CMS-10316 MA Only Survey

Medicare Advantage Health Plan
Disenrollment Survey

The questions in this survey are about your former health plan.
The name and contract number of your former plan are --

< PREV_BENEFIT>
Provided by

** [sequence]

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OMB 0938-1113

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Survey Instructions
Thank you for taking time to complete this survey! Your answers are very important to us
and will help other people with Medicare choose a health or drug plan.
You received this survey because records show you recently switched or dropped your
Medicare health plan.
How to complete this survey:
 Answer each question based only on your experiences with your former plan (the

plan name is printed on the cover of this survey).
 Answer each question thinking about yourself.
 Answer each question by putting an “X” in the box to the left of your answer,

like this:
X Yes


 Read all the answer choices 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].
 Return your completed survey in the enclosed postage-paid envelope.

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, with an expiration date of TBD. The time required to complete this information collection is estimated to
average 13 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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YOUR FORMER HEALTH PLAN
1. Our records show that you used to belong to this health plan:
< PREV_BENEFIT>
Provided by
but that you no longer belong to that plan. Is that correct?

 Yes, I left the health plan printed above  Go to Question 2
 No, I left a different health plan  Go to Question 2
 Stop.
 No, I did not switch plans or leave
ANY Medicare health plan recently

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?

 I moved outside of the area where the plan
was available

 I was dropped by the plan

Stop.

 The plan was cancelled or discontinued in my area
 The plan was changed or discontinued by the
organization that provides my insurance
(such as a former employer or a union)



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

 None of the above  Continue survey, go to Question 3

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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).

GETTING HEALTH CARE YOU
NEEDED FROM YOUR FORMER
HEALTH PLAN
5. How often was it easy to get the
care, tests, or treatment you needed
through your former plan?

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

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

 Yes
 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?

 Never
 Sometimes
 Usually
 Always
 I did not try to get information or
help from my former plan’s
customer service

tests, or treatment through my
former plan

6. Did you make any appointments to
see a specialist?

 Yes
 No  If No, go to Question 8
 Someone else made my specialist
appointments for me

7. How often did you get an
appointment to see a specialist as
soon as you needed?

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

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8. 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?

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

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

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

11. Did you leave your former plan
because you found a plan with a
lower copayment for doctors' visits?

 Yes
 No
12. Some people have to pay their health
plan a monthly premium (fee) out of
their own pocket for health coverage.
Did you leave your former plan
because the monthly premium went
up?

REASONS YOU LEFT YOUR
FORMER HEALTH PLAN

 Yes
 No
 I did not have to pay my former plan

The next questions are about reasons
you may have had for switching or
dropping your former health plan.
9. Did you leave your former plan
because someone else signed
you up for the plan without your
permission?

 Yes
 No

a monthly premium out of my own
pocket

13. Did you leave your former plan
because you found a plan with a
lower monthly premium?

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

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

19. Did you leave your former plan
because the doctors or other health
care providers you wanted to see did
not belong to the plan?

 Yes
 No

 Yes
 No

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

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

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

 Yes
 No
18. Did you leave your former plan
because you had problems getting
the plan to pay a claim?

 Yes
 No

20. Did you leave your former plan
because the clinics or hospitals you
wanted to go to were not covered by
the plan?

 Yes
 No
21. Did you leave your former plan
because it was hard to get
information from the plan about
which health care services were
covered or how much a specific test
or treatment would cost?

 Yes
 No
22. Did you leave your former plan
because you were unhappy with
how the plan handled a question or
complaint?

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

 Yes
 No

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24. Did you leave your former plan
because their customer service staff
did not treat you with courtesy and
respect?

 Yes
 No

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

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

25. Every year Medicare evaluates all
health plans and gives them a star
rating.

 Yes
 No

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

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

31. Did you leave your former plan
because another plan offered better
benefits or coverage (for example,
dental or vision care, hearing aids,
pre-paid cards for medications and
supplies)?

 Yes
 No

 Yes
 No

ABOUT YOU

OTHER REASONS FOR LEAVING
YOUR FORMER HEALTH PLAN

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

 Excellent
 Very good
 Good
 Fair
 Poor

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

 Yes
 No
28. Did you leave your former plan
because an insurance agent or
broker told you about a better
plan?

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

 Yes
 No
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 Excellent
 Very good
 Good
 Fair
 Poor

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

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

a. A heart attack
b. Angina or coronary
heart disease
c. High blood pressure
or hypertension
d. Cancer, other than
skin cancer
e. Emphysema, asthma
or COPD (chronic
obstructive pulmonary
disease)
f. Any kind of diabetes
or high blood sugar

 None
 1 to 2 medicines
 3 to 5 medicines
 6 or more medicines
35. In the past 12 months, have you seen
a doctor or other health provider 3 or
more times for the same condition or
problem?

 Yes
 No  If No, go to Question 36
36. Is this a condition or problem that
has lasted for at least 3 months?

No























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

 Yes
 No

 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

37. Do you now need or take medicine
prescribed by a doctor?




 More than 4-year college degree

 Yes
 No  If No, go to Question 38
38. Is this medicine to treat a condition
that has lasted for at least 3 months?

 Yes
 No

Yes

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

 Yes, Hispanic or Latino
 No, not Hispanic or Latino

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

 American Indian or Alaska Native
 Asian
 Black or African-American
 Native Hawaiian or other Pacific

44. Did someone help you complete this
survey?

 Yes
 No  If No, go to Question 45
45. How did that person help you?
Please mark one or more.

Islander

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

 White

43. What language do you mainly speak
at home?

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



language
Helped in some other way (please
print):

46. May we contact you again if we have
any questions about your survey
responses or the health care services
you received?

 Yes
 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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