Crosswalk - MA PD

Question Number	2010 Version: MA_PD_Pilot	Question Number	2013 Version: 2MA_PD Survey	Description of Change	Comments
Heading	YOUR FORMER HEALTH PLAN	Heading	YOUR FORMER HEALTH PLAN	No change to wording.
Directions	We are sending you this survey because we believe you recently left, switched or were dropped by a health plan.	Directions	We are sending you this survey because we believe you recently left or were dropped by a health plan, or switched health plans.	Changed word order for clarity.
1	Our records show that you used to belong to [PLAN NAME], but no longer belong to that plan. Is that right?  Yes  No If No, go to #3	1	Our records show that you used to belong to [PLAN NAME], but no longer belong to that plan. Is that right? Yes If Yes, go to Question 2 I left or was dropped by a plan but it was not [HEALTH PLAN] Go to Question 2 No, I did not belong to [HEALTH PLAN] No, I still belong to [HEALTH PLAN] If you answered No to Question 1, please stop and return the survey. You DO NOT have to complete the survey.	Expanded the response options.
2	Did you move outside of the area where [PLAN NAME] was available?  Yes  If Yes, Please stop and return this survey  No  If No, go to #6	2	Did you have to leave or switch [PLAN NAME] for any of the following reasons?  I moved outside of the area where the plan was available  I was dropped by the plan The plan was cancelled or discontinued in my area  The plan was changed by the organization that provides my insurance (such as an employer or a union) PLEASE READ: If you checked any of the reasons above, please stop and return the survey. You DO NOT have to complete the survey. o None of the above --> If you did not choose any of the reasons in Question 2 please continue to Question 3	Findings from the field test indicate that some beneficiaries had difficulty navigating the front end questions. We re-worded question 2 and expanded the response options to make it easier to navigate this question and to better identify and screen out beneficiaries who truly didn't disenroll voluntarily.
3	Do you still belong to [PLAN NAME]?  Yes  If Yes, Please stop and return this survey  No		Dropped	Dropped this question to improve navigation and to make it easier to screen out beneficiaries who did not disenroll voluntarily (this question was folded into the response options for question 1).
4	Did you recently leave, switch, or were you dropped by a health plan?  Yes  No If No, Please stop and return this survey		Dropped	Dropped this question to improve navigation and to make it easier to screen out beneficiaries who did not disenroll voluntarily (this question was folded into the response options for question 1).
5	What is the name of the health plan you recently left, switched or were dropped by? (Please print) _________________________ Please think of this plan as you answer the questions in this survey.		Dropped	Dropped this question as it did not seem to include navigation of the survey.
Heading	GETTING INFORMATION OR HELP FROM YOUR FORMER HEALTH PLAN	Heading	GETTING INFORMATION OR HELP FROM YOUR FORMER HEALTH PLAN	No change to wording.
Directions	These questions ask about your experience with your former health plan.		These questions ask about your experience with your former health plan. As you answer the rest of the questions in this survey, please think only of your former plan.	Added text for clarity.
6	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 If No, go to #8	3	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 If No, go to #5	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	4	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	No change to item wording.
8	Did you ever try to get information from the plan about which prescription medicines were covered?  Yes  No  If No, go to #10	5	Did you ever try to get information from the plan about which prescription medicines were covered?  Yes  No  If No, go to #7	No change to item wording.
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	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 to get information about which prescription medicines were covered	No change to item wording.
10	Did you ever try to get information from the plan about how much you would have to pay for a prescription medicine?  Yes  No If No, go to #12	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  If No, go to #9	No change to item wording.
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	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 to get information about how much I would have to pay for a prescription medicine	No change to item wording.
12	Did you ever need written information from the plan in a language other than English?  Yes  No If No, go to #14	9	Did you ever need written information from the plan in a language other than English?  Yes  No If No, go to #11	No change to item wording.
13	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	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	No change to item wording.
Heading	GETTING HEALTH CARE AND THE PRESCRIPTION MEDICINES YOU NEEDED FROM YOUR FORMER HEALTH PLAN	Directions	GETTING HEALTH CARE AND THE PRESCRIPTION MEDICINES YOU NEEDED FROM YOUR FORMER HEALTH PLAN	No change to item wording.
14	Did you ever try to get any kind of care, tests, or treatment through the plan?  Yes  No If No, go to #16	11	Did you ever try to get any kind of care, tests, or treatment through the plan?  Yes  No  If No, go to #13	No change to item wording.
15	How often was it easy to get the care, tests, or treatment you thought you needed through the plan?  Never  Sometimes  Usually  Always	12	How often was it easy to get the care, tests, or treatment you thought you needed through the plan?  Never  Sometimes  Usually  Always	No change to item wording.
