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 <PREV_PLAN_CODE>

*<finder>* <version_wave> [sequence] ^{E27_1 Page 1 OMB 0938-1113 [bc]}

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 0938- 1113, with an expiration date of TBD. The time required to complete this information collection is estimated to average 11minutes 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.

YOUR FORMER HEALTH PLAN

1. Our records show that you used to belong to this health plan:

< PREV_BENEFIT>

Provided by <PREV_PLAN_CODE>

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

• No, I did not switch plans or leave ANY 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?

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

• I was dropped by the plan

Stop.

Do not complete the rest

• 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)

 ^{of this survey.}

Please return the survey

in the enclosed envelope.

• None of the above _ Continue survey, go to Question 3

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).

3. 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, tests, or treatment through my former plan

4. 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

• 

  REASONS YOU LEFT YOUR FORMER HEALTH PLAN

  10 Best health plan possible

5. Did you leave your former plan because someone else signed you up for the plan without your permission?

• Yes

• No

6. 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

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

• Yes

• No

8. 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?

• Yes

• No

• I did not have to pay my former plan a monthly premium out of my own

pocket

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 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

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

• Yes

• No

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

• Yes

• No

12. Did you leave your former plan because you were frustrated by the plan’s approval process for care, tests, or treatment?

• Yes

• No

13. Did you leave your former plan because you had problems getting the care, tests, or treatment you needed?

• Yes

• No

14. Did you leave your former plan because you had problems getting the plan to pay a claim?

• Yes

• No

15. 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

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

• Yes

• No

17. 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

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

• Yes

• No

19. Did you leave your former plan because you could not get the information or help you needed from the plan?

• Yes

• No

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

• Yes

• No

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

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

• Yes

• No

22. Did you leave your former plan because you found another plan with a higher Medicare star rating?

• Yes

• 

  OTHER REASONS FOR LEAVING YOUR FORMER HEALTH PLAN

  No

24. Did you leave your former plan because an insurance agent or broker told you about a better plan?

• Yes

• No

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

• Yes

• No

24. Did you leave your former plan because you found another plan that better met your prescription needs?

• Yes

• No

24. 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

• 

  ABOUT YOU

  No

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

• Yes

• No

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

• Excellent

• Very good

• Good

• Fair

• Poor

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

• Excellent

• Very good

• Good

• Fair

• Poor

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

• None

• 1 to 2 medicines

• 3 to 5 medicines

• 6 or more medicines

24. 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 33

24. Is this a condition or problem that has lasted for at least 3 months?

• Yes

• No

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

• Yes

• No  If No, go to Question 35

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

• Yes

• No

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

	Yes	No
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		

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

• 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

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

• Yes, Hispanic or Latino

• No, not Hispanic or Latino

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

• American Indian or Alaska Native

• Asian

• Black or African-American

• Native Hawaiian or other Pacific Islander

• White

24. What language do you mainly speak at home?

• Chinese

• English

• Russian

• Spanish

• Vietnamese

• Some other language

(please print):

24. Did someone help you complete this survey?

• Yes

• No  If No, go to Question 42

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

• 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 (please print):

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

• Yes

• No

This page intentionally left blank.

This page intentionally left blank.

This page intentionally left blank.