MA Survey Crosswalk

Current MA-Only Survey
Item Number and Text

Proposed MA-Only Survey
Item Number and Text/English

Proposed MA-Only Survey
Item Number and Text/Spanish

Item Count=56

Item Count=45

Item Count=47

(Directions) We are sending you this survey
because we believe you recently left or were
dropped by a health plan, or switched health
plans.

(Directions) We are sending you
this survey because we believe you
recently changed or switched to
another health plan or dropped
your Medicare health plan.

(Directions) We are sending you
this survey because we believe you
recently changed or switched to
another health plan or dropped
your Medicare health plan.

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.

1. Our records show that you used
to belong to [MARKETING]
(Contract Number [PREV_PLAN])
but no longer belong to that plan.
Is that right?
RESPONSES: Yes, I changed or
switched health plans; I changed or
switched health plans but my
former plan was not [PLAN NAME];
No, I did not change, switch or drop
health plans recently

1. Our records show that you used Revised response
to belong to [MARKETING]
option #2.
(Contract Number [PREV_PLAN])
but no longer belong to that plan.
Is that right?
RESPONSES: Yes, I changed or
switched health plans; I changed or
switched health plans but my
former plan was not [PLAN NAME];
No, I did not change, switch or drop
health plans recently

2. Did you have to switch or leave [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)

2. Did you have to change, switch
or drop your former health plan 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 or
discontinued by the organization
that provides my insurance (such as
a former employer or a union)
None of the above → Continue
survey, go to Question 3

2. Did you have to change, switch
or drop your former health plan 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 or
discontinued by the organization
that provides my insurance (such as
a former employer or a union)
None of the above → Continue
survey, go to Question 3

Comments

Revised
instructions.

Revised intro and
added response
option to make
item easier to
navigate and to
better screen out
beneficiaries who
did not disenroll
voluntarily.

(Preamble) 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 the plan that you
left, dropped, or switched.

(Q3 Preamble) As you answer the
questions in this survey, please
think only of your former health
plan.

(Q3 Preamble) As you answer the
questions in this survey, please
think only of your former health
plan.

Revised preamble.

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

3. Did you ever try to get
information or help from your
former plan’s customer service?
Yes/No

3. Did you ever try to get
information or help from your
former plan’s customer service?
Yes/No

Deleted first
sentence to make
item easier to
understand.

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

4. How often did your former 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 my former health plan's
customer service

4. How often did your former 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 my former health plan's
customer service

Changed "the
plan's customer
service" to "your
former plan's
customer service."

5. Did you ever need written information from
the plan in a language other than English?
Yes
No → If No, go to #11

N/A

5. Did you ever need written
information from the plan in
Spanish?
Yes
No → If No, go to #11

Simplified
question, now for
Spanish version
only. Removed
from English
version.

6. 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

N/A

6. How often did the plan give you
written information in Spanish?
Never
Sometimes
Usually
Always
I did not need written
information in a language other
than English

Simplified
question, now for
Spanish version
only. Removed
from English
version.

7. Did you ever try to get any kind of care, tests, 5. Did you ever try to get any kind
or treatment through the plan?
of care, tests, or treatment through
Yes
your former plan? Yes/No
No → If No, go to #13

7. Did you ever try to get any kind
of care, tests, or treatment through
your former plan? Yes/No

Changed "the plan"
to "your former
plan."

8. How often was it easy to get the care, tests,
or treatment you thought you needed through
the plan?
Never
Sometimes
Usually
Always

6. How often was it easy to get the
care, tests, or treatment you
needed through your former plan?
Never/Sometimes/Usually/Always/
I did not try to get any kind of care,
tests, or treatment through my
former plan

8. How often was it easy to get the
care, tests, or treatment you
needed through your former plan?
Never/Sometimes/Usually/Always/
I did not try to get any kind of care,
tests, or treatment through my
former plan

Changed "the plan"
to "your former
plan." Added N/A
response category.

9. 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

7. 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 former plan?

9. 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 former plan?

Changed "the plan"
to "your former
plan."

(Intro) 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].

(Q9 Preamble) The next questions
are about reasons you may have
had for changing, switching or
dropping your former health plan.

(Q10 Preamble) The next questions
are about reasons you may have
had for changing, switching or
dropping your former health plan.

Deleted first
sentence; revised
second sentence.

10. Did you leave the plan because you found
out that someone had signed you up for the
plan without your permission?
Yes
No

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

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

Changed "the plan"
to "your former
plan."

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

9. Did you leave your former plan
because you were taken off the
plan by mistake? Yes/No

11. Did you leave your former plan
because you were taken off the
plan by mistake? Yes/No

Simplified question
and changed "the
plan" to "your
former plan."

12. 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

11. Some people have to pay their
health plan a monthly fee (called a
premium) out of their own pocket
for health coverage.

13. Some people have to pay their
health plan a monthly fee (called a
premium) out of their own pocket
for health coverage.

Changed "the plan"
to "your former
plan."

Did you leave your former plan
because this monthly fee went up?
Yes
No
I did not have to pay my former
plan a monthly fee out of my own
pocket

Did you leave your former plan
because this monthly fee went up?
Yes
No
I did not have to pay my former
plan a monthly fee out of my own
pocket

13. 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

N/A

N/A

Removed question.

14. 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

N/A

N/A

Removed question.

15. Did you leave the plan because the dollar
amount you had to pay each time you visited a
doctor went up?
Yes
No

10. Did you leave your former plan
because the dollar amount you had
to pay each time you visited a
doctor went up?
Yes
No
I did not have to pay for doctor
visits

12. Did you leave your former plan
because the dollar amount you had
to pay each time you visited a
doctor went up?
Yes
No
I did not have to pay for doctor
visits

Changed "the plan"
to "your former
plan."

16. Did you leave the plan because you found a
health plan that costs less?
Yes
No

12. Did you leave your former plan
because you found a health plan
that costs less? Yes/No

14. Did you leave your former plan
because you found a health plan
that costs less? Yes/No

Changed "the plan"
to "your former
plan."

17. Did you leave the plan because a change in
your personal finances meant you could no
longer afford the plan?
Yes
No

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

15. Did you leave your former plan Changed "the plan"
because a change in your personal to "your former
finances meant you could no longer plan."
afford the plan? Yes/No

18. Did you leave the plan because you were
frustrated by the plan’s approval process for
care, tests, or treatment?
Yes
No

14. Did you leave your former plan
because you were frustrated by the
plan’s approval process for care,
tests, or treatment? Yes/No

16. Did you leave your former plan Changed "the plan"
because you were frustrated by the to "your former
plan’s approval process for care,
plan."
tests, or treatment? Yes/No

19. Did you leave the plan because you had
problems getting the care, tests, or treatment
you needed?
Yes
No

15. Did you leave your former plan
because you had problems getting
the care, tests, or treatment you
needed? Yes/No

17. Did you leave your former plan
because you had problems getting
the care, tests, or treatment you
needed? Yes/No

Changed "the plan"
to "your former
plan."

20. 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

16. 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 your former plan
because you had problems getting
the plan to pay a claim? Yes/No

18. 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 your former plan
because you had problems getting
the plan to pay a claim? Yes/No

Changed "the plan"
to "your former
plan."

21. 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

17. Did you leave your former plan
because the doctors or other
health care providers you wanted
to see did not belong to the plan?
Yes/No

19. .Did you leave your former plan
because the doctors or other
health care providers you wanted
to see did not belong to the plan?
Yes/No

Changed "the plan"
to "your former
plan."

22. Did you leave the plan because clinics or
hospitals you wanted to go to for care were not
covered by the plan?
Yes
No

18. Did you leave your former plan
because clinics or hospitals you
wanted to go to for care were not
covered by the plan? Yes/No

20. Did you leave your former plan
because clinics or hospitals you
wanted to go to for care were not
covered by the plan? Yes/No

Changed "the plan"
to "your former
plan."

23. 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

19. Did you leave your former 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

21. Did you leave your former 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

Changed "the plan"
to "your former
plan."

24. Did you leave the plan because you were
unhappy with how the plan handled a question
or complaint?
Yes
No

20. Did you leave your former plan
because you were unhappy with
how the plan handled a question or
complaint?

22. Did you leave your former plan
because you were unhappy with
how the plan handled a question or
complaint?

Changed "the plan"
to "your former
plan."

25. Did you leave the plan because you could
not get the information or help you needed
from the plan?
Yes
No

21. Did you leave your former plan
because you could not get the
information or help you needed
from the plan? Yes/No

23. Did you leave your former plan
because you could not get the
information or help you needed
from the plan? Yes/No

Changed "the plan"
to "your former
plan."

26. Did you leave the plan because their
customer service staff did not treat you with
courtesy and respect?
Yes
No

22. Did you leave your former plan
because their customer service
staff did not treat you with
courtesy and respect? Yes/No

24. Did you leave your former plan
because their customer service
staff did not treat you with
courtesy and respect? Yes/No

Changed "the plan"
to "your former
plan."

(Q27 Intro) 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.

23. Every year Medicare evaluates
all health plans and gives them a
star rating that gives information
on health plan quality.
Have you ever seen the Medicare
Star Rating for any health plan?
Yes/No

25. Every year Medicare evaluates
all health plans and gives them a
star rating that gives information
on health plan quality.
Have you ever seen the Medicare
Star Rating for any health plan?
Yes/No

Simplified intro and
added new
question.