16	Did a doctor ever prescribe a medicine for you that the plan did not cover?  Yes  No	13	Did a doctor ever prescribe a medicine for you that the plan did not cover?  Yes  No	No change to item wording.
17	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	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	No change to item wording.
18	Did you ever use the plan to fill a prescription at a local pharmacy?  Yes  No  If No, go to #20	15	Did you ever use the plan to fill a prescription at a local pharmacy?  Yes  No If No, go to #17	No change to item wording.
19	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	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	No change to item wording.
20	Did you ever use the plan to fill any prescriptions by mail?  Yes  No  If No, go to #22	17	Did you ever use the plan to fill any prescriptions by mail?  Yes  No If No, go to #19	No change to item wording.
21	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	18	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	No change to item wording.
22	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  1  2  3  4  5  6  7  8  9  10 Best health plan possible	19	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  1  2  3  4  5  6  7  8  9  10 Best health plan possible	No change to item wording.
Heading	REASONS YOU LEFT YOUR FORMER HEALTH PLAN	Heading	REASONS YOU LEFT YOUR FORMER HEALTH PLAN	No change to wording.
Directions	People leave, switch or drop a health plan for different reasons. These questions are about reasons you may have had for leaving, switching or dropping [PLAN NAME]. In this survey we use the words “did you leave” to ask about why you left, dropped or switched from your former health plan.	Directions	People leave, drop, or switch health plans for different reasons. These questions are about reasons you may have had for switching, leaving, or dropping [PLAN NAME].	Changed wording order in the first sentence and dropped the last sentence to reduce reading burden.
23	Did you leave the plan because you found out that someone had signed you up for the plan without your permission?  Yes  No	20	Did you leave the plan because you found out that someone had signed you up for the plan without your permission?  Yes  No	No change to item wording.
24	Did you leave the plan because you were accidentally taken off the plan (or because of some other paperwork or clerical error)?  Yes  No	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	No change to item wording.
25	A premium is the amount that you pay to have health care and prescription medicine coverage from a health plan. Some health plans charge a premium to people on Medicare who are enrolled in that health plan. This premium that the health plan charges is separate from the premium that people on Medicare pay for Medicare Part B. Medicare Part B premiums are usually deducted each month from a person’s Social Security check. Did you leave the plan because the monthly premium for health care and prescription medicine coverage went up?  Yes  No	22	Some Medicare beneficiaries have to pay their health plan a monthly fee out of their own pocket for coverage for health and prescription medicines. Did you leave the plan because the monthly fee that the health plan charges to provide coverage for health care and prescription medicines went up?  Yes  No	Shortened and revised question wording to make it easier to understand based on findings from cognitive interviews (avoid using the term "premium" and instead describe what a premium is).
26	Did you leave the plan because you stopped paying the monthly premium for the plan?  Yes  No If No, go to #28	23	Did you leave the plan because you stopped paying the monthly fee for coverage for health care and prescription medicines?  Yes  No If No, go to #25	Revised question wording to make it easier to understand based on findings from cognitive interviews.
27	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	24	Why did you stop paying the plan’s monthly fee?  I stopped paying the monthly fee because I could not afford it  I stopped paying the monthly fee because I was unhappy with the plan  I stopped paying the monthly fee for some other reason	Revised question wording to make it easier to understand based on findings from cognitive interviews.
28	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	25	Health plans have a list of the prescription medicines that the plan will cover. Did you leave the plan because they changed the list of prescription medicines they cover?  Yes  No	Revised question wording to make it easier to understand based on findings from cognitive interviews (avoid using the word "formulary").
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		Dropped	Dropped based on findings from field test (item with low endorsement).
30	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	26	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	No change to item wording.
31	Did you leave the plan because the dollar amount you had to pay each time you visited a doctor went up?  Yes  No	27	Did you leave the plan because the dollar amount you had to pay each time you visited a doctor went up?  Yes  No	No change to item wording.
32	Did you leave the plan because you found a health plan that costs less?  Yes  No	28	Did you leave the plan because you found a health plan that costs less?  Yes  No	No change to item wording.
33	Did you leave the plan because a change in your personal finances meant you could no longer afford the plan?  Yes  No	29	Did you leave the plan because a change in your personal finances meant you could no longer afford the plan?  Yes  No	No change to item wording.
34	Did you leave the plan because the plan refused to pay for a medicine your doctor prescribed?  Yes  No	30	Did you leave the plan because the plan refused to pay for a medicine your doctor prescribed?  Yes  No	No change to item wording.
