Form CMS-R-246 Medicare Advantage Plan Survey

MA & PDP CAHPS Survey
MA-only Survey
INITIAL COVER LETTER
[SURVEY VENDOR LOGO]
[SURVEY VENDOR ADDRESS]

[PLAN LOGO ONLY NO 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 (Expires: TBD). 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?

5.

Yes If Yes, Go to Question 3
No
2.

Yes
No If No, Go to Question 7

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)

6.

Your Health Care in the Last 6 Months

7.

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

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

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
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?

39.

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

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

About You
41. In general, how would you rate
your overall health?
Excellent
Very good
Good
Fair
Poor

42. In general, how would you rate
your overall mental or emotional
health?
Excellent
Very good
Good
Fair
Poor
43. In the last 6 months, did you spend
one or more nights in a hospital?
Yes
No
44. In the last 6 months, how often
was it easy to get the medicines
your doctor prescribed?
Never
Sometimes
Usually
Always
My doctor did not prescribe
any medicines for me in the
last 6 months
45. Do you have insurance that pays
part or all of the cost of your
prescription medicines?
Yes
No
Don’t know

46. 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
47. In the last 6 months, did you
receive any mail order medicines
that you did not request?
Yes
No
Don’t know
48. 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. Hypertension
or high blood
pressure?
d. Cancer, other than
skin cancer?
e. Emphysema, asthma
or COPD (chronic
obstructive pulmonary disease)?
f. Any kind of diabetes
or high blood
sugar?

No

49. Do you have serious difficulty
walking or climbing stairs?
Yes
No
50. Do you have difficulty dressing or
bathing?
Yes
No
51. 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
52. Have you had a flu shot since July
1, 2016?
Yes
No
Don’t know
53. 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

54. 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 56
Don’t know If Don’t know,
Go to Question
56
55. 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
56. What is the highest grade or level
of school that you have
completed?
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

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

61.

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

Yes
No

White
Black or African-American
Asian
Native Hawaiian or other Pacific
Islander
American Indian or Alaska Native
59. How many people live in your
household now, including
yourself?
1 person
2 to 3 people
4 or more people
60.

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?

62. Did someone help you complete
this survey?
Yes
No Thank you. Please
return the completed
survey in the postagepaid envelope.
63. 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

Do you ever use the internet at
home?
Yes
No

Thank you.
Please return the completed survey in the postage-paid envelope.
[SURVEY VENDOR ADDRESS]
Contract Name:_____________________