| Existing Question | Proposed Question | Type of Change | Reason for Change | Burden Change | ||||
| 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. |
- | - | - | ||||
| 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? | - | - | - | ||||
| 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 needed? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No | ||||
| 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? | 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? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No | ||||
| 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? | 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? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No | ||||
| 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? | - | - | - | ||||
| 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? | - | - | - | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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 | No comparable question | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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? | 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? | - | - | - | ||||
| 44. In the last 6 months, how often was it easy to get the care, tests or treatment you thought you needed through Medicare? | 10. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? | Change in wording and placement in survey | Wording change and change in placement of item both reflect AHRQ 5.0 Health Plan update | No | ||||
| 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? | 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? | - | - | - | ||||
| 14. In the last 6 months, how many times did you visit your personal doctor to get care for yourself? | 12. 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? | 13. 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? | 14. 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? | 15. 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? | 16. 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? | 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? | - | - | - | ||||
| 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? | 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? | - | - | - | ||||
| 21. In the last 6 months, did your personal doctor order a blood test, x-ray or other test for you? | 19. 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? | 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? | - | - | - | ||||
| 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? | 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? | - | - | - | ||||
| 24. In the last 6 months, did you take any prescription medicine? | 22. 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? | 23. 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? | No comparable question | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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? | 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? | - | - | - | ||||
| 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? | 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? | - | - | - | ||||
| 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? | 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? | - | - | - | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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? | 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? | - | - | - | ||||
| 34. In the last 6 months, did you try to make any appointments to see a specialist? | 28. In the last 6 months, did you make any appointments to see a specialist? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No | ||||
| 35. In the last 6 months, how often was it easy to get appointments with specialists? | 29. In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No | ||||
| 36. How many specialists have you seen in the last 6 months? | 30. 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? | 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? | - | - | - | ||||
| 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? | 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? | - | - | - | ||||
| 39. How likely are you to change doctors if you are dissatisfied with the way you and your doctor communicate? | 33. 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? | 34. 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? | 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? | - | - | - | ||||
| 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? | 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? | - | - | - | ||||
| 43. In the last 6 months, did you try to get any kind of care, tests or treatment through Medicare? | No comparable question | Removed item | Removed to align with MA survey proposed change. Item deletion reflects AHRQ 5.0 Health Plan update which deletes this item from Health Plan core. | Yes, burden reduced | ||||
| 44. In the last 6 months, how often was it easy to get the care, tests or treatment you thought you needed through Medicare? | 10. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? | Change in wording and placement in survey | Wording change and change in placement of item both reflect AHRQ 5.0 Health Plan update | No | ||||
| 45. In the last 6 months, did you try to get information or help from Medicare’s customer service? | 37. In the last 6 months, did you get information or help from Medicare’s customer service? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No | ||||
| 46. In the last 6 months, how often did Medicare’s customer service give you the information or help you needed? | 38. 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? | 39. 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? | 40. 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? | 41. 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? | 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? | - | - | - | ||||
| 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? |
No comparable question | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 52. In the last 6 months, did you spend one or more nights in a hospital? | 45. In the last 6 months, did you spend one or more nights in a hospital? | Change in placement in survey | Change in placement to improve flow of topics within survey | No | ||||
