Form CMS-10316 Medicare Disenrollee Survey - MA

Attachment VIII. MA-Only 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:
[PLAN NAME] [CONTRACT #]


Your new Medicare plan or coverage is:
[PLAN NAME] [CONTRACT #]

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

[PLAN MARKETING NAME/CONTRACT #]

 If you were not enrolled in [PLAN 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)

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

 None of the above  Continue survey, go to Question 3

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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

Never
Sometimes
Usually
Always
I did not try to get any kind of care,
tests, or treatment through my
former plan

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?







6. 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 information or
help from my former plan’s
customer service

GETTING HEALTH CARE YOU
NEEDED FROM YOUR FORMER
HEALTH PLAN

7. 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
4
5
6
7
8
9
10 Best health plan possible

5. Did you ever try to get any kind of
care, tests, or treatment through
your former plan?




Yes
No  If No, go to Question 7

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REASONS YOU LEFT YOUR
FORMER HEALTH PLAN

The next questions are about reasons
you may have had for c h a n g i n g ,
switching, or dropping your former
health plan.
8. Did you leave your former plan
because you found out that
someone had signed you up for
the plan without your permission?




Yes
No

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




Yes
No

10. 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

11. 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
12. Did you leave your former plan
because you found a health plan
that costs less?

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

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

 Yes
 No
15. Did you leave your former plan
because you had problems getting
the care, tests, or treatment you
needed?

 Yes
 No
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16. 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

17. 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
18. 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
19. 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?

 Yes
 No

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

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

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

 Yes
 No
23. 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 27
24. Did you leave your former plan
because it got a low star rating?

 Yes
 No

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

 Yes
 No
26. 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
27. Did you leave your former plan
because a family member or friend
told you about a better plan?

 Yes
 No
28. 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
29. Did you leave your former plan
because you found another plan
that better met your prescription
needs?

 Yes
 No

30. Did you leave your former plan
because another plan offered
better benefits or coverage (for
example, dental or vision care)?




Yes
No

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

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

 Excellent
 Very good
 Good
 Fair
 Poor
33. 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

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34. 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 36
35. Is this a condition or problem that
has lasted for at least 3 months?

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

 Yes
 No  If No, go to Question 38
37. Is this medicine to treat a
condition that has lasted for at
least 3 months?

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











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

40. Are you of Hispanic or Latino origin
or descent?

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

 Yes
 No

Yes

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

No




















 White
 Black or African-American
 Asian
 Native Hawaiian or other Pacific
Islander
 American Indian or Alaska Native
42. What language do you mainly
speak at home?

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

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43. Did someone help you complete
this survey?

 Yes
 No  If No, go to Question 45
44. How did that person help you?
Please mark one or more.

45. 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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