSO RECEIVE THE QUESTIONNAIRE VIA EMAIL AND IF SO, MAKE SURE TO FILL IN THE EMAIL ADDRESS BELOW.

Q7. NAME:

TITLE:

ORGANIZATION:

ADDRESS 1:

ADDRESS 2:

CITY:

STATE:

ZIP CODE:

TELEPHONE NUMBER:

EMAIL ADDRESS:

Q8. IF MORE THAN ONE QUESTIONNAIRE SHOULD BE SENT BECAUSE QUALITY IMPROVEMENT PROGRAMS DIFFER SUBSTANTIALLY ACROSS PLANS WITHIN THIS CONTRACT, RECORD THE ADDITIONAL RESPONDENT’S MAILING INFORMATION HERE. BRING THIS CASE TO THE ATTENTION OF YOUR SURVEY SUPERVISOR.

NAME:

TITLE:

ORGANIZATION:

ADDRESS 1:

ADDRESS 2:

CITY:

STATE:

ZIP CODE:

TELEPHONE NUMBER:

EMAIL ADDRESS: