Beneficiaries Survey

ID Number: CMS-10615
OMB Control Number: 0938-1300

Si usted tiene preguntas acerca de esta encuesta o desea recibirla en español, por favor llame al Thoroughbred Research Group al 1-844-859-7862.

[DATE]

ID#

[FIRST NAME] [LAST NAME]

[ADDRESS]

[CITY, STATE AND ZIP]

IMPORTANT MESSAGE ABOUT YOUR HEALTHY INDIANA PLAN 2.0

Dear [HONORIFIC.] [LAST NAME]:

This is an important survey for current and previous members of the Healthy Indiana Plan 2.0 (HIP 2.0) from the Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicare and Medicaid. Please take a few minutes to read this letter and then complete the survey about the care you receive in the HIP 2.0 program. After completing the survey, please return it in the enclosed, postage-paid envelope.

All of your answers are protected by the Federal Privacy Act. No one will be able to link your answers to your identity. Your participation is voluntary and will not affect any health care or benefits you receive.

Please do not ask anyone from the HIP 2.0 program for help when completing the survey. If you need help, you may ask a family member or friend to assist you. It is important that your answers reflect your own opinions about the care you receive.

You can complete this survey now by typing the link below into your Internet browser’s address bar and using your personal login ID and password to access the survey.

https://www.torfasttrack.com/wn434mem <final link to be inserted later>

Login = ID# Password = ????????

If you have any questions about this survey or wish to receive the survey in Spanish, please call Thoroughbred Research Group, at 1-844-859-7862. Thank you in advance for your participation and we look forward to receiving your completed survey!

Sincerely,

David A. Bryant

Vice President, Health Policy Research

Thoroughbred Research Group