Crosswalk - FFS Survey

Survey Item Crosswalk for FFS Questionnaires
Survey Section

Proposed Question

Your Health
Insurance Coverage

1. Some people who have Medicare also have
other insurance to help pay for some of the costs
of their health care. Do you have any other
insurance that pays at least some of the cost of
your health care?

1. Some people who have Medicare also

2. Please mark the box below for each type of
health insurance that you have.

2. Please mark the box below for each type of
health insurance that you have.

2a. Medigap, which may be identified on the
front of your policy as “Medicare Supplemental
Insurance”

2a. Medigap, which may be identified on the
front of your policy as “Medicare Supplemental
Insurance”

2b. Employer, Union, or Retiree Health Coverage
(insurance)

2b. Employer, Union, or Retiree Health Coverage
(insurance)

2c. Veteran’s Benefits, also known as VA benefits

2c. Veteran’s Benefits, also known as VA benefits

2d. Military Retiree Benefits, also known as
Tricare

2d. Military Retiree Benefits, also known as
Tricare

2e. Medicaid, also known as State medical
assistance, which is for some persons with
limited income and resources

2e. Medicaid, also known as State medical
assistance, which is for some persons with
limited income and resources

2f. Any Prescription Drug Plan

2f. Any Prescription Drug Plan

2g. Other (Please write the name of the other
health insurance you currently have on the line
below.)

2g. Other (Please write the name of the other
health insurance you currently have on the line
below.)

2h. I don’t have health insurance other than
Medicare.
3. In the last 6 months, did you have an illness,
injury, or condition that needed care right away
in a clinic, emergency room, or doctor’s office?

2h. I don’t have health insurance other than
Medicare.
3. In the last 6 months, did you have an illness,
injury, or condition that needed care right away
in a clinic, emergency room, or doctor’s office?

4. In the last 6 months, when you needed care
right away, how often did you get care as soon as
you thought you needed?

4. In the last 6 months, when you needed care
right away, how often did you get care as soon as
you thought you needed?
5. In the last 6 months, not counting the times
you needed care right away, did you make any
appointments for your health care at a doctor’s
office or clinic?
6. In the last 6 months, not counting the times
you needed care right away, how often did you
get an appointment for your health care at a
doctor’s office or clinic as soon as you thought
you needed?
7. In the last 6 months, not counting the times
you went to an emergency room, how many
times did you go to a doctor’s office or clinic to
get health care for yourself?

Your Health Care in
the Last 6 Months

5. In the last 6 months, not counting the times
you needed care right away, did you make any
appointments for your health care at a doctor’s
office or clinic?
6. In the last 6 months, not counting the times
you needed care right away, how often did you
get an appointment for your health care at a
doctor’s office or clinic as soon as you thought
you needed?
7. In the last 6 months, not counting the times
you went to an emergency room, how many
times did you go to a doctor’s office or clinic to
get health care for yourself?

Existing Question

have other insurance to help pay for some
of the costs of their health care. Do you
have any other insurance that pays at least
some of the cost of your health care?

Survey Section

Proposed Question

Existing Question

8. Wait time includes time spent in the waiting
room and exam room. In the last 6 months, how
often did you see the person you came to see
within 15 minutes of your appointment time?
9. In the last 6 months, did you phone a doctor’s
office or clinic with a medical question after
regular office hours?

8. Wait time includes time spent in the waiting
room and exam room. In the last 6 months, how
often did you see the person you came to see
within 15 minutes of your appointment time?

10. In the last 6 months, when you phoned a
doctor’s office or clinic after regular office hours,
how often did you get an answer to your medical
question as soon as you needed?
11. In the last 6 months, when you phoned a
doctor’s office or clinic after regular office hours,
how long did it take for someone to call you back
12. Using any number from 0 to 10, where 0 is
the worst health care possible and 10 is the best
health care possible, what number would you
use to rate all your health care in the last 6
months?
No comparable question

No comparable question
Your Personal
Doctor

13. A personal doctor is the one you would see if
you need a check-up, want advice about a health
problem, or get sick or hurt. Do you have a
personal doctor?
14. In the last 6 months, how many times did you
visit your personal doctor to get care for
yourself?
15. In the last 6 months, how often did your
personal doctor explain things in a way that was
easy to understand?
16. In the last 6 months, how often did your
personal doctor listen carefully to you?
17. In the last 6 months, how often did your
personal doctor show respect for what you had
to say?
18. In the last 6 months, how often did your
personal doctor spend enough time with you?
19. Using any number from 0 to 10, where 0 is
the worst personal doctor possible and 10 is the
best personal doctor possible, what number
would you use to rate your personal doctor?
20. In the last 6 months, when you visited your
personal doctor for a scheduled appointment,
how often did he or she have your medical
records or other information about your care?

