MA_PD Disenrollment Survey crosswalk

MA_PD Disenrollment Survey crosswalk_OMB_508FINAL.pdf

Implementation of the Medicare Prescription Drug Plan (PDP) and Medicare Advantage (MA) Plan Disenrollment Reasons Survey (CMS-10316)

MA_PD Disenrollment Survey crosswalk

OMB: 0938-1113

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1113 can be found here:

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Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
YOUR FORMER HEALTH PLAN
HEADER
We are sending you this survey because we Introduction to Q1
believe you recently switched or dropped
your Medicare health plan.

Proposed English
Language Survey
Question Number
Item Count=63
HEADER
Introduction to Q1

Proposed Spanish
Language Survey
Question Number
Item Count=63
HEADER
Introduction to Q1

COMMENTS

Our records show that you used to belong to 1
the health plan whose name is printed on
the cover of the survey but that you no
longer belong to that plan. Is that right?
o Yes, I switched to a different Medicare
health plan
o I switched health plans but my former
plan was not the plan printed on the cover of
this survey
o No, I did not switch plans or drop my
Medicare plan recently

For streamlining and to reduce
fielding costs, the survey no
longer displays customized text
with the prior contract
name/number. Wording to Q1
and response options changed
for new version.

Did you have to change, switch or drop your former
health plan for any of the following reasons?
o I moved outside of the area where the plan was
available
o I was dropped by the plan
o The plan was cancelled or discontinued in my area
o The plan was changed or discontinued by the
organization that provides my insurance (such as a
former employer or a union)
o None of the above

Did you have to switch plans or drop your 2
former Medicare health plan for any of the
following reasons?
o I moved outside of the area where the plan
was available
o I was dropped by the plan
o The plan was cancelled or discontinued in
my area
o The plan was changed or discontinued by
the organization that provides my insurance
(such as a former employer or a union)
o None of the above

Re-worded Q2 to improve
usability (changed "did you
have to change, switch or drop"
to "did you have to switch
plans or drop").

GETTING INFORMATION OR HELP FROM YOUR
FORMER HEALTH PLAN

GETTING INFORMATION OR HELP FROM
YOUR FORMER HEALTH PLAN

HEADER

No change to wording.

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

As you answer the questions in this survey, Q3 preamble
please think only of your former health plan
(whose name is printed on the cover of this
survey).

Q3 preamble

Added reference to the plan
name printed on the cover of
the survey.

No change to wording.

YOUR FORMER HEALTH PLAN
We are sending you this survey because we believe
you recently changed or switched to another
Medicare health plan or dropped your Medicare
health plan.
Our records show that you used to belong to
[MARKETING] (Contract Number [PREV_PLAN]) but no
longer belong to that plan. Is that right?
o Yes, I changed or switched health plans
o I changed or switched health plans but my former
plan was not [PLAN NAME]
o No, I did not change, switch or drop health plans
recently

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

HEADER

No change to wording.
Minor revisions made to Q1
introduction to improve
usability

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
How often did your former plan’s customer service
How often did your former plan’s customer 4
service give you the information or help you
give you the information or help you needed?
needed?
o Never
o Never
o Sometimes
o Sometimes
o Usually
o Usually
o Always
o Always
o I did not try to get information or help from my
o I did not try to get information or help
former plan's customer service
from my former plan's customer service
Did you ever try to get information from your former Item has been dropped.
5
plan about which prescription medicines were
covered? Yes/No

Proposed English
Language Survey
Question Number
Item Count=63
4

Proposed Spanish
Language Survey
Question Number
Item Count=63
4

COMMENTS

DROPPED

How often did your former plan give you all the
Item has been dropped.
information you needed about which prescription
medicines were covered?
o Never
o Sometimes
o Usually
o Always
o I did not try to get information from my former plan
about which prescription medicines were covered

DROPPED

Equivalent item no longer
exists on the MA & PD CAHPS
survey for comparison of
enrollee experiences.
Equivalent item no longer
exists on the MA & PD CAHPS
survey for comparison of
enrollee experiences.

