Form CMS-10316 Medicare Disenrollee Survey - MA PD

Attachment VI. MA-PD Survey
Survey Instructions
This survey asks about you and the healthcare you received from your former health
plan. 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 CSS (the survey
research organization assisting CMS in conducting this survey).


Answer all the questions by putting an “X” in the box to the left of your answer,
like this:



Yes



Be sure to read all the answer choices given before marking your answer.



Some questions have instructions that tell you to skip questions that may not apply to
you. 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].

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1113 (Expires: TBD). The time required to complete this information
collection is estimated to average 18 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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Please read below:

According to CMS records, the following change was made to your Medicare coverage in
[MONTH/YEAR]:

 Your former Medicare plan or coverage was:
[PLANMARKETING NAME] [Contract #: x]
 Your new Medicare plan or coverage is:
[PLAN MARKETING NAME]

[Contract #: x]

 Please answer this survey based only on your experiences with your former plan:

[PLAN MARKETING NAME/CONTRACT #]

 If you were not enrolled in [CONTRACT NAME/NUMBER] recently, please answer
the survey based on your experiences with the plan you had before you enrolled in
your current plan.

GO TO NEXT PAGE

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ATTENTION: Some questions have instructions that tell you to skip questions that
may not apply to you. Please check for a skip instruction after you answer each
question.

YOUR FORMER HEALTH PLAN
We are sending you this survey because we believe you recently changed or switched to
another Medicare health plan or dropped your Medicare health plan.
1. Our records show that you used to belong to [PLAN_NAME] (Contract
Number [CONTRACTID]) but no longer belong to that plan. Is that right?

 Yes, I changed or switched health plans  Go to Question 2
 I changed or switched health plans but my former plan was not
[PLAN_NAME]  Go to Question 2

 No, I did not change, switch, or drop health plans recently

Stop. Do not
complete the rest
of this survey.
Please
return the survey
in the enclosed
envelope.

2. Did you have to change, switch, or drop your former health plan for any of the
following reasons?

 I moved outside of the area where the plan was available
 I was dropped by the plan
 The plan was cancelled or discontinued in my area
 The plan was changed or discontinued by the organization

}

that provides my insurance (such as a former employer or
a union)
 None of the above  Continue survey, go to Question 3

Stop. Do not
complete the rest of
this survey. Please
return the survey
in the enclosed
envelope.

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GETTING INFORMATION OR HELP
FROM YOUR FORMER
HEALTH PLAN
As you answer the questions in this
survey, please think only of your former
health plan.
3. Did you ever try to get information or
help from your former plan’s customer
service?

 Yes
 No  If No, go to Question 5
4. How often did your former plan’s
customer service give you the
information or help you needed?

 Never
 Sometimes
 Usually
 Always
 I did not try to get information or help
from my former plan’s customer
service
5. Did you ever try to get information
from your former plan about which
prescription medicines were
covered?

 Yes
 No If No, go to Question 7

6. How often did your former plan give
you all the information you needed
about which prescription medicines
were covered?

 Never
 Sometimes
 Usually
 Always
 I did not try to get information from my
former plan about which prescription
medicines were covered
7. Did you ever try to get information
from your former plan about how
much you would have to pay for a
prescription medicine?

Yes
No  If No, go to Question 9
8. How often did your former plan give
you information about how much you
would have to pay for a prescription
medicine?

 Never
 Sometimes
 Usually
 Always
 I did not try to get information from my
former plan about how much I would
have to pay for a prescription medicine

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GETTING HEALTH CARE AND THE
PRESCRIPTION MEDICINES
YOU NEEDED FROM YOUR FORMER
HEALTH PLAN
9. Did you ever try to get any kind of
care, tests, or treatment through your
former plan?
 Yes
 No If No, go to Question 11
10. How often was it easy to get the care,
tests, or treatment you needed
through your former plan?
 Never
 Sometimes
 Usually
 Always
 I did not try to get any kind of care,
tests, or treatment through my former
plan
11. Did a doctor ever prescribe a medicine
for you that your former plan did not
cover?

 Yes
 No
12. How often was it easy to use your
former plan to get the medicines
your doctor prescribed?

13. Did you ever use your former plan to fill
a prescription at a pharmacy?




Yes
No If No, go to Question 15

14. How often was it easy to use your
former plan to fill a prescription at a
pharmacy?

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to fill a
prescription at a pharmacy
15. Did you ever use your former plan to
fill any prescriptions by mail?

 Yes
 No  If No, go to Question 17
16. How often was it easy to use your
former plan to fill prescriptions by
mail?

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to fill a
prescription by mail

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to get
any prescription medicines

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17.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 your former plan?













0 Worst health plan possible
1
2
3




Yes
No

20. Did you leave your former plan
because the dollar amount you had to
pay each time you filled or refilled a
prescription went up?

6

 Yes
 No
 I did not have to pay for my

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prescription medicines

4
5

8
9
10 Best health plan possible

REASONS YOU LEFT YOUR FORMER
HEALTH PLAN
The next questions are about reasons you
may have had for changing, switching, or
dropping your former health plan.
18. Did you leave your former plan
because you found out that someone
had signed you up for the plan without
your permission?




19. Did you leave your former plan because
you were taken off the plan by mistake?

Yes
No

21. Did you leave your former plan
because the dollar amount you had
to pay each time you visited a
doctor went up?

 Yes
 No
 I did not have to pay for doctor visits
22. Some people have to pay their health
plan a monthly fee (called a premium)
out of their own pocket for health
coverage.
Did you leave your former plan
because this monthly fee went up?

 Yes
 No
 I did not have to pay my former plan a
monthly fee out of my own pocket

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23. Health plans have a list of the
prescription medicines they will
cover. Did you leave your former
plan because they changed the list
of prescription medicines they
cover?

 Yes
 No
24. Did you leave your former plan
because you found a health plan
that costs less?

 Yes
 No
25. Did you leave your former plan
because a change in your personal
finances meant you could no longer
afford the plan?

 Yes
 No
26. Did you leave your former plan
because the plan refused to pay
for a medicine your doctor
prescribed?

 Yes
 No
27. Did you leave your former plan
because you had problems getting
the medicines your doctor
prescribed?

 Yes
 No

28. Did you leave your former plan because
it was difficult to get brand name
medicines?

 Yes
 No
 I did not try to get brand name
medicines through my former plan
29. Did you leave your former plan because
you were frustrated by the plan’s
approval process for medicines your
doctor prescribed?

 Yes
 No
30. Did you leave your former plan
because you did not know whom to
contact when you had a problem filling
or refilling a prescription?

 Yes
 No
31. Did you leave your former plan
because it was hard to get information
from the plan—like which prescription
medicines were covered or how much
a specific medicine would cost?

 Yes
 No
32. Did you leave your former plan
because you were frustrated by the
plan’s approval process for care, tests,
or treatment?

 Yes
 No

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33. Did you leave your former plan
because you had problems getting
the care, tests, or treatment you
needed?

 Yes
 No
34. Claims are sent to a health plan for
payment. You may send in the
claims yourself or doctors,
hospitals, or others may do this for
you. Did you leave your former plan
because you had problems getting
the plan to pay a claim?

 Yes
 No
35. Did you leave your former plan
because the doctors or other health
care providers you wanted to see did
not belong to the plan?

 Yes
 No
36. Did you leave your former plan
because clinics or hospitals you
wanted to go to for care were not
covered by the plan?

 Yes
 No
37. Did you leave your former plan
because it was hard to get
information from the plan—like
which health care services were
covered or how much a specific test
or treatment would cost?

38. Did you leave your former plan
because you were unhappy with
how the plan handled a question or
complaint?

 Yes
 No
39. Did you leave your former plan
because you could not get the
information or help you needed from
the plan?

 Yes
 No
40. Did you leave your former plan
because their customer service staff
did not treat you with courtesy and
respect?

 Yes
 No
41. Every year Medicare evaluates all
health plans and gives them a star
rating that gives information on health
plan quality.
Have you ever seen the Medicare Star
Rating for any health plan?

 Yes
 No If No, go to Question 45
42. Did you leave your former plan
because it got a low star rating?

 Yes
 No

 Yes
 No

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43. Did you leave your former plan
because you found another plan
with a higher star rating?

 Yes
 No
44. In the past year, did you consider
the Medicare Star Ratings when
trying to choose a plan?

 Yes
 No
OTHER REASONS FOR LEAVING
YOUR FORMER HEALTH PLAN
45. Did you leave your former plan
because a family member or friend
told you about a better plan?

 Yes
 No
46. Did you leave your former plan
because you saw a commercial or
advertisement for a health plan you
thought you would like better?

 Yes
 No
47. Did you leave your former plan
because you found another plan
that better met your prescription
needs?

 Yes
 No
48. Did you leave your former plan
because another plan offered
better benefits or coverage (for
example, dental or vision care)?

 Yes
 No

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

 Excellent
 Very good
 Good
 Fair
 Poor
50. In general, how would you rate your
overall mental or emotional health?

 Excellent
 Very good
 Good
 Fair
 Poor
51. In the past 12 months, how many
different prescription medicines did
you take?

 None
 1 to 2 medicines
 3 to 5 medicines
 6 or more medicines
52. 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 54
53. Is this a condition or problem that has
lasted for at least 3 months?

 Yes
 No

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54. Do you now need or take any
medicine prescribed by a doctor for
any condition?

 Yes
 No  If No, go to Question 56
55. Is this medicine to treat a condition
that has lasted for at least 3
months?

 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
58. Are you of Hispanic or Latino origin or
descent?

 Yes
 No
56. Has a doctor ever told you that you
had any of the following conditions?
Yes

a. A heart attack

b. Angina or coronary

heart disease
c. High blood pressure or
hypertension

d. Cancer, other than
skin cancer
e. Emphysema, asthma
or COPD (chronic
obstructive pulmonary
disease)
f. Any kind of diabetes
or high blood sugar

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

No

















 Yes, Hispanic or Latino
 No, not Hispanic or Latino
59. 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
60. What language do you mainly speak at
home?

 Chinese
 English
 Russian
 Spanish
 Vietnamese
 Some other language (please print)

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61. Did someone help you complete
this survey?

 Yes
 No  If No, go to Question 63
62. How did that person help you? Please
mark one or more.

63. May we contact you again if we have
any questions about your survey
responses or if we have other questions
about the health care services that you
received?

 Yes
 No

 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 (please
print)

THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage paid envelope to:
MEDICARE SATISFACTION SURVEY
PO BOX 1920
MANCHESTER, CT 06045-9939

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