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pdfMEDICARE
EXPERIENCE
SURVEY
SURVEY INSTRUCTIONS
EXAMPLE
This survey asks about you and the health care
you received in the last six months. Answer each
question thinking about yourself. Please take the
time to complete this survey. Your answers are very
important to us. Please return the survey with your
answers in the enclosed postage-paid envelope
to: NORC at the University of Chicago, 55 East
Monroe Street, 19th Floor, Chicago, IL 60603.
1. Do you wear a hearing aid now?
Yes
û
No à If No, Go to Question 3
2. How long have you been wearing a
hearing aid?
Less than one year
1 to 3 years
More than 3 years
I don’t wear a hearing: aid
Answer all the questions by putting an “X” in the box
to the left of your answer, like this:
û
Yes
Be sure to read all the answer choices given before
marking your answer. You are sometimes told not
to answer some questions in this survey. When this
happens you will see an arrow with a note that tells
you what question to answer next, like this:
3. In the last 6 months, did you have any
headaches?
û
Yes
No
à If No, Go to Question 3
See the example to the right.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The time required to complete this information collections is estimated to average
20 minutes per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850.
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MEDICARE EXPERIENCE SURVEY
INTRODUCTION
YOUR HEALTH CARE IN THE LAST
6 MONTHS
Our records show that you are now in Medicare, the
health insurance program for people 65 years old or
older or persons with certain disabilities.
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?
Please answer the following questions in
this survey as fully as possible regardless of
whether you consider yourself in Medicare.
Yes
No à If No, Go to Question 5
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?
4. In the last 6 months, when you needed care
right away, how often did you get care as soon
as you needed?
Never
Sometimes
Usually
Always
Yes
No à If No, Go to Question 3
2. Please mark the box below for each type of
health insurance that you have.
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?
Medigap, which may be identified on the front
of your policy as “Medicare Supplemental
Insurance”
Employer, Union, or Retiree Health Coverage
(insurance)
Veteran’s Benefits, also known as VA benefits
Military Retiree Benefits, also known as Tricare
Medicaid, also known as State medical
assistance, which is for some persons with
limited income and resources
Any Prescription Drug Plan
Other (Please write the name of the other health
insurance you currently have on the line below.)
Yes
No à If No, Go to Question 7
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?
Never
Sometimes
Usually
Always
I don’t have health insurance other than
Medicare
I am not on Medicare
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?
None à If None, Go to Question 9
1 time
2
3
4
5 to 9
10 or more times
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MEDICARE EXPERIENCE SURVEY
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?
13. 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?
Never
Sometimes
Usually
Always
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible
9. In the last 6 months, did you and a doctor or
other health provider talk about starting or
stopping a prescription medicine (including
hormone therapies)?
Yes
No à If No, Go to Question 13
14. In the last 6 months, how often was it easy to
get the care, tests or treatment you needed?
10. When you talked about starting or stopping a
prescription medicine, how much did a doctor
or other health provider talk about the reasons
you might want to take a medicine?
Never
Sometimes
Usually
Always
Not at all
A little
Some
A lot
15. In the last 6 months, were you ever not able to
get medical care, tests, or treatments you or a
doctor believed necessary?
11. When you talked about starting or stopping a
prescription medicine, how much did a doctor
or other health provider talk about the reasons
you might not want to take a medicine?
Yes
No à If No, Go to Question 17
Not at all
A little
Some
A lot
16. What is the main reason you were not able to
get medical care, tests, or treatments you or a
doctor believed necessary? Choose one.
Couldn’t afford care
My health plan wouldn’t approve, cover, or pay
for care
Doctor refused to accept my insurance
Doctor doesn’t speak my language
Couldn’t get transportation to doctor’s office
Couldn’t take time off work or get child care
Didn’t know where to go to get care
The wait took too long
12. When you talked about starting or stopping
a prescription medicine, did a doctor or other
health provider ask you what you thought was
best for you?
