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pdfHOS Baseline Text for Prenotification
Letters, Survey Cover Letters and
Reminder/Thank-You Postcards
HOS Baseline Prenotification Letter
[CMS Privacy Office Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, is responsible
for monitoring the quality of care that Medicare health plans provide. One of the ways we do this is by asking
people with Medicare about their physical and mental health and how it has changed over time.
You have been selected to receive the “Medicare Health Outcomes Survey.” If you are enrolled in a larger
health plan, your name was selected at random. If you are enrolled in a smaller plan, all members with
Medicare are being asked to participate. In a few days, you will receive the questionnaire in the mail. We
would greatly appreciate it if you would take the time to complete and return it in the enclosed postage-paid
envelope.
Your answers will provide important information about your health. In 2 years, we will ask you to complete the
survey again. We will compare the results from both surveys to determine if your health plan is keeping you
as healthy as possible. After the 2 year study is complete, we will use the results to see how well your health
plan can maintain or improve health and well-being over time.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will have no effect on your Medicare benefits.
[SURVEY VENDOR NAME] is a survey organization working with CMS to carry out this survey. If you have
questions about the survey or would like to request the survey in Spanish, please call [SURVEY VENDOR
NAME] toll-free at [800 NUMBER]. Thank you for your help with this important survey.
Sincerely,
Walter Stone
CMS Privacy Officer
HOS Baseline Letter for First Questionnaire Mailing (Double-Sided—English)
[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, monitors the
quality of care Medicare health plans provide. One of the ways CMS does this is by asking people with
Medicare about their health to determine whether the care their health plan provides is keeping them as
healthy as possible.
CMS is conducting a survey called the “Medicare Health Outcomes Survey.” This survey asks about your
physical and mental health and how it has changed over time. If you are enrolled in a larger health plan, your
name was selected at random. If you are enrolled in a smaller plan, all members with Medicare are being
asked to take the survey.
We would greatly appreciate your taking the time to fill out this questionnaire and return it to us in the
postage-paid envelope. If you choose to participate, CMS may ask you to take the survey again in 2 years.
CMS will compare results from both surveys to see how well your health plan can maintain or improve the
health and well-being of its members over time. The results will be used to improve the quality of care people
with Medicare receive and to help them make more informed choices when selecting a health plan.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will not affect your Medicare benefits in any way. However, your knowledge can help others
with Medicare, so we hope you will choose to help us.
If you have questions about the survey or would like to request the questionnaire in Spanish, please call
[SURVEY VENDOR NAME] toll-free at [800 NUMBER] or e-mail [E-MAIL ADDRESS]. Thank you for your
help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures
Espanol Al Otro Lado
HOS Baseline Letter for First Questionnaire Mailing (Double-Sided—Spanish)
[Survey Vendor Letterhead]
Estimado(a) beneficiario(a) de Medicare:
Los Centros de Servicios de Medicare y Medicaid (CMS por sus siglas en inglés), la agencia federal que
administra el programa Medicare, revisan la calidad del cuidado médico que proporcionan los planes de
salud de Medicare. Una de las maneras en las que CMS hace eso es preguntando a las personas con
Medicare sobre su salud para determinar si los servicios que les proporciona su plan médico los mantienen
tan sanos como sea posible.
CMS está llevando a cabo una encuesta llamada “Encuesta de Medicare Sobre la Salud”. En esta encuesta
se le pregunta acerca de su salud física y mental y cómo ha cambiado esta con el tiempo. Si está inscrito(a)
en un plan médico grande, su nombre fue seleccionado al azar. Si forma parte de un plan médico más
pequeño, a todos los miembros con Medicare se les pide que participen en la encuesta.
Le agradeceremos mucho que dedique tiempo para completar este cuestionario y lo regrese en el sobre
adjunto que no necesita estampilla de correo. Si decide participar, CMS pudiera pedirle que responda la
encuesta nuevamente en 2 años. CMS va a comparar los resultados de ambas encuestas para ver qué tan
bien su plan de salud puede mantener o mejorar la salud y el bienestar de sus miembros con el tiempo. Los
resultados se utilizarán para mejorar la calidad de los servicios que reciben las personas con Medicare y
ayudarles a tomar decisiones informadas al seleccionar un plan de salud.
La precisión de los resultados depende de poder obtener respuestas de usted y de las otras personas
seleccionadas para la encuesta. CMS mantendrá en confidencialidad toda la información que usted
proporcione, la cual está protegida por la Ley de privacidad. No es obligatorio participar en esta encuesta.