35	Did you leave the plan because you had problems getting the medicines your doctor prescribed?  Yes  No	31	Did you leave the plan because you had problems getting the medicines your doctor prescribed?  Yes  No	No change to item wording.
36	Did you leave the plan because it was difficult to get brand name medicines?  Yes  No	32	Did you leave the plan because it was difficult to get brand name medicines?  Yes  No	No change to item wording.
37	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	33	Did you leave the plan because you were frustrated by the plan’s approval process for medicines your doctor prescribed that were not on the plan’s list of medicines that the plan covers?  Yes  No	Revised question wording to make it easier to understand based on findings from cognitive interviews (avoid using the word "formulary").
38	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	34	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	No change to item wording.
39	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	35	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	No change to item wording.
40	Did you leave the plan because you were frustrated by the plan’s approval process for care, tests, or treatment?  Yes  No	36	Did you leave the plan because you were frustrated by the plan’s approval process for care, tests, or treatment?  Yes  No	No change to item wording.
41	Did you leave the plan because you had problems getting the care, tests or treatment you needed?  Yes  No	37	Did you leave the plan because you had problems getting the care, tests, or treatment you needed?  Yes  No	No change to item wording.
42	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	38	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	No change to item wording.
43	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	39	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	No change to item wording.
44	Did you leave the plan because clinics or hospitals you wanted to go to for care were not covered by the plan?  Yes  No	40	Did you leave the plan because clinics or hospitals you wanted to go to for care were not covered by the plan?  Yes  No	No change to item wording.
45	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	41	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	No change to item wording.
46	Did you leave the plan because you were unhappy with how the plan handled a question or complaint?  Yes  No	42	Did you leave the plan because you were unhappy with how the plan handled a question or complaint?  Yes  No	No change to item wording.
47	Did you leave the plan because you could not get the information or help you needed from the plan?  Yes  No	43	Did you leave the plan because you could not get the information or help you needed from the plan?  Yes  No	No change to item wording.
48	Did you leave the plan because their customer service staff did not treat you with courtesy and respect?  Yes  No	44	Did you leave the plan because their customer service staff did not treat you with courtesy and respect?  Yes  No	No change to item wording.
	Not Included		Every year Medicare evaluates all Medicare health and prescription drug plans and gives each plan a quality rating. The ratings are referred to as the Medicare Star or Plan Ratings. The ratings provide Medicare beneficiaries information on the quality of services a plan provides. Did you leave the plan because it got a low Medicare Star Rating?  Yes  No	New Item added upon request from CMS.
	Not Included		Did you leave the plan because you found another plan with a higher Medicare Star Rating?  Yes  No	New Item added upon request from CMS.
	Not Included	47	In the past year, did you think about the Medicare Star or Plan ratings when making a decision about enrolling in a health plan?  Yes  No	New Item added upon request from CMS.
Heading	OTHER REASONS FOR LEAVING YOUR FORMER HEALTH PLAN	Heading	OTHER REASONS FOR LEAVING YOUR FORMER HEALTH PLAN	No change to wording.
49	Did you leave [PLAN NAME] because it wasn’t what you expected?  Yes  No		Dropped	Dropped based on findings from field test (item with low endorsement).
50	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		Dropped	Dropped based on findings from field test (item with low endorsement).
51	51. Did you leave the plan because a family member or friend told you that another health plan was a better plan?  Yes  No	48	Did you leave the plan because a family member or friend told you that another health plan was a better plan?  Yes  No	No change to item wording.
52	Did you leave the plan because you saw a commercial or advertisement for a health plan you thought you would like better?  Yes  No	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	No change to item wording.
53	Did you leave the plan because you found another plan that better met your prescription needs?  Yes  No	50	Did you leave the plan because you found another plan that better met your prescription needs?  Yes  No	No change to item wording.
54	Did you leave the plan because another plan offered better benefits or coverage for some types of care, treatment, or services?  Yes  No	51	Did you leave the plan because another plan offered better benefits or coverage for some types of care, treatment, or services (for example, dental or vision care)?  Yes  No	Added examples of services based on findings from cognitive interviews.
55	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		Dropped	Dropped based on findings from field test (item with low endorsement).
56	What was the one most important reason you left [PLAN NAME]? (Please print) __________________________________________________	52	What was the one most important reason you left [PLAN NAME]? (Check one)  Financial or cost reasons  Problems getting prescription drugs through the plan  Problems getting the care, tests, or treatment you needed through the plan  Problems with plan not covering doctors or hospitals you wanted to see  Problems getting information from the plan about prescription drugs  Switched to another plan that offers better benefits or coverage  Another reason. Please specify: __________________________ __________________________ __________________________	Revised item to make it a close-ended item (created response options from open ended responses from the field test).
