Form CMS-10316 MA PD Survey

Attachment VI: MA-PD Survey

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Medicare Advantage Health and Prescription Drug Plan
Disenrollment Survey

As you answer the questions in this survey, please think only of your former health
plan whose name and contract number are printed in the box below:

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OMB 0938-1113

SURVEY INSTRUCTIONS
This survey asks about you and the care you received from your former health
plan. The name of your former plan is printed on the cover of this survey.
◆
◆

Answer each question based only on your experiences with your former plan.
Answer each question thinking about yourself.

As you complete the survey:
◆

Answer all the questions by putting an “X” in the box to the left of your answer,
like this:

X
o
◆

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].
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 helping CMS conduct this
survey).

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 09381113 (expires: TBD). The time required to complete this information collection is estimated to average 14 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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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 switched or dropped your
Medicare health plan.
1. Our records show that you used to belong to the health plan whose name is
printed on the cover of this survey but that you no longer belong to that plan. Is
that right?

o Yes, I switched to a different Medicare health plan Go to Question 2
o I switched health plans but my former plan was not the plan printed on the cover
of this survey Go to Question 2

o No, I did not switch plans or drop my
Medicare health plan recently

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

2. Did you have to switch plans or drop your former Medicare health plan for any of
the following reasons?

o I moved outside of the area where the plan was available
Stop. Do not complete the rest of this survey. Please
return the survey in the enclosed envelope.
o I was dropped by the plan
Stop. Do not complete the rest of this survey. Please
return the survey in the enclosed envelope.
o The plan was cancelled or discontinued in my area
Stop. Do not complete the rest of this survey. Please
return the survey in the enclosed envelope.
o 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.

o None of the above Continue survey, go to Question 3
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GETTING HEALTH CARE AND THE
PRESCRIPTION MEDICINES YOU
NEEDED FROM YOUR
FORMER HEALTH PLAN

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 (whose name is printed on
the cover of this survey).

5. How often was it easy to get the
care, tests, or treatment you needed
through your former plan?

3. Did you ever try to get information
or help from your former plan’s
customer service?

o Never
o Sometimes
o Usually
o Always
o I did not try to get any kind of care,

o Yes
o 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?

o Never
o Sometimes
o Usually
o Always
o I did not try to get information or

tests, or treatment through my
former plan

6. In the last 6 months, did you
make an appointment to see a
specialist?

o Yes
o No If no, go to Question 8
o Someone else made my specialist

help from my former plan’s
customer service

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

o Never
o Sometimes
o Usually
o Always
o I did not make an appointment to
see a specialist

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8. How often was it easy to use your
former plan to get the medicines your
doctor prescribed?

12. How often was it easy to use your
former plan to fill prescriptions by
mail?

o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to fill

o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to get
any prescription medicines

a prescription by mail

9. Did you ever use your former plan to
fill a prescription at a pharmacy?

o Yes
o No If No, go to Question 15

13. 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?

10. How often was it easy to use your
former plan to fill a prescription at a
pharmacy?

o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to fill
a prescription at a pharmacy

11. Did you ever use your former plan to
fill any prescriptions by mail?

o Yes
o No If No, go to Question 17

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o 0 Worst health plan possible
o1
o2
o3
o4
o5
o6
o7
o8
o9
o 10 Best health plan possible

REASONS YOU LEFT
YOUR FORMER HEALTH PLAN

18. Some people have to pay their health
plan a monthly fee (called a premium)
out of their own pocket for health
coverage.

The next questions are about reasons
you may have had for switching or
dropping your former health plan.

Did you leave your former plan
because this monthly fee went up?

14. Did you leave your former plan
because you found out that someone
had signed you up for the plan
without your permission?

o Yes
o No

o Yes
o No
o I did not have to pay my former plan
a monthly fee out of my own pocket

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

19. Health plans have a list of the
prescription medicines they will
cover. Did you leave your former
plan because they changed the list of
prescription medicines they cover?

o Yes
o No

o Yes
o No

16. Did you leave your former plan
because the dollar amount you had
to pay each time you filled or
refilled a prescription went up?

o Yes
o No
o I did not have to pay for
my prescription
medicines

17. Did you leave your former plan
because the dollar amount you had
to pay each time you visited a
doctor went up?

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

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

o Yes
o No

o Yes
o No
o I did not have to pay for
doctor visits

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27. Did you leave your former plan
because you were frustrated by
the plan’s approval process for
medicines your doctor prescribed?