Su ayuda es voluntaria, y su decisión de participar o no participar no afectará sus beneficios de
Medicare de ninguna manera. Sin embargo, su conocimiento puede ayudar a otras personas con Medicare,
por lo que esperamos que decida ayudarnos.
Si tiene preguntas sobre la encuesta o desea solicitar el cuestionario en inglés, por favor llame a [SURVEY
VENDOR NAME] al número de teléfono gratuito [800 NUMBER] o envíe un correo electrónico al [E-MAIL
ADDRESS]. Gracias por su ayuda en esta importante encuesta.
Atentamente,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Material adjunto
English on the other side
HOS Baseline Letter for Replacement Questionnaire Mailing
[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
Recently we mailed you the “Medicare Health Outcomes Survey.” If you already returned the survey, thank
you! If you did not, we are sending you another copy and ask that you complete and return the questionnaire
in the enclosed postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, monitors the
quality of care Medicare health plans provide. One of the ways CMS does this is by conducting the “Medicare
Health Outcomes Survey,” which asks people with Medicare about their health to determine whether the care
their health plan provides is keeping them as healthy as possible. If you are enrolled in a larger health plan,
your name was selected at random. If you are enrolled in a smaller plan, all members with Medicare are being
asked to take the survey.
We would greatly appreciate your taking the time to fill out this survey. If you choose to participate, CMS may
ask you to take the survey again in 2 years. CMS will compare results from both surveys to see how well your
health plan is able to maintain or improve the health and well-being of its members over time. The results will
be used to improve the quality of care people with Medicare receive and to help them make more informed
choices when selecting a health plan.
The accuracy of the results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will not affect your Medicare benefits in any way. However, your answers are important so we
hope you will choose to help us.
If you have questions about the survey or would like to receive the questionnaire in Spanish, please call
[SURVEY VENDOR NAME] toll-free at [800 NUMBER] or e-mail [E-MAIL ADDRESS]. Thank you for your
help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures
HOS Baseline Reminder/Thank-You Postcard
[Survey Vendor Logo]
Medicare Health Outcomes Survey
Dear Medicare Beneficiary:
About 1 week ago, you should have received the “Medicare Health Outcomes Survey” in the mail. If you have
already returned the survey, thank you!
If not, this is a reminder that we would like you to complete and return it in the postage-paid envelope. Your
answers can help the Centers for Medicare & Medicaid Services (CMS) and your health plan to improve the
quality of care people with Medicare receive.
If you did not receive the survey or misplaced it, you should receive another in the mail soon. If you do not
receive the survey or would like to request it in Spanish, please call [SURVEY VENDOR NAME] toll-free at
[800 NUMBER] or e-mail [E-MAIL ADDRESS].
Thank you!
[SURVEY VENDOR NAME]
HOS Follow-Up Text for Prenotification
Letter, Survey Cover Letters and
Reminder/Thank-You Postcards
HOS Follow-Up Prenotification Letter
[CMS Privacy Office Letterhead]
Dear Medicare Beneficiary:
About 2 years ago, you participated in the “Medicare Health Outcomes Survey.” At that time, we said that we
would like you to take the survey again in 2015. In a few days, you will receive the new survey in the mail.
When it arrives, we would greatly appreciate it if you would take the time to complete and return it in the
enclosed postage-paid envelope.
As you may recall, the Centers for Medicare & Medicaid Services (CMS) monitors the quality of care that
Medicare health plans provide. One of the ways that we do this is by asking people with Medicare about their
health and how it has changed over time.
The information you provide is important and can help us improve the quality of care provided to you and
other people with Medicare. We will compare results from both surveys to determine if your health plan is
keeping people with Medicare as healthy as possible. Our goal is to determine how well each health plan is
able to maintain or improve the health and well-being of its members over time.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will have no effect on your Medicare benefits.
[SURVEY VENDOR NAME] is a survey organization working with CMS to carry out this survey. If you have
questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER]. Thank you for
your ongoing help with this important survey.
Sincerely,
Walter Stone
CMS Privacy Officer
HOS Follow-Up Letter for First Questionnaire Mailing—No Proxy at Baseline
[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
About 2 years ago you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2015. We would greatly appreciate your taking the time to fill out
this questionnaire and return it to us in the postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS) monitors the quality of care Medicare health plans
provide. One of the ways that CMS does this is by asking people with Medicare about their health to
determine whether the care their health plan provides is keeping them as healthy as possible.
