Medicare Parts C & D - Senior Citizens Survey

Medicare Parts C & D - Senior Citizens Survey

NYS Coalition for the Aging (NYSCA) needs your help
to improve the new Medicare Drug benefit!

NYSCA has received a subcontract from the NY Statewide Senior Action Council to development outreach and education efforts regarding Medicare Part D & EPIC. We will be hosting outreach events throughout the grant year as well as surveying seniors on their experience enrolling in Medicare Part D & EPIC.

Your feedback will assist us in shaping our advocacy efforts and assist seniors with difficulties in the enrollment process. All submissions will be kept anonymous unless NYSCA obtains specific permission from you. Thank you for contributing to this monitoring project.

County: Problems you are experiencing:
	Inconsistent/lag in updating of enrollment information by CMS
	Inconsistent/lag in updating of enrollment information by EPIC
	Medicines not covered or restricted by Part D plan
	Not made aware of change in Part D plan’s coverage
	Difficulty switching Part D plans
	Unknowingly signed up for a Medicare Advantage (e.g. HMO, PPO) plan
	Unknowingly disenrolling from Medicare Advantage plan
	Paying more for medicines
	Reached the coverage gap for plan where senior has to pay 100% of the cost of the drugs (hit the doughnut hole)
	Losing retiree coverage
	Losing Patient Assistance Program coverage
	Denied or still waiting to hear on application for extra help paying for Part D
	Confusion and chaos at the pharmacy
	Other: Please describe:
What steps have you take to address these problems?
What happened? What results did you get?
Can we follow up with you? If so, please complete the information below:
	First Name:	Last Name:
	Organization:
	Address:
	City:	State: Zip:
	Email:
	Phone:	Fax: