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pdfAppendix B. Medicare IVIG Demonstration Evaluation Survey
This Appendix contains all beneficiary notifications, including: 1) a pre-notification letter; 2) a
cover letter to be included in the survey package; 3) beneficiary survey Form A, for beneficiaries who are
not enrolled in the Medicare In-home IVIG Demonstration; 4) beneficiary survey Form B, for
beneficiaries who are enrolled; 5) the survey reminder letter; and 6) a survey reminder postcard. All
notification letters and the postcard will contain the logos of CMS and the Department of Health and
Human Services. The cover pages of the survey forms will bear the CMS logo.
B.1. Pre-Notification Letter
Nota: Estos materiales están disponibles en español. Para solicitar una copia de la encuesta en español,
por favor llame al 1-800-674-7381. These materials are available in Spanish. To request a copy of the
survey in Spanish, please call 1-800-674-7381.
NAME
ADDRESS
CITY, STATE ZIP
Dear [Medicare Beneficiary],
Medicare is surveying all beneficiaries being treated with immunoglobulin for Primary Immune
Deficiency Disease (PIDD). Because our records show that you are receiving immunoglobulin
for PIDD, you will soon be getting our survey package in the mail.
I am writing to urge you to take the time (about 30 minutes) to complete this important survey
soon after you receive it. The results of the survey will help us improve our services to you and
other Medicare beneficiaries.
You can complete the survey on line now, by going to the secure survey web site at
www.IGsurvey.com. Your personal survey identifiers are:
Username: XXXXX
Password: XXXXX
Your answers and participation in this survey are PRIVATE, CONFIDENTIAL, and
PROTECTED under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Your answers to the survey will be grouped with answers from all other survey participants; your
name and identifying information will not be linked to your answers.
Your participation in this survey is voluntary and will not affect any health care or benefits you
receive.
The questions are mainly about your immunoglobulin treatment experiences—how long your
treatment takes, your travel and waiting time (if any), how often you receive treatment, any trouble
you’ve had getting the right medicine, any other difficulties you may have had getting treatment,
and so on. The results of this survey will help Medicare improve services in the future.
Thank you in advance for participating in this important survey!
Sincerely,
Pauline Karikari-Martin, PhD., MPH, MSN
Centers for Medicare & Medicaid Services
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410-786-1040 | [email protected]
B.2. Cover Letter
Nota: Estos materiales están disponibles en español. Para solicitar una copia de la encuesta en español,
por favor llame al 1-800-674-7381. These materials are available in Spanish. To request a copy of the
survey in Spanish, please call 1-800-674-7381.
Dear [Medicare beneficiary],
Medicare is surveying all beneficiaries treated with immunoglobulin for Primary Immune Deficiency
Disease (PIDD). We need your feedback to help us improve services for you and other people taking
immunoglobulin for PIDD.
Medicare needs your help to improve our services to you and others. We want to learn more about
beneficiaries’ experiences with getting immunoglobulin treatment (intravenous or subcutaneous) for
treatment of PIDD. We also want to know how people are doing with Medicare’s in-home IVIG
Demonstration, and why some people have enrolled and others haven’t.
Your answers and participation in this survey are PRIVATE, CONFIDENTIAL, and PROTECTED under
the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Your answers to the survey
will be grouped with answers from all other survey participants; your name and identifying information
will not be linked to your answers.
Your participation in this survey is voluntary and will not affect any health care or benefits you receive.
If it’s more convenient, you can complete the survey on-line at www.IGsurvey.com. The cover page of
your survey form has your unique username and password.
Two versions of this survey are enclosed. Please fill out the form that applies to you and mail it back in the
postage-paid envelope provided. Please call the survey helpline at 800-674-7381 if you have questions about
which form to fill out.
If you ARE NOT ENROLLED
in the Medicare in-home IVIG Demonstration*
If you ARE ENROLLED
in the Medicare in-home IVIG Demonstration*
Complete Form A
Complete Form B
If you have any questions about the survey after reading the instructions, please call the survey helpline at
800-674-7381.
Thank you for participating in this survey. Please accept the enclosed $2.00 as a small gesture of our
appreciation.
Sincerely,
Pauline Karikari-Martin, PhD, MPH, MSN
Center for Medicare & Medicaid Services
410-786-1040 | [email protected]
* This demonstration provides in home IVIG services to enrolled beneficiaries. If you have any questions
about the Medicare in-home IVIG Demonstration, please call the demonstration hotline toll-free at 1-844
625-6284, or visit www.medicarenhic.com.
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B.3. Survey Instrument Form A - For beneficiaries not enrolled in the
Medicare In-home IVIG Demonstration
Please complete Form A if you are NOT ENROLLED in the Medicare In-home IVIG Demonstration, or
if you’ve applied but haven’t heard yet from Medicare about your enrollment.
Want a quicker and easier way to fill out the survey?
Go to www.IGsurvey.com and sign in with this information:
Your Username: XXXX3
Your Password: XXXX3
IGsurvey.com is a SECURE website administered by a Medicare contractor.
OMB Control No. XXXX-XXXX. Approval expires XX/XX/20XX.
SURVEY OF MEDICARE BENEFICIARIES
TAKING IMMUNOGLOBULIN (IG) FOR PRIMARY
IMMUNE DEFICIENCY DISEASE (PIDD)
FORM A INFORMATION AND INSTRUCTIONS
IMPORTANT: If you have been continuously confined to your home since October 1, 2014, AND you
have been continuously receiving all of your medical care at home since October 1, 2014 under
Medicare’s Home Health Prospective Payment System, you may be ineligible for this survey. Please call
the survey helpline at 1-800-674-7381 if you think this applies to you.
FOR CAREGIVERS AND/OR RELATIVES: If you’re a caregiver or relative of the beneficiary
and you’re helping them with the survey, please tell us about their experiences when answering
the questions.
ALL RESPONSES ARE PROTECTED UNDER THE HIPAA PRIVACY RULE. The rules of
the Health Insurance Portability and Accountability Act (HIPAA) ensure that we won’t use or
associate your name with your survey responses. We will combine the information you give with
information from other people’s surveys. No one outside of the project team will see your survey
or your responses.
QUESTIONS OR CONCERNS ABOUT THE SURVEY? Call the Survey Helpline at 800-674
7381. We’ll be happy to assist you.
QUESTIONS ABOUT ENROLLMENT IN THE DEMONSTRATION? Please call NHIC, Inc.,
the Medicare demonstration contractor, toll-free at 844-625-6284 or go to
http://www.medicarenhic.com.
INSTRUCTIONS FOR COMPLETING THE QUESTIONNAIRE:
Please read all the response options before moving on to the next question. Some questions ask
you to Check all that apply. If you skip to the next question before reading all the options, you
may be missing a response that applies to you.
Watch for the GO TO and Continue arrows!
The word “home” used in the questions throughout the survey refers to your primary residence—
the address at which you received this survey package. This may be your house, an assisted living
facility, a nursing home, or another location. Even if you reside in different locations throughout
the year, please respond for your primary residence only.
