Medicare Health Outcomes Survey (HOS)

HOS Baseline Text for Prenotification
Letters, Survey Cover Letters and
Reminder/Thank-You Postcards

HOS Baseline Prenotification Letter

[CMS Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicare, monitors the
quality of care that Medicare health plans provide. One way CMS does this is to ask people with Medicare
about their physical and mental health—to determine whether the care their health plan provides keeps them
as healthy as possible.
You have been randomly selected to receive the “Medicare Health Outcomes Survey.” (For some health
plans that have fewer enrollees, all members with Medicare are asked to participate.) In a few days, you will
receive the survey in the mail. Please take the time to complete and return it in the enclosed postage-paid
envelope.
Your answers will provide important information about your health. In two years, we will ask you to complete
the same survey. CMS compares results from both surveys to see how well your health plan maintains or
improves the health and well-being of its members over time.
The accuracy of these results depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits.
[SURVEY VENDOR NAME] is a survey organization working with CMS to carry out this survey. If you have
questions about the survey please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or e-mail [EMAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,

Amy Larrick Chavez-Valdez, Director
Medicare Drug Benefit and C & D Data Group

HOS Baseline Letter for First Questionnaire Mailing (Double-Sided—English)

[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicare, monitors the
quality of care Medicare health plans provide. One way CMS does this is to ask people with Medicare about
their health—to see if the care their health plan provides keeps them as healthy as possible.
CMS conducts a survey called the “Medicare Health Outcomes Survey.” This survey asks about your physical
and mental health. Your name was randomly selected for the survey. (For some health plans that have fewer
enrollees, all members with Medicare are asked to participate.)
Please take the time to fill out this survey and return it to us in the postage-paid envelope. If you choose to
participate, CMS may ask you to take the survey again in two years. CMS will compare results from both
surveys to see how well your health plan maintains or improves the health and well-being of its members over
time. The results will be used to improve the quality of care for people with Medicare.
The accuracy of these results depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits. Because your answers can help others with Medicare, we hope you will
help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,

[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures
Español Al Otro Lado

HOS Baseline Letter for Replacement Questionnaire Mailing

[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
Recently we mailed you the “Medicare Health Outcomes Survey.” If you already returned the survey, thank
you! If you did not, we are sending you another copy. Please complete it and return it in the enclosed
postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicare, monitors the
quality of care Medicare health plans provide. One way CMS does this is by conducting the “Medicare Health
Outcomes Survey,” which asks people with Medicare about their health to see if the care their health plan
provides is keeping them as healthy as possible. Your name was randomly selected for the survey. For some
health plans that have fewer enrollees, all members with Medicare are being asked to participate.
Please take the time to fill out this survey. If you choose to participate, CMS may ask you to take the survey
again in two years. CMS will compare results from both surveys to see how well your health plan is
maintaining or improving the health and well-being of its members over time. The results will be used to
improve the quality of care people with Medicare receive.
The accuracy of the survey depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits. Because your answers can help others with Medicare, we hope you will
help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.

Sincerely,

[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures

HOS Baseline Reminder/Thank-You Postcard

Medicare Health Outcomes Survey
Dear Sir or Madam:
About a week ago, you should have received the “Medicare Health Outcomes Survey” in the mail. If you have
already returned the survey, thank you!
If not, this is a reminder to complete the survey and return it in the postage-paid envelope. Your answers can
help the Centers for Medicare & Medicaid Services (CMS) and your health plan to improve the quality of care
for people with Medicare.
You will receive another copy of the survey in the mail soon. If you have questions about the survey, please
call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or e-mail [E-MAIL ADDRESS].

Thank you!
[SURVEY VENDOR NAME]

HOS Follow-Up Text for Prenotification
Letter, Survey Cover Letters and
Reminder/Thank-You Postcards

Appendix 4—HOS Follow-Up Prenotification Letter

4-9

HOS Follow-Up Prenotification Letter

[CMS Letterhead]

Dear Medicare Beneficiary:
About two years ago, you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2017. In a few days, you will receive the new survey in the mail.
When it arrives, please take the time to complete it and return it in the enclosed postage-paid envelope.
As you may recall, the Centers for Medicare & Medicaid Services (CMS) monitors the quality of care that
Medicare health plans provide. One way CMS does this is to ask people with Medicare about their health and
how it changes over time.
The information you provide in the survey can help us improve the quality of care provided to you and other
people with Medicare. We compare results from both surveys to determine if your health plan keeps people
with Medicare as healthy as possible. Our goal is to see how well health plans maintain or improve the health
and well-being of their members.
The accuracy of the results depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits.
[SURVEY VENDOR NAME] is a survey organization working with CMS to carry out this survey. If you have
questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or e-mail [EMAIL ADDRESS]. Thank you for your ongoing help with this important survey.

