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

Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C1-25-05
Baltimore, Maryland 21244-1850

Dear [FNAME] [LNAME]:
The Centers for Medicare & Medicaid Services (CMS) is asking for feedback from
people with Medicare. We’d greatly appreciate your time to tell us about your care.
Your input will improve Medicare services and help others like you choose coverage.
Please take a few minutes to tell us about your experiences. Medicare uses this
information to improve quality and to rate and share information on all coverage options.
This information will be publicly available at medicare.gov/plan-compare.
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 1-888-942-2477.
Thank you for your help with this important project.
Sincerely,

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

Si quiere recibir una copia de la encuesta en español, llame gratis al 1-888-942-2477.
若您想收到中文版的調查問卷，請致電免費電話 1-888-942-2477。

MEDICARE EXPERIENCE SURVEY
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: Medicare Experience Survey, PO Box 3416, Hopkins, MN 55343.
Answer all the questions by putting an “X” in the box to the left of your answer, like this:
X Yes
o
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?
o Yes
X No → If No, Go to Question 3
o
2. How long have you been wearing a hearing aid?
o Less than one year
o 1 to 3 years
o More than 3 years
o I don’t wear a hearing aid
3. In the last 6 months, did you have any headaches?
X Yes
o
o 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 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 C1-25-05,
Baltimore, Maryland 21244-1850.
OMB 0938-0732

Page 1

F20GEN1E01

YOUR HEALTH INSURANCE
COVERAgE

YOUR HEALTH CARE IN THE
LAST 6 MONTHS

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.

3.

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?

o
o
2.

o
o
o
o
o
o

o
o
4.

5.

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.)
______________________________

o

I don’t have health insurance other than
Medicare.

F20GEN1E02

Page 2

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?

o
o
6.

Yes
No → If No, Go to Question 5

In the last 6 months, when you needed care
right away, how often did you get care as soon
as you needed?

o
o
o
o

Yes
No → If No, Go to Question 3

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

o

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 7

In the last 6 months, how often did you get an
appointment for a check-up or routine care as
soon as you needed?

o
o
o
o

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?

o
o
o
o
o
o
o
8.

o
o
o
o

None → If None, Go to Question 9
1 time
2
3
4
5 to 9
10 or more times

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?

o
o

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

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?

Never
Sometimes
Usually
Always

o
o
o
o
o
o
o

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?

o
o
o
o
o
o
o
o
o
o
o

Never
Sometimes
Usually
Always

YOUR PERSONAL DOCTOR

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?

o
o
o
o
9.

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

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?

o
o
o
o

Page 3

Never
Sometimes
Usually
Always

F20GEN1E03

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

o
o
o
o

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

o
o
o
o

15. In the last 6 months, how often did your
personal doctor show respect for what you
had to say?

o
o
o
o

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

o
o

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

o
o
o
o

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?

o
o
o
o
o
o
o
o
o
o
o

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

F20GEN1E04

Never
Sometimes
Usually
Always

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?

o
o
o
o

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?

o
o
o
o

Never
Sometimes
Usually
Always

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

o
o

Page 4

Yes
No → If No, Go to Question 24

gETTINg HEALTH CARE FROM
SPECIALISTS

23. In the last 6 months, how often did you
and your personal doctor talk about all the
prescription medicines you were taking?

o
o
o
o

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?

Never
Sometimes
Usually
Always

o

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?

o
o

o
o

Yes
No → If No, Go to Question 27

28. In the last 6 months, did you make any
appointments to see a specialist?

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?

o
o

o
o
o

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?

o
o
o

Yes, definitely
Yes, somewhat
No

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

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?

o
o
o
o

Never
Sometimes
Usually
Always

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

o
o
o
o
o
o

Page 5

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

F20GEN1E05

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?

o
o
o
o
o
o
o
o
o
o
o

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

o

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

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

o
o
o
o

o
o
o
o

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?

o
o
o
o

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?

o
o
o
o
o

F20GEN1E06

Very likely
Likely
Unlikely
Very unlikely

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

32. In the last 6 months, how often did your
personal doctor seem informed and up-todate about the care you got from specialists?

o
o
o
o
o
o

MANAgINg YOUR HEALTH
CARE

Page 6

Never
Sometimes
Usually
Always
I did not have any medical tests or
procedures in the last 6 months

MEDICARE EXPERIENCE

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?

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?

o
o

o
o
o
o
o
o
o
o
o
o
o

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?

o
o
o
o

Never
Sometimes
Usually
Always

ABOUT YOU

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

o
o
o
o

o
o

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

o
o
o
o
o

Never
Sometimes
Usually
Always

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

o
o
o
o
o

Yes
No → If No, Go to Question 42

Never
Sometimes
Usually
Always

Excellent
Very good
Good
Fair
Poor

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

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

o
o
o
o

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

Excellent
Very good
Good
Fair
Poor

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

o
o

Page 7

Yes
No

F20GEN1E07

46. In the last 6 months, how often was it easy to
get the medicines your doctor prescribed?

o
o
o
o
o

Never
Sometimes
Usually
Always
My doctor did not prescribe any
medicines for me in the last 6 months

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?

o
o
o

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

o
o
o

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?

o
o
o

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

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?

o
o

Yes
No → If No, Go to Question 56

o
o
o

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?

o
o
o

F20GEN1E08

Yes
No → If No, Go to Question 55

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

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

o
o

Yes
No → If No, Go to Question 56
Don’t know → If Don’t know,
Go to Question 56

Page 8

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?

o
o
o
o

Very satisfied
Satisfied
Dissatisfied
Very dissatisfied

o
o
o

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

o
o
o
o

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.

59. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?

Very satisfied
Satisfied
Dissatisfied
Very dissatisfied

o
o
o
o

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

No

a.

A heart attack?

o

o

b.

Angina or coronary
heart disease?

o

o

c.

Hypertension or
high blood pressure?

o

o

d.

Cancer, other than
skin cancer?

o

o

e.

Emphysema,
asthma or COPD
(chronic obstructive
pulmonary disease)?

o

o

Any kind of diabetes
or high blood sugar?

o

o

f.

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?

o
o
o
o
o

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?

o
o
o
o
o
o

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

o
o
o

Yes
No
Don’t know

Yes
No
Don’t know

Page 9

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

F20GEN1E09

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

o
o

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.)

Yes, Hispanic or Latino
No, not Hispanic or Latino

I am
unable
to do
this
activity

63. What is your race? Please mark one or more.

o
o
o
o
o

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?

o
o
o

1 person
2 to 3 people
4 or more people

Yes,
I have
difficulty

No,
I do not
have
difficulty

a.

Bathing

o

o

o

b.

Dressing

o

o

o

c.

Eating

o

o

o

d.

Getting
in or out
of chairs

o

o

o

e.

Walking

o

o

o

f.

Using the
toilet

o

o

o

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?

o
o

Yes
No

67. Do you ever use the internet at home?

o
o

F20GEN1E10

Page 10

Yes
No

68. 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?

o
o

Yes
No

69. Did someone help you complete this survey?

o
o

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.

o
o
o
o
o

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 postagepaid envelope to:
Medicare Experience Survey
PO Box 3416
Hopkins, MN 55343
Please do not include any other correspondence.
Page 11

F20GEN1E11