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Please feel free to give an explanation for any of your responses if you feel it’s necessary. There
is space on the last page for your comments. If you comment on a particular question, please tell
us the question number your comment refers to.
ABBREVIATIONS AND DEFINITIONS:
IVIG—intravenous immunoglobulin (infusion into a vein)
SCIG—subcutaneous immunoglobulin (infusion under the skin)
PIDD—primary immune deficiency disease
Home—your primary residence
SURVEY ELIGIBILITY
IMPORTANT: If you have been continuously confined to your home since October 1, 2014, AND
continuously receiving all of your medical care at home under Medicare’s Home Health Prospective
Payment System since October 1, 2014, you may be ineligible for this survey. If you think this applies to
you, please call the survey helpline at 1-800-674-7381. Otherwise, please continue.
1. Please read each of the following questions and check YES, NO, or NOT SURE.
1a. Have you been diagnosed with primary immune deficiency disease (PIDD)?
Yes
No
Not sure
1b. Do you require immunoglobulin for the treatment of PIDD?
Yes
No
Not sure
1c. Since October 1, 2014, have you been covered under Medicare Part A and Part B (“Original
Medicare” coverage) at any time?
Yes
No
Not sure
If you checked YES to all of these three questions PLEASE CONTINUE TO Q2. If you checked NO to
any of these three questions, STOP and go to END. If you checked “NOT SURE,” or have any questions
about taking this survey, please call the Survey Helpline at 1-800-674-7381
YOUR PRIMARY IMMUNE DEFICIENCY DISEASE (PIDD) EXPERIENCE
2. In what year were you first diagnosed with primary immune deficiency disease (PIDD)?
__________________
3. Which type of PIDD are you diagnosed with now? Please check all that apply.
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Common Variable Immunodeficiency (CVID)
Selective IgM Immunodeficiency
Wiskott-Aldrick Syndrome (WAS)
Congenital Hypogammaglobulinemia
Immunodeficiency with Increased IgM
Other (please specify)__________________________
Don’t know
4. In what year did you first start immunoglobulin (IG) treatment?
__________________
5. What type of immunoglobulin treatment did your doctor prescribe for your condition most
recently?
Intravenous immunoglobulin (infusion into a vein-IVIG)
Subcutaneous immunoglobulin (infusion under the skin—SCIG)
I have prescriptions for both IVIG and SCIG
Other _________________________________
6. Which brand(s) of immunoglobulin are you currently prescribed? If you have a prescription for
both IVIG and SCIG, please check off your medicine under both categories.
Intravenous Immunoglobulin (IVIG) Brands:
Bivigam (IVIG)
Carimune NF (IVIG)
Flebogamma DIF (IVIG)
Gammagard (IVIG)
Gammaked (IVIG)
Gammaplex (IVIG)
Gamunex-C (IVIG)
Iveegam (IVIG)
Octagam (IVIG)
Panglobulin (IVIG)
Polygam (IVIG)
Privigen (IVIG)
Venoglobulin (IVIG)
Other (please specify) _____________
Don’t know
Subcutaneous Immunoglobulin (SCIG) Brands:
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Gammagard (SCIG)
Gammaked (SCIG)
Gamunex-C (SCIG)
Hizentra (SCIG)
Other (please specify) _________________
Don’t know
7. How often do you receive immunoglobulin treatment currently? Please check the ONE best
response.
Every week
Every two weeks
Every three weeks
Every four weeks
Every five weeks
Every six weeks
Other (please specify) __________________________
8. Where do you usually receive immunoglobulin treatment now? Please check the ONE best
response.
At a medical setting (such as an infusion center, doctor’s office, or hospital)
At home
Sometimes at home and sometimes at a medical setting (such as an infusion center, doctor’s
office, or hospital)
Other (please specify) __________________________
9. About how long does your usual immunoglobulin treatment take per session? Do NOT include
travel time or waiting room time, but DO include time required for any procedure or treatment
that you get with your immunoglobulin treatment, such as hydrating fluids or Benadryl.) Please
check the ONE best response.
Less than 2 hours
From 2 hours to 4 hours
From 4 hours to 6 hours
Six hours or more
Other (please specify)__________________________
10. How would you rate your overall health?
Excellent
Very Good
Good
Fair
6
Poor
11. Since October 1, 2014, Medicare has offered beneficiaries the opportunity to enroll in a Medicare
In-home IVIG Demonstration. This demonstration pays providers to administer IVIG in patients’
homes even if the patient doesn’t qualify for Medicare-covered home health care services.
Did a provider—other than your doctor—ever express an opinion to you about whether or not
you should enroll in the Medicare In-home IVIG Demonstration?
Yes, a provider—other than my doctor— suggested I should enroll.
Yes, a provider—other than my doctor— suggested I should NOT enroll.
No, no provider—other than my doctor— has expressed an opinion to me about my
enrollment.
Other (please specify)__________________________
THE MEDICARE IN-HOME IVIG DEMONSTRATION
12. Did you apply for the Medicare In-home IVIG Demonstration?
No, I did not apply. Continue to 13
Yes, I applied but haven’t heard back yet. GO TO 14
Yes, I applied but my application was denied. GO TO END.
13. Why did you NOT apply to enroll in the Medicare In-home IVIG Demonstration? Please check
all that apply.
I wasn’t aware it was available.
I wasn’t eligible because I was receiving Medicare covered home health services.
I wasn’t eligible because I was enrolled in a Medicare Advantage plan.
I didn’t think I could find a provider willing or able to give me infusions at home.
I tried, but I couldn’t find a provider willing or able to give me infusions at home.
I was taking SCIG treatments at home and saw no need to enroll.
I can’t receive IVIG treatments at home for medical reasons.
I prefer to receive my IVIG treatments at a medical setting (such as an infusion center,
doctor’s office, or hospital).
My provider recommended that I not enroll.
Other (please specify)__________________________
14. If you applied to the Medicare In-home IVIG Demonstration, but haven’t heard back yet: Why
did you apply for the Medicare in-home IVIG Demonstration? Please check all that apply.
I wanted to receive IVIG in the comfort of my home.
I wanted to cut out travel time and waiting time at my IVIG infusion site.
I’ve had difficulty finding an infusion site.
I wanted to avoid being exposed to sick patients in a health care setting.
I previously had difficulty paying for the in-home service.
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I felt too sick to travel to an infusion site.
It was recommended by my doctor or other health care professional.
I had been taking SCIG at home but wanted to get IVIG instead.
I wasn’t sure I wanted to receive IVIG at home when I applied, but I wanted to enroll in the
demonstration in case I change my mind in the future.
I wanted to have access to the demonstration as a backup to my usual immunoglobulin
treatment.
