Crosswalk - FFS Survey

Table: Survey Item Crosswalk for FFS Questionnaire

Survey Section	Proposed Question	Existing 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 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?
	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” 2b. Employer, Union, or Retiree Health Coverage (insurance) 2c. Veteran’s Benefits, also known as VA benefits 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 2f. Any Prescription Drug Plan 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.	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” 2b. Employer, Union, or Retiree Health Coverage (insurance) 2c. Veteran’s Benefits, also known as VA benefits 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 2f. Any Prescription Drug Plan 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.
Your Health Care in the Last 6 Months	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?	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?
	CHANGE IN WORDING 4. In the last 6 months, when you needed care right away, how often did you get care as soon as 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?
	CHANGE IN WORDING 5. In the last 6 months, did you make any appointments for a check-up or routine care at a doctor’s office or clinic?	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?
	CHANGE IN WORDING 6. In the last 6 months, how often did you get an appointment for a check-up or routine care as soon as you needed?	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?	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?

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?	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?
	No comparable question	9. In the last 6 months, did you phone a doctor’s office or clinic with a medical question after regular office hours?
	No comparable question	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?
	No comparable question	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
	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?	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?
	CHANGE IN WORDING AND PLACEMENT 10. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed?	44. In the last 6 months, how often was it easy to get the care, tests or treatment you thought you needed through Medicare?
Your Personal Doctor	11. 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. 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?
	12. 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 many times did you visit your personal doctor to get care for yourself?
	13. 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 explain things in a way that was easy to understand?
	14. 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 listen carefully to you?
	15. 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 show respect for what you had to say?
	16. In the last 6 months, how often did your personal doctor spend enough time with you?	18. In the last 6 months, how often did your personal doctor spend enough time with you?
	17. 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. 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?
	18. 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?	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?

Survey Section	Proposed Question	Existing Question
	19. 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, did your personal doctor order a blood test, x-ray or other test for you?
	20. 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 someone from your personal doctor’s office follow up to give you those results?
	21. 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?	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?
	22. In the last 6 months, did you take any prescription medicine?	24. In the last 6 months, did you take any prescription medicine?
	23. In the last 6 months, how often did you and your personal doctor talk about all the prescription medicines you were taking?	25. 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	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?
	No comparable question	27. During your visits in the last 6 months, was your personal doctor’s use of a computer or handheld device helpful to you?
	No comparable 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?
	24. 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 get care from more than one kind of health care provider or use more than one kind of health care service?
	25. 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 need help from anyone in your personal doctor’s office to manage your care among these different providers and services?
	26. 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. 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	Existing Question
	No comparable question	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?
Getting Health Care from Specialists	27. 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?	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?
	CHANGE IN WORDING 28. In the last 6 months, did you make any appointments to see a specialist?	34. In the last 6 months, did you try to make any appointments to see a specialist?
	CHANGE IN WORDING 29. In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed?	35. In the last 6 months, how often was it easy to get appointments with specialists?
	30. How many specialists have you seen in the last 6 months?	36. How many specialists have you seen in the last 6 months?
	31. 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. 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?
	32. 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, how often did your personal doctor seem informed and up-to-date about the care you got from specialists?
Managing Your Health Care	33. How likely are you to change doctors if you are dissatisfied with the way you and your doctor communicate?	39. How likely are you to change doctors if you are dissatisfied with the way you and your doctor communicate?
	34. How likely are you to tell your doctor when you disagree with him or her?	40. How likely are you to tell your doctor when you disagree with him or her?
	35. 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?	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?
	36. 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?	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?
Medicare Experience	No comparable question	43. In the last 6 months, did you try to get any kind of care, tests or treatment through Medicare?
	CHANGE IN WORDING AND PLACEMENT 10. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed?	44. In the last 6 months, how often was it easy to get the care, tests or treatment you thought you needed through Medicare?
	CHANGE IN WORDING 37. In the last 6 months, did you get information or help from Medicare’s customer service?	45. In the last 6 months, did you try to get information or help from Medicare’s customer service?