Sincerely,

Amy Larrick Chavez-Valdez, Director
Medicare Drug Benefit and C & D Data Group

HOS Follow-Up Letter for First Questionnaire Mailing—No Proxy at Baseline

[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
About two years ago, you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2017. Please take the time to fill out the survey and return it to us in
the postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS) monitors the quality of care Medicare health plans
provide. One way CMS does this is by asking people with Medicare about their health to see if the care their
health plan provides is keeping them as healthy as possible.
The information you provide is important. CMS will compare results from both surveys to see how well your
health plan can maintain or improve the health and well-being of its members over time. The results will be
used to improve the quality of care that people with Medicare receive.
The accuracy of the survey depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits. Because your answers can help others with Medicare, we hope you will
help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,

[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures

Appendix 4—HOS Follow-Up Letter for Replacement Questionnaire Mailing—
No Proxy at Baseline

4-11

HOS Follow-Up Letter for Replacement Questionnaire Mailing—No Proxy at Baseline

[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
About two years ago, you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2017. We recently mailed you the survey, but have not received it
back from you. If you have already returned the completed survey, thank you. We have enclosed another
copy of the same survey in case you did not receive it. Please take the time to fill out the survey and return it
to us in the postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS) monitors the quality of care Medicare health plans
provide. One way CMS does this is by asking people with Medicare about their health to see if the care their
health plan provides is keeping them as healthy as possible.
The information you provide is important. CMS will compare results from both surveys to see how well your
health plan can maintain or improve the health and well-being of its members over time. The results will be
used to improve the quality of care that people with Medicare receive.
The accuracy of the survey depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits. Because your answers can help others with Medicare, we hope you will
help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,

[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]

Enclosures

4-12

Appendix 4—HOS Follow-Up Letter for First Questionnaire Mailing—Proxy at Baseline

HOS Follow-Up Letter for First Questionnaire Mailing—Proxy at Baseline

[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
About two years ago, you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2017. Please take the time to fill out the survey and return it to us in
the postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS) monitors the quality of care Medicare health plans
provide. One way CMS does this is by asking people with Medicare about their health to see if the care their
health plan provides is keeping them as healthy as possible.
The information you provide is important. CMS will compare results from both surveys to see how well your
health plan can maintain or improve the health and well-being of its members over time. The results will be
used to improve the quality of care that people with Medicare receive.
Two years ago, someone completed this survey for you. This person’s name is [SURVEY VENDOR
INSERTS APPROPRIATE INFORMATION]. If you are not able to take the survey, please ask this
person to complete the survey about you again. If that person cannot help you, please ask someone
else who knows about your health to complete the survey about you.
The accuracy of the survey depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits. Because your answers can help others with Medicare, we hope you will
help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,

[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures

HOS Follow-Up Letter for Replacement Questionnaire Mailing—Proxy at Baseline

[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
About two years ago, you participated in the “Medicare Health Outcomes Survey.” At that time, we said we
would like you to take the survey again in 2017. We recently mailed you the survey, but have not received it
back from you. If you have already returned the completed survey, thank you. We have enclosed another
copy of the same survey in case you did not receive it. Please take the time to fill out the survey and return it
to us in the postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS) monitors the quality of care Medicare health plans
provide. One way CMS does this is by asking people with Medicare about their health to see if the care their
health plan provides is keeping them as healthy as possible.
The information you provide is important. CMS will compare results from both surveys to see how well your
health plan can maintain or improve the health and well-being of its members over time. The results will be
used to improve the quality of care that people with Medicare receive.
Two years ago, someone completed this survey for you. This person’s name is [SURVEY VENDOR
INSERTS APPROPRIATE INFORMATION]. If you are not able to take the survey, please ask this
person to complete the survey about you again. If that person cannot help you, please ask someone
else who knows about your health to complete the survey about you.
The accuracy of the survey depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits. Because your answers can help others with Medicare, we hope you will
help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,
[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]
Enclosures

4-14

Appendix 4—HOS Follow-Up Reminder/Thank-You Postcard

HOS Follow-Up Reminder/Thank-You Postcard

Medicare Health Outcomes Survey
Dear Sir or Madam:
About a week ago, you should have received the “Medicare Health Outcomes Survey” in the mail. If you have
already returned the survey, thank you!
If not, this is a reminder to complete the survey and return it in the postage-paid envelope. Your answers can
help the Centers for Medicare & Medicaid Services (CMS) and your health plan to improve the quality of care
for people with Medicare.
You will receive another copy of the survey in the mail soon. If you have questions about the survey, please
call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or e-mail [E-MAIL ADDRESS].