Yes
No
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MEDICARE EXPERIENCE SURVEY
17. Is there a place that you usually go to when
you are sick or need advice about your health?
21. In the last 6 months, how many times did
you visit your personal doctor to get care for
yourself?
Yes à If Yes, Go to Question 19
There is NO place
None à If None, Go to Question 34
1 time
2
3
4
5 to 9
10 or more times
18. Why don’t you have a usual source of medical
care? Mark one or more.
Haven’t had any problems
No doctors take my insurance
No doctors speak my language
Doctors office is too far away or not convenient
Don’t plan to see a doctor even when I’m sick
22. In the last 6 months, how often did your
personal doctor explain things in a way that
was easy to understand?
19. What kind of place do you go to most often for
your medical care? Choose one.
Never
Sometimes
Usually
Always
Clinic or health center
Doctor’s office or HMO
Hospital emergency room
Hospital outpatient department
Some other place
Don’t go to one place most often
23. In the last 6 months, how often did your
personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
YOUR PERSONAL DOCTOR
20. 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?
24. In the last 6 months, how often did your
personal doctor show respect for what you had
to say?
Yes
No à If No, Go to Question 34
Never
Sometimes
Usually
Always
25. In the last 6 months, how often did your
personal doctor spend enough time with you?
Never
Sometimes
Usually
Always
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MEDICARE EXPERIENCE SURVEY
26. 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?
30. 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?
0 Worst personal doctor possible
1
2
3
4
5
6
7
8
9
Never
Sometimes
Usually
Always
31. 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?
Yes
No à If No, Go to Question 34
10 Best personal doctor possible
27. 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?
32. 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?
Never
Sometimes
Usually
Always
Yes
No à If No, Go to Question 34
28. In the last 6 months, did your personal doctor
order a blood test, x-ray or other test for you?
33. 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?
Yes
No à If No, Go to Question 31
Yes, definitely
Yes, somewhat
No
29. 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?
Never à If Never, Go to Question 31
Sometimes
Usually
Always
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MEDICARE EXPERIENCE SURVEY
GETTING HEALTH CARE FROM
SPECIALISTS
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?
34. Specialists are doctors like surgeons,
endocrinologists, heart doctors, allergy
doctors, skin doctors, and other doctors who
specialize in one area of health care. Is your
personal doctor a specialist?
0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible
Yes à If Yes, Please include your personal
doctor as you answer these questions about
specialists
No
I do not have a personal doctor
35. In the last 6 months, did you make any
appointments to see a specialist?
Yes
No à If No, Go to Question 39
Someone else made my specialist appointments
for me
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?
Never
Sometimes
Usually
Always
I do not have a personal doctor
I did not visit my personal doctor in the last 6
months
My personal doctor is a specialist
36. How many specialists have you seen in the
last 6 months?
None à If None, go to Question 39
1 specialist
2
3
4
5 or more specialists
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MEDICARE EXPERIENCE SURVEY
YOUR HEALTH PLAN
44. 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?
39. In the last 6 months, did you get information or
help from your health plan’s customer service?
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
Yes
No à If No, go to Question 42
40. In the last 6 months, how often did your
health plan’s customer service give you the
information or help you needed?
Never
Sometimes
Usually
Always
10 Best health plan possible
ABOUT YOU
41. In the last 6 months, how often did your health
plan’s customer service staff treat you with
courtesy and respect?
45. In general, how would you rate your overall
health?
Never
Sometimes
Usually
Always
Excellent
Very good
Good
Fair
Poor
42. In the last 6 months, did your health plan give
you any forms to fill out?
46. In general, how would you rate your overall
mental or emotional health?
Yes
No à If No, Go to Question 44
Excellent
Very good
Good
Fair
Poor
43. In the last 6 months, how often were the forms
from your health plan easy to fill out?
Never
Sometimes
Usually
Always
47. In the last 6 months, did you spend one or
more nights in a hospital?
