Form CMS-R-246 Medicare Fee-For-Service CAHPS Survey

FFS CAHPS Survey
INTIAL COVER LETTER
Dear Medicare Beneficiary:
As a person with Medicare, you deserve to get the highest quality medical care when you need it,
from doctors that you trust. The Centers for Medicare & Medicaid Services (CMS) is the federal
agency that administers the Medicare program, and its responsibility is to ensure that you get
high quality care at a reasonable price. One of the ways CMS can fulfill that responsibility is to
find out directly from you about the care you are currently receiving under the Medicare
program.
CMS is conducting a survey of people with Medicare to learn more about the health care services
you receive. Your name was selected at random by CMS from among Medicare enrollees. We
would greatly appreciate it if you would take the time, about 20 minutes, to fill out this
questionnaire. The accuracy of the results depends on getting answers from you and other
people with Medicare selected for this survey. This is your opportunity to help CMS serve you
better.
If you changed your Medicare plan for 2016, please answer the questions in the survey thinking
about your experiences in the last six months of 2015. All information you provide will be held
in confidence and is protected by the Privacy Act. The information you provide will not be
shared with anyone other than authorized persons at CMS and IMPAQ International, the survey
research organization assisting us in this survey. You do not have to participate in this survey.
Your help is voluntary and your decision to participate or not to participate will not affect
your Medicare benefits in any way. However, your knowledge and experiences will help other
people with Medicare make more informed choices, so we hope you will choose to help us.
If you have any questions about the survey or would like to find out how to complete the survey
by phone, please don’t hesitate to call IMPAQ International toll-free at 1-888-942-2477 anytime
from 9:00 am to 9:00 pm your local time.
Thank you in advance for your participation.
Sincerely,

Walter Stone
CMS Privacy Officer

MEDICARE SURVEY INSTRUCTIONS
This survey asks about you and the health care you received in the last six months.
Answer each question thinking about yourself. Please take the time to complete this
survey. Your answers are very important to us.
Please return the survey with your answers in the enclosed postage-paid envelope to:
Medicare Satisfaction Survey, PO Box 1800, Manchester, CT 06045-9989.
Answer all the questions by putting an “X” in the box to the left of your answer, like
this:



Yes

X
Be sure to read all the answer choices given before marking your answer. You are
sometimes told not to answer some questions in this survey. When this happens you
will see an arrow with a note that tells you what question to answer next, like this:
[→ If No, Go to Question 3].
See the examples below:
EXAMPLE
1. Do you wear a hearing aid now?

 Yes
 No → If No, Go to Question 3
2. How long have you been wearing a hearing aid?






Less than one year
1 to 3 years
More than 3 years
I don’t wear a hearing aid

3. In the last 6 months, did you have any headaches?

 Yes
 No

YOUR HEALTH INSURANCE COVERAGE
Our records show that you are now in Medicare, the health insurance program for
people 65 years old or older or persons with certain disabilities.
Please answer the following questions in this survey as fully as possible regardless of
whether you consider yourself in Medicare.
1. Some people who have Medicare also have other insurance to help pay for some of
the costs of their health care. Do you have any other insurance that pays at least
some of the cost of your health care?

 Yes
 No → If No, Go to Question 3
2. Please mark the box below for each type of health insurance that you have.

 Medigap, which may be identified on the front of your policy as “Medicare







Supplemental Insurance”
Employer, Union, or Retiree Health Coverage (insurance)
Veteran’s Benefits, also known as VA benefits
Military Retiree Benefits, also known as Tricare
Medicaid, also known as State medical assistance, which is for some persons
with limited income and resources
Any Prescription Drug Plan
Other (Please write the name of the other health insurance you currently have
on the line below.)

______________________________
 I don’t have health insurance other than Medicare.

YOUR HEALTH CARE IN THE LAST 6 MONTHS
3. In the last 6 months, did you have an illness, injury, or condition that needed care
right away in a clinic, emergency room, or doctor’s office?

 Yes
 No → If No, Go to Question 5

4. In the last 6 months, when you needed care right away, how often did you get care
as soon as you thought you needed?






Never
Sometimes
Usually
Always

5. In the last 6 months, not counting the times you needed care right away, did you
make any appointments for your health care at a doctor’s office or clinic?

 Yes
 No → If No, Go to Question 7
6. In the last 6 months, not counting the times you needed care right away, how often
did you get an appointment for your health care at a doctor’s office or clinic as soon
as you thought you needed?






Never
Sometimes
Usually
Always

7. In the last 6 months, not counting the times you went to an emergency room, how
many times did you go to a doctor’s office or clinic to get health care for yourself?









None → If None, Go to Question 9
1
2
3
4
5 to 9
10 or more

8. Wait time includes time spent in the waiting room and exam room. In the last 6
months, how often did you see the person you came to see within 15 minutes of
your appointment time?






Never
Sometimes
Usually
Always

9. In the last 6 months, did you phone a doctor’s office or clinic with a medical
question after regular office hours?

 Yes
 No → If No, Go to Question 12
10. In the last 6 months, when you phoned a doctor’s office or clinic after regular office
hours, how often did you get an answer to your medical question as soon as you
needed?






Never
Sometimes
Usually
Always

11. In the last 6 months, when you phoned a doctor’s office or clinic after regular office
hours, how long did it take for someone to call you back?









Less than 1 hour
1 to 3 hours
More than 3 hours but less than 6 hours
More than 6 hours
I did not ask for a return call
I did not get a return call
I was told to go to the Emergency Room

12. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is
the best health care possible, what number would you use to rate all your health
care in the last 6 months?

 0 Worst health care possible
 1
 2










3
4
5
6
7
8
9
10 Best health care possible

YOUR PERSONAL DOCTOR
13. A personal doctor is the one you would see if you need a check-up, want advice
about a health problem, or get sick or hurt. Do you have a personal doctor?

 Yes
 No → If No, Go to Question 33
14. In the last 6 months, how many times did you visit your personal doctor to get care
for yourself?









None → If None, Go to Question 33
1
2
3
4
5 to 9
10 or more

15. In the last 6 months, how often did your personal doctor explain things in a way
that was easy to understand?






Never
Sometimes
Usually
Always

16. In the last 6 months, how often did your personal doctor listen carefully to you?






Never
Sometimes
Usually
Always

17. In the last 6 months, how often did your personal doctor show respect for what you
had to say?






Never
Sometimes
Usually
Always

18. In the last 6 months, how often did your personal doctor spend enough time with
you?






Never
Sometimes
Usually
Always

19. Using any number from 0 to 10, where 0 is the worst personal doctor possible and
10 is the best personal doctor possible, what number would you use to rate your
personal doctor?













0 Worst personal doctor possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor possible

20. In the last 6 months, when you visited your personal doctor for a scheduled
appointment, how often did he or she have your medical records or other
information about your care?






Never
Sometimes
Usually
Always

21. In the last 6 months, did your personal doctor order a blood test, x-ray or other test
for you?

 Yes
 No → If No, Go to Question 24
22. In the last 6 months, when your personal doctor ordered a blood test, x-ray or other
test for you, how often did someone from your personal doctor’s office follow up to
give you those results?






Never → If Never, Go to Question 24
Sometimes
Usually
Always

23. In the last 6 months, when your personal doctor ordered a blood test, x-ray or other
test for you, how often did you get those results as soon as you needed them?






Never
Sometimes
Usually
Always

24. In the last 6 months, did you take any prescription medicine?

 Yes
 No → If No, Go to Question 26

25. In the last 6 months, how often did you and your personal doctor talk about all the
prescription medicines you were taking?






Never
Sometimes
Usually
Always

26. Doctors may use computers or handheld devices during an office visit to do things
like look up your information or order prescription medicines. In the last 6 months,
did your personal doctor use a computer or handheld device during any of your
visits?

 Yes
 No → If No, Go to Question 29
27. During your visits in the last 6 months, was your personal doctor’s use of a
computer or handheld device helpful to you?

 Yes, a lot
 Yes, a little
 No, not at all
28. During your visits in the last 6 months, did your personal doctor’s use of a computer
or handheld device make it harder or easier for you to talk to him or her?

 Harder
 Not harder or easier
 Easier
29. In the last 6 months, did you get care from more than one kind of health care
provider or use more than one kind of health care service?

 Yes
 No → If No, Go to Question 32
30. In the last 6 months, did you need help from anyone in your personal doctor’s office
to manage your care among these different providers and services?

 Yes
 No → If No, Go to Question 32
31. In the last 6 months, did you get the help you needed from your personal doctor’s
office to manage your care among these different providers and services?

 Yes, definitely
 Yes, somewhat
 No
32. Visit notes sum up what was talked about on a visit to a doctor’s office. Visit notes
may be available on paper, on a website or by e-mail. In the last 6 months, did
anyone in your personal doctor’s office offer you visit notes?

 Yes
 No

GETTING HEALTH CARE FROM SPECIALISTS
33. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors,
and other doctors who specialize in one area of health care. Is your personal doctor
a specialist?