No comparable question

No comparable question

No comparable question
9. Using any number from 0 to 10, where 0 is the
worst health care possible and 10 is the best
health care possible, what number would you
use to rate all your health care in the last 6
months?
10. In the last 6 months, did you have a health
problem for which you needed special medical
equipment, such as a cane, a wheelchair, oxygen
equipment, or diabetic supplies and equipment?
11. In the last 6 months, how often was it easy to
get the medical equipment you needed through
Medicare?
12. A personal doctor is the one you would see if
you need a check-up, want advice about a health
problem, or get sick or hurt. Do you have a
personal doctor?
13. In the last 6 months, how many times did you
visit your personal doctor to get care for
yourself?
14. In the last 6 months, how often did your
personal doctor explain things in a way that was
easy to understand?
15. In the last 6 months, how often did your
personal doctor listen carefully to you?
16. In the last 6 months, how often did your
personal doctor show respect for what you had
to say?
17. In the last 6 months, how often did your
personal doctor spend enough time with you?
18. Using any number from 0 to 10, where 0 is
the worst personal doctor possible and 10 is the
best personal doctor possible, what number
would you use to rate your personal doctor?
19. In the last 6 months, when you visited your
personal doctor for a scheduled appointment,
how often did he or she have your medical
records or other information about your care?

Survey Section

Proposed Question

Existing Question

21. In the last 6 months, did your personal
doctor order a blood test, x-ray or other test for
you?
22. In the last 6 months, when your personal
doctor ordered a blood test, x-ray or other test
for you, how often did someone from your
personal doctor’s office follow up to give you
those results?
23. In the last 6 months, when your personal
doctor ordered a blood test, x-ray or other test
for you, how often did you get those results as
soon as you needed them?

20. In the last 6 months, did your personal
doctor order a blood test, x-ray or other test for
you?
21. In the last 6 months, when your personal
doctor ordered a blood test, x-ray or other test
for you, how often did someone from your
personal doctor’s office follow up to give you
those results?
22. In the last 6 months, when your personal
doctor ordered a blood test, x-ray or other test
for you, how often did you get those results as
soon as you needed them?

24. In the last 6 months, did you take any
prescription medicine?

23. In the last 6 months, did you take any
prescription medicine?

25. In the last 6 months, how often did you and
your personal doctor talk about all the
prescription medicines you were taking?

24. In the last 6 months, how often did you and
your personal doctor talk about all the
prescription medicines you were taking?

26. Doctors may use computers or handheld
devices during an office visit to do things like
look up your information or order prescription
medicines. In the last 6 months, did your
personal doctor use a computer or handheld
device during any of your visits?
27. During your visits in the last 6 months, was
your personal doctor’s use of a computer or
handheld device helpful to you?
28. During your visits in the last 6 months, did
your personal doctor’s use of a computer or
handheld device make it harder or easier for you
to talk to him or her?
No comparable question

No comparable question

No comparable question
29. In the last 6 months, did you get care from
more than one kind of health care provider or
use more than one kind of health care service?
30. In the last 6 months, did you need help from
anyone in your personal doctor’s office to
manage your care among these different
providers and services?
31. In the last 6 months, did you get the help you
needed from your personal doctor’s office to
manage your care among these different
providers and services?

No comparable question

No comparable question

No comparable question
25. In the last 6 months, did you see your
personal doctor for a specific illness or for any
health conditions?
26. In the last 6 months, how often did your
personal doctor give you easy to understand
instructions about what to do to take care of this
illness or health condition?
27. In the last 6 months, how often did your
personal doctor ask you to describe how you
were going to follow these instructions?
28. In the last 6 months, did you get care from
more than one kind of health care provider or
use more than one kind of health care service?
29. In the last 6 months, did you need help from
anyone in your personal doctor’s office to
manage your care among these different
providers and services?
30. In the last 6 months, did you get the help you
needed from your personal doctor’s office to
manage your care among these different
providers and services?

Survey Section

Proposed Question

No comparable question

Getting Health Care
from Specialists

Managing Your
Health Care

Medicare
Experience

32. Visit notes sum up what was talked about on
a visit to a doctor’s office. Visit notes may be
available on paper, on a website or by e-mail. In
the last 6 months, did anyone in your personal
doctor’s office offer you visit notes?
33. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and other
doctors who specialize in one area of health
care. Is your personal doctor a specialist?
34. In the last 6 months, did you try to make any
appointments to see a specialist?