27. Did you leave the plan because it got a low
Medicare Star Rating? Yes/no

24. Did you leave your former plan
because it got a low star rating?
Yes/No

26. Did you leave your former plan
because it got a low star rating?
Yes/No

28. Did you leave the plan because you found
another plan with a higher Medicare Star
Rating?
Yes
No

25. Did you leave your former plan
because you found another plan
with a higher star rating? Yes/No

27. Did you leave your former plan
because you found another plan
with a higher star rating? Yes/No

29. 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
30. Did you leave the plan because a family
member or friend told you that another health
plan was a better plan?
Yes
No
31. .Did you leave the plan because you saw a
commercial or advertisement for a health plan
you thought you would like better?
Yes
No

26. In the past year, did you
consider Medicare Star Ratings
when trying to choose a plan?
Yes/No

28. In the past year, did you
consider Medicare Star Ratings
when trying to choose a plan?
Yes/No

27. Did you leave your former plan
because a family member or friend
told you about a better plan?
Yes/No

29. Did you leave your former plan
because a family member or friend
told you about a better plan?
Yes/No

32. Did you leave the plan because you found
another plan that better met your prescription
needs?
Yes
No

29. Did you leave your former plan
because you found another plan
that better met your prescription
needs? Yes/No

31. Did you leave your former plan
because you found another plan
that better met your prescription
needs? Yes/No

Added new
question (see
above) and made
this a separate
question.
Based on cognitive
testing, changed
"the plan" to "your
former plan" to
make it clearer to
respondents.
Reivsed question
for clarity.

Changed "the plan"
to "your former
plan" and
underlined "family
member or friend.
28. Did you leave your former plan 30. Did you leave your former plan Changed "the plan"
because you saw a commercial or
because you saw a commercial or
to "your former
advertisement for a health plan you advertisement for a health plan you plan."
thought you would like better?
thought you would like better?
Yes/No
Yes/No
Changed "the plan"
to "your former
plan."

33. 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
34. 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:
__________________________
__________________________

30. Did you leave your former plan
because another plan offered
better benefits or coverage (for
example, dental or vision care)?
Yes/No

32. Did you leave your former plan
because another plan offered
better benefits or coverage (for
example, dental or vision care)?
Yes/No

Shortened
question and
changed "the plan"
to "your former
plan."

N/A

N/A

Removed question.

(Header) YOUR EXPERIENCE WITH INSURANCE
AGENTS, BROKERS, OR PLAN
REPRESENTATIVES

N/A

N/A

Removed item.

35. 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

N/A

N/A

Removed question.

36. Did an insurance agent, broker, or plan
N/A
representative ever visit your home without
your asking them to, to tell you about insurance
for health care or prescription medicines?
Yes
No

N/A

Removed question.

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

N/A

N/A

Removed question.

38. Did an insurance agent, broker, or plan
representative give you any information that
was not correct?
Yes
No → If No, go to #58

N/A

N/A

Removed question.

39. 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)
_____________________________
_____________________________

N/A

N/A

Removed question.

41. In general, how would you rate your overall
mental health?
Excellent
Very good
Good
Fair
Poor

32. In general, how would you rate
your overall mental or emotional
health ?

34. In general, how would you rate
your overall mental or emotional
health ?

Underlined
"mental or
emotional."

42. 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

33. In the past 12 months, how
many different prescription
medicines did you take?

35. In the past 12 months, how
many different prescription
medicines did you take?

Shortened
question and used
"did you take"
rather than "did
you fill."

44. Is this a condition or problem that has
lasted for at least 3 months?
Yes
No

34. In the past 12 months, have you
seen a doctor or other health
provider 3 or more times for the
same condition or problem?

36. In the past 12 months, have you
seen a doctor or other health
provider 3 or more times for the
same condition or problem?

Revised for
consistency across
surveys. Also
changed question
order.

43. 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
45. Do you now need or take medicine
prescribed by a doctor?
Yes
No → If No, go to #65

35. Is this a condition or problem
that has lasted at least 3 months?

37. Is this a condition or problem
that has lasted at least 3 months?

Revised for
consistency across
surveys. Also
changed question
order.
36. Do you now need or take any
38. Do you now need or take any
Revised question
medicine prescribed by a doctor for medicine prescribed by a doctor for for clarity.
any condition?
any condition?

46. Is this to treat a condition that has lasted
for at least 3 months?
Yes
No

37. Is this medicine to treat a
condition that has lasted for at
least 3 months?

39. Is this medicine to treat a
condition that has lasted for at
least 3 months?

Revised question
for clarity.

47. 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

38. Has a doctor ever told you that
you have any of the following
conditions?
A heart attack
Angina or coronary heart disease
High blood pressure or
hypertension
Cancer, other than skin cancer
Emphysema, asthma or COPD
(chronic obstructive pulmonary
disease)
Any kind of diabetes or high
blood sugar

40. Has a doctor ever told you that
you have any of the following
conditions?
A heart attack
Angina or coronary heart disease
High blood pressure or
hypertension
Cancer, other than skin cancer
Emphysema, asthma or COPD
(chronic obstructive pulmonary
disease)
Any kind of diabetes or high
blood sugar

Revised response
option #3.

48. 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

N/A

N/A

Removed question.

49. Are you male or female?
Male
Female

N/A

N/A

Removed question.

55. 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)
_____________________________

44. How did that person help you?
Please mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way
(please
print)
45. May we contact you again if we
have questions about your survey
responses or if we have other
questions about the health care
services that you received?

46. How did that person help you?
Please mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way
(please
print)
47. May we contact you again if we
have questions about your survey
responses or if we have other
questions about the health care
services that you received?

Revised question
for clarity.

56. 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

Deleted first
sentence; revised
second sentence.