Other (please specify)__________________________
15. Since October 1, 2014, did you miss any immunoglobulin treatments?
Yes, I have missed approximately ______ treatments since October 1, 2014. Continue to 16
No GO TO 17
Other (please specify)__________________________
16. Why did you miss treatment(s)? Please check all that apply.
My usual provider (infusion clinic, doctor’s office, etc.) cancelled one or more scheduled
treatment(s).
I switched providers and missed a treatment as a result.
I had transportation problems that caused one or more missed treatment(s).
My travel schedule caused me to miss one or more treatment(s).
I was too sick to travel to my usual treatment setting.
Other (please specify) __________________________
HOW YOU TAKE YOUR IMMUNOGLOBULIN
17. Since you were first diagnosed with PIDD, have you ever switched treatment methods from
intravenous immunoglobulin (IVIG) to subcutaneous immunoglobulin (SCIG)?
Yes Continue to 18
No GO TO 19
18. Why did you switch from IVIG to SCIG? Please check all that apply.
SCIG was recommended by my doctor.
I wanted to lessen the side effects from IVIG.
I wanted to use SCIG in the comfort of my home.
I wanted to cut out travel time to the IVIG infusion facility.
I had difficulty finding an infusion facility.
I wanted to avoid being exposed to sick patients in a health care setting.
SCIG costs me less.
Other (please specify)__________________________
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19. Since you were first diagnosed with PIDD, have you ever switched treatment methods from SCIG
to IVIG?
Yes Continue to 20
No GO TO 21
20. Why did you switch from SCIG to IVIG? Please check all that apply.
IVIG was recommended by my doctor.
I had difficulty with self-administration of SCIG.
I switched from SCIG to IVIG so I could be eligible for the demonstration and get help with
infusions at home.
I wanted to have less frequent treatments.
I preferred to receive IVIG in a health care setting.
IVIG costs me less.
Other (please specify)__________________________
21. Since October 1, 2014, has the brand of immunoglobulin medicine you usually receive changed?
Yes Continue to 22
No GO TO 25
22. Why was there a change in the brand of immunoglobulin medicine you receive? Please check all
that apply.
My former immunoglobulin product became unavailable or hard to get.
My insurance reimbursement was reduced.
Insurance did not cover or stopped covering my former product.
My co-pays and/or other out-of-pocket expenses were too high.
My doctor recommended changing because my former product was not working well.
I switched from IVIG to SCIG.
I switched from SCIG to IVIG.
Other (please specify)__________________________
Don’t know
23. After you changed brands of immunoglobulin medicine, did you experience any of the following
side effects? Please check all that apply.
Chills
Fainting
Fever
Headaches
High blood pressure
Hives
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Nausea
Rash
Shortness of breath
Vomiting
Other (please specify)__________________________
None
24. Which of the following best describes your experience with the brand of immunoglobulin
medicine you switched to? Please check the ONE best response.
There was no difference in side effects between my new and previous medicine.
My new brand caused fewer side effects than my previous one.
My new brand caused more side effects than my previous one.
Other (please specify)__________________________
IMMUNOGLOBULIN TREATMENT LOCATION
25. Between September 30, 2012 and October 1, 2014, where were you usually receiving your
immunoglobulin treatments? Please check the ONE location where you received most of your
treatments.
At home
Doctor’s private office
Hospital, as an inpatient
Hospital outpatient clinic
Infusion clinic
I was not receiving immunoglobulin treatments at that time.
Other (please specify)__________________________
Don’t know
26. Since October 1, 2014, has your usual immunoglobulin treatment location changed?
Yes Continue to 27
No GO TO 28
27. Where are you getting your immunoglobulin treatments now? Please check all that apply.
At home
Doctor’s private office
Hospital, as an inpatient
Hospital outpatient clinic
Infusion clinic
I am not receiving immunoglobulin treatments now.
10
Other (please specify)__________________________
FLUIDS FOR HYDRATION
28. Before October 1, 2014, did you usually receive hydrating fluids when you had immunoglobulin
treatment? Please read each statement and check YES or NO.
Before October 1, 2014, I usually received hydrating fluids intravenously before, during, or after
receive immunoglobulin.
Yes
No
Not sure
Before October 1, 2014, I was instructed to drink extra fluids on the day of my immunoglobulin
treatment.
Yes
No
Not sure
Before October 1, 2014, I usually drank extra fluids on the day of my immunoglobulin treatment
on my own.
Yes
No
Not sure
Before October 1, 2014, I did not usually drink extra fluids or receive hydrating fluids
intravenously before, during, or after immunoglobulin treatment.
Yes
No
Not sure
Other (please specify)__________________________
Don’t know
29. After October 1, 2014, have you usually been receiving hydrating fluids when you get
immunoglobulin treatment? Please read each statement and check YES or NO.
Since October 1, 2014, I usually received hydrating fluids intravenously before, during, or after
receive immunoglobulin.
Yes
No
Not sure
11
Since October 1, 2014, I have been instructed to drink extra fluids on the day of my
immunoglobulin treatment.
Yes
No
Not sure
Since October 1, 2014, I usually drink extra fluids on the day of my immunoglobulin treatment on
my own.
Yes
No
Not sure
Since October 1, 2014, I do not usually drink extra fluids or receive hydrating fluids
intravenously before, during, or after immunoglobulin treatment.
Yes
No
Not sure
Other (please specify)__________________________
Don’t know
IMMUNOGLOBULIN TREATMENT FREQUENCY
30. Since October 1, 2014, how many of your immunoglobulin treatments have been postponed?
None, no treatments have been postponed. GO TO 32
One treatment was postponed. Continue to 31
Two or three treatments were postponed. Continue to 31
Four or more treatments were postponed. Continue to 31
31. Why was treatment postponed? Please check all that apply.
I postponed my treatment to accommodate my personal schedule.
I was too sick to travel to my treatment.
My doctor recommended postponement.
My provider postponed treatment.
My insurance reimbursement was reduced.
My insurance wouldn’t cover all of the treatments.
I was unable to afford the cost of co-pays and/or other out-of-pocket expenses.
Immunoglobulin wasn’t available.
Other (please specify)__________________________
12
Don’t know
32. Since October 1, 2014, has the usual time between your immunoglobulin treatments gotten
longer? That is, are you getting treatments less often?
Yes Continue to 33
No, the time between my immunoglobulin treatments has not increased. GO TO 34
33. IF YOU CHECKED YES TO 32: Why did the time interval between your immunoglobulin
treatments increase? Please check all that apply.
My doctor recommended it.
I switched from SCIG to IVIG, so time between treatments increased.
My insurance reimbursement was reduced.
My insurance wouldn’t cover all of the treatments.
Higher co-pays and/or other out-of-pocket expenses caused me to get treatment less often.
Immunoglobulin wasn’t available.
My dosage increased, so I got treatment less often.
Other (please specify) ____________________________________
Don’t know
34. Since October 1, 2014, has the time between your immunoglobulin treatments gotten shorter?
That is, are you getting treatments more often?