Yes
No
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MEDICARE EXPERIENCE SURVEY
48. In the last 6 months, did you get health care
3 or more times for the same condition or
problem?
54. In the last 6 months, did you delay or not fill
a prescription because you felt you could not
afford it?
Yes
No à If No, Go to Question 50
Yes
No
My doctor did not prescribe any medicines for
me in the last 6 months
49. Is this a condition or problem that has
lasted for at least 3 months? Do not include
pregnancy or menopause.
55. Has a doctor ever told you that you had any of
the following conditions?
Yes
No
50. Do you now need or take any medicine
prescribed by a doctor for any condition
(including hormone therapies)? Do not include
birth control.
Yes
No à If No, Go to Question 52
51. Is this medicine to treat a condition that has
lasted for at least 3 months? Do not include
pregnancy or menopause.
Yes
No
52. In the last 6 months, how often was it easy to
get the medicines your doctor prescribed?
Yes
No
a.
Heart attack
£
£
b.
Angina or coronary heart
disease
£
£
c.
Hypertension or high blood
pressure
£
£
d
Cancer, other than skin cancer
£
£
e
Emphysema, asthma or COPD
(chronic obstructive pulmonary
disease)
£
£
f
Any kind of diabetes or high
blood sugar
£
£
g
High cholesterol
£
£
56. Have you had a flu shot since July 1, 2017?
Never
Yes
No
Don’t know
Sometimes
Usually
Always
My doctor did not prescribe any medicines for
me in the last 6 months
57. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
Every day
Some days
Not at all à If Not at all, Go to Question 59
Don’t know à If Don’t know, Go to Question 59
53. Do you have insurance that pays part or all of
the cost of your prescription medicines?
Yes
No
Don’t know
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MEDICARE EXPERIENCE SURVEY
58. In the last 6 months, how often were you
advised to quit smoking or using tobacco by a
doctor or other health provider?
62. How well do you speak English?
Very well
Well
Not well
Not at all
Never
Sometimes
Usually
Always
I had no visits in the last 6 months
63. Do you speak a language other than English
at home?
Yes
No à If No, Go to Question 65
59. What is the highest grade or level of school
that you have completed?
8th grade or less
Some high school, but did not graduate
64. What is this language?
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
Spanish
Other language (specify)
65. How many people live in your household now,
including yourself?
60. Are you of Hispanic, Latino/a, or Spanish
origin? (One or more categories may be
selected.)
1 person
2 to 3 people
4 or more people
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
66. Which of the following best represents how
you think of yourself?
Lesbian or Gay
Straight, that is, not lesbian or gay
Bisexual
Something else
I don’t know the answer
61. What is your race? (One or more categories
may be selected.)
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
67. What sex were you assigned at birth, on your
original birth certificate?
Male
Female
Don’t know
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MEDICARE EXPERIENCE SURVEY
68. Do you currently describe yourself as male,
female, or transgender?
72. Do you have serious difficulty walking or
climbing stairs?
Male
Female
Transgender
None of these
Yes
No
73. Do you have difficulty dressing or bathing?
Yes
No
69. Are you deaf or do you have serious difficulty
hearing?
Yes
No
74. Because of a physical, mental, or emotional
condition, do you have difficulty doing errands
alone such as visiting a doctor’s office or
shopping?
70. Are you blind or do you have serious difficulty
seeing, even when wearing glasses?
Yes
No
Yes
No
75. Did someone help you complete this survey?
71. Because of a physical, mental, or emotional
condition, do you have serious difficulty
concentrating, remembering, or making
decisions?
Yes à If Yes, Go to Question 76
No à Thank you. Please return the completed
survey in the postage-paid envelope.
Yes
No
76. How did that person help you? Mark one or
more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage-paid envelope to:
NORC at the University of Chicago
55 East Monroe Street, 19th Floor
Chicago, IL 60603
Please do not include any other correspondence.
10
| File Type | application/pdf |
| File Modified | 2017-07-21 |
| File Created | 2017-07-21 |