Medicare Disenrollee MA Crosswalk w response options

Medicare Disenrollee Survey: Medicare Advantage with Prescription Drug Coverage

Original #

Original Question

New #

New Question

1

Our records show that you used to belong to [PLAN
NAME], but no longer belong to that plan. Is that
right? (Yes / No)

1

No change to item wording.

2

Did you move outside of the area where [PLAN
NAME] was available? (Yes / No)

2

No change to item wording.

NA

NA

3

Do you still belong to [PLAN NAME]? (Yes / No)

NA

NA

4

Did you recently leave, switch, or were you
dropped by a health plan? (Yes / No)

NA

NA

5

What is the name of the health plan you recently
left, switched or were dropped by? (Please print:)

6

No change to item wording.

7

How often did the plan's customer service give you
the information or help you needed? (Never /
Sometimes / Usually / Always / I did not try to get
information or help from the plan’s customer
service)

3

4

9/2/2010

Customer service is information you get from staff
about what is covered and how to use the plan. Did
you ever try to get information or help from [PLAN
NAME]'s customer service? (Yes / No)
How often did the plan's customer service give you
the information or help you needed? (Never /
Sometimes / Usually / Always / I did not try and get
information or help from the plan’s customer
service)

1

5

Did you ever try to get information from the plan
about which prescription medicines were covered?
(Yes / No)

8

No change to item wording.

6

How often did the plan give you all the information
you needed about which prescription medicines
were covered? (Never / Sometimes / Usually /
Always / I did not try and get information about
which prescription medicines were covered)

9

How often did the plan give you all the information
you needed about which prescription medicines
were covered? (Never / Sometimes / Usually /
Always / I did not try to get information about which
prescription medicines were covered)

7

Did you ever try to get information from the plan
about how much you would have to pay for a
prescription medicine? (Yes / No)

10

No change to item wording.

8

How often did the plan give you all the information
you needed about how much you would have to pay
for a prescription medicine? (Never / Sometimes /
Usually / Always / I did not try and get information
about how much I would have to pay for a
prescription medicine)

11

How often did the plan give you all the information
you needed about how much you would have to
pay for a prescription medicine? (Never /
Sometimes / Usually / Always / I did not try to get
information about how much I would have to pay
for a prescription medicine)

9

Did you ever need written information from the plan
in a language other than English? (Yes / No)

12

No change to item wording.

10

How often did the plan give you written information
in a language other than English? (Never /
Sometimes / Usually / Always / I did not need
written information in a language other than English)

13

No change to item wording.

11

Did you ever try to get any kind of care, tests, or
treatment through the plan? (Yes / No)

14

No change to item wording.

12

How often was it easy to get the care, tests, or
treatment you thought you needed through the
plan? (Never / Sometimes / Usually / Always)

15

No change to item wording.

9/2/2010

2

13

Did a doctor ever prescribe a medicine for you that
the plan did not cover? (Yes / No)

16

No change to item wording.

14

How often was it easy to use the plan to get the
medicines your doctor prescribed? (Never /
Sometimes / Usually / Always / I did not use the
plan to get any prescription medicines)

17

No change to item wording.

15

Did you ever use the plan to fill a prescription at a
local pharmacy? (Yes / No)

18

No change to item wording.

16

How often was it easy to use the plan to fill a
prescription at a local pharmacy? (Never /
Sometimes / Usually / Always / I did not use the
plan to fill a prescription at a local pharmacy)

19

No change to item wording.

17

Did you ever use the plan to fill any prescriptions by
mail? (Yes / No)

20

No change to item wording.

21

No change to item wording.

22

No change to item wording.

18

19

How often was it easy to use the plan to fill
prescriptions by mail? (Never / Sometimes / Usually
/ Always / I did not use the plan to fill a prescription
by mail)
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 the
plan? (0 Worst health plan possible / 2 / 3 / 4 / 5 / 6
/ 7 / 8 / 9 / 10 Best health plan possible)

20

Did you leave the plan because you found out that
someone had signed you up for the plan without
your permission? (Yes / No)

23

No change to item wording.

21

Did you leave the plan because you were
accidentally taken off the plan (or because of some
other paperwork or clerical error)? (Yes / No)

24

No change to item wording.

9/2/2010

3

22

Did you leave the plan because the monthly
premium for health care and prescription medicine
coverage went up? (Yes / No)

25

No change to item wording.

23

Did you leave the plan because you stopped paying
the monthly premium for the plan? (Yes / No)

26

No change to item wording.

24

Why did you stop paying the monthly premium for
the plan? (I stopped paying the monthly premium
because I could not afford it / I stopped paying the
monthly premium because I was unhappy with the
plan / I stopped paying the monthly premium for
some other reason)

27

No change to item wording.

25

A formulary is the list of prescription medicines
covered by a health plan. Did you leave the plan
because of a change in the formulary? (Yes / No)

28

No change to item wording.

26

Did you leave the plan because you hit the
temporary limit (also called the "coverage gap")
when you had to pay all of the costs of your
prescription medicines up to a yearly limit? (Yes /
No)

29

Did you leave the plan because you hit the
temporary limit (also called the "coverage gap" or
"donut hole") when you had to pay all of the costs
of your prescription medicines up to a yearly limit?
(Yes / No)

27

Did you leave the plan because the dollar amount
you had to pay each time you filled or refilled a
prescription went up? (Yes / No)

30

No change to item wording.

28

Did you leave the plan because the dollar amount
you had to pay each time you visited a doctor went
up? (Yes / No)

31

No change to item wording.

29

Did you leave the plan because you found a health
plan that costs less? (Yes / No)

32

No change to item wording.

9/2/2010

4

30

Did you leave the plan because a change in your
personal finances meant you could no longer afford
the plan? (Yes / No)

33

No change to item wording.

31

Did you leave the plan because the plan refused to
pay for a medicine your doctor prescribed? (Yes /
No)

34

No change to item wording.

32

Did you leave the plan because you had problems
getting the medicines your doctor prescribed? (Yes
/ No)

35

No change to item wording.

33

Did you leave the plan because the plan required
you to take a generic medicine when you preferred
the name brand medicine? (Yes / No)

36

Did you leave the plan because it was difficult to
get brand name medicines? (Yes / No)

34

Did you leave the plan because you were frustrated
by the plan’s approval process for medicines your
doctor prescribed that were not on their formulary?
(Yes / No)

37

No change to item wording.

35

Did you leave the plan because you did not know
whom to contact when you had a problem filling or
refilling a prescription? (Yes / No)

38

No change to item wording.

36

Did you leave the plan because it was hard to get
information from the plan -- like which prescription
medicines were covered or how much a specific
medicine would cost? (Yes / No)

39

No change to item wording.

37

Did you leave the plan because you were frustrated
by the plan’s approval process for care, tests, or
treatment? (Yes / No)

40

No change to item wording.

38

Did you leave the plan because you had problems
getting the care, tests or treatment you needed?
(Yes / No)

41

No change to item wording.

9/2/2010

5

39

Claims are sent to a health plan for payment. You
may send in the claims yourself, or doctors,
hospitals, or others may do this for you. Did you
leave the plan because you had problems getting
the plan to pay a claim? (Yes / No)

42

No change to item wording.

40

Did you leave the plan because the doctors or other
health care providers you wanted to see did not
belong to the plan? (Yes / No)

43

No change to item wording.

41

Did you leave the plan because clinics or hospitals
you wanted to go to for care were not covered by
the plan? (Yes / No)

44

No change to item wording.

42

Did you leave the plan because it was hard to get
information from the plan -- like which health care
services were covered or how much a specific test
or treatment would cost? (Yes / No)

45

No change to item wording.

43

Did you leave the plan because you were unhappy
with how the plan handled a question or complaint?
(Yes / No)

46

No change to item wording.

44

Did you leave the plan because you could not get
the information or help you needed from the plan?
(Yes / No)

47

No change to item wording.

45

Did you leave the plan because their customer
service staff did not treat you with courtesy and
respect? (Yes / No)

48

No change to item wording.

46

Did you leave [PLAN NAME] because it wasn’t what
you expected? (Yes / No)

49

No change to item wording.

47

Did you leave the plan because a doctor or
pharmacist told you that another plan had better
benefits or coverage for prescription medicines?
(Yes / No)

50

No change to item wording.

9/2/2010

6

48

Did you leave the plan because a family member or
friend told you that another health plan was a better
plan? (Yes / No)

51

No change to item wording.

49

Did you leave the plan because you saw a
commercial or advertisement for a health plan you
thought you would like better? (Yes / No)

52

No change to item wording.

50

Did you leave the plan because you found another
plan that better met your prescription needs? (Yes /
No)

53

No change to item wording.

51

Did you leave the plan because another plan offered
better benefits or coverage for some types of care,
treatment, or services? (Yes / No)

54

No change to item wording.

