MCAHPS Crosswalk

MCAHPS - Crosswalk 2020.pdf

Medicare Advantage, Medicare Part D, and Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey (CMS-R-246)

MCAHPS Crosswalk

OMB: 0938-0732

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0732 can be found here:

2023-05-05 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

Burden Change

Reason for Change

Type of Change

Proposed Question

Existing Question

FFS Survey

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, 3. In the last 6 months, did you have an illness, injury,
or condition that needed care right away in a clinic,
or condition that needed care right away in a clinic,
emergency room, or doctor’s office?
emergency room, or doctor’s office?

FFS Survey

4. In the last 6 months, when you needed care right
away, how often did you get care as soon as you
needed?

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?

6. In the last 6 months, how often did you get an
6. In the last 6 months, how often did you get an
appointment for a check-up or routine care as soon as appointment for a check-up or routine care as soon as
you needed?
you needed?
7. In the last 6 months, not counting the times you
went to an emergency room, how many times did you
go to a doctor’s office or clinic to get health care for
yourself?

7. In the last 6 months, not counting the times you
went to an emergency room, how many times did you
go to a doctor’s office or clinic to get health care for
yourself?

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. 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?

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. Using any number from 0 to 10, where 0 is the
worst health care possible and 10 is the best health
care possible, what number would you use to rate all
your health care in the last 6 months?
-

12. In the last 6 months, how many times did you visit 12. In the last 6 months, how many times did you visit your personal doctor to get care for yourself?
your personal doctor to get care for yourself?

10. In the last 6 months, how often was it easy to get 10. In the last 6 months, how often was it easy to get
the care, tests, or treatment you needed?
the care, tests, or treatment you needed?

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?

FFS Survey
-

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?
21. In the last 6 months, when your personal doctor 21. In the last 6 months, when your personal doctor
ordered a blood test, x-ray or other test for you, how ordered a blood test, x-ray or other test for you, how
often did you get those results as soon as you needed often did you get those results as soon as you needed
them?
them?

13. In the last 6 months, how often did your personal 13. In the last 6 months, how often did your personal
doctor explain things in a way that was easy to
doctor explain things in a way that was easy to
understand?
understand?

14. In the last 6 months, how often did your personal 14. In the last 6 months, how often did your personal
doctor listen carefully to you?
doctor listen carefully to you?

15. In the last 6 months, how often did your personal 15. In the last 6 months, how often did your personal
doctor show respect for what you had to say?
doctor show respect for what you had to say?

16. In the last 6 months, how often did your personal 16. In the last 6 months, how often did your personal
doctor spend enough time with you?
doctor spend enough time with you?
17. Using any number from 0 to 10, where 0 is the
worst personal doctor possible and 10 is the best
personal doctor possible, what number would you
use to rate your personal doctor?
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?
19. In the last 6 months, did your personal doctor
order a blood test, x-ray or other test for you?
20. In the last 6 months, when your personal doctor
ordered a blood test, x-ray or other test for you, how
often did someone from your personal doctor’s office
follow up to give you those results?

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?
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?
19. In the last 6 months, did your personal doctor
order a blood test, x-ray or other test for you?

FFS Survey
-

23. In the last 6 months, how often did you and your 23. In the last 6 months, how often did you and your personal doctor talk about all the prescription
personal doctor talk about all the prescription
medicines you were taking?
medicines you were taking?
24. In the last 6 months, did you get care from more 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 provider or use more
than one kind of health care service?
than one kind of health care service?

22. In the last 6 months, did you take any prescription 22. In the last 6 months, did you take any prescription
medicine?
medicine?

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?

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?

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?

28. In the last 6 months, did you make any
appointments to see a specialist?

29. In the last 6 months, how often did you get an
appointment to see a specialist as soon as you
needed?

30. How many specialists have you seen in the last 6
months?

FFS Survey
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?

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?

32. In the last 6 months, how often did your personal 32. In the last 6 months, how often did your personal
doctor seem informed and up-to-date about the care doctor seem informed and up-to-date about the care
you got from specialists?
you got from specialists?

33. How likely are you to change doctors if you are
dissatisfied with the way you and your doctor
communicate?

34. How likely are you to tell your doctor when you
disagree with him or her?

33. How likely are you to change doctors if you are
dissatisfied with the way you and your doctor
communicate?

34. How likely are you to tell your doctor when you
disagree with him or her?

35. In the last 6 months, how often did you leave your 35. In the last 6 months, how often did you leave your
doctor’s office feeling that all of your concerns or
doctor’s office feeling that all of your concerns or
questions were fully answered?
questions were fully answered?
36. In the last 6 months, how often did you make sure
you understood the results of any medical test or
procedure such as x-ray, blood test, or EKG for heart
conditions?