| 53. In the last 6 months, did anyone from a doctor’s office or Medicare contact you to follow up about your hospital stay? | No comparable question | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 57. In the last 6 months, have you called or written Medicare with a complaint or problem? | No comparable question | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 59. How long did it take for Medicare to settle your complaint? | No comparable question | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 60. Was your complaint or problem settled to your satisfaction? | No comparable question | Removed item | Removed to align with MA survey proposed change. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced | ||||
| 61. In general, how would you rate your overall health? | 43. In general, how would you rate your overall health? | - | - | - | ||||
| 62. In general, how would you rate your overall mental or emotional health? | 44. In general, how would you rate your overall mental or emotional health? | - | - | - | ||||
| 52. In the last 6 months, did you spend one or more nights in a hospital? | 45. In the last 6 months, did you spend one or more nights in a hospital? | Change in placement in survey | Change in placement to improve flow of topics within survey | No | ||||
| 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 | Removed item | Removed to align with MA survey proposed change. Replaced by proposed question 66, which fulfills requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced | ||||
| 64. Is this a condition or problem that has lasted for at least 3 months? | No comparable question | Removed item | Removed to align with MA survey proposed change. Replaced by proposed question 66, which fulfills requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced | ||||
| 65. Do you now need or take any medicine prescribed by a doctor for any condition? | No comparable question | Removed item | Removed to align with MA survey proposed change. Replaced by proposed question 66, which fulfills requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced | ||||
| 66. Is this to treat a condition that has lasted for at least 3 months? | No comparable question | Removed item | Removed to align with MA survey proposed change. Replaced by proposed question 66, which fulfills requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced | ||||
| 67. In the last 6 months, how often was it easy to get the medicines your doctor prescribed? | 46. 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? | 47. 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? | 48. 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)? | 49. Are you currently enrolled in a Medicare Part D plan (prescription drug plan)? | - | - | - | ||||
| 71. Are you also enrolled in your Medicare Part D Plan’s Medication Therapy Management Program? | 50. Are you enrolled in a Medicare Part D Medication Therapy Management program? | Change in wording | Change in wording to improve clarity of question | No | ||||
| 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? | 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? | - | - | - | ||||
| 73. Did the review increase your understanding of your medications and how to use them? | 52. 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? | 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? | - | - | - | ||||
| 75. How satisfied were you with the information in the printed summary of the review? | 54. 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? | 55. 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? 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? |
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? |
- | - | - | ||||
| 78. Have you had a flu shot since July 1, 2015? | 57. Have you had a flu shot since July 1, 2016? | - | - | - | ||||
| 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. | 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. | Change in wording | Wording change reflects NCQA update | No | ||||
| 80. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? | 59. 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? | 60. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider? | - | - | - | ||||
| 82. What is the highest grade or level of school that you have completed? | 61. What is the highest grade or level of school that you have completed? | - | - | - | ||||
| 83. Are you of Hispanic or Latino origin or descent? | 62. Are you of Hispanic or Latino origin or descent? | - | - | - | ||||
| 84. What is your race? Please mark one or more. | 63. What is your race? Please mark one or more. | - | - | - | ||||
| 85. How many people live in your household now, including yourself? | 64. 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.) | 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.) | - | - | - | ||||
| No comparable question | 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? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items | ||||
| No comparable question | 67. Do you ever use the internet at home? | Added item | Fulfills CMS information need. CMS will monitor this item over time to inform decision making about survey administration protocols that include internet | Yes, but offset by removed items | ||||
| 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? | 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? | - | - | - | ||||
| 88. Did someone help you complete this survey? | 69. Did someone help you complete this survey? | - | - | - | ||||
| 89. How did that person help you? Please mark one or more. | 70. How did that person help you? Please mark one or more. | - | - | - | ||||
| Existing Question | Proposed Question | Type of Change | Reason for Change | Burden Change |
| 1. Our records show that in 2015 your health services were covered by the plan named on the back page. Is that right? | 1. Our records show that in 2016 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) | 2. Please write below the name of the health plan you had in 2016 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? | 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 needed? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 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? | 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? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 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? | 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? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 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? | - | - | - |
| 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? | - | - | - |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | 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? | - | - | - |
| 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? | 10. In the last 6 months, how often was it easy to get the care, tests or treatment you needed? | Change in wording and placement in survey | Wording change and change in placement of item both reflect AHRQ 5.0 Health Plan update | No |
| 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? | 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? | - | - | - |
| 14. In the last 6 months, how many times did you visit your personal doctor to get care for yourself? | 12. 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? | 13. 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? | 14. 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? | 15. 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? | 16. 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 21. In the last 6 months, did your personal doctor order a blood test, x-ray or other test for you? | 19. 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 24. In the last 6 months, did you take any prescription medicine? | 22. 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? | 23. 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | 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? | - | - | - |
| 34. In the last 6 months, did you try to make any appointments to see a specialist? | 28. In the last 6 months, did you make any appointments to see a specialist? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 35. In the last 6 months, how often was it easy to get appointments with specialists? | 29. In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 36. How many specialists have you seen in the last 6 months? | 30. 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 39. In the last 6 months, did you try to get any kind of care, tests, or treatment through your health plan? | No comparable question | Removed item | Item is not used in Star Ratings. Item deletion reflects AHRQ 5.0 Health Plan update which deletes this item from Health Plan core. | Yes, burden reduced |
| 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? | 10. In the last 6 months, how often was it easy to get the care, tests or treatment you needed? | Change in wording and placement in survey | Wording change and change in placement of item both reflect AHRQ 5.0 Health Plan update | No |
| 41. In the last 6 months, did you try to get information or help from your health plan’s customer service? | 33. In the last 6 months, did you get information or help from your health plan’s customer service? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 42. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed? | 34. 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? | 35. 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? | 36. 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? | 37. 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? | 38. 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 | 39. A co-pay is the amount of money you pay at the time of a visit to a doctor’s office or clinic. In the last 6 months, did your health plan offer to lower the amount of your co-pay because you have a health condition (like high blood pressure)? | Added item | Added item to meet information needs associated with the Value-Based Insurance Design (VBID) model | Yes, but offset by removed items |
| No comparable question | 40. Your health plan benefits are the types of health care and services you can get under the plan. In the last 6 months, did your health plan offer you extra benefits because you have a health condition (like high blood pressure)? | Added item | Added item to meet information needs associated with the VBID model | Yes, but offset by removed items |
| 47. In the last 6 months, did anyone from a doctor’s office or your health plan contact you: 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? |
No comparable question | Removed item | Item is not used in Star Ratings. Information need met by this item no longer exists. | Yes, burden reduced |
| 48. In the last 6 months, did you spend one or more nights in a hospital? | 50. In the last 6 months, did you spend one or more nights in a hospital? | Change in placement in survey | Change in placement to improve flow of topics within survey | No |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 53. In the last 6 months, have you called or written your health plan with a complaint or problem? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 55. How long did it take for your health plan to settle your complaint? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 56. Was your complaint or problem settled to your satisfaction? | No comparable question | Removed item | Item is not used in Star Ratings. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 60. In the last 6 months, did you try to get information from your prescription drug plan about which prescription medicines were covered? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 64. In the last 6 months, how many different prescription medicines did you fill or have refilled? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 65. In the last 6 months, did a doctor prescribe a medicine for you that your prescription drug plan did not cover? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 66. When this happened, did you contact your prescription drug plan to ask them to cover the medicine your doctor prescribed? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 67. 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 |
No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 68. In the last 6 months, did anyone from a doctor’s office, pharmacy or your prescription drug plan contact you: 68a. To make sure you filled or refilled a prescription? 68b. To make sure you were taking medications as directed? |
41. In the last 6 months, did anyone from a doctor’s office, pharmacy or your prescription drug plan contact you: 41a. To make sure you filled or refilled a prescription? 41b. 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? | 42. 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? | 43. 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? | 44. 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? | 45. 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? | 46. 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? | 47. 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? | No comparable question | Removed item | Item is not used in Star Ratings. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 76. In general, how would you rate your overall health? | 48. In general, how would you rate your overall health? | - | - | - |