Thank you!
[SURVEY VENDOR NAME]

HOS-M Text for Prenotification Letters,
Survey Cover Letters and Reminder/
Thank-You Postcards

HOS-M Prenotification Letter
[CMS Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicare, monitors the
quality of care that Medicare health plans provide. One way CMS does this is to ask people with Medicare
about their physical and mental health--to determine whether the care their health plan provides keeps them
as healthy as possible.
You have been randomly selected to receive the “Medicare Health Outcomes Survey-Modified.” (For some
health plans that have fewer enrollees, all members with Medicare are asked to participate.) In a few days,
you will receive the survey in the mail. Please take the time to complete and return it in the enclosed postagepaid envelope.
Your answers are important and will help us determine if your health plan keeps you as healthy as possible.
All information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits.
[SURVEY VENDOR NAME] is a survey organization working with CMS to carry out this survey. If you have
questions about the survey please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or e-mail
[EMAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,

Amy Larrick Chavez-Valdez, Director
Medicare Drug Benefit and C & D Data Group

HOS-M Letter for First Questionnaire Mailing

[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicare, monitors the
quality of care Medicare health plans provide. One way CMS does this is to ask people with Medicare about
their health-- to see if the care their health plan provides keeps them as healthy as possible.
CMS conducts a survey called the “Medicare Health Outcomes Survey-Modified.” This survey asks about
your physical and mental health. Your name was randomly selected for the survey. (For some health plans
that have fewer enrollees, all members with Medicare are being asked to participate.)
Please take the time fill out this survey and return it to us in the postage-paid envelope.
The accuracy of the survey depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits. Because your answers can help others with Medicare, we hope you will
help us.
If you have questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800 NUMBER] or
e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,

[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]

P.S. If you have trouble completing the survey, a relative, friend, or caregiver who knows about your health
can fill out the survey for you.

HOS-M Letter for Replacement Questionnaire Mailing

[Survey Vendor Letterhead]
Dear Medicare Beneficiary:
Recently we mailed you the “Medicare Health Outcomes Survey-Modified.” If you already returned the survey,
thank you! If you did not, we are sending you another copy. Please complete it and return it in the enclosed
postage-paid envelope.
The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicare, monitors the
quality of care Medicare health plans provide. One way CMS does this is by conducting the “Medicare Health
Outcomes Survey-Modified,” which asks people with Medicare about their health to see if the care their health
plan provides is keeping them as healthy as possible. Your name was randomly selected for the survey. For
some health plans that have fewer enrollees, all members with Medicare are being asked to participate.
Please take the time to fill out this survey and return it to us in the postage-paid envelope.
The accuracy of the survey depends on answers we get from you and others selected for this survey. All
information you provide is protected by the Privacy Act and will not be shared. You do not have to
participate in this survey. Your help is voluntary and your decision to participate or not participate will
not affect your Medicare benefits. Because your answers can help others with Medicare, we hope you will
help us.
If you have any questions about the survey, please call [SURVEY VENDOR NAME] toll-free at [800
NUMBER] or e-mail [E-MAIL ADDRESS]. Thank you for your help with this important survey.
Sincerely,

[SENIOR SURVEY VENDOR STAFF]
[SURVEY VENDOR]

P.S. If you have trouble completing the survey, a relative, friend, or caregiver who knows about your health
can fill out the survey for you.

HOS-M Reminder/Thank-You Postcard

[Survey Vendor Logo]
Medicare Health Outcomes Survey-Modified
Dear Sir or Madam:
About a week ago, you should have received the “Medicare Health Outcomes Survey-Modified” in the mail. If
you have already returned the survey, thank you!
If not, this is a reminder to complete the survey and return it in the postage-paid envelope. Your answers can
help the Centers for Medicare & Medicaid Services (CMS) and your health plan to improve the quality of care
for people with Medicare.
If you did not receive the survey or misplaced it, please call [SURVEY VENDOR NAME] toll-free at [800
NUMBER] or e-mail [E-MAIL ADDRESS].
Thank you!
[SURVEY VENDOR NAME]