22. Did you leave your former plan
because a change in your health
meant the plan no longer met your
needs?

o Yes
o No

o Yes
o No

28. Did you leave your former plan
because you did not know whom to
contact when you had a problem
filling or refilling a prescription?

23. Did you leave your former plan
because it turned out to be more
expensive than you expected?

o Yes
o No

o Yes
o No

24. Did you leave your former plan
because the plan refused to pay for a
medicine your doctor prescribed?

o Yes
o No

29. Did you leave your former plan
because it was hard to get
information from the plan—like which
prescription medicines were covered
or how much a specific medicine
would cost?

25. Did you leave your former plan
because you had problems
getting the medicines your doctor
prescribed?

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

o Yes
o No
26. Did you leave your former plan
because it was difficult to get
brand-name medicines?

o Yes
o No
o I did not try to get brand-name
medicines through my former
plan

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

o Yes
o No
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32. 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?

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

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

o Yes
o No
33. Did you leave your former plan
because the doctors or other health
care providers you wanted to see did
not belong to the plan?

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

o Yes
o No
34. Did you leave your former plan
because clinics or hospitals you
wanted to go to for care were not
covered by the plan?

o Yes
o No
39. Every year Medicare evaluates all
health plans and gives them a star
rating.

o Yes
o No

Did you leave your former plan
because it got a low Medicare star
rating?

35. 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?

o Yes
o No

o Yes
o No
40. Did you leave your former plan
because you found another plan with
a higher Medicare star rating?

o Yes
o No

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ABOUT YOU
OTHER REASONS FOR LEAVING
YOUR FORMER HEALTH PLAN

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

o Excellent
o Very good
o Good
o Fair
o Poor

41. Did you leave your former plan
because a family member or friend
told you about a better plan?

o Yes
o No

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

42. Did you leave your former plan
because you saw a commercial or
advertisement for a health plan you
thought you would like better?

o Excellent
o Very good
o Good
o Fair
o Poor

o Yes
o No
43. Did you leave your former plan
because you found another plan that
better met your prescription needs?

47. In the past 12 months, how many
different prescription medicines did
you take?

o None
o 1 to 2 medicines
o 3 to 5 medicines
o 6 or more medicines

o Yes
o No
44. Did you leave your former plan
because another plan offered better
benefits or coverage (for example,
dental or vision care)?

o Yes
o No

48. In the past 12 months, have you seen
a doctor or other health provider 3 or
more times for the same condition or
problem?

o Yes
o No If No, go to Question 54
49. Is this a condition or problem that
has lasted for at least 3 months?

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

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

o 8th grade or less
o Some high school, but did not

o Yes
o No If No, go to Question 56

o
o
o
o

51. Is this medicine to treat a condition
that has lasted for at least 3 months?

o Yes
o No
52. Has a doctor ever told you that you
had any of the following conditions?
a. A heart attack
b. Angina or
coronary heart
disease

o Yes o No
o Yes o No

c. High blood
pressure or
hypertension

o Yes o No

d. Cancer, other
than skin
cancer

o Yes o No

e. Emphysema,
asthma or
COPD (chronic
obstructive
pulmonary
disease)

o Yes o No

f. Any kid of
diabetes or high
blood sugar

o Yes o No

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graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

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

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

o White
o Black or African-American
o Asian
o Native Hawaiian or other Pacific
Islander

o American Indian or Alaska Native
56. What language do you mainly speak
at home?

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

57. Did someone help you complete
this survey?

o Yes
o No If No, go to Question 63
58. How did that person help
you? Please mark one or
more.

o Read the questions to me
o Wrote down the answers I
gave
o Answered the questions for
me
o Translated the questions into
o

my language
Helped in some other way
(please print)

59. 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?

o Yes
o No

THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage paid envelope to:
MEDICARE SATISFACTION SURVEY
PO BOX 3416
HOPKINS, MN 55343-9740

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