Form CMS-R-246 Medicare Advantage Plan Survey

Centers for Medicare & Medicaid Services
c/o Survey Processing
[INSERT VENDOR ADDRESS]

Dear FNAME LNAME:
The Centers for Medicare & Medicaid Services (CMS) is asking for feedback from
people in Medicare health and drug plans. We’d greatly appreciate your time to tell
us about your Medicare plan. Your input will improve Medicare services and help
others like you choose a health plan.
Please take a few minutes to tell us about your experiences. Medicare uses this
information to improve plan quality and to rate and share information on all plans. Plan
ratings are publicly available at medicare.gov/plan-compare and in the “Medicare &
You” handbook.
The survey takes about 15 minutes. Participation is voluntary, and your information is
kept private by law.
For questions about this survey, please call the survey organization working with
Medicare toll-free at 1-XXX-XXX-XXXX, Monday - Friday, from XX am - XX pm
[INSERT TIME ZONE].
Thank you for your help with this important project.
Sincerely,

Amy Larrick Chavez-Valdez
Director, Medicare Drug Benefit and C & D Data Group
Nota: Si le gustaría recibir una copia de la encuesta en español, por favor llame gratis
al 1-XXX-XXX-XXXX de lunes a viernes entre XX am y XX pm de [INSERT TIME
ZONE].

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 and the times you got health care in
person, by phone or by video call. 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].
If you changed your Medicare plan for 2021, answer the questions thinking about your
experiences in the last 6 months of 2020.
• 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. This applies to both mandatory and voluntary collections of
information. 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.

5.

Our records show that in 2020 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.

Yes
No If No, Go to Question 7
6.

Please write below the name of
the health plan you had in 2020
and complete the rest of the
survey based on the experiences
you had with that plan.
(Please print)

7.

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?

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

Yes
No If No, Go to Question 5
4.

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

Your Health Care in the Last 6 Months
3.

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, when you
needed care right away, how often did
you get care as soon as you needed?
Never
Sometimes
Usually
Always

1

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?

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?

Never
Sometimes
Usually
Always
9.

Yes
No If No, Go to Question 27

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?

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

0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible

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

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

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

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

2

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?

15. In the last 6 months, how often did
your personal doctor show respect for
what you had to say?
Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

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

19. In the last 6 months, did your personal
doctor order a blood test, x-ray or
other test for you?

Never
Sometimes
Usually
Always

Yes
No If No, Go to Question 22

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?

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?

0 Worst personal doctor
possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor
possible

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

3

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

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
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?

Yes If Yes, Please include your
personal doctor as you
answer these questions
about specialists
No
I do not have a personal doctor

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?

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

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?

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

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

4

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

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?

None If None, Go to
Question 33
1 specialist
2
3
4
5 or more 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

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?

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

0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible

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

5

39.

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?

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
I am not sure
I do not have a co-pay
I do not have a health condition
I was offered a lower co-pay
for another reason

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?

40.

0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible

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
I am not sure
I do not have a health condition
I was offered extra benefits for
another reason

6

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

About You
41. In general, how would you rate
your overall health?

Yes
No
Don’t know

Excellent
Very good
Good
Fair
Poor

46. In the last 6 months, did you delay
or not fill a prescription because
you felt you could not afford it?

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

Yes
No
My doctor did not prescribe
any medicines for me in the
last 6 months

Excellent
Very good
Good
Fair
Poor

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

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

Yes
No
Don’t know

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

7

52. Have you had a flu shot since July
1, 2020?

48. Has a doctor ever told you that you
had any of the following conditions?
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?

Yes

No

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?

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

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

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

8

55. In the last 6 months, how often
were you advised to quit smoking
or using tobacco by a doctor or
other health provider?

58. 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

Never
Sometimes
Usually
Always
I had no visits in the last 6
months

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

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

1 person
2 to 3 people
4 or more people

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

60.

Do you ever use the internet at
home?
Yes
No

61.

57. Are you of Hispanic or Latino origin
or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino

May the Medicare Program follow
up with you to learn more about
your health care, or to invite you
to a group discussion or interview
on topics related to health care?
Yes
No

9

62. Did someone help you complete
this survey?

63. How did that person help you?
Please mark one or more.

Yes
No Thank you. Please
return the completed
survey in the postagepaid envelope.

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 RETURN ADDRESS FOR MAIL PROCESSING]
Contract Name:_____________________
[OPTIONAL]
You may also know your plan by one of the following:

10