| 77. In general, how would you rate your overall mental or emotional health? | 49. In general, how would you rate your overall mental or emotional health? | - | - | - |
| 48. In the last 6 months, did you spend one or more nights in a hospital? | 50. In the last 6 months, did you spend one or more nights in a hospital? | - | - | - |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 54, 55, and 56, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 79. Is this a condition or problem that has lasted for at least 3 months? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 54, 55, and 56, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 80. Do you now need or take any medicine prescribed by a doctor for any condition? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 54, 55, and 56, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 81. Is this to treat a condition that has lasted for at least 3 months? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 54, 55, and 56, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 82. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it? | 51. 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? | 52. 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? 84a. A heart attack? 84b. Angina or coronary heart disease? 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? |
53. Has a doctor ever told you that you had any of the following conditions? 53a. A heart attack? 53b. Angina or coronary heart disease? 53c. Hypertension or high blood pressure? 53d. Cancer, other than skin cancer? 53e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? 53f. Any kind of diabetes or high blood sugar? |
- | - | - |
| No comparable question | 54. Do you have serious difficulty walking or climbing stairs? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| No comparable question | 55. Do you have difficulty dressing or bathing? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| No comparable question | 56. Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| 85. Have you had a flu shot since July 1, 2015? | 57. Have you had a flu shot since July 1, 2016? | - | - | - |
| 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. | 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. | Change in wording | Wording change reflects NCQA update | No |
| 87. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? | 59. 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? | 60. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider? | - | - | - |
| 89. What is the highest grade or level of school that you have completed? | 61. What is the highest grade or level of school that you have completed? | - | - | - |
| 90. Are you of Hispanic or Latino origin or descent? | 62. Are you of Hispanic or Latino origin or descent? | - | - | - |
| 91. What is your race? Please mark one or more. | 63. What is your race? Please mark one or more. | - | - | - |
| 92. How many people live in your household now, including yourself? | 64. How many people live in your household now, including yourself? | - | - | - |
| No comparable question | 65. Do you ever use the internet at home | Added item | Fulfills CMS information need. CMS will monitor this item over time to inform decision making about survey administration protocols that include internet | Yes, but offset by removed items |
| 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? | 66. 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? | 67. Did someone help you complete this survey? | - | - | - |
| 95. 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 |
68. How did that person help you? Please mark one or more. 68a. Read the questions to me 68b. Wrote down the answers I gave 68c. Answered the questions for me 68d. Translated the questions into my language 68e. Helped in some other way |
- | - | - |
| Existing Question | Proposed Question | Type of Change | Reason for Change | Burden Change |
| 1. Our records show that in 2015 your health services were covered by the plan named on the back page. Is that right? | 1. Our records show that in 2016 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) | 2. Please write below the name of the health plan you had in 2016 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? | 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 needed? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 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? | 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? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 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? | 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? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 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? | - | - | - |
| 8. In the last 6 months, how often did you see the person you came to see within 15 minutes of your appointment time? | 8. 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | 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? | - | - | - |
| 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? | 10. In the last 6 months, how often was it easy to get the care, tests or treatment you needed? | Change in wording and placement in survey | Wording change and change in placement of item both reflect AHRQ 5.0 Health Plan update | No |
| 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? | 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? | - | - | - |
| 14. In the last 6 months, how many times did you visit your personal doctor to get care for yourself? | 12. 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? | 13. 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? | 14. 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? | 15. 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? | 16. 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 21. In the last 6 months, did your personal doctor order a blood test, x-ray or other test for you? | 19. 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 24. In the last 6 months, did you take any prescription medicine? | 22. 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? | 23. 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 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 | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | 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? | - | - | - |
