Medicare Advantage and Prescription Drug Plan CAHPS® Survey

Participation Form
     

Medicare Advantage and Prescription Drug Plan  (MA & PDP) CAHPS® Survey  2020 Survey Administration Participation Form for Survey Vendors

A survey vendor must meet all of the Minimum Business Requirements in order to apply to administer the Medicare Advantage and Prescription Drug Plan (MA & PDP) CAHPS® Survey.

This participation form is to be completed by organizations requesting approval to administer the 2020 Medicare Advantage and Prescription Drug Plan CAHPS® Survey (MA & PDP CAHPS). Organizations that are approved to administer the MA & PDP CAHPS Survey must conduct all of their business operations within the United States so the MA & PDP CAHPS Survey Project Team can perform the required oversight activities. This requirement also applies to all staff and subcontractors.

ALL VENDOR APPLICATIONS AND MATERIALS ARE DUE BY 7/12/2019 AT 5:00 PM (EDT)

* Fields marked with an asterisk are required
10/15/2019

I. General Participation Application Information

This section is to be completed with general information for participation in MA & PDP CAHPS Survey Data Collection.

1. Applicant Organization

The Name of the Organization is required.
The Address is required.
The City is required.
The State is required.
The Zip Code is required.
Telephone is required.
Fax must at least 10 digits.

2. Applicant Contact Person

First Name is required.
Last Name is required.
Title is required.
Mailing Address 1 is required.
City is required.
State is required.
Zip Code is required.
Telephone is required.
Fax must at least 10 digits.
Email is required.

3. LIST OF PHYSICAL LOCATION(S) WHERE SURVEY VENDOR CONDUCTS SURVEY ADMINISTRATION ACTIVITIES

At least one entry is required.
Activity is required.
Address is required.
Add
(click on a row in the grid to edit it)

CMS-Sponsored and CMS CAHPS Survey Experience

1. Have you been approved as a vendor to implement other CMS or CMS CAHPS surveys in the past five years?

Answer Required.

If Yes, please provide the name of the survey(s) for which you have been approved as a vendor in the table below (Section II. 1. Relevant Survey Experience).

2. Have you been a subcontractor to an approved vendor for other CMS or CMS CAHPS surveys in the past five years?

Answer Required.

If Yes, please provide the name of the survey vendor(s) and the survey(s) for which you have been a subcontractor.

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3. If Yes to 1 or 2 above, have you had any past performance issues that resulted in corrective action memos, special CMS requests for quality improvement plans, submission of data that was withheld from public reporting, or withdrawal for approval? If Yes, please detail.

Answer Required.
At least one entry is required.
Project Name is required.
Role is required.
Issues is required.

Add

(click on a row in the grid to edit it)

CMS will consider past performance, as either a survey vendor or subcontractor, on CMS or CMS CAHPS surveys when reviewing your organization’s MA & PDP CAHPS Survey Participation Form.

II. Medicare Advantage and Prescription Drug Plan CAHPS Survey Minimum Business Requirements

Survey vendors must meet the following Minimum Business Requirements. Please check Yes or No for each item below to indicate that the organization has read and meets the following Minimum Business Requirements.

1. Relevant Survey Experience 
Demonstrate recent experience in fielding surveys via Mixed Mode (mail survey administration followed by survey administration via computer assisted telephone interview [CATI] follow-up of non-respondents).

*

Survey experience: Organization has minimum of 3 years demonstrated prior experience conducting surveys with the Medicare population and administering CAHPS surveys. Organization has minimum of 3 years experience conducting large-scale Mixed Mode Survey (mail survey administration with CATI system telephone follow-up to non-respondents) within the most recent two year time period.

The SurveyExperience field is required.

For Medicare population and CAHPS surveys list the five most recent survey projects in which your organization administered surveys:

At least one entry is required.
Name is required.
Average Sample Size is required.
Data Collection Period is required.
Number of Contracted Clients is required.
Mode of Survey Administration is required.
Languages in which Survey was Administered is required.
Add
(click on a row in the grid to edit it)
*

Number of years in business: Survey vendor has been in business a minimum of four years.

The FourYearsInBusiness field is required.
*

Experience with Multiple Survey Languages: Survey vendor has prior experience in conducting surveys in both English and Spanish. A survey vendor will have the option of electing to conduct the MA & PDP CAHPS Survey in Chinese, Korean and Vietnamese.

The ExperienceWithMultipleSurveyLanguages field is required.

2. Organizational Survey Capacity 
Capability and capacity to handle a required volume of mail questionnaires and conduct standardized telephone interviewing in a specified time frame.

*

Personnel: Survey vendor has designated personnel, including: a Project Manager with minimum of 3 years relevant Mixed Mode survey administration experience; a Telephone Survey Supervisor with a minimum of 1 year prior call center experience; a Mail Survey Supervisor with a minimum of 1 year prior experience in role; and Lead or Primary Programmer with a minimum of 1 year prior experience in survey data processing and preparing data files for electronic submission.

The Personnel field is required.
*

System Resources: Survey vendor has physical plant resources available to handle the volume of surveys being administered, including: physical facilities, electronic equipment and software for secure data collection processing and reporting and an electronic survey management system to track fielded surveys through the entire protocol that protects the confidentiality of personally identifiable information and survey data received from beneficiaries (e.g., password protections, firewalls, data encryption software, personnel access limitation procedures and virus and spyware protection). Survey vendor has a disaster recovery plan in place for continued business operations in the event of a natural or human-related disaster. Survey vendor business operations are conducted in a secure commercial work environment.

The SystemResources field is required.
*

Mixed-Mode of Survey Administration: Survey vendor is capable of reproducing, printing and mailing survey materials in accordance with specifications and timeline provided and uses commercial software/resources to ensure that addresses and telephone numbers are accurate and correct for all the sample members. Survey vendor has capacity for conducting telephone interviews using CATI system. Note: If a survey vendor intends to administer the MA & PDP CAHPS Survey in Chinese, Korean and/or Vietnamese, both mail and telephone modes must be administered in these languages. Survey vendor must have the capacity to maintain an interviewer pool that meets the needs of beneficiaries in all languages in which the survey is administered, and conduct accurate monitoring of interviewers in these languages. Mail survey administration and telephone interviews shall not be conducted from a residence or from a virtual office.

The MixedModeOfSurveyAdministration field is required.
*

Data submission: Survey vendor has the capacity to register with the RAND Corporation for access to the MA & PDP CAHPS Data Warehouse and follow data specifications and procedures in order to submit and receive encrypted data via the Internet. Authorizations and business associate agreements will be established between survey vendor and health or drug plan.

The DataSubmission field is required.
*

Data Security: Survey vendor will ensure Data Use Agreement (DUA) with CMS is kept up to date and that all DUA requirements are followed, including cell size suppression rules. Vendors must receive approval from CMS to append any additional data to the sample file.

The DataSecurity field is required.
*

Data Retention: Survey vendor has the capacity to retain all data files for a minimum of 3 years, including sample information. Archived electronic data files, paper copies and/or scanned images will be easily retrievable.

The DataRetention field is required.
*

Confidentiality: Survey vendor has the capacity to comply with all HIPAA rules and regulations and store MA & PDP CAHPS data files, including sample information, securely and confidentially. Survey vendor will execute confidentiality agreements with staff and subcontractors (if applicable). Vendors must not share identifying information about beneficiaries in the survey sample with health or drug plans.

The Confidentiality field is required.
*

Technical Assistance/Customer Support: Survey vendor has the capability and capacity to provide toll-free customer support telephone lines with the ability to respond to both Spanish and English inquiries. Note: If a survey vendor intends to administer the MA & PDP CAHPS Survey in Chinese, Korean and/or Vietnamese, the survey vendor must have the capability and capacity to respond to inquiries received in these optional languages.

The TechnicalAssistanceCustomerSupport field is required.

3. Quality Control Procedures 
Personnel training and quality control mechanisms employed to collect valid, reliable survey data.

*

Demonstrated Quality Control Procedures: Survey vendor has the capacity to set-up, conduct and document quality control procedures for all phases of survey implementation including: monitoring of subcontractors, if applicable; training; printing, mailing, and recording receipt of surveys; telephone administration and monitoring of survey (electronic telephone interviewing system) in all languages in which the survey is administered; coding, editing, or keying in survey data; preparing final person-level data files for submission; and all other functions and processes that affect the administration of the MA & PDP CAHPS Survey. Survey vendors must develop and submit Quality Assurance Plan by specified due date. Survey vendor must submit an Event Report to CMS within one business day of becoming aware of an event in survey administration.

The DemonstratedQualityControlProcedures field is required.

4. Explanation 
Please explain any “NO” responses above.

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III. List of Key Project Staff

List of key project staff

At least one entry is required.
Project Staff Name is required.
Role is required.
Email is required.
Telephone Number is required.
Add
(click on a row in the grid to edit it)

IV. List of Subcontractors

A subcontractor is any organization that performs key survey administration functions on behalf of an MA & PDP CAHPS Survey vendor that requires receipt of an electronic file containing beneficiary-level personally identifiable information (PII).

The HasSubContractors field is required.
4a. Do you currently use subcontractors? Yes No If no, go to Section V.

LIST OF SUBCONTRACTORS (add more lines if necessary or include as a separate attachment). Note: Survey vendors must submit any changes in subcontractors to CMS for approval. CMS will review all subcontractors prior to authorization.

At least one entry is required.
Organization Name is required.
Add
(click on a row in the grid to edit it)

V. Curriculum Vitae (CV)

Please submit a CV for all identified key project staff for both survey vendor and subcontractor(s) via the MA & PDP CAHPS Technical Assistance email at MA-PDPCAHPS@HCQIS.org.

I. Rules of Participation

Any organization participating in the Medicare Advantage and Prescription Drug Plan (MA & PDP) CAHPS Survey must adhere to the following Rules of Participation. To be eligible, the organization must:

  1. Participate in a teleconference call with the MA & PDP CAHPS Survey Project Team to discuss relevant survey experience, organizational survey capability and capacity, quality control procedures, and role of subcontractors (as requested).
  2. Submit an interim and final MA & PDP CAHPS Survey data file to CMS. Survey vendors must submit a signed Attestation document with the interim and final data submissions confirming all data collected and submitted in the data file are accurate and complete.
  3. Participate in and successfully complete MA & PDP CAHPS training webinars for vendors. At a minimum, the organization’s Project Manager, Mail Survey Supervisor and Telephone Survey Supervisor must attend training as representatives of the organization. Project staff member(s) responsible for the following functions are also recommended to attend training:
      • Decrypting the sample file and performing sample file quality checks
      • Programming the CATI script
      • Preparing and submitting the survey data file
    If a subcontractor will be conducting any of the functions below, at least one representative from that subcontractor organization must attend training:
      • Inserting or survey packet preparation
      • Processing of returned mail surveys
      • Conducting telephone interviews (CATI administration)
  4. Review and follow the MA & PDP CAHPS Quality Assurance Protocols & Technical Specifications and Policy Updates.
  5. Attest to the accuracy of the organization’s data collection (as determined by CMS), following guidelines set forth in the most current version of the MA & PDP Quality Assurance Protocols & Technical Specifications.
  6. Develop and submit an MA & PDP CAHPS Survey Quality Assurance Plan (QAP) by due date. In addition, submit materials relevant to the survey administration (as determined by CMS), including mailing materials (e.g., cover letters and questionnaires) and telephone scripts.
  7. Participate and cooperate (including subcontractors) in all oversight activities conducted by the MA & PDP CAHPS Survey Project Team, including in-person visits to business operation site(s) to observe MA & PDP CAHPS mail survey packet production, CATI survey administration and/or activities related to data preparation and submission.
  8. Acknowledge that review of and agreement with the Rules of Participation are necessary for participation and public reporting of results by the Centers for Medicare and Medicaid Services' Web site.

VII. Applicant Organization Qualification and Acceptance:

I certify that:

  • I have reviewed and agree to meet the Rules of Participation for participating in the Medicare Advantage and Prescription Drug Plan (MA & PDP) CAHPS Survey.
  • The statements herein are true, complete, and accurate to the best of my knowledge, and I accept the obligation to comply with the MA & PDP CAHPS Survey Minimum Business Requirements.
AUTHORIZED REPRESENTATIVE
Rep name required.
Title required.
Organization name is required.
10/15/2019

Submit this form online at www.ma-pdpcahps.org.

For assistance, please contact the MA & PDP CAHPS Survey Project Team by telephone at 1-877-735-8882 or email at ma-pdpcahps@hcqis.org.

 

You will receive notification once the form has been successfully submitted.


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