Yes Continue to 35
No, the time between my immunoglobulin treatments has not gotten shorter. GO TO 36
Don’t know/Not sure
35. IF YOU CHECKED YES TO 34: Why are you getting treatments more often since October 1,
2014? Please check all that apply.
My doctor recommended it.
My dosage had to be decreased, so I needed treatments more often.
I switched from IVIG to SCIG, so I started having treatments more often.
Other (please specify)__________________________
Don’t know
IMMUNOGLOBULIN TREATMENT DURATION
36. Since October 1, 2014, have your immunoglobulin treatment sessions gotten longer, shorter, or
do they take about the same amount of time? DO NOT include travel or waiting time, if any. DO
include time required for any procedure or treatment that you get with your immunoglobulin
infusion, such as hydrating fluids or Benadryl.
My immunoglobulin treatment sessions have gotten longer since October 1, 2014.
My immunoglobulin treatment sessions have gotten shorter since October 1, 2014.
13
My immunoglobulin treatment sessions take about the same amount of time since October
1, 2014.
My immunoglobulin treatment sessions are sometimes shorter and sometimes longer since
October 1, 2014.
Other (please specify) ____________________________
TRAVEL TIME
37. During the summer of 2014, about how long did it normally take you to travel to and from your
immunoglobulin treatment location? DO NOT include the time you spent being treated or time
spent on other activities. Please read each statement and check the ONE best response.
No travel time—during the summer of 2014, I was getting ALL of my immunoglobulin
treatments at home.
No travel time— during the summer of 2014, I was too sick to travel to receive treatment.
No travel time— during the summer of 2014, I was not getting any immunoglobulin
treatments.
Less than one hour total travel time per treatment.
One to two hours total travel time per treatment.
More than two hours, up to three hours total travel time per treatment.
More than three hours total travel time per treatment.
38. Since October 1, 2014, about how long does it normally take you to travel to and from your
immunoglobulin treatment location? DO NOT include the time you spend being treated or time
you spend on other activities.
No travel time—I have been getting ALL of my immunoglobulin treatments at home since
October 1, 2014.
Less than one hour total travel time per treatment.
One to two hours total travel time per treatment.
More than two hours, up to three hours total travel time per treatment.
More than three hours total travel time per treatment.
AMOUNT OF IMMUNOGLOBULIN PER TREATMENT
39. Since October 1, 2014, has the number of grams of immunoglobulin per treatment you receive
been REDUCED for any reason? That is, did you receive less medicine per treatment at any time
since October 1, 2014?
Yes Continue to 40
No GO TO 41
Don’t know GO TO 41
40. Why was the amount of immunoglobulin per treatment reduced? Please check all that apply.
My doctor recommended a reduction.
My dose was reduced because of side effects.
14
My insurance reimbursement was reduced, so I had to get less medicine.
My insurance wouldn’t cover all of my treatments.
The cost of co-pays and/or of other out-of-pocket expenses went up, so I had to get less
medicine.
Immunoglobulin wasn’t available.
I switched to SCIG, so required less immunoglobulin per treatment.
The time interval between treatments decreased.
Other (please specify)__________________________
Don’t know
PROBLEMS WITH IMMUNOGLOBULIN TREATMENT
41. Since October 1, 2014, have you had less trouble overall, or more trouble overall getting
immunoglobulin treatments than before?
More trouble
Less trouble
No change
42. In the two years between October 1, 2012 and October 1, 2014, did you experience any of the
following health issues? Please read each item and check YES or NO.
During the two years between October 1, 2012 and October 1, 2014…
I had to be hospitalized.
Yes
No
I experienced more infections than I had in the previous two years.
Yes
No
I required increased use of antibiotics.
Yes
No
I experienced additional/new side effects.
Yes
No
I had pneumonia.
Yes
15
No
I had bronchitis.
Yes
No
I had other health issue(s) (please specify)__________________________
Yes
No
None of the above
Can’t remember
43. Since October 1, 2014, did you experience any of the following health issues? Please read each
item and check YES or NO.
Since October 1, 2014…
I had to be hospitalized.
Yes
No
I experienced more infections than I had in the previous two years.
Yes
No
I required increased use of antibiotics.
Yes
No
I experienced additional/new side effects.
Yes
No
I had pneumonia.
Yes
No
I had bronchitis.
Yes
16
No
I had other health issue(s) (please specify)__________________________
Yes
No
None of the above
Can’t remember
BACKGROUND INFORMATION
44. Which of the following types of health insurance do you currently have? Please check all that
apply.
Original Medicare (Part A and Part B)
Medicare Advantage (like an HMO or PPO)
Original Medicare Supplement Insurance (Medigap)
Medicaid or Medi-Cal
Private health insurance (like Blue Cross Blue Shield, Aetna, United Healthcare, etc.)
COBRA
TRICARE
Other (please specify)__________________________
45. What year were you born?
_______________________
46. Please check the response that best describes your level of education.
Some high school
High school graduate or GED
Some college or technical/vocational school
Two-year college graduate (Associate’s degree)
Four-year college graduate (Bachelor’s degree)
Technical/vocational school graduate
Post-graduate school or degree
47. Do you live alone?
Yes
No
48. Are you of Hispanic or Latino origin or descent?
17
Yes
No
49. What is your race? Please check all that apply.
Asian
Black or African-American
Native American or Alaska native
Native Hawaiian or other Pacific Islander
White
50. What language do you usually speak at home?
English
Spanish
Other (please specify) _______________________
END
Thank you for participating in this important survey!
Please return this form in the enclosed postage-paid envelope to:
Eastern Research Group, Inc.
Attn: Medicare Immunoglobulin Survey
110 Hartwell Avenue
Lexington, MA 02421
We welcome any additional comments or remarks from you. Please write in the space below or attach
another sheet of paper with any comments or remarks you may have.
18
19
B.4. Survey Instrument Form B - For beneficiaries not enrolled in the
Medicare In-home IVIG Demonstration
Please complete Form B if you are ENROLLED in the Medicare In-home IVIG Demonstration, even if
you haven’t yet received a treatment under the demonstration.
Want a quicker and easier way to fill out the survey?
Go to www.IGsurvey.com and sign in with this information:
Your Username: XXXX3
Your Password: XXXX3
IGsurvey.com is a SECURE website administered by a Medicare contractor.
OMB Control No. XXXX-XXXX. Approval expires XX/XX/20XX.
SURVEY OF MEDICARE BENEFICIARIES
TAKING IMMUNOGLOBULIN (IG) FOR PRIMARY
IMMUNE DEFICIENCY DISEASE (PIDD)
FORM B INFORMATION AND INSTRUCTIONS
IMPORTANT: If you have been continuously confined to your home since October 1, 2014, AND you
have been continuously receiving all of your medical care at home since October 1, 2014 under
Medicare’s Home Health Prospective Payment System, you may be ineligible for this survey. Please call
the survey helpline at 1-800-674-7381 if you think this applies to you.