Did you ever try to get information from your former Item has been dropped.
plan about how much you would have to pay for a
prescription medicine? Yes/No

DROPPED

How often did your former plan give you information Item has been dropped.
about how much you would have to pay for a
prescription medicine?
o Never
o Sometimes
o Usually
o Always
o I did not try to get information from my former plan
about how much I would have to pay for a
prescription medicine

DROPPED

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
Did you ever need written information from the plan Item has been dropped
9 (SPANISH VERSION
ONLY)
in Spanish? Yes/No

Proposed English
Language Survey
Question Number
Item Count=63
NA

Proposed Spanish
Language Survey
Question Number
Item Count=63
DROPPED

How often did the plan give you written information
in Spanish?
o Never
o Sometimes
o Usually
o Always
o I did not need written information in Spanish

Item has been dropped

10 (SPANISH VERSION
ONLY)

DROPPED

GETTING HEALTH CARE AND THE PRESCRIPTION
MEDICINES YOU NEEDED FROM YOUR FORMER
HEALTH PLAN
Did you ever try to get any kind of care, tests, or
treatment through your former plan? Yes/No

GETTING HEALTH CARE AND THE
PRESCRIPTION MEDICINES YOU NEEDED
FROM YOUR FORMER HEALTH PLAN
Item has been dropped.

HEADER

No change to wording.

DROPPED

Equivalent item no longer
exists on the MA & PD CAHPS
survey for comparison of
enrollee experiences.

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

How often was it easy to get the care, tests, 10
or treatment you needed through your
former plan?
o Never
o Sometimes
o Usually
o Always
o I did not try to get any kind of care, tests,
or treatment through my former plan
In the last 6 months, did you make an
NA
appointment to see a specialist?
o Yes
o No if no go to question 8
o Someone else made my specialist
appointments for me

No change to wording.

New item enables comparison
to enrollee experiences on MA
& PDP CAHPS survey.

COMMENTS

Spanish language version of the
survey is distributed almost
exclusively in Puerto Rico
where plans customarily
provide information in Spanish.
Item dropped due to low
endorsement and to reduce
burden.
Spanish language version of the
survey is distributed almost
exclusively in Puerto Rico
where plans customarily
provide information in Spanish.
Item dropped due to low
endorsement and to reduce
burden.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
In the last 6 months, how often did you get NA
an appointment to see a specialist as soon as
you needed?
o Never
o Sometimes
o Usually
o Always
o I did not make an appointment to see a
specialist

Proposed English
Language Survey
Question Number
Item Count=63
7

Proposed Spanish
Language Survey
Question Number
Item Count=63
7

COMMENTS

Item has been dropped.

DROPPED

How often was it easy to use your former
plan to get the medicines your doctor
prescribed?
o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to get any
prescription medicines
Did you ever use your former plan to fill a
Did you ever use your former plan to fill a
prescription at a pharmacy? Yes/No
prescription at a pharmacy? Yes/No
How often was it easy to use your former plan to fill a How often was it easy to use your former
prescription at a pharmacy?
plan to fill a prescription at a pharmacy?
o Never
o Never
o Sometimes
o Sometimes
o Usually
o Usually
o Always
o Always
o I did not have to use my former plan to fill a
o I did not have to use my former plan to fill
a prescription at a pharmacy
prescription at a pharmacy
Did you ever use your former plan to fill any
Did you ever use your former plan to fill any
prescriptions by mail? Yes/No
prescriptions by mail? Yes/No

Equivalent item no longer
exists on the MA & PD CAHPS
survey for comparison of
enrollee experiences.
No change to wording.

No change to wording.

How often was it easy to use your former plan to fill
prescriptions by mail?
o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to fill a prescription by
mail

No change to wording.

Did a doctor ever prescribe a medicine for you that
your former plan did not cover? Yes/No

How often was it easy to use your former plan to get
the medicines your doctor prescribed?
o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to get any prescription
medicines

How often was it easy to use your former
plan to fill prescriptions by mail?
o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to fill a
prescription by mail

New item enables comparison
to enrollee experiences on MA
& PDP CAHPS survey.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
Using any number from 0 to 10, where 0 is the worst Using any number from 0 to 10, where 0 is
17
the worst health plan possible and 10 is the
health plan possible and 10 is the best health plan
best health plan possible, what number
possible, what number would you use to rate your
would you use to rate your former plan?
former plan?
REASONS YOU LEFT YOUR FORMER HEALTH PLAN
REASONS YOU LEFT YOUR FORMER HEALTH HEADER
PLAN
The next questions are about reasons you may have The next questions are about reasons you
Q18 preamble
had for changing, switching or dropping your former may have had for switching or dropping
health plan.
your former health plan.

Proposed English
Language Survey
Question Number
Item Count=63
13

Proposed Spanish
Language Survey
Question Number
Item Count=63
13

COMMENTS

HEADER

No change to wording.

Q18 preamble

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

Did you leave your former plan because you 18
found out that someone had signed you up
for the plan without your permission?
Yes/No

Re-worded preamble to
improve usability by revising
"changing, switching or
dropping" to "switching or
dropping."
No change to wording.

Did you leave your former plan because you were
taken off the plan by mistake? Yes/No
Did you leave your former plan because the dollar
amount you had to pay each time you filled or refilled
a prescription went up?
o Yes
o No
o I did not have to pay for my prescription medicines

Did you leave your former plan because you 19
were taken off the plan by mistake? Yes/No
Did you leave your former plan because the 20
dollar amount you had to pay each time you
filled or refilled a prescription went up?
o Yes
o No
o I did not have to pay for my prescription
medicines

No change to wording.

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

Did you leave your former plan because the 21
dollar amount you had to pay each time you
visited a doctor went up?
o Yes
o No
o I did not have to pay for doctor visits

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
Some people have to pay their health plan a monthly Some people have to pay their health plan a 22
fee (called a premium) out of their own pocket for
monthly fee (called a premium) out of their
health coverage.
own pocket for health coverage.

Proposed English
Language Survey
Question Number
Item Count=63
18

Proposed Spanish
Language Survey
Question Number
Item Count=63
18

COMMENTS

No change to wording.

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

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

Health plans have a list of the prescription medicines
they will cover. Did you leave your former plan
because they changed the list of prescription
medicines they cover? Yes/No

Health plans have a list of the prescription 23
medicines they will cover. Did you leave your
former plan because they changed the list of
prescription medicines they cover? Yes/No

No change to wording.

Did you leave your former plan because you found a
health plan that costs less? Yes/No
Did you leave your former plan because a change in
your personal finances meant you could no longer
afford the plan? Yes/No
NOT INCLUDED

Did you leave your former plan because you 24
found a health plan that costs less? Yes/No
Did you leave your former plan because a
25
change in your personal finances meant you
could no longer afford the plan? Yes/No
Did you leave your former plan because a
NOT INCLUDED
change in your health meant the plan no
longer met your needs? Yes/No

No change to wording.

NOT INCLUDED

Did you leave your former plan because it
turned out to be more expensive than you
expected? Yes/No

Did you leave your former plan because the plan
refused to pay for a medicine your doctor prescribed?
Yes/No
Did you leave your former plan because you had
problems getting the medicines your doctor
prescribed? Yes/No
Did you leave your former plan because it was
difficult to get brand name medicines?
o Yes
o No
o I did not try to get brand name medicines through
my former plan

Did you leave your former plan because the 26
plan refused to pay for a medicine your
doctor prescribed? Yes/No
Did you leave your former plan because you 27
had problems getting the medicines your
doctor prescribed? Yes/No
Did you leave your former plan because it
28
was difficult to get brand name medicines?
o Yes
o No
o I did not try to get brand name medicines
through my former plan

New item added to further
assess possible reasons
beneficiaries leave their former
plan.
New item added to further
assess possible reasons
beneficiaries leave their former
plan.
No change to wording.

No change to wording.

NOT INCLUDED

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
Did you leave your former plan because you were
Did you leave your former plan because you 29
were frustrated by the plan’s approval
frustrated by the plan’s approval process for
process for medicines your doctor
medicines your doctor prescribed?
prescribed?
Yes/No
Yes/No
Did you leave your former plan because you did not Did you leave your former plan because you 30
know whom to contact when you had a problem
did not know whom to contact when you
filling or refilling a prescription?
had a problem filling or refilling a
Yes/No
prescription? Yes/No
Did you leave your former plan because it was hard to Did you leave your former plan because it
31
get information from the plan
was hard to get information from the plan
-- like which prescription medicines were covered or -- like which prescription medicines were
how much a specific medicine would cost? Yes/No
covered or how much a specific medicine
would cost? Yes/No

Proposed English
Language Survey
Question Number
Item Count=63
27

Proposed Spanish
Language Survey
Question Number
Item Count=63
27

COMMENTS

No change to wording.

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

Did you leave your former plan because you 32
were frustrated by the plan’s approval
process for care, tests, or treatment? Yes/No

No change to wording.

Did you leave your former plan because you had
problems getting the care, tests, or treatment you
needed? Yes/No
Claims are sent to a health plan for payment. You
may send in the claims yourself or doctors, hospitals,
or others may do this for you.
Did you leave your former plan because you had
problems getting the plan to pay a claim?
Yes/No

Did you leave your former plan because you 33
had problems getting the care, tests, or
treatment you needed? Yes/No
Claims are sent to a health plan for payment. 34
You may send in the claims yourself or
doctors, hospitals, or others may do this for
you. Did you leave your former plan because
you had problems getting the plan to pay a
claim? Yes/No

No change to wording.

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

Did you leave your former plan because the 35
doctors or other health care providers you
wanted to see did not belong to the plan?
Yes/No

No change to wording.

Did you leave your former plan because clinics or
hospitals you wanted to go to for care were not
covered by the plan? Yes/No
Did you leave your former plan because it was hard to
get information from the plan -- like which health
care services were covered or how much a specific
test or treatment would cost? Yes/No

Did you leave your former plan because
36
clinics or hospitals you wanted to go to for
care were not covered by the plan? Yes/No
Did you leave your former plan because it
37
was hard to get information from the plan -like which health care services were covered
or how much a specific test or treatment
would cost? Yes/No

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
Did you leave your former plan because you 38
were unhappy with how the plan handled a
question or complaint?
Yes/No

Proposed English
Language Survey
Question Number
Item Count=63
36

Proposed Spanish
Language Survey
Question Number
Item Count=63
36

COMMENTS

Did you leave your former plan because you could not
get the information or help you needed from the
plan? Yes/No
Did you leave your former plan because their
customer service staff did not treat you with courtesy
and respect? Yes/No
Every year Medicare evaluates all health plans and
gives them a star rating that gives information on
health plan quality.

Did you leave your former plan because you 39
could not get the information or help you
needed from the plan? Yes/No
Did you leave your former plan because their 40
customer service staff did not treat you with
courtesy and respect? Yes/No
Every year Medicare evaluates all health
Q41 preamble
plans and gives them a star rating.

No change to wording.

Q39 preamble

Re-worded the preamble to
improve usability.

Have you ever seen the Medicare Star Rating for any
health plan? Yes/No

Item has been dropped

DROPPED

Low endorsement; removed to
reduce respondent burden

Did you leave your former plan because it got a low
star rating? Yes/No
Did you leave your former plan because you found
another plan with a higher star rating? Yes/No

Did you leave your former plan because it
42
got a low Medicare star rating? Yes/No
Did you leave your former plan because you 43
found another plan with a higher Medicare
star rating? Yes/No
Item has been dropped
44

Inserted "Medicare" before
"star rating" for added clarity.
Inserted "Medicare" before
"star rating" for added clarity.

DROPPED

Low endorsement; removed to
reduce respondent burden

HEADER

No change in wording.

No change to wording.

HEADER

No change to wording.

Did you leave your former plan because you were
unhappy with how the plan handled a question or
complaint?
Yes/No

In the past year, did you consider the Medicare Star
Ratings when trying to choose a plan? Yes/No
OTHER REASONS FOR LEAVING YOUR FORMER
HEALTH PLAN
Did you leave your former plan because a family
member or friend told you about a better plan?
Yes/No
Did you leave your former plan because you saw a
commercial or advertisement for a health plan you
thought you would like better?
Yes/No
Did you leave your former plan because you found
another plan that better met your prescription
needs? Yes/No

OTHER REASONS FOR LEAVING YOUR
FORMER HEALTH PLAN
Did you leave your former plan because a
family member or friend told you about a
better plan? Yes/No
Did you leave your former plan because you
saw a commercial or advertisement for a
health plan you thought you would like
better? Yes/No
Did you leave your former plan because you
found another plan that better met your
prescription needs?
Yes/No
Did you leave your former plan because another plan Did you leave your former plan because
offered better benefits or coverage (for example,
another plan offered better benefits or
dental or vision care)?
coverage (for example, dental or vision
Yes/No
care)? Yes/No
ABOUT YOU
ABOUT YOU

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
In general, how would you rate your overall health? In general, how would you rate your overall 49
health?
o Excellent
o Excellent
o Very good
o Very good
o Good
o Good
o Fair
o Fair
o Poor
o Poor
In general, how would you rate your overall mental or In general, how would you rate your overall 50
emotional health?
mental or emotional health?
o Excellent
o Excellent
o Very good
o Very good
o Good
o Good
o Fair
o Fair
o Poor
o Poor

Proposed English
Language Survey
Question Number
Item Count=63
45

Proposed Spanish
Language Survey
Question Number
Item Count=63
45

COMMENTS

No change to wording.

In the past 12 months, how many different
prescription medicines did you take?
o None
o 1 to 2 medicines
o 3 to 5 medicines
o 6 or more medicines
In the past 12 months, have you seen a doctor or
other health provider 3 or more times for the same
condition or problem?
Yes/No

In the past 12 months, how many different
prescription medicines did you take?
o None
o 1 to 2 medicines
o 3 to 5 medicines
o 6 or more medicines
In the past 12 months, have you seen a
doctor or other health provider 3 or more
times for the same condition or problem?
Yes/No

No change to wording.

Is this a condition or problem that has lasted for at
least 3 months? Yes/No
Do you now need or take any medicine prescribed by
a doctor for any condition?
Yes/No
Is this medicine to treat a condition that has lasted for
at least 3 months? Yes/No
Has a doctor ever told you that you have any of the
following conditions?
o A heart attack
o Angina or coronary heart disease
o High blood pressure or hypertension
o Cancer, other than skin cancer
o Emphysema, asthma or COPD (chronic obstructive
pulmonary disease)
o Any kind of diabetes or high blood sugar

Is this a condition or problem that has lasted
for at least 3 months? Yes/No
Do you now need or take any medicine
prescribed by a doctor for any condition?
Yes/No
Is this medicine to treat a condition that has
lasted for at least 3 months? Yes/No
Has a doctor ever told you that you have any
of the following conditions?
o A heart attack
o Angina or coronary heart disease
o High blood pressure or hypertension
o Cancer, other than skin cancer
o Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)
o Any kind of diabetes or high blood sugar

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=63
What is the highest grade or level of school 57
that you have completed?
o 8th grade or less
o Some high school, but did not graduate
o High school graduate or GED
o Some college or 2-year degree
o 4-year college graduate
o More than 4-year college degree

Proposed English
Language Survey
Question Number
Item Count=63
53

Proposed Spanish
Language Survey
Question Number
Item Count=63
53

COMMENTS

Are you of Hispanic or Latino origin or
58
descent?
o Yes, Hispanic or Latino
o No, not Hispanic or Latino
What is your race? Please mark one or more. 59
o White
o Black or African-American
o Asian
o Native Hawaiian or other Pacific Islander
o American Indian or Alaska Native

No change to wording.

What language do you mainly speak at
60
home?
o Chinese
o English
o Russian
o Spanish
o Vietnamese
o Some other language (please print)
Did someone help you complete this survey? Yes/No Did someone help you complete this survey? 61
Yes/No

No change to wording.

How did that person help you? Please mark one or
more.
o Read the questions to me
o Wrote down the answers I gave
o Answered the questions for me
o Translated the questions into my
language
o Helped in some other way (please
print)
May we contact you again if we have questions about
your survey responses or if we have other questions
about the health care services that you received?
Yes/No

No change to wording.

What is the highest grade or level of school that you
have completed?
o 8th grade or less
o Some high school, but did not graduate
o High school graduate or GED
o Some college or 2-year degree
o 4-year college graduate
o More than 4-year college degree
Are you of Hispanic or Latino origin or descent?
o Yes, Hispanic or Latino
o No, not Hispanic or Latino
What is your race? Please mark one or more.
o White
o Black or African-American
o Asian
o Native Hawaiian or other Pacific Islander
o American Indian or Alaska Native
What language do you mainly speak at home?
o Chinese
o English
o Russian
o Spanish
o Vietnamese
o Some other language (please print)

How did that person help you? Please mark
one or more.
o Read the questions to me
o Wrote down the answers I gave
o Answered the questions for me
o Translated the questions into my
language
o Helped in some other way (please
print)
May we contact you again if we have
questions about your survey responses or if
we have other questions about the health
care services that you received? Yes/No

No change to wording.

File Type	application/pdf
File Title	MA PD Disenrollment Survey Crosswalk
Author	RAND Corporation
File Modified	2020-02-06
File Created	2020-02-05