Crosswalk - MA PD Survey

Survey Item Crosswalk for MA-PD Questionnaires
Survey Section

Proposed Question

Existing Question

Introductory Items

1. Our records show that in 2015 your health
services were covered by the plan named on the
back page. Is that right?
2. Please write below the name of the health plan
you had in 2015 and complete the rest of the
survey based on the experiences you had with
that plan. (Please print)
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?
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?
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?
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?

1. Our records show that in 2011 your health
services were covered by the plan named on the
back page. Is that right?
2. Please write below the name of the health plan
you had in 2011 and complete the rest of the
survey based on the experiences you had with
that plan. (Please print)
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?
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?
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?
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?

Your Health Care in
the Last 6 Months

Survey Section

Proposed Question
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?
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?
24. 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?
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?

Existing Question
13. 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?
14. In the last 6 months, how often was it easy to
get the medical equipment you needed through
your health plan?
15. 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?
16. In the last 6 months, how many times did you
visit your personal doctor to get care for yourself?
17. In the last 6 months, how often did your
personal doctor explain things in a way that was
easy to understand?
18. In the last 6 months, how often did your
personal doctor listen carefully to you?
19. In the last 6 months, how often did your
personal doctor show respect for what you had to
say?
20. In the last 6 months, how often did your
personal doctor spend enough time with you?
21. 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?
22. 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?
23. In the last 6 months, did your personal doctor
order a blood test, x-ray or other test for you?
24. 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?
25. 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?
26. In the last 6 months, did you take any
prescription medicine?
27. In the last 6 months, how often did you and
your personal doctor talk about all the
prescription medicines you were taking?
No comparable question

No comparable question

Survey Section

Proposed Question
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?
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

Getting Health Care
From Specialists

Your Health Plan

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?

Existing Question
No comparable question

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?
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

35. In the last 6 months, how often was it easy to
get appointments with specialists?

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?

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. In the last 6 months, did you try to get any
kind of care, tests, or treatment through your
health plan?

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?
38. In the last 6 months, did you try to get any
kind of care, tests or treatment through your
health plan?

Survey Section

Your Medicare
Rights

Proposed Question

Existing Question

40. In the last 6 months, how often was it easy to
get the care, tests or treatment you thought you
needed through your health plan?
41. In the last 6 months, did you try to get
information or help from your health plan’s
customer service?
42. In the last 6 months, how often did your
health plan’s customer service give you the
information or help you needed?
43. In the last 6 months, how often did your
health plan’s customer service staff treat you with
courtesy and respect?
44. In the last 6 months, did your health plan give
you any forms to fill out?
45. In the last 6 months, how often were the
forms from your health plan easy to fill out?
46. 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 your health plan?
47. In the last 6 months, did anyone from a
doctor’s office or your health plan contact you:

39. In the last 6 months, how often was it easy to
get the care, tests or treatment you thought you
needed through your health plan?
40. In the last 6 months, did you try to get
information or help from your health plan’s
customer service?
41. In the last 6 months, how often did your
health plan’s customer service give you the
information or help you needed?
42. In the last 6 months, how often did your
health plan’s customer service staff treat you with
courtesy and respect?
43. In the last 6 months, did your health plan give
you any forms to fill out?
44. In the last 6 months, how often were the
forms from your health plan 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 your health plan?
No comparable question

47a. To remind you to make appointments for
tests or treatment?
47b. To remind you to get a flu shot or other
immunization?
47c. To remind you about screening tests such as
breast cancer or colorectal cancer screening?
48. In the last 6 months, did you spend one or
more nights in a hospital?
49. In the last 6 months, did anyone from a
doctor’s office or your health plan contact you to
follow up about your hospital stay?
50. In the last 6 months, was there a time when
you believed you needed care or services that
your health plan decided not to give you?
51. In the last 6 months, have you ever asked
anyone at your health plan to reconsider a
decision not to provide or pay for health care or
services?
52. When you spoke to your health plan about
the decision not to provide care or services, did
they…Please mark one or more.
52a.Tell you that you can file an appeal
52b. Offer to send you forms that you need in
order to file an appeal
52c. Suggest how to resolve your complaint
52d. Listen to your complaint but did not help to
resolve it
52e. Discourage you from taking action
52f. Do none of these things

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
your health plan decided not to give you?
47. In the last 6 months, have you ever asked
anyone at your health plan to reconsider a
decision not to provide or pay for health care or
services?
48. When you spoke to your health plan about
the decision not to provide care or services, did
they…Please mark one or more.
48a.Tell you that you can file an appeal
48b. Offer to send you forms that you need in
order to file an appeal
48c. Suggest how to resolve your complaint
48d. Listen to your complaint but did not help to
resolve it
48e. Discourage you from taking action
48f. Do none of these things

Survey Section

Your Prescription
Drug Plan

Proposed Question

Existing Question

53. In the last 6 months, have you called or
written your health plan with a complaint or
problem?
54. Thinking about the complaint process,
regardless of whether you agree or disagree with
the final outcome, how satisfied are you with how
your health plan handled your complaint?
55. How long did it take for your health plan to
settle your complaint?
56. Was your complaint or problem settled to
your satisfaction?
57. You contact customer service to get
information about what is covered and how to
use a drug plan. In the last 6 months, did you try
to get information or help about prescriptions
from your prescription drug plan’s customer
service?
58. In the last 6 months, how often did your
prescription drug plan’s customer service give you
the information or help you needed about
prescription drugs?
59. In the last 6 months, how often did your
prescription drug plan’s customer service staff
treat you with courtesy and respect when you
tried to get information or help about
prescription drugs?
60. In the last 6 months, did you try to get
information from your prescription drug plan
about which prescription medicines were
covered?
61. In the last 6 months, how often did your
prescription drug plan’s customer service give you
all the information you needed about which
prescription medicines were covered?
62. In the last 6 months, did you try to get
information from your prescription drug plan
about how much you would have to pay for your
prescription medicines?
63. In the last 6 months, how often did your
prescription drug plan’s customer service give you
all the information you needed about how much
you would have to pay for your prescription
medicines?
64. In the last 6 months, how many different
prescription medicines did you fill or have
refilled?
65. In the last 6 months, did a doctor prescribe a
medicine for you that your prescription drug plan
did not cover?

49. In the last 6 months, have you called or
written your health plan 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
your health plan handled your complaint?
51. How long did it take for your health plan to
settle your complaint?
52. Was your complaint or problem settled to
your satisfaction?
53. You contact customer service to get
information about what is covered and how to
use a drug plan. In the last 6 months, did you try
to get information or help about prescriptions
from your prescription drug plan’s customer
service?
54. In the last 6 months, how often did your
prescription drug plan’s customer service give you
the information or help you needed about
prescription drugs?
55. In the last 6 months, how often did your
prescription drug plan’s customer service staff
treat you with courtesy and respect when you
tried to get information or help about
prescription drugs?
56. In the last 6 months, did you try to get
information from your prescription drug plan
about which prescription medicines were
covered?
57. In the last 6 months, how often did your
prescription drug plan’s customer service give you
all the information you needed about which
prescription medicines were covered?
58. In the last 6 months, did you try to get
information from your prescription drug plan
about how much you would have to pay for your
prescription medicines?
59. In the last 6 months, how often did your
prescription drug plan’s customer service give you
all the information you needed about how much
you would have to pay for your prescription
medicines?
60. In the last 6 months, how many different
prescription medicines did you fill or have
refilled?
61. In the last 6 months, did a doctor prescribe a
medicine for you that your prescription drug plan
did not cover?

Survey Section

About You

Proposed Question

Existing Question

66. When this happened, did you contact your
prescription drug plan to ask them to cover the
medicine your doctor prescribed?

62. When this happened, did you contact your
prescription drug plan to ask them to cover the
medicine your doctor prescribed?

67. When you contacted your prescription drug
plan about the decision not to cover a
prescription medicine did they…

63. When you contacted your prescription drug
plan about the decision not to cover a
prescription medicine did they…

67a. Tell you that you can file an appeal
67b. Offer to send you forms that you need in
order to file an appeal
67c. Suggest how to resolve your complaint
67d. Listen to your complaint but did not help to
resolve it
67e. Discourage you from taking action
67f. Do none of the above
67g. All my prescribed medicines were covered
68. In the last 6 months, did anyone from a
doctor’s office, pharmacy or your prescription
drug plan contact you:

63a. Tell you that you can file an appeal
63b. Offer to send you forms that you need in
order to file an appeal
63c. Suggest how to resolve your complaint
63d. Listen to your complaint but did not help to
resolve it
63e. Discourage you from taking action
63f. Do none of the above
63g. All my prescribed medicines were covered
No comparable question

68a. To make sure you filled or refilled a
prescription?
68b. To make sure you were taking medications
as directed?
69. In the last 6 months, how often was it easy to
use your prescription drug plan to get the
medicines your doctor prescribed?
70. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription at your
local pharmacy?
71. In the last 6 months, how often was it easy to
use your prescription drug plan to fill a
prescription at your local pharmacy?
72. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription by
mail?
73. In the last 6 months, how often was it easy to
use your prescription drug plan to fill a
prescription by mail?

64. In the last 6 months, how often was it easy to
use your prescription drug plan to get the
medicines your doctor prescribed?
65. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription at your
local pharmacy?
66. In the last 6 months, how often was it easy to
use your prescription drug plan to fill a
prescription at your local pharmacy?
67. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription by
mail?
68. In the last 6 months, how often was it easy to
use your prescription drug plan to fill a
prescription by mail?

74. Using any number from 0 to 10, where 0 is the
worst prescription drug plan possible and 10 is
the best prescription drug plan possible, what
number would you use to rate your prescription
drug plan?
75. Would you recommend your prescription
drug plan for coverage of prescription drugs to
other people like yourself?
76. In general, how would you rate your overall
health?
77. In general, how would you rate your overall
mental or emotional health?

69. Using any number from 0 to 10, where 0 is the
worst prescription drug plan possible and 10 is
the best prescription drug plan possible, what
number would you use to rate your prescription
drug plan?
70. Would you recommend your prescription
drug plan for coverage of prescription drugs to
other people like yourself?
71. In general, how would you rate your overall
health?
72. In general, how would you rate your overall
mental health?

Survey Section

Proposed Question

Existing Question

78. In the past 12 months, have you seen a doctor
or other health provider 3 or more times for the
same condition or problem?
79. Is this a condition or problem that has lasted
for at least 3 months?
80. Do you now need or take any medicine
prescribed by a doctor for any condition?
81. Is this to treat a condition that has lasted for
at least 3 months?
82. In the last 6 months, did you delay or not fill a
prescription because you felt you could not afford
it?
83. In the last 6 months, did you receive any mail
order medicines that you did not request?
84. Has a doctor ever told you that you had any of
the following conditions?

73. In the past 12 months, have you seen a doctor
or other health provider 3 or more times for the
same condition or problem?
74. Is this a condition or problem that has lasted
for at least 3 months?
75. Do you now need or take medicine prescribed
by a doctor?
76. Is this to treat a condition that has lasted for
at least 3 months?
77. In the last 6 months, did you delay or not fill a
prescription because you felt you could not afford
it?
No comparable question

84a. A heart attack?
84b. Angina or coronary heart disease?
NO SUCH RESPONSE OPTION
84c. Hypertension or high blood pressure?
84d. Cancer, other than skin cancer?
84e. Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)?
84f. Any kind of diabetes or high blood sugar?
85. Have you had a flu shot since July 1, 2015?
86. 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.
87. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
88. 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
No comparable question

78a. A heart attack?
78b. Angina or coronary heart disease?
78c. A stroke
NO SUCH RESPONSE OPTION
78d. Cancer, other than skin cancer?
78e. Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)?
78f. Any kind of diabetes or high blood sugar?
79. Have you had a flu shot since September 1,
2011?
80. 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.
81. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
82. In the last 6 months, how often were you
advised to quit smoking or using tobacco by a
doctor or other health provider?
83. What is your age?
84. Are you male or female?

89. What is the highest grade or level of school
that you have completed?
90. Are you of Hispanic or Latino origin or
descent?
91. What is your race? Please mark one or more.

85. What is the highest grade or level of school
that you have completed?
86. Are you of Hispanic or Latino origin or
descent?
87. What is your race? Please mark one or more.

92. How many people live in your household now,
including yourself?
93. 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?
94. Did someone help you complete this survey?

No comparable question

78. Has a doctor ever told you that you had any of
the following conditions?

91. 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?

Survey Section

Proposed Question

Existing Question

95. How did that person help you? Please mark
one or more.

89. How did that person help you? Please mark
one or more.

95a. Read the questions to me
95b. Wrote down the answers I gave
95c. Answered the questions for me
95d. Translated the questions into my language
95e. Helped in some other way
No comparable question

89a. Read the questions to me
89b. Wrote down the answers I gave
89c. Answered the questions for me
89d. Translated the questions into my language
89e. Helped in some other way
90. Do you live alone?