| 34. In the last 6 months, did you try to make any appointments to see a specialist? | 28. In the last 6 months, did you make any appointments to see a specialist? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 35. In the last 6 months, how often was it easy to get appointments with specialists? | 29. In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 36. How many specialists have you seen in the last 6 months? | 30. 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? | 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? | - | - | - |
| 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? | 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? | - | - | - |
| 39. In the last 6 months, did you try to get any kind of care, tests or treatment through your health plan? | No comparable question | Removed item | Item is not used in Star Ratings. Item deletion reflects AHRQ 5.0 Health Plan update which deletes this item from Health Plan core. | Yes, burden reduced |
| 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? | 10. In the last 6 months, how often was it easy to get the care, tests or treatment you needed? | Change in wording and placement in survey | Wording change and change in placement of item both reflect AHRQ 5.0 Health Plan update | No |
| 41. In the last 6 months, did you try to get information or help from your health plan’s customer service? | 33. In the last 6 months, did you get information or help from your health plan’s customer service? | Change in wording | Wording change reflects AHRQ 5.0 Health Plan update | No |
| 42. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed? | 34. 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? | 35. 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? | 36. 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? | 37. 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? | 38. 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 | 39. A co-pay is the amount of money you pay at the time of a visit to a doctor’s office or clinic. In the last 6 months, did your health plan offer to lower the amount of your co-pay because you have a health condition (like high blood pressure)? | Added item | Added item to meet information needs associated with the Value-Based Insurance Design (VBID) model | Yes, but offset by removed items |
| No comparable question | 40. Your health plan benefits are the types of health care and services you can get under the plan. In the last 6 months, did your health plan offer you extra benefits because you have a health condition (like high blood pressure)? | Added item | Added item to meet information needs associated with the VBID model | Yes, but offset by removed items |
| 47. In the last 6 months, did anyone from a doctor’s office or your health plan contact you: 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? |
No comparable question | Removed item | Item is not used in Star Ratings. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 48. In the last 6 months, did you spend one or more nights in a hospital? | 43. In the last 6 months, did you spend one or more nights in a hospital? | Change in placement in survey | Change in placement to improve flow of topics within survey | No |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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 | Removed item | Item is not used in Star Ratings. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 53. In the last 6 months, have you called or written your health plan with a complaint or problem? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 55. How long did it take for your health plan to settle your complaint? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 56. Was your complaint or problem settled to your satisfaction? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 57. In general, how would you rate your overall health? | 41. In general, how would you rate your overall health? | - | - | - |
| 58. In general, how would you rate your overall mental or emotional health? | 42. In general, how would you rate your overall mental or emotional health? | - | - | - |
| 48. In the last 6 months, did you spend one or more nights in a hospital? | 43. In the last 6 months, did you spend one or more nights in a hospital? | Change in placement in survey | Change in placement to improve flow of topics within survey | No |
| 59. 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 | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 49, 50, and 51, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 60. Is this a condition or problem that has lasted for at least 3 months? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 49, 50, and 51, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 61. Do you now need or take any medicine prescribed by a doctor for any condition? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 49, 50, and 51, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 62. Is this to treat a condition that has lasted for at least 3 months? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 49, 50, and 51, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 63. In the last 6 months, how often was it easy to get the medicines your doctor prescribed? | 44. In the last 6 months, how often was it easy to get the medicines your doctor prescribed? | - | - | - |
| 64. Do you have insurance that pays part or all of the cost of your prescription medicines? | 45. Do you have insurance that pays part or all of the cost of your prescription medicines? | - | - | - |
| 65. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it? | 46. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it? | - | - | - |
| 66. In the last 6 months, did you receive any mail order medicines that you did not request? | 47. In the last 6 months, did you receive any mail order medicines that you did not request? | - | - | - |
| 67. Has a doctor ever told you that you had any of the following conditions? 67a. A heart attack? 67b. Angina or coronary heart disease? 67c. Hypertension or high blood pressure? 67d. Cancer, other than skin cancer? 67e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? 67f. Any kind of diabetes or high blood sugar? |
48. Has a doctor ever told you that you had any of the following conditions? 48a. A heart attack? 48b. Angina or coronary heart disease? 48c. Hypertension or high blood pressure? 48d. Cancer, other than skin cancer? 48e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? 48f. Any kind of diabetes or high blood sugar? |