The information you provide is important. CMS will compare results from both surveys to see how well your
health plan can maintain or improve the health and well-being of its members over time. The results will be
used to improve the quality of care people with Medicare receive and to help them make more informed
choices when selecting a health plan.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will not affect your Medicare benefits in any way. However, your knowledge can help others
with Medicare, so we hope you will choose to help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures
HOS Follow-Up Letter for Replacement Questionnaire Mailing—No Proxy at Baseline
[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
About 2 years ago you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2015. We recently mailed you this survey, but we have not received
it back from you. If you already returned it, thank you for completing the survey. We have enclosed another
copy of the same survey in case you did not receive it and ask that you complete and return it in the postagepaid envelope.
The Centers for Medicare & Medicaid Services (CMS) monitors the quality of care Medicare health plans
provide. One of the ways that CMS does this is by asking people with Medicare about their health to
determine whether the care their health plan provides is keeping them as healthy as possible.
We would greatly appreciate your taking the time to fill out this survey. CMS will compare results from both
surveys to see how well your health plan is able to maintain or improve the health and well-being of its
members over time. The results will be used to improve the quality of care people with Medicare receive and
to help them make more informed choices when selecting a health plan.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will not affect your Medicare benefits in any way. However, your answers are important so we
hope you will choose to help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures
HOS Follow-Up Letter for First Questionnaire Mailing—Proxy at Baseline
[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
About 2 years ago you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2015. We would greatly appreciate your taking the time to fill out
this questionnaire and return it to us in the postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS) monitors the quality of care Medicare health plans
provide. One of the ways that CMS does this is by asking people with Medicare about their health to
determine whether the care their health plan provides is keeping them as healthy as possible.
The information you provide is important. CMS will compare results from both surveys to see how well your
health plan can maintain or improve the health and well-being of its members over time. The results will be
used to improve the quality of care people with Medicare receive and to help them make more informed
choices when selecting a health plan.
Two years ago, someone completed this survey for you. This person’s name is [SURVEY VENDOR
INSERTS APPROPRIATE INFORMATION]. If you are not able to take the survey, please ask this
person to complete the survey about you again. If that person cannot help you, please ask someone
else who knows about your health to complete the survey about you.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will not affect your Medicare benefits in any way. However, your knowledge can help others
with Medicare, so we hope you will choose to help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures
HOS Follow-Up Letter for Replacement Questionnaire Mailing—Proxy at Baseline
[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
About 2 years ago you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2015. We recently mailed you this survey, but we have not received
it back from you. If you already returned it, thank you for completing the survey. We have enclosed another
copy of the same survey in case you did not receive it and ask that you complete and return it in the postagepaid envelope.
The Centers for Medicare & Medicaid Services (CMS) monitors the quality of care Medicare health plans
provide. One of the ways CMS does this is by asking people with Medicare about their health to determine
whether the care their health plan provides is keeping them as healthy as possible.
We would greatly appreciate your taking the time to fill out this survey. CMS will compare results from both
surveys to see how well your health plan is able to maintain or improve the health and well-being of its
members over time. The results will be used to improve the quality of care people with Medicare receive and
to help them make more informed choices when selecting a health plan.
Two years ago, someone completed this survey for you. This person’s name is [SURVEY VENDOR
INSERTS APPROPRIATE INFORMATION]. If you are not able to take the survey, please ask this
person to complete the survey about you again. If that person cannot help you, please ask someone
else who knows about your health to complete the survey about you.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will not affect your Medicare benefits in any way. However, your answers are important so we
hope you will choose to help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures
HOS Follow-Up Reminder/Thank-You Postcard
[Survey Vendor Logo]
Medicare Health Outcomes Survey
Dear Medicare Beneficiary:
About 1 week ago, you should have received the “Medicare Health Outcomes Survey” in the mail. If you have
already returned the survey, thank you!
If not, this is a reminder that we would like you to complete and return it in the postage-paid envelope. Your
answers can help the Centers for Medicare & Medicaid Services (CMS) and your health plan to improve the
quality of care people with Medicare receive.
If you did not receive the survey or misplaced it, you should receive another in the mail soon. If you do not
receive the survey or would like to request it in Spanish, please call [SURVEY VENDOR NAME] toll-free at
[800 NUMBER] or e-mail [E-MAIL ADDRESS].
Thank you!