35. In the last 6 months, how often was it easy to
get appointments with specialists?
36. How many specialists have you seen in the
last 6 months?
37. We want to know your rating of the specialist
you saw most often in the last 6 months. Using
any number from 0 to 10, where 0 is the worst
specialist possible and 10 is the best specialist
possible, what number would you use to rate
that specialist?
38. In the last 6 months, how often did your
personal doctor seem informed and up-to-date
about the care you got from specialists?
39. How likely are you to change doctors if you
are dissatisfied with the way you and your doctor
communicate?
40. How likely are you to tell your doctor when
you disagree with him or her?
41. In the last 6 months, how often did you leave
your doctor’s office feeling that all of your
concerns or questions were fully answered?
42. In the last 6 months, how often did you make
sure you understood the results of any medical
test or procedure such as x-ray, blood test, or
EKG for heart conditions?
43. In the last 6 months, did you try to get any
kind of care, tests or treatment through
Medicare?
44. In the last 6 months, how often was it easy to
get the care, tests or treatment you thought you
needed through Medicare?
45. In the last 6 months, did you try to get
information or help from Medicare’s customer
service?

Existing Question
31. How satisfied are you with the help you got
from your personal doctor’s office to manage
your care among these different providers and
services in the last 6 months?
32. Visit notes sum up what was talked about on
a visit to a doctor’s office. Visit notes may be
available on paper, on a website or by e-mail. In
the last 6 months, did anyone in your personal
doctor’s office offer you visit notes?
No comparable question
33. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and other
doctors who specialize in one area of health
care. In the last 6 months, did you try to make
any appointments to see a specialist?
34. In the last 6 months, how often was it easy to
get appointments with specialists?
35. How many specialists have you seen in the
last 6 months?
36. We want to know your rating of the specialist
you saw most often in the last 6 months. Using
any number from 0 to 10, where 0 is the worst
specialist possible and 10 is the best specialist
possible, what number would you use to rate
that specialist?
37. In the last 6 months, how often did your
personal doctor seem informed and up-to-date
about the care you got from specialists?
No comparable question
No comparable question
No comparable question

No comparable question
38. In the last 6 months, did you try to get any
kind of care, tests or treatment through
Medicare?
39. In the last 6 months, how often was it easy to
get the care, tests or treatment you thought you
needed through Medicare?
40. In the last 6 months, did you try to get
information or help from Medicare’s customer
service?

Survey Section

Your Medicare
Rights

Proposed Question

Existing Question

46. In the last 6 months, how often did
Medicare’s customer service give you the
information or help you needed?
47. In the last 6 months, how often did
Medicare’s customer service staff treat you with
courtesy and respect?
48. In the last 6 months, did Medicare give you
any forms to fill out?
49. In the last 6 months, how often were the
forms from Medicare easy to fill out?
50. 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 Medicare?
51. In the last 6 months, did anyone from a
doctor’s office or Medicare contact you:

41. In the last 6 months, how often did
Medicare’s customer service give you the
information or help you needed?
42. In the last 6 months, how often did
Medicare’s customer service staff treat you with
courtesy and respect?
43. In the last 6 months, did Medicare give you
any forms to fill out?
44. In the last 6 months, how often were the
forms from Medicare easy to fill out?
45. 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 Medicare?

51a. To remind you to make appointments for
tests or treatment?
51b. To remind you to get a flu shot or other
immunization?
51c. To remind you about screening tests such as
breast cancer or colorectal cancer screening?
52. In the last 6 months, did you spend one or
more nights in a hospital?
53. In the last 6 months, did anyone from a
doctor’s office or Medicare contact you to follow
up about your hospital stay?
54. In the last 6 months, was there a time when
you believed you needed care or services that
Medicare decided not to give you?
55. In the last 6 months, have you ever asked
anyone at Medicare to reconsider a decision not
to provide or pay for health care or services?
56. When you spoke to Medicare about the
decision not to provide care or services, did
they…Please mark one or more.
56a. Tell you that you can file an appeal
56b. Offer to send you forms that you need in
order to file an appeal
56c. Suggest how to resolve your complaint
56d. Listen to your complaint but did not help
resolve it
56e. Discourage you from taking action
56f. Do none of these things
57. In the last 6 months, have you called or
written Medicare with a complaint or problem?
58. Thinking about the complaint process,
regardless of whether you agree or disagree with
the final outcome, how satisfied are you with
how Medicare handled your complaint?
59. How long did it take for Medicare to settle
your complaint?

No comparable question

No comparable question
No comparable question
46. In the last 6 months, was there a time when
you believed you needed care or services that
Medicare decided not to give you?
47. In the last 6 months, have you ever asked
anyone at Medicare to reconsider a decision not
to provide or pay for health care or services?
56. When you spoke to Medicare about the
decision not to provide care or services, did
they…Please mark one or more.
56a. Tell you that you can file an appeal
56b. Offer to send you forms that you need in
order to file an appeal
56c. Suggest how to resolve your complaint
56d. Listen to your complaint but did not help
resolve it
56e. Discourage you from taking action
56f. Do none of these things
49. In the last 6 months, have you called or
written Medicare with a complaint or problem?
50. Thinking about the complaint process,
regardless of whether you agree or disagree with
the final outcome, how satisfied are you with how
Medicare handled your complaint?
51. How long did it take for Medicare to settle
your complaint?