- | - | - |
| No comparable question | 49. Do you have serious difficulty walking or climbing stairs? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| No comparable question | 50. Do you have difficulty dressing or bathing? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| No comparable question | 51. Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| 68. Have you had a flu shot since July 1, 2015? | 52. Have you had a flu shot since July 1, 2016? | - | - | - |
| 69. 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. | 53. 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. | Change in wording | Wording change reflects NCQA update | No |
| 70. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? | 54. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? | - | - | - |
| 71. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider? | 55. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider? | - | - | - |
| 72. What is the highest grade or level of school that you have completed? | 56. What is the highest grade or level of school that you have completed? | - | - | - |
| 73. Are you of Hispanic or Latino origin or descent? | 57. Are you of Hispanic or Latino origin or descent? | - | - | - |
| 74. What is your race? Please mark one or more. | 58. What is your race? Please mark one or more. | - | - | - |
| 75. How many people live in your household now, including yourself? | 59. How many people live in your household now, including yourself? | - | - | - |
| No comparable question | 60. Do you ever use the internet at home? | Added item | Fulfills CMS information need. CMS will monitor this item over time to inform decision making about survey administration protocols that include internet | Yes, but offset by removed items |
| 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? | 61. 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? | - | - | - |
| 77. Did someone help you complete this survey? | 62. Did someone help you complete this survey? | - | - | - |
| 78. How did that person help you? Please mark one or more. 78a. Read the questions to me 78b. Wrote down the answers I gave 78c. Answered the questions for me 78d. Translated the questions into my language 78e. Helped in some other way |
63. How did that person help you? Please mark one or more. 63a. Read the questions to me 63b. Wrote down the answers I gave 63c. Answered the questions for me 63d. Translated the questions into my language 63e. Helped in some other way |
- | - | - |
| Existing Question | Proposed Question | Type of Change | Reason for Change | Burden Change |
| 1. Our records show that in 2015 your prescriptions were covered by the Medicare prescription drug plan named on the back page. Is that right? | 1. Our records show that in 2016 your prescriptions were covered by the Medicare prescription drug plan named on the back page. Is that right? | - | - | - |
| 2. Please write below the name of the Medicare prescription drug plan you had in 2015 and complete the rest of the survey based on the experiences you had with that plan. (Please print) | 2. Please write below the name of the Medicare prescription drug plan you had in 2016 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 try to get information or help about prescription drugs from your prescription drug plan’s customer service? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 4. 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 5. 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 6. In the last 6 months, did you try to get information from your prescription drug plan about which prescription medicines were covered? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 7. 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 8. 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? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 9. 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 medicine? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 10. In the last 6 months, how many different prescription medicines did you fill or have refilled? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 11. In the last 6 months, did a doctor prescribe a medicine for you that your prescription drug plan did not cover? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 12. When this happened, did you contact your prescription drug plan to ask them to cover the medicine your doctor prescribed? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 13. When you contacted your prescription drug plan about the decision not to cover a prescription medicine did they… 13a. Tell you that you can file an appeal 13b. Offer to send you forms that you need in order to file an appeal 13c. Suggest how to resolve your complaint 13d. Listen to your complaint but did not help to resolve it 13e. Discourage you from taking action 13f. Do none of the above 13g. All my prescribed medicines were covered |
No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 14. Thinking about the complaint process, regardless of whether you agree or disagree with the final outcome, how satisfied are you with how your plan handled your complaint? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 15. How long did it take for your plan to settle your complaint? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 16. Was your complaint or problem settled to your satisfaction? | No comparable question | Removed item | Item is not used in Star Ratings. Item achieved reliability of less than 0.70 for the majority of contracts. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 17. In the last 6 months, did anyone from a doctor’s office, pharmacy or your prescription drug plan contact you: 17a. To make sure you filled or refilled a prescription? 17b. To make sure you were taking medications as directed? |
3. In the last 6 months, did anyone from a doctor’s office, pharmacy or your prescription drug plan contact you: 3a. To make sure you filled or refilled a prescription? 3b. To make sure you were taking medications as directed? |
- | - | - |
| 18. In the last 6 months, how often was it easy to use your prescription drug plan to get the medicines your doctor prescribed? | 4. In the last 6 months, how often was it easy to use your prescription drug plan to get the medicines your doctor prescribed? | - | - | - |
| 19. In the last 6 months, did you ever use your prescription drug plan to fill a prescription at your local pharmacy? | 5. In the last 6 months, did you ever use your prescription drug plan to fill a prescription at your local pharmacy? | - | - | - |