FOR CAREGIVERS AND/OR RELATIVES: If you’re a caregiver or relative of the beneficiary
and you’re helping them with the survey, please tell us about their experiences when answering
the questions.
ALL RESPONSES ARE PROTECTED UNDER THE HIPAA PRIVACY RULE. The rules of
the Health Insurance Portability and Accountability Act (HIPAA) ensure that we won’t use or
associate your name with your survey responses. We will combine the information you give with
information from other people’s surveys. No one outside of the project team will see your survey
or your responses.
QUESTIONS OR CONCERNS ABOUT THE SURVEY? Call the Survey Helpline at 800-674
7381. We’ll be happy to assist you.
QUESTIONS ABOUT ENROLLMENT IN THE DEMONSTRATION? Please call NHIC, Inc.,
the Medicare demonstration contractor, toll-free at 844-625-6284, or go to
http://www.medicarenhic.com.
INSTRUCTIONS FOR COMPLETING THE QUESTIONNAIRE:
Please read all the response options before moving on to the next question. Some questions ask
you to Check all that apply. If you skip to the next question before reading all the options, you
may be missing a response that applies to you.
Watch for the GO TO and Continue arrows!
The word “home” used in the questions throughout the survey refers to your primary residence—
the address at which you received this survey package. This may be your house, an assisted living
20
facility, a nursing home, or another location. Even if you reside in different locations throughout
the year, please respond for your primary residence only.
Please feel free to give an explanation for any of your responses if you feel it’s necessary. There
is space on the last page for your comments. If you comment on a particular question, please tell
us the question number your comment refers to.
ABBREVIATIONS AND DEFINITIONS:
IVIG—intravenous immunoglobulin (infusion into a vein)
SCIG—subcutaneous immunoglobulin (infusion under the skin)
PIDD—primary immune deficiency disease
Home—your primary residence
SURVEY ELIGIBILITY
IMPORTANT: If you have been continuously confined to your home since October 1, 2014, AND
continuously receiving all of your medical care at home under Medicare’s Home Health Prospective
Payment System since October 1, 2014, you may be ineligible for this survey. If you think this applies to
you, please call the survey helpline at 1-800-674-7381. Otherwise, please continue.
1. Please read each of the following questions and check YES, NO, or NOT SURE.
1a. Have you been diagnosed with primary immune deficiency disease (PIDD)?
Yes
No
Not sure
1b. Do you require immunoglobulin for the treatment of PIDD?
Yes
No
Not sure
1c. Since October 1, 2014, have you been covered under Medicare Part A and Part B (“Original
Medicare” coverage) at any time?
Yes
No
Not sure
If you checked YES to all of these three questions PLEASE CONTINUE TO Q2. If you checked NO to
any of these three questions, STOP and go to END. If you checked “NOT SURE,” or have any questions
about taking this survey, please call the Survey Helpline at 1-800-674-7381
YOUR PRIMARY IMMUNE DEFICIENCY DISEASE (PIDD) EXPERIENCE
2. In what year were you first diagnosed with primary immune deficiency disease (PIDD)?
_________________
21
3. Which type of PIDD are you diagnosed with now? Please check all that apply.
Common Variable Immunodeficiency (CVID)
Selective IgM Immunodeficiency
Wiskott-Aldrick Syndrome (WAS)
Congenital Hypogammaglobulinemia
Immunodeficiency with Increased IgM
Other (please specify)__________________________
Don’t know
4. In what year did you first start immunoglobulin (IG) treatment?
_______________
5. What type of immunoglobulin treatment did your doctor prescribe for your condition most
recently?
Intravenous immunoglobulin (infusion into a vein-IVIG)
Subcutaneous immunoglobulin (infusion under the skin—SCIG)
I have prescriptions for both IVIG and SCIG
Other _________________________________
6. Which brand of immunoglobulin are you currently prescribed? If you have a prescription for both
IVIG and SCIG, please check off your medicine under both categories.
Intravenous immunoglobulin (IVIG) Brands:
Bivigam (IVIG)
Carimune NF (IVIG)
Flebogamma DIF (IVIG)
Gammagard (IVIG)
Gammaked (IVIG)
Gammaplex (IVIG)
Gamunex-C (IVIG)
Iveegam (IVIG)
Octagam (IVIG)
Panglobulin (IVIG)
Polygam (IVIG)
Privigen (IVIG)
Venoglobulin (IVIG)
Other (please specify) _____________
Don’t know
22
Subcutaneous immunoglobulin (SCIG) Brands
Gammagard (SCIG)
Gammaked (SCIG)
Gamunex-C (SCIG)
Hizentra (SCIG)
Other (please specify) _________________
Don’t know
7. How often do you receive immunoglobulin treatment currently? Please check the ONE best
response.
Every week
Every two weeks
Every three weeks
Every four weeks
Every five weeks
Every six weeks
Other (please specify)__________________________
8. Where do you usually receive immunoglobulin treatment currently? Please check the ONE best
response.
At a medical setting (such as an infusion center, doctor’s office, or hospital)
At home
Sometimes at home and sometimes at a medical setting (such as an infusion center, doctor’s
office, or hospital)
Other (please specify)__________________________
9. About how long does your usual immunoglobulin treatment take per session? Do NOT include
travel or waiting room time. DO include time required for any procedure or treatment that you get
with your immunoglobulin treatment, such as hydrating fluids or Benadryl. Please check the ONE
best response.
Less than 2 hours
From 2 hours to 4 hours
From 4 hours to 6 hours
Six hours or more
Other (please specify)__________________________
10. How would you rate your overall health?
Excellent
Very Good
Good
23
Fair
Poor
11. Since October 1, 2014, Medicare has offered beneficiaries the opportunity to enroll in a Medicare
In-home IVIG Demonstration. This demonstration pays providers to administer IVIG in patients’
homes, even if the patient doesn’t qualify for Medicare-covered home health care services.
Did a provider—other than your doctor—ever express an opinion to you about whether or not
you should enroll in the Medicare In-home IVIG Demonstration?
Yes, a provider—other than my doctor— suggested I should enroll.
Yes, a provider—other than my doctor— suggested I should NOT enroll.
No, no provider—other than my doctor— has expressed an opinion to me about my
enrollment.
Other (please specify)__________________________
THE MEDICARE IN-HOME IVIG DEMONSTRATION
12. When did you apply for the Medicare In-home IVIG Demonstration?
_____________
Month
_____________
Year
13. Why did you apply for the Medicare In-home IVIG Demonstration? Please check all that apply.
I wanted to receive IVIG in the comfort of my home.
I wanted to cut out travel and waiting time at my IVIG infusion facility.
I’ve had difficulty finding an infusion facility.
I wanted to avoid being exposed to sick patients in a health care setting.
I previously had difficulty paying for the in-home service.
I felt too sick to travel to an infusion facility.
It was recommended by my doctor or other health care provider.
I had been taking SCIG at home but wanted to receive IVIG instead.