 Yes → If Yes, Please include your pers onal doctor as you answer these
questions about specialists
 No
 I do not have a personal doctor
34. In the last 6 months, did you try to make any appointments to see a specialist?

 Yes
 No → If No, Go to Question 39
 Someone else made my specialist appointments for me
35. In the last 6 months, how often was it easy to get appointments with specialists?

 Never






Sometimes
Usually
Always
Someone else made my specialist appointments for me

36. How many specialists have you seen in the last 6 months?








None → If None, Go to Question 39
1 specialist
2
3
4
5 or more specialists

37. We want to know your rating of the specialist you saw most often in the last 6
months. Using any number from 0 to 10, where 0 is the worst specialist possible
and 10 is the best specialist possible, what number would you use to rate that
specialist?













0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible

38. In the last 6 months, how often did your personal doctor seem informed and up-todate about the care you got from specialists?

 Never
 Sometimes
 Usually






Always
I do not have a personal doctor
I did not visit my personal doctor in the last 6 months
My personal doctor is a specialist

MANAGING YOUR HEALTH CARE
39. How likely are you to change doctors if you are dissatisfied with the way you and
your doctor communicate?






Very likely
Likely
Unlikely
Very unlikely

40. How likely are you to tell your doctor when you disagree with him or her?






Very likely
Likely
Unlikely
Very unlikely

41. In the last 6 months, how often did you leave your doctor’s office feeling that all of
your concerns or questions were fully answered?






Never
Sometimes
Usually
Always

42. In the last 6 months, how often did you make sure you understood the results of
any medical test or procedure such as x-ray, blood test, or EKG for heart conditions?






Never
Sometimes
Usually
Always

 I did not have any medical tests or procedures in the last 6 months

MEDICARE EXPERIENCE
The next questions ask about your experience with Medicare.
43. In the last 6 months, did you try to get any kind of care, tests or treatment through
Medicare?

 Yes
 No → If No, Go to Question 45
44. In the last 6 months, how often was it easy to get the care, tests or treatment you
thought you needed through Medicare?






Never
Sometimes
Usually
Always

45. In the last 6 months, did you try to get information or help from Medicare’s
customer service?

 Yes
 No → If No, Go to Question 48
46. In the last 6 months, how often did Medicare’s customer service give you the
information or help you needed?






Never
Sometimes
Usually
Always

47. In the last 6 months, how often did Medicare’s customer service staff treat you with
courtesy and respect?

 Never

 Sometimes
 Usually
 Always
48. In the last 6 months, did Medicare give you any forms to fill out?

 Yes
 No → If No, Go to Question 50
49. In the last 6 months, how often were the forms from Medicare easy to fill out?






Never
Sometimes
Usually
Always

50. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is
the best health plan possible, what number would you use to rate Medicare?













0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible

51. In the last 6 months, did anyone from a doctor’s office or Medicare contact you:
Yes
a. To remind you
to make
appointments

No

for tests or
treatment?





b. To remind you
to get a flu
shot or other
immunization?









c.

To remind you
about screening
tests such as
breast cancer or
colorectal cancer
screening?

52. In the last 6 months, did you spend one or more nights in a hospital?

 Yes
 No → If No, Go to Question 54
53. In the last 6 months, did anyone from a doctor’s office or Medicare contact you to
follow up about your hospital stay?

 Yes
 No

YOUR MEDICARE RIGHTS
54. In the last 6 months, was there a time when you believed you needed care or
services that Medicare decided not to give you?

 Yes
 No → If No, Go to Question 57
55. In the last 6 months, have you ever asked anyone at Medicare to reconsider a
decision not to provide or pay for health care or services?

 Yes

 No → If No, Go to Question 57
 Don’t know → If Don’t know,
Go to Question 57
56. When you spoke to Medicare about the decision not to provide care or services, did
they…
Please mark one or more.








Tell you that you can file an appeal
Offer to send you forms that you need in order to file an appeal
Suggest how to resolve your complaint
Listen to your complaint but did not help resolve it
Discourage you from taking action
Do none of these things

57. In the last 6 months, have you called or written Medicare with a complaint or
problem?

 Yes
 No → If No, Go to Question 61
58. Thinking about the complaint process, regardless of whether you agree or disagree
with the final outcome, how satisfied are you with how Medicare handled your
complaint?







Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied

59. How long did it take for Medicare to settle your complaint?

 Same day
 1 week
 2 weeks

 3 weeks
 4 or more weeks
 I am still waiting for it to be settled
60. Was your complaint or problem settled to your satisfaction?

 Yes
 No
 I am still waiting for it to be settled

ABOUT YOU
61. In general, how would you rate your overall health?







