Form CMS-R-246 Prescription Drug Plan Survey

MA & PDP CAHPS Survey

MA-PD Survey

INTIAL COVER LETTER

[SURVEY VENDOR LOGO] [PLAN LOGO ONLY NO ADDRESS]

[SURVEY VENDOR ADDRESS]

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 and your Medicare health plan.

CMS is conducting a survey of people in Medicare health plans to learn more about the health care services you receive. Your name was selected at random by CMS from among the enrollees in your health plan. We would greatly appreciate it if you would take the time, about 15 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 and your health plan serve you better.

If you changed your Medicare plan for 2017, please answer the questions in the survey thinking about your experiences in the last six months of 2016. 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 [SURVEY VENDOR NAME]. 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 about their health plan, so we hope you will choose to help us.

If you have any questions about the survey, please call [VENDOR DESIGNATE] with [SURVEY VENDOR NAME] toll-free at 1-XXX-XXXX, Monday through Friday, between XX:XX a.m. and XX:XX p.m.

Thank you in advance for your participation.

Sincerely,

Signature

[SENIOR OFFICIAL OF SURVEY VENDOR]

Nota: Si le gustaría recibir una copia de la encuesta en español, por favor llame gratis a [VENDOR DESIGNATE] de [SURVEY VENDOR NAME] al 1-xxx- xxx-xxxx de lunes a viernes entre XX:XX a.m. y XX:XX p.m.

Medicare Experience Survey

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 [Survey Vendor].

• 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.

• 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 example 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

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 0938-0732. The time required to complete this information collection is estimated to average 15 minutes, 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 C1-25-05, Baltimore, Maryland 21244-1850.

1. Our records show that in 2016 your health services were covered by the plan named on the back page. Is that right?

Yes If Yes, Go to Question 3

No

2. Please write below the name of the health plan you had in 2016 and complete the rest of the survey based on the experiences you had with that plan. (Please print)

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 needed?

Never

Sometimes

Usually

Always

5. In the last 6 months, did you make any appointments for a check-up or routine care at a doctor’s office or clinic?

Yes

No If No, Go to Question 7

6. In the last 6 months, how often did you get an appointment for a check-up or routine care as soon as 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 time

2

3

4

5 to 9

10 or more times

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. 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

10. In the last 6 months, how often was it easy to get the care, tests or treatment you needed?

Never

Sometimes

Usually

Always

Your Personal Doctor

11. 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 27

12. 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 27

1 time

2

3

4

5 to 9

10 or more times

13. 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

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

Never

Sometimes

Usually

Always

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

Never

Sometimes

Usually

Always

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

Never

Sometimes

Usually

Always

17. 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

18. 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

19. 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 22

20. 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 22

Sometimes

Usually

Always

21. 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

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

Yes

No If No, Go to Question 24

23. 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

24. 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 27

25. 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 27

26. 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

Getting Health Care From Specialists

27. 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 personal doctor as you answer these questions about specialists

No

I do not have a personal doctor

28. In the last 6 months, did you make any appointments to see a specialist?

Yes

No If No, Go to Question 33

Someone else made my specialist appointments for me

29. In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed?

Never

Sometimes

Usually

Always

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

None If None, Go to Question 33

1 specialist

2

3

4

5 or more specialists

31. 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

32. In the last 6 months, how often did your personal doctor seem informed and up-to-date 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

Your Health Plan

33. In the last 6 months, did you get information or help from your health plan’s customer service?

Yes

No If No, Go to Question 36

34. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed?

Never

Sometimes

Usually

Always

35. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect?

Never

Sometimes

Usually

Always

36. In the last 6 months, did your health plan give you any forms to fill out?

Yes

No If No, Go to Question 38

37. In the last 6 months, how often were the forms from your health plan easy to fill out?

Never

Sometimes

Usually

Always

38. 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 health plan?

0 Worst health plan possible

1

2

3

4

5

6

7

8

9

10 Best health plan possible

39. A co-pay is the amount of money you pay at the time of a visit to a doctor’s office or clinic. In the last 6 months, did your health plan offer to lower the amount of your co-pay because you have a health condition (like high blood pressure)?

Yes

No

40. Your health plan benefits are the types of health care and services you can get under the plan. In the last 6 months, did your health plan offer you extra benefits because you have a health condition (like high blood pressure)?

Yes

No

Your Prescription Drug Plan

Now we would like to ask you some questions about the prescription drug coverage you get through your prescription drug plan.

41. In the last 6 months, did anyone from a doctor’s office, pharmacy or your prescription drug plan contact you:

Yes No

a. To make sure you filled or refilled a prescription?

b. To make sure you were taking medications as directed?

42. In the last 6 months, how often was it easy to use your prescription drug plan to get the medicines your doctor prescribed?

Never

Sometimes

Usually

Always

I did not use my prescription drug plan to get any medicines in the last 6 months

43. In the last 6 months, did you ever use your prescription drug plan to fill a prescription at your local pharmacy?

Yes

No If No, Go to Question 45

44. In the last 6 months, how often was it easy to use your prescription drug plan to fill a prescription at your local pharmacy?

Never

Sometimes

Usually

Always

I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months

45. In the last 6 months, did you ever use your prescription drug plan to fill a prescription by mail?

Yes

No If No, Go to Question 47

I am not sure if my drug plan offers prescriptions by mail Go to Question 47

46. In the last 6 months, how often was it easy to use your prescription drug plan to fill a prescription by mail?

Never

Sometimes

Usually

Always

I did not use my prescription drug plan to fill a prescription by mail in the last 6 months

I am not sure if my drug plan offers prescriptions by mail

47. Using any number from 0 to 10, where 0 is the worst prescription drug plan possible and 10 is the best prescription drug plan possible, what number would you use to rate your prescription drug plan?

0 Worst prescription drug plan possible

1

2

3

4

5

6

7

8

9

10 Best prescription drug plan possible

About You

48. In general, how would you rate your overall health?

Excellent

Very good

Good

Fair

Poor

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

Excellent

Very good

Good

Fair

Poor

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

Yes

No

51. 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

52. In the last 6 months, did you receive any mail order medicines that you did not request?

Yes

No

Don’t know

53. 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?

c. Hypertension

or high blood

pressure?

d. Cancer, other than skin cancer?

e. Emphysema, asthma or COPD (chronic obstructive pulmo- nary disease)?

f. Any kind of diabetes or high blood

sugar?

54. Do you have serious difficulty walking or climbing stairs?

Yes

No

55. Do you have difficulty dressing or bathing?

Yes

No

56. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

Yes

No

57. Have you had a flu shot since July 1, 2016?

Yes

No

Don’t know

58. Have you ever had one or more pneumonia shots? Two shots are usually given in a person’s lifetime and these are different from a flu shot. It is also called the pneumococcal vaccine.

Yes

No

Don’t know

59. 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 61

Don’t know If Don’t know, Go to Question 61

60. 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

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

8^th 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

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

Yes, Hispanic or Latino

No, not Hispanic or Latino

63. 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

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

1 person

2 to 3 people

4 or more people

65. Do you ever use the internet at home?

Yes

No

66. 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

67. Did someone help you complete this survey?

Yes

No  Thank you. Please

return the completed survey in the postage-paid envelope.

68. 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.

Please return the completed survey in the postage-paid envelope.

[SURVEY VENDOR ADDRESS]

Contract Name: _____________________

3