I wasn’t sure I wanted to receive IVIG at home when I applied, but I wanted to enroll in the
demonstration in case I change my mind in the future.
I wanted to have access to the demonstration as a backup to my usual immunoglobulin
treatment.
Other (please specify)__________________________
14. After your application to the Demonstration was approved, did you experience any of the
following issues regarding in-home IVIG treatments? Please read each statement and check YES
or NO.
I had trouble getting an in-home IVIG treatment provider.
Yes
No
24
I missed one or more immunoglobulin treatments because of problems finding or scheduling an
in-home IVIG treatment provider.
Yes
No
I had to get IVIG at a treatment location away from home one or more times because of problems
finding or scheduling an in-home IVIG treatment provider.
Yes
No
I had to get IVIG at a treatment location away from home one or more times because of my travel
commitments.
Yes
No
My in-home IVIG treatment provider stopped performing the service, and I had to look for a new
in-home IVIG treatment provider.
Yes
No
I switched over to SCIG because of problems getting an in-home IVIG treatment provider.
Yes
No
I had no trouble getting or maintaining an in-home IVIG treatment provider.
Yes
No
I haven’t tried to schedule any treatments at home yet.
Yes
No
Other (please specify)__________________________
15. After you enrolled in the Demonstration, did you miss any immunoglobulin treatments?
Yes, I missed approximately ______ treatments since enrolling. Continue to 16
No, I haven’t missed any treatments since enrolling. GO TO 18
Other (please specify)______________________________
16. Where were you expecting to have the immunoglobulin treatment(s) that you missed? Please
check all that apply.
25
In my home
At my doctor’s office
At an infusion clinic or other medical setting
Other (please specify)_______________________________
Not sure
17. Why did you miss treatment(s) after you enrolled in the in-home Demonstration? Please check all
that apply.
I had trouble getting an in-home provider.
My in-home provider cancelled a scheduled treatment(s).
My usual medical setting (infusion clinic, doctor’s office, etc.) cancelled a scheduled
treatment(s).
I was too sick to travel to my usual treatment setting (infusion clinic, doctor's office, etc.)
I had transportation problems that caused one or more missed treatment(s).
My travel schedule caused me to miss one or more treatment(s).
Other (please specify)__________________________
18. Have you received IVIG treatment at home under the Medicare In-home IVIG Demonstration?
Yes. Continue to 19
No. GO TO 21
Not sure (please explain, then GO TO 22)_______________________
19. About how long after you were enrolled in the Demonstration did you have your first in-home
IVIG treatment under the Demonstration?
1 to 2 weeks
3 to 4 weeks
5 to 6 weeks
6 to 8 weeks
More than 8 weeks (please enter approximate number of weeks) _____
20. How satisfied are you with the in-home IVIG administration service you’ve had since you
enrolled in the Demonstration? Please check the ONE best response, THEN GO TO 22
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Unsatisfied
Very unsatisfied
21. If you haven’t yet received an in-home IVIG treatment under the Demonstration, Medicare would
like to know why not? Please check all that apply.
26
I contacted one or more in-home IVIG treatment providers, but haven’t heard back from
them.
I spoke with an in-home IVIG treatment provider, but haven’t yet gotten an appointment
scheduled.
I haven’t been able to find a provider that will agree to provide my in-home IVIG
treatments.
I have an in-home IVIG treatment provider and have an appointment for my first in-home
IVIG treatment.
After I enrolled, my doctor decided that in-home IVIG treatments wouldn’t be a good idea
for me.
I decided I would rather take SCIG at home.
I decided I would rather receive IVIG at a medical setting (such as an infusion center,
doctor’s office, or hospital).
I haven’t had time to arrange in-home treatments yet.
I receive immunoglobulin treatments at home under my state Medicaid.
I enrolled to reserve a spot in the demonstration in case I changed my mind, but am not
currently interested in receiving in-home IVIG treatments.
Other (please specify)__________________________
Don’t know
HOW YOU TAKE YOUR IMMUNOGLOBULIN
22. Since you were first diagnosed with PIDD, have you ever switched treatment methods from
intravenous immunoglobulin (IVIG) to subcutaneous immunoglobulin (SCIG)?
Yes. Continue to 23
No. GO TO 24
23. Why did you switch from IVIG to SCIG? Please check all that apply.
SCIG was recommended by my doctor.
My in-home IVIG treatment provider stopped performing the in-home infusion service.
I wanted to lessen the side effects from IVIG.
I wanted to cut out travel time to the IVIG infusion facility.
I had difficulty finding an infusion facility.
I wanted to avoid being exposed to sick patients in a health care setting.
SCIG costs me less.
Other (please specify)__________________________
24. Have you ever switched treatment methods from SCIG to IVIG? Please check all that apply.
Yes Continue to 25
No GO TO 26
27
25. Why did you switch from SCIG to IVIG? Please check all that apply.
IVIG was recommended by my doctor.
I had difficulty with self-administration of SCIG.
I switched from SCIG to IVIG so I could be in the demonstration and get help with in-home
infusions.
I wanted to have less frequent treatments.
I preferred to receive IVIG in a health care setting.
IVIG costs me less.
Other (please specify)__________________________
26. Since you enrolled in the Demonstration, has the brand of immunoglobulin medicine you usually
receive changed?
Yes
Continue to 27
No
GO TO 30
27. Why was there a change in the brand of immunoglobulin medicine you receive? Please check all
that apply.
My former immunoglobulin product became unavailable or hard to get.
My insurance reimbursement was reduced.
Insurance did not cover, or stopped covering, my former product.
My co-pays and/or other out-of-pocket expenses were too high.
My doctor recommended changing because my former product was not working well.
I switched from IVIG to SCIG.
I switched from SCIG to IVIG.
Other (please specify)__________________________
Don’t know
28. After you changed brands of immunoglobulin medicine, did you experience any of the following
side effects? Please check all that apply.
Chills
Fainting
Fever
Headaches
High blood pressure
Hives
Nausea
Rash
Shortness of breath
28
Vomiting
Other (please specify)__________________________
None
29. Which of the following best describes your experience with the brand of immunoglobulin
medicine you switched to? Please check the ONE best response.
There was no difference in side effects between my new brand and my previous medicine.
My new brand caused fewer side effects than my previous one.
My new brand caused more side effects than my previous one.
Other (please specify)__________________________
IMMUNOGLOBULIN TREATMENT LOCATION
30. During the 2 years before you enrolled in the Demonstration, where were you usually receiving
your immunoglobulin treatments? Please check the ONE location where you received most of
your treatments.
At home
Doctor’s private office
Hospital, as an inpatient
Hospital outpatient clinic
Infusion clinic
I was not receiving immunoglobulin treatments before I enrolled.
Other (please specify)__________________________
Don’t know
31. Since you enrolled in the Demonstration, has your usual immunoglobulin treatment location
changed?