Survey Section

About You

Proposed Question

Existing Question

60. Was your complaint or problem settled to
your satisfaction?
61. In general, how would you rate your overall
health?
62. In general, how would you rate your overall
mental or emotional health?
63. In the past 12 months, have you seen a
doctor or other health provider 3 or more times
for the same condition or problem?
64. Is this a condition or problem that has lasted
for at least 3 months?
65. Do you now need or take any medicine
prescribed by a doctor for any condition?
66. Is this to treat a condition that has lasted for
at least 3 months?
67. In the last 6 months, how often was it easy to
get the medicines your doctor prescribed?
68. Do you have insurance that pays part or all of
the cost of your prescription medicines?
69. In the last 6 months, did you delay or not fill
a prescription because you felt you could not
afford it?
70. Are you currently enrolled in a Medicare Part
D plan (prescription drug plan)?
71. Are you enrolled in a Medicare Part D
Medication Therapy Management program?
72. Did a health care provider, such as a
pharmacist, call or meet with you to review your
medications and answer your questions about
your medications?
73. Did the review increase your understanding
of your medications and how to use them?
74. A printed summary of the review includes a
letter, a medication action plan, and a personal
medication list. Did you receive a printed
summary of the review?
75. How satisfied were you with the information
in the printed summary of the review?
76. Overall, how satisfied are you with the
Medication Therapy Management program
provided by your Medicare Part D plan?
77. Has a doctor ever told you that you had any of
the following conditions?

52. Was your complaint or problem settled to
your satisfaction?
53. In general, how would you rate your overall
health?
54. In general, how would you rate your overall
mental health?
55. In the past 12 months, have you seen a
doctor or other health provider 3 or more times
for the same condition or problem?
56. Is this a condition or problem that has lasted
for at least 3 months?
57. Do you now need or take medicine
prescribed by a doctor?
58. Is this to treat a condition that has lasted for
at least 3 months?
59. In the last 6 months, how often was it easy to
get the medicines your doctor prescribed?
60. Do you have insurance that pays part or all of
the cost of your prescription medicines?
61. In the last 6 months, did you delay or not fill
a prescription because you felt you could not
afford it?

77a. A heart attack?
77b. Angina or coronary heart disease?
NO SUCH RESPONSE OPTION
77c. Hypertension or high blood pressure?
77d. Cancer, other than skin cancer?
77e. Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)?
77f. Any kind of diabetes or high blood sugar?

62a. A heart attack?
62b. Angina or coronary heart disease?
62c. A stroke
NO SUCH RESPONSE OPTION
62d. Cancer, other than skin cancer?
62e. Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)?
62f. Any kind of diabetes or high blood sugar?
63. Have you had a flu shot since September 1,
2011?

78. Have you had a flu shot since July 1, 2015?

No comparable question
No comparable question

No comparable question

No comparable question

No comparable question

No comparable question
No comparable question
62. Has a doctor ever told you that you had any of
the following conditions?

Survey Section

Proposed Question

Existing Question

79. Have you ever had a pneumonia shot? This
shot is usually given only once or twice in a
person’s lifetime and is different from a flu shot.
It is also called the pneumococcal vaccine.
80. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
81. In the last 6 months, how often were you
advised to quit smoking or using tobacco by a
doctor or other health provider?
No comparable question

64. Have you ever had a pneumonia shot? This
shot is usually given only once or twice in a
person’s lifetime and is different from the flu
shot. It is also called the pneumococcal vaccine.
65. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
66. In the last 6 months, how often were you
advised to quit smoking or using tobacco by a
doctor or other health provider?
67. What is your age?

No comparable question
82. What is the highest grade or level of school
that you have completed?
83. Are you of Hispanic or Latino origin or
descent?
84. What is your race? Please mark one or more.
85. How many people live in your household
now, including yourself?
86. Because of a health or physical problem are
you unable to do or have any difficulty doing the
following activities? (Please mark one response
for each activity.)
87. The Medicare Program is trying to learn more
about the health care or services provided to
people with Medicare. May Medicare contact
you again about the health care services that you
received?
88. Did someone help you complete this survey?
89. How did that person help you? Please mark
one or more.
No comparable question

68. Are you male or female?
69. What is the highest grade or level of school
that you have completed?
70. Are you of Hispanic or Latino origin or
descent?
71. What is your race? Please mark one or more.
No comparable question
75. Because of a health or physical problem are
you unable to do or have any difficulty doing the
following activities? (Please mark one response
for each activity.)
76. The Medicare Program is trying to learn more
about the health care or services provided to
people with Medicare. May Medicare contact
you again about the health care services that you
received?
72. Did someone help you complete this survey?
73. How did that person help you? Please mark
one or more.
74. Do you live alone?