Form CMS-R-246 Fee-For-Service (FFS) Survey

FFS CAHPS Survey

INTIAL COVER LETTER

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.

CMS is conducting a survey of people with Medicare to learn more about the health care services you receive. Your name was selected at random by CMS from among Medicare enrollees. 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 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 IMPAQ International, the survey research organization assisting us in this survey. 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, so we hope you will choose to help us.

If you have any questions about the survey or would like to find out how to complete the survey by phone, please don’t hesitate to call IMPAQ International toll-free at 1-888-942-2477 anytime from 9:00 am to 9:00 pm your local time.

Thank you in advance for your participation.

Sincerely,

Amy Larrick Chavez-Valdez

Director, Medicare Drug Benefit and C & D Data Group

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: Medicare Experience Survey, PO Box 1800, Manchester, CT 06045-9989.

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 examples 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

Your Health Insurance Coverage

Our records show that you are now in Medicare, the health insurance program for people 65 years old or older or persons with certain disabilities.

Please answer the following questions in this survey as fully as possible regardless of whether you consider yourself in Medicare.

1. Some people who have Medicare also have other insurance to help pay for some of the costs of their health care. Do you have any other insurance that pays at least some of the cost of your health care?

_ Yes

_ No → If No, Go to Question 3

2. Please mark the box below for each type of health insurance that you have.

_ Medigap, which may be identified on the front of your policy as “Medicare Supplemental Insurance”

_ Employer, Union, or Retiree Health Coverage (insurance)

_ Veteran’s Benefits, also known as VA benefits

_ Military Retiree Benefits, also known as Tricare

_ Medicaid, also known as State medical assistance, which is for some persons with limited income and resources

_ Any Prescription Drug Plan

_ Other (Please write the name of the other health insurance you currently have on the line below.)

______________________________

_ I don’t have health insurance other than Medicare.

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

managing your health care

33. How likely are you to change doctors if you are dissatisfied with the way you and your doctor communicate?

_ Very likely

_ Likely

_ Unlikely

_ Very unlikely

34. How likely are you to tell your doctor when you disagree with him or her?

_ Very likely

_ Likely

_ Unlikely

_ Very unlikely

35. In the last 6 months, how often did you leave your doctor’s office feeling that all of your concerns or questions were fully answered?

_ Never

_ Sometimes

_ Usually

_ Always

36. In the last 6 months, how often did you make sure you understood the results of any medical test or procedure such as x-ray, blood test, or EKG for heart conditions?

_ Never

_ Sometimes

_ Usually

_ Always

_ I did not have any medical tests or procedures in the last 6 months

MEDICARE EXPERIENCE

The next questions ask about your experience with Medicare.

37. In the last 6 months, did you get information or help from Medicare’s customer service?

_ Yes

_ No → If No, Go to Question 40

38. In the last 6 months, how often did Medicare’s customer service give you the information or help you needed?

_ Never

_ Sometimes

_ Usually

_ Always

39. In the last 6 months, how often did Medicare’s customer service staff treat you with courtesy and respect?

_ Never

_ Sometimes

_ Usually

_ Always

40. In the last 6 months, did Medicare give you any forms to fill out?

_ Yes

_ No → If No, Go to Question 42

41. In the last 6 months, how often were the forms from Medicare easy to fill out?

_ Never

_ Sometimes

_ Usually

_ Always

42. 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 Medicare?

_ 0 Worst health plan possible

_ 1

_ 2

_ 3

_ 4

_ 5

_ 6

_ 7

_ 8

_ 9

_ 10 Best health plan possible

ABOUT YOU

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

_ Excellent

_ Very good

_ Good

_ Fair

_ Poor

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

_ Excellent

_ Very good

_ Good

_ Fair

_ Poor

⁴⁵. In the last 6 months, did you spend one or more nights in a hospital?

_ Yes

_ No

46. 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

47. Do you have insurance that pays part or all of the cost of your prescription medicines?

_ Yes

_ No

_ Don’t know

48. 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

49. Are you currently enrolled in a Medicare Part D plan (prescription drug plan)?

_ Yes

_ No → If No, Go to Question 56

The following questions are about the Medicare Part D Medication Therapy Management program. The program is available to people enrolled in a Medicare Part D plan who have multiple chronic conditions, take multiple medications, and meet other qualifying criteria.

50. Are you enrolled in a Medicare Part D Medication Therapy Management program?

_ Yes

_ No → If No, Go to Question 56

_ Don’t know → If Don’t know,

Go to Question 56

51. Did a health care provider, such as a pharmacist, call or meet with you to review your medications and answer your questions about your medications?

_ Yes

_ No → If No, Go to Question 55

52. Did the review increase your understanding of your medications and how to use them?

_ Yes, it increased my understanding

_ No, it did not change my understanding

_ No, it decreased my understanding

53. A printed summary of the review includes a letter, a medication action plan, and a personal medication list. Did you receive a printed summary of the review?

_ Yes

_ No → If No, Go to Question 55

_ Don’t know → If Don’t know,

Go to Question 55

54. How satisfied were you with the information in the printed summary of the review?

_ Very satisfied

_ Satisfied

_ Dissatisfied

_ Very dissatisfied

55. Overall, how satisfied are you with the Medication Therapy Management program provided by your Medicare Part D plan?

_ Very satisfied

_ Satisfied

_ Dissatisfied

_ Very dissatisfied

56. 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

pulmonary disease)? _{ }

f. Any kind of diabetes

or high blood sugar? _{ }

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?

_ 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

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. Because of a health or physical problem are you unable to do or have any difficulty doing the following activities? (Please mark one response for each activity.)

I am

unable No,

to do Yes, I do not

this I have have

activity difficulty difficulty

a. Bathing _{  }

b. Dressing _{  }

c. Eating _{  }

d. Getting

in or out

of chairs _{  }

e. Walking _{  }

f. Using the

toilet _{  }

66. 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

⁶⁷. Do you ever use the internet at home?

_ Yes

_ No

68. 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

69. Did someone help you complete this survey?

_ Yes

_ No → Thank you. Please return the completed survey in the postage-paid envelope.

70. 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 FOR COMPLETING THIS SURVEY

Please return your completed survey in the postage-paid envelope to:

Medicare Experience Survey

PO Box 1800

Manchester, CT 06045-9989

Please do not include any other correspondence.