Excellent
Very good
Good
Fair
Poor

62. In general, how would you rate your overall mental or emotional health?







Excellent
Very good
Good
Fair
Poor

63. In the past 12 months, have you seen a doctor or other health provider 3 or more
times for the same condition or problem?

 Yes
 No → If No, Go to Question 65
64. Is this a condition or problem that has lasted for at least 3 months?

 Yes

 No
65. Do you now need or take any medicine prescribed by a doctor for any condition?

 Yes
 No → If No, Go to Question 67
66. Is this to treat a condition that has lasted for at least 3 months?

 Yes
 No
67. In the last 6 months, how often was it easy to get the medicines your doctor
prescribed?







Never
Sometimes
Usually
Always
My doctor did not prescribe any medicines for me in the last 6 months

68. Do you have insurance that pays part or all of the cost of your prescription
medicines?

 Yes
 No
 Don’t know
69. In the last 6 months, did you delay or not fill a prescription because you felt you
could not afford it?

 Yes
 No
 My doctor did not prescribe any medicines for me in the last 6 months
70. Are you currently enrolled in a Medicare Part D plan (prescription drug plan)?

 Yes
 No → If No, Go to Question 77
The following questions are about the Medicare Part D Medication Therapy
Management program. The program is available to people enrolled in a Medicare Part
D plan who have multiple chronic conditions, take multiple medications, and meet
other qualifying criteria.
71. Are you enrolled in a Medicare Part D Medication Therapy Management program?

 Yes
 No → If No, Go to Question 77
 Don’t know → If Don’t know,
Go to Question 77
72. Did a health care provider, such as a pharmacist, call or meet with you to review
your medications and answer your questions about your medications?

 Yes
 No → If No, Go to Question 76
73. Did the review increase your understanding of your medications and how to use
them?

 Yes, it increased my understanding
 No, it did not change my understanding
 No, it decreased my understanding
74. A printed summary of the review includes a letter, a medication action plan, and a
personal medication list. Did you receive a printed summary of the review?

 Yes
 No → If No, Go to Question 76
 Don’t know → If Don’t know,
Go to Question 76
75. How satisfied were you with the information in the printed summary of the review?






Very satisfied
Satisfied
Dissatisfied
Very dissatisfied

76. Overall, how satisfied are you with the Medication Therapy Management program
provided by your Medicare Part D plan?






Very satisfied
Satisfied
Dissatisfied
Very dissatisfied

77. Has a doctor ever told you that you had any of the following conditions?
Yes

No

a. A heart attack?





b. Angina or coronary
heart disease?





Hypertension or
high blood pressure? 



c.

d. Cancer, other than
skin cancer?





e. Emphysema,
asthma or COPD
(chronic obstructive
pulmonary disease)? 



f.

Any kind of diabetes
or high blood sugar? 



78. Have you had a flu shot since July 1, 2015?

 Yes
 No
 Don’t know
79. Have you ever had a pneumonia shot? This shot is usually given only once or twice
in a person’s lifetime and is different from a flu shot. It is also called the
pneumococcal vaccine.

 Yes
 No
 Don’t know
80. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?

 Every day
 Some days
 Not at all → If Not at all,
Go to Question 82
 Don’t know → If Don’t know,
Go to Question 82
81. In the last 6 months, how often were you advised to quit smoking or using tobacco
by a doctor or other health provider?







Never
Sometimes
Usually
Always
I had no visits in the last 6 months

82. What is the highest grade or level of school that you have completed?







8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate

 More than 4-year college degree
83. Are you of Hispanic or Latino origin or descent?

 Yes, Hispanic or Latino
 No, not Hispanic or Latino
84. What is your race? Please mark one or more.







White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native

85. How many people live in your household now, including yourself?

 1 person
 2 to 3 people
 4 or more people
86. Because of a health or physical problem are you unable to do or have any difficulty
doing the following activities? (Please mark one response for each activity.)
I am
unable
to do
this
activity

No,
Yes,
I do not
I have
have
difficulty difficulty

a. Bathing







b. Dressing







c.







Eating

d. Getting
in or out

of chairs







e. Walking







Using the
toilet






f.

87. The Medicare Program is trying to learn more about the health care or services
provided to people with Medicare. May Medicare contact you again about the
health care services that you received?

 Yes
 No
88. Did someone help you complete this survey?

 Yes
 No → Thank you. Please return the completed survey in the postage-paid
envelope.
89. How did that person help you? Please mark one or more.







Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way

THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage-paid envelope to:
Medicare Satisfaction Survey
PO Box 1800
Manchester, CT 06045-9989
Please do not include any other correspondence.