[SURVEY VENDOR NAME]
HOS-M Text for Prenotification Letters,
Survey Cover Letters and Reminder/
Thank-You Postcards
HOS-M Prenotification Letter
[CMS Privacy Office Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, is responsible
for monitoring the quality of care that Medicare health plans provide. One of the ways we do this is by asking
people with Medicare about their physical and mental health.
You have been selected to receive the “Medicare Health Outcomes Survey-Modified.” If you are enrolled in a
larger health plan, your name was selected at random. If you are enrolled in a smaller plan, all members with
Medicare are being asked to participate. In a few days, you will receive the questionnaire in the mail. We
would greatly appreciate it if you would take the time to complete and return it in the enclosed postage-paid
envelope.
Your answers are important and will help us determine if your health plan is keeping you as healthy as
possible. All information you provide will be held in confidence by CMS and is protected by the Privacy Act.
You do not have to participate in this survey. Your help is voluntary and your decision to participate
or not participate will have no effect on your Medicare benefits.
[SURVEY VENDOR NAME] is a survey organization working with CMS to carry out this survey. If you have
questions about the survey or would like to request the survey in Spanish, please call [SURVEY VENDOR
NAME] toll-free at [800 NUMBER]. Thank you for your help with this important survey.
Sincerely,
Walter Stone
CMS Privacy Officer
HOS-M Letter for First Questionnaire Mailing
[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, monitors the
quality of care Medicare health plans provide. One of the ways CMS does this is by asking people with
Medicare about their health to determine whether the care their health plan provides is keeping them as
healthy as possible.
CMS is conducting a survey called the “Medicare Health Outcomes Survey-Modified.” This survey asks about
your physical and mental health. If you are enrolled in a larger health plan, your name was selected at
random. If you are enrolled in a smaller health plan, all members with Medicare are being asked to take the
survey.
We would greatly appreciate your taking the time fill out this questionnaire and return it to us in the enclosed
postage-paid envelope.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will not affect your Medicare benefits in any way. However, your knowledge can help others
with Medicare, so we hope you will choose to help us.
If you have questions about the survey or would like to request the survey in Spanish or Chinese, please call
[SURVEY VENDOR NAME] toll-free number at [800 NUMBER] or e-mail [E-MAIL ADDRESS]. Thank you for
your help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
P.S. If you have trouble completing the survey, a relative, friend or caregiver who knows about your health
can fill out the survey for you.
HOS-M Letter for Replacement Questionnaire Mailing
[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
Recently we mailed you the “Medicare Health Outcomes Survey—Modified.” If you already returned the
survey, thank you! If you did not, we are sending you another copy and ask that you complete and return the
questionnaire in the enclosed postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, monitors the
quality of care Medicare health plans provide. One of the ways CMS does this is by asking people with
Medicare about their health to determine whether the care their health plan provides is keeping them as
healthy as possible. If you are enrolled in a larger health plan, your name was selected at random. If you are
enrolled in a smaller health plan, all members with Medicare are being asked to take the survey.
We would greatly appreciate your taking the time fill out this questionnaire and return it to us in the enclosed
postage-paid envelope.
The accuracy of these results depends on getting answers from you and others selected for this survey. All
information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not
have to participate in this survey. Your help is voluntary and your decision to participate or not
participate will not affect your Medicare benefits in any way. However, your answers are important so we
hope you will choose to help us.
If you have any questions about the survey or would like to request the survey in Spanish or Chinese, please
call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or e-mail [E-MAIL ADDRESS]. Thank you for your
help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
P.S. If you have trouble completing the survey, a relative, friend or caregiver who knows about your health
can fill out the survey for you.
HOS-M Reminder/Thank-You Postcard
[Survey Vendor Logo]
Medicare Health Outcomes Survey-Modified
Dear Medicare Beneficiary:
About 1 week ago, you should have received the “Medicare Health Outcomes Survey—Modified” in the mail.
If you have already returned the survey, thank you!
If not, this is a reminder that we would like you to complete and return it in the postage-paid envelope. Your
answers can help the Centers for Medicare & Medicaid Services (CMS) and your health plan to improve the
quality of care people with Medicare receive.
If you did not receive the survey or misplaced it, please call [SURVEY VENDOR NAME] toll-free at [800
NUMBER] or e-mail [E-MAIL ADDRESS].
Thank you!
[SURVEY VENDOR NAME]
| File Type | application/pdf |
| File Title | Appendix 3 |
| Author | Judy Lacourciere |
| File Modified | 2014-02-18 |
| File Created | 2014-02-18 |