Yes. Continue to 32
No. GO TO 34
32. Where are you getting your immunoglobulin treatments now? Please check all that apply.
At home
Doctor’s private office
Hospital, as an inpatient
Hospital outpatient clinic
Infusion clinic
I am not receiving immunoglobulin treatments now.
Other (please specify)__________________________
29
33. What is your understanding of the main reason for the change in your usual treatment location?
Please check the ONE best response.
I started getting IVIG treatments at home.
I started taking SCIG at home.
My former location closed.
My former location stopped providing IVIG.
I changed locations for convenience.
I became unhappy with the service at the former location.
My doctor recommended a different location.
My out of pocket costs increased too much.
Other (please specify)__________________________
Don’t know
FLUIDS FOR HYDRATION
34. Before you enrolled in the Demonstration, did you usually receive hydrating fluids when you had
immunoglobulin treatment? Please read each statement and check YES or NO.
Before I enrolled in the Demonstration, I usually received hydrating fluids intravenously before,
during, or after receive immunoglobulin.
Yes
No
Not sure
Before I enrolled in the Demonstration, I was instructed to drink extra fluids on the day of my
immunoglobulin treatment.
Yes
No
Not sure
Before I enrolled in the Demonstration, I usually drank extra fluids on the day of my
immunoglobulin treatment on my own.
Yes
No
Not sure
Before I enrolled in the Demonstration, I did not usually drink extra fluids or receive hydrating
fluids intravenously before, during, or after immunoglobulin treatment.
Yes
No
30
Not sure
Other (please specify)__________________________
Don’t know
35. Since you enrolled in the Demonstration, have you usually been receiving hydrating fluids when
you get immunoglobulin treatment? Please read each statement and check YES or NO.
Since I enrolled in the Demonstration, I usually received hydrating fluids intravenously before,
during, or after receive immunoglobulin.
Yes
No
Not sure
Since I enrolled in the Demonstration, I have been instructed to drink extra fluids on the day of
my immunoglobulin treatment.
Yes
No
Not sure
Since I enrolled in the Demonstration, I usually drink extra fluids on the day of my
immunoglobulin treatment on my own.
Yes
No
Not sure
Since I enrolled in the Demonstration, I do not usually drink extra fluids or receive hydrating
fluids intravenously before, during, or after immunoglobulin treatment.
Yes
No
Not sure
Other (please specify)__________________________
Don’t know
IMMUNOGLOBULIN TREATMENT FREQUENCY
36. Since you enrolled in the Demonstration, how many of your immunoglobulin treatments have
been postponed?
None, no treatments have been postponed.GO TO 38
31
One treatment was postponed.Continue to 37
Two or three treatments were postponed.Continue to 37
Four or more treatments were postponed.Continue to 37
37. Why was treatment postponed? Please check all that apply.
I postponed my treatment to accommodate my personal schedule.
My doctor recommended postponement.
My in-home provider postponed treatment.
My doctor’s office, infusion clinic, or other provider postponed treatment.
My insurance wouldn’t cover all of the treatments.
I was unable to afford the cost of co-pays and/or other out-of-pocket expenses.
Immunoglobulin wasn’t available.
Other (please specify)__________________________
Don’t know.
38. Since you enrolled in the Demonstration, has the usual time between your immunoglobulin
treatments gotten longer? That is, are you getting treatments less often?
Yes. Continue to 39
No, the time between my immunoglobulin treatments has not gotten longer. GO TO 40
39. Why are you getting treatments less often since you enrolled? Please check all that apply.
I have had trouble scheduling an in-home IVIG treatment provider, causing delayed or
missed treatments.
My doctor recommended it.
I switched from SCIG to IVIG, so time between treatments increased.
My insurance wouldn’t cover all of the treatments.
Higher co-pays and/or other out-of-pocket expenses caused me to get treatment less often.
Immunoglobulin wasn’t available.
My dosage increased, so I got treatments less often.
Other (please specify)__________________________
Don’t know
40. Since you enrolled in the Demonstration has the time between your immunoglobulin treatments
gotten shorter? That is, are you getting treatments more often?
Yes. Continue to 41
No, the time between my immunoglobulin treatments has not gotten shorter. GO TO 42
41. Why did the time interval between your immunoglobulin treatments decrease? Please check all
that apply.
32
My doctor recommended it.
My dosage had to be decreased, so I needed treatments more often.
I switched from IVIG to SCIG, so I started having treatments more often.
Other (please specify)__________________________
Don’t know
IMMUNOGLOBULIN TREATMENT DURATION
42. Since you enrolled in the Demonstration, have your immunoglobulin treatment sessions gotten
longer, shorter, or do they take about the same amount of time? Do not include travel or waiting
time, if any. DO include time required for any procedure or treatment that you get with your
immunoglobulin infusion, such as hydrating fluids or Benadryl. Please check the ONE best
response.
My immunoglobulin treatment sessions have gotten longer since I enrolled.
My immunoglobulin treatment sessions have gotten shorter since I enrolled.
My immunoglobulin treatment sessions take about the same amount of time since I
enrolled.
My immunoglobulin treatment sessions are sometimes shorter and sometimes longer since I
enrolled.
Other (please specify) ____________________________
TRAVEL TIME
43. During the 3 months before you enrolled in the Demonstration, about how long did it normally
take you to travel to and from your immunoglobulin treatment location? Don’t include the time
you spent being treated or time spent on other activities.
No travel time—during the summer of 2014, I was getting ALL of my immunoglobulin
treatments at home.
No travel time— during the summer of 2014, I was too sick to travel to receive treatment.
No travel time— during the summer of 2014, I was not getting any immunoglobulin
treatments.
Less than one hour total travel time per treatment.
One to two hours total travel time per treatment.
More than two hours, up to three hours total travel time per treatment.
More than three hours total travel time per treatment.
I was getting ALL of my immunoglobulin treatments at home and had no travel time.
44. Since you enrolled in the Demonstration, about how long does it normally take you to travel to
and from your immunoglobulin treatment location for those immunoglobulin treatments you DO
NOT receive at home (if any)? Don’t include the time you spend being treated or time you spend
on other activities.
33
No travel time—I have been getting ALL of my immunoglobulin treatments at home since I
enrolled.
No travel time—I have not had an immunoglobulin treatment since I enrolled.
Less than one hour total travel time per treatment.
One to two hours total travel time per treatment.
More than two hours, up to three hours total travel time per treatment.
More than three hours total travel time per treatment.
AMOUNT OF IMMUNOGLOBULIN PER TREATMENT
45. Since you enrolled in the Demonstration, has the number of grams of immunoglobulin per
treatment you receive been REDUCED for any reason?
Yes. Continue to 46
No. GO TO 47
46. Why was the amount of immunoglobulin reduced? Please check all that apply.
My doctor recommended a reduction.
My dose was reduced because of side effects.
My insurance reimbursement was reduced, so I had to get less medicine.
My insurance wouldn’t cover all of my treatments.
The cost of co-pays and/or of other out-of-pocket expenses went up, so I had to get less
medicine.