37. In the last 6 months, did you get information or
help from Medicare’s customer service?

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?

37. In the last 6 months, did you get information or
help from Medicare’s customer service?

38. In the last 6 months, how often did Medicare’s
38. In the last 6 months, how often did Medicare’s
customer service give you the information or help you customer service give you the information or help you
needed?
needed?

FFS Survey

39. In the last 6 months, how often did Medicare’s
customer service staff treat you with courtesy and
respect?

40. In the last 6 months, did Medicare give you any
forms to fill out?

41. In the last 6 months, how often were the forms
from Medicare easy to fill out?

42. Using any number from 0 to 10, where 0 is the
worst health plan possible and 10 is the best health
plan possible, what number would you use to rate
Medicare?

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

45. In the last 6 months, did you spend one or more
nights in a hospital?

40. In the last 6 months, did Medicare give you any
forms to fill out?

41. In the last 6 months, how often were the forms
from Medicare easy to fill out?

43. In general, how would you rate your overall
health?

39. In the last 6 months, how often did Medicare’s
customer service staff treat you with courtesy and
respect?

43. In general, how would you rate your overall
health?

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

45. In the last 6 months, did you spend one or more
nights in a hospital?

46. In the last 6 months, how often was it easy to get 46. In the last 6 months, how often was it easy to get
the medicines your doctor prescribed?
the medicines your doctor prescribed?

FFS Survey
-

47. Do you have insurance that pays part or all of the 47. Do you have insurance that pays part or all of the
cost of your prescription medicines?
cost of your prescription medicines?

48. In the last 6 months, did you delay or not fill a
48. In the last 6 months, did you delay or not fill a
prescription because you felt you could not afford it? prescription because you felt you could not afford it?

49. Are you currently enrolled in a Medicare Part D
plan (prescription drug plan)?

50. Are you enrolled in a Medicare Part D Medication 50. Are you enrolled in a Medicare Part D Medication
Therapy Management program?
Therapy Management program?

51. Did a health care provider, such as a pharmacist, 51. Did a health care provider, such as a pharmacist,
call or meet with you to review your medications and call or meet with you to review your medications and
answer your questions about your medications?
answer your questions about your medications?

52. Did the review increase your understanding of
your medications and how to use them?

53. A printed summary of the review includes a letter, 53. A printed summary of the review includes a letter,
a medication action plan, and a personal medication a medication action plan, and a personal medication
list. Did you receive a printed summary of the review? list. Did you receive a printed summary of the review?

54. How satisfied were you with the information in
the printed summary of the review?

FFS Survey
-

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?
-

55. Overall, how satisfied are you with the Medication 55. Overall, how satisfied are you with the Medication
Therapy Management program provided by your
Therapy Management program provided by your
Medicare Part D plan?
Medicare Part D plan?
56. Has a doctor ever told you that you had any of the
following conditions?
56a. A heart attack?
56b. Angina or coronary heart disease?
56c. Hypertension or high blood pressure?
56d. Cancer, other than skin cancer?
56e. Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)?
56f. Any kind of diabetes or high blood sugar?

57. Have you had a flu shot since July 1, 2017?

57. Have you had a flu shot since July 1, 2020?

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.

59. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?

60. In the last 6 months, how often were you advised 60. In the last 6 months, how often were you advised
to quit smoking or using tobacco by a doctor or other to quit smoking or using tobacco by a doctor or other
health provider?
health provider?

61. What is the highest grade or level of school that
you have completed?

FFS Survey
-

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.)
65a. Bathing
65b. Dressing
65c. Eating
65d. Getting in or out of chairs
65e. Walking
65f. Using the toilet
66. Because of a physical, mental or emotional
66. Because of a physical, mental or emotional
condition, do you have difficulty doing errands alone condition, do you have difficulty doing errands alone
such as visiting a doctor’s office or shopping?
such as visiting a doctor’s office or shopping?

62. Are you of Hispanic or Latino origin or descent?

63. What is your race? Please mark one or more.

64. How many people live in your household now,
including yourself?

62. Are you of Hispanic or Latino origin or descent?

63. What is your race? Please mark one or more.

64. How many people live in your household now,
including yourself?

67. Do you ever use the internet at home?

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?

Change in
68. May the Medicare Program follow up with you to
wording
learn more about your health care, or to invite you to
a group discussion or interview on topics related to
health care?

Wording change to communicate the range of reasons No
CMS may follow up with a survey respondent

FFS Survey

69. Did someone help you complete this survey?

70. How did that person help you? Please mark one
or more.
70a. Read the questions to me
70b. Wrote down the answers I gave
70c. Answered the questions for me
70d. Translated the questions into my language
70e. Helped in some other way

1. Our records show that in 2017 your health services 1. Our records show that in 2020 your health services
were covered by the plan named on the back page. Is were covered by the plan named on the back page. Is
that right?
that right?
2. Please write below the name of the health plan you
had in 2017 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 2020 and complete the rest of the survey
based on the experiences you had with that plan.
(Please print)

4. In the last 6 months, when you needed care right
away, how often did you get care as soon as you
needed?

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?

Burden Change

Reason for Change

Type of Change

Proposed Question

Existing Question

MA-PD Survey

MA-PD Survey
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?

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?

10. In the last 6 months, how often was it easy to get 10. In the last 6 months, how often was it easy to get
the care, tests or treatment you needed?
the care, tests or treatment you needed?

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?

12. In the last 6 months, how many times did you visit 12. In the last 6 months, how many times did you visit
your personal doctor to get care for yourself?
your personal doctor to get care for yourself?

14. In the last 6 months, how often did your personal 14. In the last 6 months, how often did your personal
doctor listen carefully to you?
doctor listen carefully to you?

MA-PD Survey
-

15. In the last 6 months, how often did your personal 15. In the last 6 months, how often did your personal
doctor show respect for what you had to say?
doctor show respect for what you had to say?

16. In the last 6 months, how often did your personal 16. In the last 6 months, how often did your personal
doctor spend enough time with you?
doctor spend enough time with you?

17. Using any number from 0 to 10, where 0 is the
worst personal doctor possible and 10 is the best
personal doctor possible, what number would you
use to rate your personal doctor?

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?

19. In the last 6 months, did your personal doctor
order a blood test, x-ray or other test for you?

20. In the last 6 months, when your personal doctor
ordered a blood test, x-ray or other test for you, how
often did someone from your personal doctor’s office
follow up to give you those results?

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?

22. In the last 6 months, did you take any prescription 22. In the last 6 months, did you take any prescription
medicine?
medicine?

MA-PD Survey

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?

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?

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?

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?

28. In the last 6 months, did you make any
appointments to see a specialist?

29. In the last 6 months, how often did you get an
appointment to see a specialist as soon as you
needed?

30. How many specialists have you seen in the last 6
months?

MA-PD Survey
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?

33. In the last 6 months, did you get information or
help from your health plan’s customer service?

34. In the last 6 months, how often did your health
plan’s customer service give you the information or
help you needed?

35. In the last 6 months, how often did your health
plan’s customer service staff treat you with courtesy
and respect?

36. In the last 6 months, did your health plan give you 36. In the last 6 months, did your health plan give you
any forms to fill out?
any forms to fill out?

37. In the last 6 months, how often were the forms
from your health plan easy to fill out?

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?

MA-PD Survey

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)?

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?

42. In the last 6 months, how often was it easy to use 42. In the last 6 months, how often was it easy to use
your prescription drug plan to get the medicines your your prescription drug plan to get the medicines your
doctor prescribed?
doctor prescribed?

43. In the last 6 months, did you ever 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 44. In the last 6 months, how often was it easy to use
your prescription drug plan to fill a prescription at
your prescription drug plan to fill a prescription at
your local pharmacy?
your local pharmacy?

45. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription by mail?

MA-PD Survey

46. In the last 6 months, how often was it easy to use 46. In the last 6 months, how often was it easy to use
your prescription drug plan to fill a prescription by
your prescription drug plan to fill a prescription by
mail?
mail?
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?

48. In general, how would you rate your overall
health?

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

50. In the last 6 months, did you spend one or more
nights in a hospital?

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?

48. In general, how would you rate your overall
health?

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

50. In the last 6 months, did you spend one or more
nights in a hospital?

51. In the last 6 months, did you delay or not fill a
51. In the last 6 months, did you delay or not fill a
prescription because you felt you could not afford it? prescription because you felt you could not afford it?

52. In the last 6 months, did you receive any mail
order medicines that you did not request?

MA-PD Survey

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?

54. Do you have serious difficulty walking or climbing 54. Do you have serious difficulty walking or climbing
stairs?
stairs?

55. Do you have difficulty dressing or bathing?

56. Because of a physical, mental, or emotional
56. Because of a physical, mental, or emotional
condition, do you have difficulty doing errands alone condition, do you have difficulty doing errands alone
such as visiting a doctor’s office or shopping?
such as visiting a doctor’s office or shopping?

57. Have you had a flu shot since July 1, 2017?

57. Have you had a flu shot since July 1, 2020?

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.

59. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?

MA-PD Survey

61. What is the highest grade or level of school that
you have completed?

62. Are you of Hispanic or Latino origin or descent?

63. What is your race? Please mark one or more.

64. How many people live in your household now,
including yourself?

61. What is the highest grade or level of school that
you have completed?

62. Are you of Hispanic or Latino origin or descent?

63. What is your race? Please mark one or more.

64. How many people live in your household now,
including yourself?

65. Do you ever use the internet at home?

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?

Change in
66. May the Medicare Program follow up with you to
wording
learn more about your health care, or to invite you to
a group discussion or interview on topics related to
health care?

67. Did someone help you complete this survey?

Wording change to communicate the range of reasons No
CMS may follow up with a survey respondent

MA-PD Survey

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

2. Please write below the name of the health plan you
had in 2020 and complete the rest of the survey
based on the experiences you had with that plan.
(Please print)

4. In the last 6 months, when you needed care right
away, how often did you get care as soon as you
needed?

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?

Burden Change

Reason for Change

Type of Change

Proposed Question

Existing Question

MA-Only Survey

MA-Only Survey
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?

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?

10. In the last 6 months, how often was it easy to get 10. In the last 6 months, how often was it easy to get
the care, tests or treatment you needed?
the care, tests or treatment you needed?

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?

12. In the last 6 months, how many times did you visit 12. In the last 6 months, how many times did you visit
your personal doctor to get care for yourself?
your personal doctor to get care for yourself?

14. In the last 6 months, how often did your personal 14. In the last 6 months, how often did your personal
doctor listen carefully to you?
doctor listen carefully to you?

MA-Only Survey
-

15. In the last 6 months, how often did your personal 15. In the last 6 months, how often did your personal
doctor show respect for what you had to say?
doctor show respect for what you had to say?

16. In the last 6 months, how often did your personal 16. In the last 6 months, how often did your personal
doctor spend enough time with you?
doctor spend enough time with you?

17. Using any number from 0 to 10, where 0 is the
worst personal doctor possible and 10 is the best
personal doctor possible, what number would you use
to rate your personal doctor?

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?

19. In the last 6 months, did your personal doctor
order a blood test, x-ray or other test for you?

20. In the last 6 months, when your personal doctor
ordered a blood test, x-ray or other test for you, how
often did someone from your personal doctor’s office
follow up to give you those results?

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?

22. In the last 6 months, did you take any prescription 22. In the last 6 months, did you take any prescription
medicine?
medicine?

MA-Only Survey

23. In the last 6 months, how often did you and your
personal doctor talk about all the prescription
medicines you were taking?

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?

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?

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?

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?

28. In the last 6 months, did you make any
appointments to see a specialist?

29. In the last 6 months, how often did you get an
appointment to see a specialist as soon as you
needed?

30. How many specialists have you seen in the last 6
months?

MA-Only Survey
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 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 possible
and 10 is the best specialist possible, what number
would you use to rate that specialist?

33. In the last 6 months, did you get information or
help from your health plan’s customer service?

34. In the last 6 months, how often did your health
plan’s customer service give you the information or
help you needed?

35. In the last 6 months, how often did your health
plan’s customer service staff treat you with courtesy
and respect?

36. In the last 6 months, did your health plan give you 36. In the last 6 months, did your health plan give you
any forms to fill out?
any forms to fill out?

37. In the last 6 months, how often were the forms
from your health plan easy to fill out?

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?

MA-Only Survey
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)?
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)?
41. In general, how would you rate your overall
health?

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

43. In the last 6 months, did you spend one or more
nights in a hospital?

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)?
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)?

41. In general, how would you rate your overall
health?

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

43. In the last 6 months, did you spend one or more
nights in a hospital?

44. In the last 6 months, how often was it easy to get 44. In the last 6 months, how often was it easy to get
the medicines your doctor prescribed?
the medicines your doctor prescribed?

45. Do you have insurance that pays part or all of the 45. Do you have insurance that pays part or all of the
cost of your prescription medicines?
cost of your prescription medicines?

46. In the last 6 months, did you delay or not fill a
46. In the last 6 months, did you delay or not fill a
prescription because you felt you could not afford it? prescription because you felt you could not afford it?

MA-Only Survey

47. In the last 6 months, did you receive any mail
order medicines that you did not request?

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?

49. Do you have serious difficulty walking or climbing 49. Do you have serious difficulty walking or climbing
stairs?
stairs?

50. Do you have difficulty dressing or bathing?

51. Because of a physical, mental, or emotional
51. Because of a physical, mental, or emotional
condition, do you have difficulty doing errands alone condition, do you have difficulty doing errands alone
such as visiting a doctor’s office or shopping?
such as visiting a doctor’s office or shopping?

52. Have you had a flu shot since July 1, 2017?

52. Have you had a flu shot since July 1, 2020?

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.

MA-Only Survey

54. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?

57. Are you of Hispanic or Latino origin or descent?

58. What is your race? Please mark one or more.

59. How many people live in your household now,
including yourself?

54. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?

55. In the last 6 months, how often were you advised 55. In the last 6 months, how often were you advised
to quit smoking or using tobacco by a doctor or other to quit smoking or using tobacco by a doctor or other
health provider?
health provider?

56. What is the highest grade or level of school that
you have completed?

57. Are you of Hispanic or Latino origin or descent?

58. What is your race? Please mark one or more.

59. How many people live in your household now,
including yourself?

60. Do you ever use the internet at home?

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?

Change in Wording change to communicate the range of reasons No
61. May the Medicare Program follow up with you to
wording CMS may follow up with a survey respondent
learn more about your health care, or to invite you to
a group discussion or interview on topics related to
health care?

MA-Only Survey

62. Did someone help you complete this survey?

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

1. Our records show that in 2017 your prescriptions 1. Our records show that in 2020 your prescriptions
were covered by the Medicare prescription drug plan were covered by the Medicare prescription drug plan
named on the back page.
named on the back page.
Is that right?
Is that right?
2. Please write below the name of the Medicare
prescription drug plan you had in 2017 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 2020 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 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?

4. In the last 6 months, how often was it easy to use 4. In the last 6 months, how often was it easy to use
your prescription drug plan to get the medicines your your prescription drug plan to get the medicines your
doctor prescribed?
doctor prescribed?

5. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription at your
local pharmacy?

Burden Change

Reason for Change

Type of Change

Proposed Question

Existing Question

PDP Survey

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?

7. In the last 6 months, did you ever 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?

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?

10. In general, how would you rate your overall
health?

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

12. In the last 6 months, did you spend one or more
nights in a hospital?

10. In general, how would you rate your overall
health?

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

12. In the last 6 months, did you spend one or more
nights in a hospital?

13. In the last 6 months, did you delay or not fill a
13. In the last 6 months, did you delay or not fill a
prescription because you felt you could not afford it? prescription because you felt you could not afford it?

PDP Survey

14. In the last 6 months, did you receive any mail
order medicines that you did not request?

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?

14. In the last 6 months, did you receive any mail
order medicines that you did not request?

16. Do you have serious difficulty walking or climbing 16. Do you have serious difficulty walking or climbing
stairs?
stairs?

17. Do you have difficulty dressing or bathing?

18. Because of a physical, mental, or emotional
18. Because of a physical, mental, or emotional
condition, do you have difficulty doing errands alone condition, do you have difficulty doing errands alone
such as visiting a doctor’s office or shopping?
such as visiting a doctor’s office or shopping?

19. What is the highest grade or level of school that
you have completed?

20. Are you of Hispanic or Latino origin or descent?

19. What is the highest grade or level of school that
you have completed?

20. Are you of Hispanic or Latino origin or descent?

PDP Survey

21. What is your race? Please mark one or more.

22. How many people live in your household now,
including yourself?

21. What is your race? Please mark one or more.

22. How many people live in your household now,
including yourself?

23. Do you ever use the internet at home?

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?

Change in Wording change to communicate the range of reasons No
24. May the Medicare Program follow up with you to
wording CMS may follow up with a survey respondent
learn more about your health care, or to invite you to
a group discussion or interview on topics related to
health care?

25. Did someone help you complete this survey?

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

File Type	application/pdf
File Title	MCAHPS - Crosswalk 2020
Author	Mitch Bryman
File Modified	2020-11-09
File Created	2020-11-09