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Medicare Advantage:
Making Informed Decisions
Evaluation Form

To ensure that the Medicare Advantage Booklet is meeting your counseling needs, we ask that you take 10 minutes to complete this evaluation form. Thank you for your time.

1. How did you use the Booklet? (Please check all that apply)



Other (please specify)

2. Which section(s) of the Booklet did you use in counseling sessions with beneficiaries? (Please check all that apply)









3. Please rate each section of the Booklet on a scale of 1 to 5, with 1 being the lowest and 5 as the highest rating. Rate each section according to how clear and useful the section was for you. (If you did not use a a section, please put N/A.)

Section  Rating 

I. Introduction (p. 2)

II. Types of Medicare Advantage Plans (p. 3-4)

III. Other Options (p. 4)

IV. Medicare Preferred Provider Organization (PPO) (p. 5-10)

V. Medicare Health Maintenance Organization (HMO) (p. 11-16)

VI. Medicare Private-Fee-for-Service (PFFS) Plans (p. 17-23)

VII. Medicare Special Needs Plans (SNPs) (p. 24-29)

VIII. Medicare Advantage (p. 30)

4. If you rated any section below 3, please indicate the section and briefly explain why.


5. Please rate the usefulness of the following on a scale of 1 to 5, with 1 being the lowest and 5 being the highest rating. Rate each section according to how useful the section is in helping a beneficiary make an informed decision. (If you did not use a a section, please put N/A.)

Section  Rating 

I. The questions in the Booklet

II. The information in the text boxes

III. The Action Steps

IV. The Notes section

6. If you rated any section below 3, please indicate the section and briefly explain why.

7. In thinking about the "average" beneficiary you counsel, was the amount of information:

8. In thinking about the "average" beneficiary you counsel, was the information explained in a way that was easy for the beneficiary to understand?

9. Did you encounter any particular difficulties with the Booklet? If yes, please describe.

10. What additional materials would you like to have included in the Booklet?

11. Any additional comments?

     
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