Immunoglobulin wasn’t available.
I switched to SCIG, so required less immunoglobulin per treatment.
The time interval between my treatments decreased.
Other (please specify)__________________________
Don’t know
PROBLEMS WITH IMMUNOGLOBULIN TREATMENT
47. Since your enrollment in the Demonstration, have you had less trouble overall, or more trouble
overall getting immunoglobulin treatments than before?
More trouble
Less trouble
No change
48. During the 2 years before you enrolled in the Demonstration, did you experience any of following
health issues? Please read each item and check YES or NO.
During the 2 years before I enrolled in the Demonstration…
34
I had to be hospitalized.
Yes
No
I experienced more infections than I had in the previous two years.
Yes
No
I required increased use of antibiotics.
Yes
No
I experienced additional/new side effects.
Yes
No
I had pneumonia.
Yes
No
I had bronchitis.
Yes
No
I had other health issue(s) (please specify)__________________________
Yes
No
None of the above
Can’t remember
49. After you enrolled in the Demonstration, did you experience any of following health issues?
Please read each item and check YES or NO.
Since I enrolled in the Demonstration…
I had to be hospitalized.
Yes
No
35
I experienced more infections than I had in the previous two years.
Yes
No
I required increased use of antibiotics.
Yes
No
I experienced additional/new side effects.
Yes
No
I had pneumonia.
Yes
No
I had bronchitis.
Yes
No
I had other health issue(s) (please specify)__________________________
Yes
No
None of the above
Can’t remember
BACKGROUND INFORMATION
50. Which of the following types of health insurance do you currently have? Please check all that
apply.
Original Medicare (Part A and Part B)
Medicare Advantage (like an HMO or PPO)
Original Medicare Supplement Insurance (Medigap)
Medicaid or Medi-Cal
Private health insurance (like Blue Cross Blue Shield, Aetna, United Healthcare, etc.)
COBRA
TRICARE
Other (please specify)__________________________
36
51. What year were you born?
_______________________
52. Please check the response that best describes your level of education.
Some high school
High school graduate or GED
Some college or technical/vocational school
Two-year college graduate (Associate’s degree)
Four-year college graduate (Bachelor’s degree)
Technical/vocational school graduate
Post-graduate school or degree
53. Do you live alone?
Yes
No
54. Are you of Hispanic or Latino origin or descent?
Yes
No
55. What is your race? Please check all that apply.
Asian
Black or African-American
Native American or Alaska native
Native Hawaiian or other Pacific Islander
White
56. What language do you usually speak at home?
English
Spanish
Other (please specify) _______________________
END
Thank you for participating in this important survey!
Please return this form in the enclosed postage-paid envelope to:
Eastern Research Group, Inc.
Attn: Medicare Immunoglobulin Survey
37
110 Hartwell Avenue
Lexington, MA 02421
We welcome any additional comments or remarks from you. Please write in the space below or attach
another sheet of paper with any comments or remarks you may have.
38
B.5. Survey Reminder Letter
Nota: Estos materiales están disponibles en español. Para solicitar una copia de la encuesta en español,
por favor llame al 1-800-674-7381. These materials are available in Spanish. To request a copy of the
survey in Spanish, please call 1-800-674-7381.
Dear [Medicare Beneficiary],
Recently, we sent you a survey package asking for your help in our effort to gather information about the
experiences of Medicare beneficiaries receiving immunoglobulin treatment for primary immune deficiency
disease (PIDD). As of today, we have not yet received your completed questionnaire. (If you have already
returned the questionnaire, please accept our thanks.)
If you have not completed the survey, please take a few minutes to complete the appropriate form and
return it in the enclosed postage-paid envelope. Your feedback is important because it will help improve
the PIDD-related services we provide. The results of the survey will help us improve our services to you
and other Medicare beneficiaries.
If you need help, please call the survey help line at 800-674-7381.
Your answers and participation in this survey are PRIVATE, CONFIDENTIAL, and PROTECTED under
the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Your answers to the survey
will be grouped with answers from all other survey participants; your name and identifying information
will not be linked to your answers.
Your participation in this survey is voluntary and will not affect any health care or benefits you receive.
If it’s more convenient, you can complete the survey on-line at www.IGsurvey.com. The cover page of
your survey form has your unique username and password.
Two versions of this survey are enclosed. Please fill out the form that applies to you and mail it back in the
postage-paid envelope provided.
If you ARE NOT ENROLLED
in the Medicare in-home IVIG Demonstration*
If you ARE ENROLLED
in the Medicare in-home IVIG Demonstration*
Complete Form A
Complete Form B
Thank you in advance for participating in this important survey!
Sincerely,
Pauline Karikari-Martin, PhD, MPH, MSN
Centers for Medicare & Medicaid Services
410-786-1040 | [email protected]
* This demonstration provides in home IVIG services to enrolled beneficiaries. If you have any questions
about the Medicare in-home IVIG Demonstration, please call the demonstration hotline toll-free at 1-844
625-6284, or visit www.medicarenhic.com.
39
B.6. Survey Reminder Postcard
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Nota: Estos materiales están disponibles en español. Para solicitar una copia de la encuesta en español, por favor llame al
1-800-674-7381. These materials are available in Spanish. To request a copy of the survey in Spanish, please call 1-800
674-7381.
Dear [Medicare Beneficiary]
We recently mailed you Medicare’s 2016 Survey of Beneficiaries Using Immunoglobulin for Treatment of PIDD. This card is
to remind you that YOUR PARTICIPATION IS HIGHLY IMPORTANT.
THIS IS AN OPPORTUNITY FOR YOU TO HAVE YOUR VOICE HEARD BY MEDICARE. Medicare needs your feedback
to understand the needs of beneficiaries taking immunoglobulin, and how we can improve our services.
THE SURVEY SHOULD TAKE LESS THAN 30 MINUTES TO COMPLETE.
You can complete the survey we mailed to you.
OR: You can take the survey on line at: www.IGsurvey.com Your password is: _____
OR: You can download another copy at: www.IGsurvey.com (Click the link at the bottom of the second page.)
OR: You can request another survey by emailing us at [email protected].
Your participation and responses are PRIVATE, CONFIDENTIAL, and PROTECTED UNDER THE
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996 (HIPAA). Your participation
in this survey is voluntary and will not affect any health care or benefits you receive.
ANY QUESTIONS OR CONCERNS? Email Pauline Karikari-Martin at: [email protected] or call 410 786
1040.
This reminder has been sent by Eastern Research Group, Inc. (ERG), under contract by Medicare to conduct this survey (OMB Approval No.__________).
40
| File Type | application/pdf |
| File Title | Appendix B. Medicare IVIG Demonstration Evaluation Survey |
| Subject | Appendix B, Medicare, IVIG Demonstration, Evaluation, Survey |
| Author | Centers for Medicare and Medicaid Services |
| File Modified | 2015-12-24 |
| File Created | 2015-12-24 |