Survey Section	Proposed Question	Existing Question
	38. In the last 6 months, how often did Medicare’s customer service give you the information or help you needed?	46. In the last 6 months, how often did Medicare’s customer service give you the information or help you needed?
	39. In the last 6 months, how often did Medicare’s customer service staff treat you with courtesy and respect?	47. In the last 6 months, how often did Medicare’s customer service staff treat you with courtesy and respect?
	40. In the last 6 months, did Medicare give you any forms to fill out?	48. In the last 6 months, did Medicare give you any forms to fill out?
	41. In the last 6 months, how often were the forms from Medicare easy to fill out?	49. In the last 6 months, how often were the forms from Medicare easy to fill out?
	42. 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?	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?
	No comparable question	51. In the last 6 months, did anyone from a doctor’s office or Medicare contact you: 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?
	CHANGE IN PLACEMENT 45. In the last 6 months, did you spend one or more nights in a hospital?	52. In the last 6 months, did you spend one or more nights in a hospital?
	No comparable question	53. In the last 6 months, did anyone from a doctor’s office or Medicare contact you to follow up about your hospital stay?
Your Medicare Rights	No comparable question	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?
	No comparable question	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?
	No comparable question	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
	No comparable question	57. In the last 6 months, have you called or written Medicare with a complaint or problem?
	No comparable question	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?
	No comparable question	59. How long did it take for Medicare to settle your complaint?

Survey Section	Proposed Question	Existing Question
	No comparable question	60. Was your complaint or problem settled to your satisfaction?
About You	43. In general, how would you rate your overall health?	61. In general, how would you rate your overall health?
	44. In general, how would you rate your overall mental or emotional health?	62. In general, how would you rate your overall mental or emotional health?
	CHANGE IN PLACEMENT 45. In the last 6 months, did you spend one or more nights in a hospital?	52. In the last 6 months, did you spend one or more nights in a hospital?
	No comparable question	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?
	No comparable question	64. Is this a condition or problem that has lasted for at least 3 months?
	No comparable question	65. Do you now need or take any medicine prescribed by a doctor for any condition?
	No comparable question	66. Is this to treat a condition that has lasted for at least 3 months?
	46. In the last 6 months, how often was it easy to get the medicines your doctor prescribed?	67. In the last 6 months, how often was it easy to get the medicines your doctor prescribed?
	47. Do you have insurance that pays part or all of the cost of your prescription medicines?	68. Do you have insurance that pays part or all of the cost of your prescription medicines?
	48. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it?	69. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it?
	49. Are you currently enrolled in a Medicare Part D plan (prescription drug plan)?	70. Are you currently enrolled in a Medicare Part D plan (prescription drug plan)?
	CHANGE IN WORDING 50. Are you enrolled in a Medicare Part D Medication Therapy Management program?	71. Are you also enrolled in your Medicare Part D Plan’s Medication Therapy Management Program?
	51. 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?	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?
	52. Did the review increase your understanding of your medications and how to use them?	73. Did the review increase your understanding of your medications and how to use them?
	53. 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?	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?
	54. How satisfied were you with the information in the printed summary of the review?	75. How satisfied were you with the information in the printed summary of the review?
	55. Overall, how satisfied are you with the Medication Therapy Management program provided by your Medicare Part D plan?	76. Overall, how satisfied are you with the Medication Therapy Management program provided by your Medicare Part D plan?
	56. Has a doctor ever told you that you had any of the following conditions? 56a. A heart attack? 56b. Angina or coronary heart disease? 56c. Hypertension or high blood pressure? 56d. Cancer, other than skin cancer? 56e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? 56f. Any kind of diabetes or high blood sugar?	77. Has a doctor ever told you that you had any of the following conditions? 77a. A heart attack? 77b. Angina or coronary heart disease? 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?

Survey Section	Proposed Question	Existing Question
	57. Have you had a flu shot since July 1, 2016?	78. Have you had a flu shot since July 1, 2015?
	CHANGE IN WORDING 58. Have you ever had one or more pneumonia shots? Two shots are usually given in a person’s lifetime and these are different from a flu shot. It is also called the pneumococcal vaccine.	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.
	59. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?	80. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?
	60. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider?	81. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider?
	61. What is the highest grade or level of school that you have completed?	82. What is the highest grade or level of school that you have completed?
	62. Are you of Hispanic or Latino origin or descent?	83. Are you of Hispanic or Latino origin or descent?
	63. What is your race? Please mark one or more.	84. What is your race? Please mark one or more.
	64. How many people live in your household now, including yourself?	85. How many people live in your household now, including yourself?
	65. 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.)	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.)
	66. Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?	No comparable question
	67. Do you ever use the internet at home?	No comparable question
	68. 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?	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?
	69. Did someone help you complete this survey?	88. Did someone help you complete this survey?
	70. How did that person help you? Please mark one or more.	89. How did that person help you? Please mark one or more.