Heading	YOUR EXPERIENCE WITH INSURANCE AGENTS, BROKERS, OR PLAN REPRESENTATIVES		YOUR EXPERIENCE WITH INSURANCE AGENTS, BROKERS, OR PLAN REPRESENTATIVES	No change to wording.
57	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	53	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	No change to item wording.
58	Did an insurance agent, broker, or plan representative ever visit your home you without your asking them to, to tell you about insurance for health care or prescription medicines?  Yes  No	54	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	No change to item wording.
59	Did you decide to leave [PLAN NAME] because of information you got from an insurance agent, broker, or plan representative?  Yes  No	55	Did you decide to leave [PLAN NAME] because of information you got from an insurance agent, broker, or plan representative?  Yes  No	No change to item wording.
60	Did an insurance agent, broker, or plan representative give you any information that was not correct?  Yes  No If No, go to #62	56	Did an insurance agent, broker, or plan representative give you any information that was not correct?  Yes  No If No, go to #58	No change to item wording.
61	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	57	What kind of information was not correct? Please check all that apply.  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) _____________________________ _____________________________	Dropped the last response option added instruction to the question for clarity.
Heading	ABOUT YOU	Heading	ABOUT YOU	No change to wording.
62	In general, how would you rate your overall health?  Excellent  Very good  Good  Fair  Poor	58	In general, how would you rate your overall health?  Excellent  Very good  Good  Fair  Poor	No change to item wording.
63	In general, how would you rate your overall mental health?  Excellent  Very good  Good  Fair  Poor	59	In general, how would you rate your overall mental health?  Excellent  Very good  Good  Fair  Poor	No change to item wording.
64	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	60	In the last 12 months, how many different prescription medicines did you fill? (Don’t count the same prescriptions twice)  None  1 to 2 medicines  3 to 5 medicines  6 or more medicines	Added instructions based on findings from cognitive interviews.
65	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  If No, go to #67	61	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 If No, go to #63	No change to item wording.
66	Is this a condition or problem that has lasted for at least 3 months?  Yes  No	62	Is this a condition or problem that has lasted for at least 3 months?  Yes  No	No change to item wording.
67	Do you now need or take medicine prescribed by a doctor?  Yes  No  If No, go to #69	63	Do you now need or take medicine prescribed by a doctor?  Yes  No  If No, go to #65	No change to item wording.
68	Is this to treat a condition that has lasted for at least 3 months?  Yes  No	64	Is this to treat a condition that has lasted for at least 3 months?  Yes  No	No change to item wording.
69	Has a doctor ever told you that you had any of the following conditions? a. A heart attack?  Yes  No b. Angina or coronary heart disease?  Yes  No c. A stroke?  Yes  No d. Cancer, other than skin cancer?  Yes  No e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)?  Yes  No f. Any kind of diabetes or high blood sugar?  Yes  No	65	Has a doctor ever told you that you had any of the following conditions? a. A heart attack?  Yes  No b. Angina or coronary heart disease?  Yes  No c. Hypertension or high blood pressure?  Yes  No d. Cancer, other than skin cancer?  Yes  No e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)?  Yes  No f. Any kind of diabetes or high blood sugar?  Yes  No	Changed option c from "Stroke" to "Hypertension or high blood pressure."
70	70. 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	66	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	No change to item wording.
71	Are you male or female?  Male  Female	67	Are you male or female?  Male  Female	No change to item wording.
72	What is the highest grade or level of school that you have completed?  8th 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	68	What is the highest grade or level of school that you have completed?  8th 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	No change to item wording.
73	Are you of Hispanic or Latino origin or descent?  Yes, Hispanic or Latino  No, not Hispanic or Latino	69	Are you of Hispanic or Latino origin or descent?  Yes, Hispanic or Latino  No, not Hispanic or Latino	No change to item wording.
74	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	70	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	No change to item wording.
75	What language do you mainly speak at home?  Chinese  English  Russian  Spanish  Vietnamese  Some other language (Please print) _________________________	71	What language do you mainly speak at home?  Chinese  English  Russian  Spanish  Vietnamese  Some other language (please print) _____________________________	No change to item wording.
76	Did someone help you complete this survey?  Yes  No  If No, Go to #78	72	72. Did someone help you complete this survey?  Yes  No  If No, Go to #74	No change to item wording.
77	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) _________________________	73	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) _____________________________	No change to item wording.
78	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	74	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	No change to item wording.