| 20. In the last 6 months, how often was it easy to use your prescription drug plan to fill a prescription at your local pharmacy? | 6. In the last 6 months, how often was it easy to use your prescription drug plan to fill a prescription at your local pharmacy? | - | - | - |
| 21. In the last 6 months, did you ever use your prescription drug plan to fill a prescription by mail? | 7. In the last 6 months, did you ever use your prescription drug plan to fill a prescription by mail? | - | - | - |
| 22. In the last 6 months, how often was it easy to use your prescription drug plan to fill a prescription by mail? | 8. In the last 6 months, how often was it easy to use your prescription drug plan to fill a prescription by mail? | - | - | - |
| 23. 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? | 9. 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? | - | - | - |
| 24. Would you recommend your prescription drug plan for coverage of prescription drugs to other people like yourself? | No comparable question | Removed item | Item is not used in Star Ratings. Additionally item does not collect information that is used to meet an information need for a current or planned CMS program. | Yes, burden reduced |
| 25. In general, how would you rate your overall health? | 10. In general, how would you rate your overall health? | - | - | - |
| 26. In general, how would you rate your overall mental or emotional health? | 11. In general, how would you rate your overall mental or emotional health? | - | - | - |
| No comparable question | 12. In the last 6 months, did you spend one or more nights in a hospital? | Added item | Fulfills CMS information need. | Yes, but offset by removed items |
| 27. 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 | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 16, 17, and 18, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 28. Is this a condition or problem that has lasted for at least 3 months? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 16, 17, and 18, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 29. Do you now need or take any medicine prescribed by a doctor for any condition? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 16, 17, and 18, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 30. Is this to treat a condition that has lasted for at least 3 months? | No comparable question | Removed item | Item is not used in Star Ratings. Replaced by proposed questions 16, 17, and 18, which fulfill requirements of Section 4302 of the Affordable Care Act. | Yes, burden reduced |
| 31. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it? | 13. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it? | - | - | - |
| 32. In the last 6 months, did you receive any mail order medicines that you did not request? | 14. In the last 6 months, did you receive any mail order medicines that you did not request? | - | - | - |
| 33. Has a doctor ever told you that you had any of the following conditions? 33a. A heart attack? 33b. Angina or coronary heart disease? 33c. Hypertension or high blood pressure? 33d. Cancer, other than skin cancer? 33e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? 33f. Any kind of diabetes or high blood sugar? |
15. Has a doctor ever told you that you had any of the following conditions? 15a. A heart attack? 15b. Angina or coronary heart disease? 15c. Hypertension or high blood pressure? 15d. Cancer, other than skin cancer? 15e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? 15f. Any kind of diabetes or high blood sugar? |
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| No comparable question | 16. Do you have serious difficulty walking or climbing stairs? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| No comparable question | 17. Do you have difficulty dressing or bathing? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| No comparable question | 18. Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? | Added item | Added to fulfill requirements of Section 4302 of the Affordable Care Act | Yes, but offset by removed items |
| 34. Have you had a flu shot since July 1, 2015? | No comparable question | Removed item | Item is not used in Star Ratings. NCQA measure; not applicable to prescription drug plans | Yes, burden reduced |
| 35. 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. | No comparable question | Removed item | Item is not used in Star Ratings. NCQA measure; not applicable to prescription drug plans | Yes, burden reduced |
| 36. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? | No comparable question | Removed item | Item is not used in Star Ratings. NCQA measure; not applicable to prescription drug plans | Yes, burden reduced |
| 37. 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 | Removed item | Item is not used in Star Ratings. NCQA measure; not applicable to prescription drug plans | Yes, burden reduced |
| 38. What is the highest grade or level of school that you have completed? | 19. What is the highest grade or level of school that you have completed? | - | - | - |
| 39. Are you of Hispanic or Latino origin or descent? | 20. Are you of Hispanic or Latino origin or descent? | - | - | - |
| 40. What is your race? Please mark one or more. | 21. What is your race? Please mark one or more. | - | - | - |
| 41. How many people live in your household now, including yourself? | 22. How many people live in your household now, including yourself? | - | - | - |
| No comparable question | 23 Do you ever use the internet at home? | Added item | Fulfills CMS information need. CMS will monitor this item over time to inform decision making about survey administration protocols that include internet | Yes, but offset by removed items |
| 42. 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? | 24. 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? | - | - | - |
| 43. Did someone help you complete this survey? | 25. Did someone help you complete this survey? | - | - | - |
| 44. How did that person help you? Please mark one or more. 44a. Read the questions to me 44b. Wrote down the answers I gave 44c. Answered the questions for me 44d. Translated the questions into my language 44e. Helped in some other way |
26. How did that person help you? Please mark one or more. 26a. Read the questions to me 26b. Wrote down the answers I gave 26c. Answered the questions for me 26d. Translated the questions into my language 26e. Helped in some other way |
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |