Medicare Disenrollment Survey

1. Can you tell us why you left Priority Health? *This question is required.

Please enter an 'other' value for this selection.

2. Can you give us more information about the reason you did not choose Priority Health?
(please check all that apply) *This question is required.

You indicated you had trouble finding information when you were with Priority Health. Can you tell us what you had problems with?
(please check all that apply) *This question is required.

I had problems finding information online (online resources)
I had problems using the self-service tools
I had problems using the mobile app
Other (please specify): Please enter an 'other' value for this selection. * This question is required.

3. Which insurance company do you have now? *This question is required.

4. Why did you choose a plan from this insurance company?
(please select up to 3) *This question is required.

What is better about the out of pocket costs of this new plan?
(please check all that apply) *This question is required.

Lower co-pay for specialist visits
Lower co-pay for primary care provider visits
Lower Rx co-pays
Lower out-of-pocket maximum
Lower Rx deductible
Lower copay for inpatient hospital visits
Other (please specify): Please enter an 'other' value for this selection. * This question is required.

5. How did you enroll in your new health insurance company? *This question is required.

Please enter an 'other' value for this selection.

6. Do you have any other comments or feedback?

Medicare Disenrollment Survey - online form