52

Did you leave the plan because your doctor or
another health care provider or someone from the
plan told you that you could get better care or
treatment elsewhere? (Yes / No)

55

No change to item wording.

53

What was the one most important reason you left
[PLAN NAME]? (Please print:)

56

No change to item wording.

54

An insurance agent or broker sells insurance for
your health, your home, or your car. Did an
insurance agent or broker ever call you without your
asking them to, to tell you about insurance for health
care or prescription medicines? (Yes / No)

57

55

Did an insurance agent or broker ever visit your
home you without your asking them to, to tell you
about insurance for health care or prescription
medicines? (Yes / No)_

58

9/2/2010

Different kinds of people sell health insurance.
Insurance may be sold by independent insurance
agents or brokers who don’t work for the health
plan OR by plan representatives who work directly
for the plan. Did an insurance agent, broker , or
plan representative ever call you without your
asking them to, to tell you about insurance for
health care or prescription medicines? (Yes / No)
Did an insurance agent, broker, or plan
representative ever visit your home without your
asking them to, to tell you about insurance for
health care or prescription medicines? (Yes / No)_

7

56

Did you decide to leave [PLAN NAME] because of
information you got from an insurance agent or
broker? (Yes / No)

59

Did you decide to leave [PLAN NAME] because of
information you got from an insurance agent,
broker, or plan representative? (Yes / No)

57

Did an insurance agent or broker give you any
information that was not correct? (Yes / No)

60

Did an insurance agent, broker, or plan
representative give you any information that was
not correct? (Yes / No)

58

What kind of information was not correct? (What
the plan covered / What the plan would cost you /
Which doctors belong to the plan / Which
pharmacies are covered by the plan / Which
hospitals are covered by the plan / Some other
information Please print: / I did not get any
information that was not correct)

61

No change to item wording. (What the plan
covered / What the plan would cost you / Which
doctors belong to the plan / Which pharmacies are
covered by the plan / Which hospitals are covered
by the plan / Some other information Please print: /
I did not get any information that was not correct)

59

In general, how would you rate your overall health?
(Excellent / Very good / Good / Fair / Poor)

62

No change to item wording.

60

In general, how would you rate your overall mental
health? (Excellent / Very good / Good / Fair / Poor)

63

No change to item wording.

61

In the last 12 months, how many different
prescription medicines did you fill or have refilled?
(None / 1 to 2 medicines / 3 to 5 medicines / 6 or
more medicines)

64

No change to item wording.

62

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)

65

No change to item wording.

63

Is this a condition or problem that has lasted for at
least 3 months? (Yes / No)

66

No change to item wording.

9/2/2010

8

64

Do you now need or take medicine prescribed by a
doctor? (Yes / No)

67

No change to item wording.

65

Is this to treat a condition that has lasted for at least
3 months? (Yes / No)

68

No change to item wording.

66

Has a doctor ever told you that you had any of the
following conditions? (a. A heart attack? / b. Angina
or coronary heart disease? / c. A stroke? / d.
Cancer, other than skin cancer? / e. Emphysema,
asthma, or COPD (chronic obstructive pulmonary
disease)? / f. Any kind of diabetes or high blood
sugar?)

69

No change to item wording.

67

What is your age? (18 to 24 / 25 to 34 / 35 to 44 /
45 to 54 / 55 to 64 / 65 to 74 / 75 to 79 / 80 to 84 /
85 or older)

70

No change to item wording.

68

Are you male or female? (Male / Female)

71

No change to item wording.

69

What is the highest grade or level of school that you
th
have completed? (8 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)

72

No change to item wording.

70

Are you of Hispanic or Latino origin or descent?
(Yes, Hispanic or Latino / No, not Hispanic or
Latino)

73

No change to item wording.

71

What is your race? Please mark one or more.
(White / Black or African-American / Asian / Native
Hawaiian or other Pacific Islander / American Indian
or Alaska Native)

74

No change to item wording.

9/2/2010

9

72

What language do you mainly speak at home?
(Chinese / English / Russian / Spanish / Vietnamese
/ Some other language Please print:)

75

No change to item wording.

73

Did someone help you complete this survey? (Yes /
No)

76

No change to item wording.

77

No change to item wording.

78

No change to item wording.

74

75

9/2/2010

How did that person help you? Please mark one or
more. (Read the questions to me / Entered the
answers I gave / Answered the questions for me /
Translated the questions into my language / Helped
in some other way Please print:)
The Medicare Program is trying to learn more about
the health care or services provided to people with
Medicare. May we contact you again about the
health care services that you received? (Yes / No)

10