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pdf2022 Medicare Advantage Plan Survey
Field Test Version
[New items compared to current MA-Only survey
highlighted in yellow]
2022 Medicare Experience Survey
MEDICARE SURVEY INSTRUCTIONS
This survey asks about you and the health care you received in the last six months.
Answer each question thinking about yourself and the times you got health care in
person, by phone or by video call. 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 [Survey Vendor].
If you changed your Medicare plan for 2022, answer the questions thinking about your
experiences in the last 6 months of 2021.
• Answer all the questions by putting an “X” in the box to the left of your answer, like
this:
•
•
•
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: [If No, Go to Question 3]. See the example below:
EXAMPLE
1. Do you wear a hearing aid now?
Yes
No 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
3. In the last 6 months, did you have any headaches?
Yes
No
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. This applies to both mandatory and voluntary collections of
information. The valid OMB control number for this information collection is 0938-XXXX. The time required to
complete this information collection is estimated to average 16 minutes, 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.
1
1.
5.
Our records show that in 2021 your
health services were covered by the
plan named on the back page. Is
that right?
Yes If Yes, Go to Question 3
No
2.
Yes
No If No, Go to Question 7
6.
Please write below the name of
the health plan you had in 2021
and complete the rest of the
survey based on the experiences
you had with that plan.
(Please print)
7.
In the last 6 months, did you have an
illness, injury, or condition that
needed care right away?
In the last 6 months, when you
needed care right away, how often did
you get care as soon as you needed?
8.
Never
Sometimes
Usually
Always
Never
Sometimes
Usually
Always
In the last 6 months, not counting the
times you went to an emergency
room, how many times did you get
health care for yourself in person, by
phone, or by video?
Yes
No If No, Go to Question 5
4.
In the last 6 months, how often did
you get an appointment for a
check-up or routine care as soon
as you needed?
Your Health Care in the Last 6 Months
These questions ask about your own health
care from a clinic, emergency room, or
doctor’s office. This includes care you got in
person, by phone, or by video.
3.
In the last 6 months, did you make any
in-person, phone, or video
appointments for a check-up or
routine care?
None If None, Go to Question 15
1 time
2
3
4
5 to 9
10 or more times
In the last 6-months, were any of your
visits to doctors, nurses, or other
health care providers by phone or
video?
Yes
No If No, Go to Question 14
2
9.
10.
13. In the last 6 months, how often did
your in-person, phone, or video visits
start on time?
In the last 6 months, how often did
you get the instructions you needed
to use phone or video for your visits?
Never
Sometimes
Usually
Always
14. In the last 6 months, when you talked
with a doctor, nurse, or other health
care provider during a scheduled
appointment, how often did they
know your health history?
In the last 6 months, how often was it
easy to have a visit by phone or video?
Never
Sometimes
Usually
Always
11. In the last 6 months, how often did
the care you got by phone or video
meet your needs?
Never
Sometimes
Usually
Always
15. 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
12. In the last 6 months, how often did
you feel comfortable talking with your
doctor, nurse, or other health care
provider by phone or video about
your health care concerns and
symptoms?
Never
Sometimes
Usually
Always
Never
Sometimes
Usually
Always
3
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible
16. In the last 6 months, how often was it
easy to get the care, tests, or
treatment you needed?
20. In the last 6 months, how often did a
doctor, nurse, or other health care
provider explain the results of your
blood test, x-ray, or other test?
Never
Sometimes
Usually
Always
17. In the last 6 months, did a doctor,
nurse, or other health care provider
order a blood test, x-ray, or other test
for you?
21. In the last 6 months, how often was
the explanation of your test results
easy to understand?
Yes
No If No, Go to Question 23
18. In the last 6 months, when a doctor,
nurse, or other health care provider
ordered a blood test, x-ray, or other
test for you, how often were you told
when to expect your test results?
Never
Sometimes
Usually
Always
Never
Sometimes
Usually
Always
22. In the last 6 months, how often did
you get as much information as you
needed about your test results?
Never
Sometimes
Usually
Always
19. In the last 6 months, when a doctor,
nurse, or other health care provider
ordered a blood test, x-ray, or other
test for you, how often did you get
your test results?
Never If Never, Go to
Question 23
Sometimes
Usually
Always
4
Never
Sometimes
Usually
Always
27. In the last 6 months, how often did
your personal doctor show respect for
what you had to say?
Your Personal Doctor
23. 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?
Yes
No If No, Go to Question 38
28. In the last 6 months, how often did
your personal doctor spend enough
time with you?
24. In the last 6 months, how many times
did you have an in-person, phone, or
video visit with your personal doctor
about your health?
None If None, Go to
Question 38
1 time
2
3
4
5 to 9
10 or more times
0 Worst personal doctor
possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor
possible
Never
Sometimes
Usually
Always
26. In the last 6 months, how often did
your personal doctor listen carefully
to you?
Never
Sometimes
Usually
Always
29. 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?
25. In the last 6 months, how often did
your personal doctor explain things in
a way that was easy to understand?
Never
Sometimes
Usually
Always
Never
Sometimes
Usually
Always
5
30. In the last 6 months, when you talked
with your personal doctor during a
scheduled appointment, how often
did he or she have your medical
records or other information about
your care?
34. 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 If No, Go to Question 38
Never
Sometimes
Usually
Always
35. 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, how often did
your personal doctor dismiss
symptoms that were important to
you?
Yes
No If No, Go to Question 38
36. 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?
Never
Sometimes
Usually
Always
32. In the last 6 months, did you take any
prescription medicine?
Yes, definitely
Yes, somewhat
No
Yes
No If No, Go to Question 34
37. In the last 6 months, did anyone from
your personal doctor’s office follow
up to ask if you had any questions
about your care from these different
providers and services?
33. In the last 6 months, how often did
you and your personal doctor talk
about all the prescription medicines
you were taking?
Never
Sometimes
Usually
Always
Yes
No
6
42. We want to know your rating of the
specialist you talked to 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?
Getting Health Care From Specialists
When you answer the next questions,
include the care you got in person, by
phone, or by video.
38. 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?
Yes If Yes, Please include your
personal doctor as you
answer these questions
about specialists
No
39. In the last 6 months, did you make
any appointments with a specialist?
43. In the last 6 months, how often did
your personal doctor seem informed
and up-to-date about the care you got
from specialists?
Yes
No If No, Go to Question 44
40. In the last 6 months, how often did
you get an appointment with a
specialist as soon as you needed?
0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible
Never
Sometimes
Usually
Always
I do not have a personal doctor
I have not talked with my
personal doctor in the last 6
months
My personal doctor is a
specialist
Never
Sometimes
Usually
Always
41. How many specialists have you talked
to in the last 6 months?
None If None, Go to
Question 44
1 specialist
2
3
4
5 or more specialists
7
47. 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?
Your Health Plan
44. In the last 6 months, did you get
information or help from your
health plan’s customer service?
Yes
No If No, Go to Question 47
45. 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
About You
46. In the last 6 months, how often did
your health plan’s customer service
staff treat you with courtesy
and respect?
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible
48. In general, how would you rate
your overall health?
Never
Sometimes
Usually
Always
Excellent
Very good
Good
Fair
Poor
49. In general, how would you rate
your overall mental or emotional
health?
8
Excellent
Very good
Good
Fair
Poor
50.
54. In the last 6 months, did you delay
or not fill a prescription because
you felt you could not afford it?
What language do you mainly
speak at home?
English
Spanish
Chinese
Korean
Tagalog
Vietnamese
Some other language
Yes
No
My doctor did not prescribe
any medicines for me in the
last 6 months
55. In the last 6 months, did anyone from
a clinic, emergency room, or doctor’s
office where you got care treat you in
an unfair or insensitive way because
of any of the following things about
you?
Yes
No
a. Medical history.........
b. Disability ...................
c. Age ............................
d. Culture or religion ....
e. Language or accent ..
f. Race or ethnicity .......
g. Gender or gender
identity .....................
h. Sexual orientation ....
↓
Please print:____________
51. In the last 6 months, did you spend
one or more nights in a hospital?
Yes
No
52. In the last 6 months, how often
was it easy to get the medicines
your doctor prescribed?
Never
Sometimes
Usually
Always
My doctor did not prescribe
any medicines for me in the
last 6 months
53. Do you have insurance that pays
part or all of the cost of your
prescription medicines?
Yes
No
Don’t know
9
56. Has a doctor ever told you that you
had any of the following conditions?
a. 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?
Yes
No
60. Have you had a flu shot since July 1,
2021?
Yes
No
Don’t know
61. 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.
Yes
No
Don’t know
62. Do you now smoke cigarettes or use
tobacco every day, some days, or not
at all?
57. Do you have serious difficulty
walking or climbing stairs?
Every day
Some days
Not at all If Not at all, Go to
Question 64
Don’t know If Don’t know,
Go to Question 64
Yes
No
58. Do you have difficulty dressing or
bathing?
63. In the last 6 months, how often
were you advised to quit smoking
or using tobacco by a doctor or
other health provider?
Yes
No
59. Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such
as visiting a doctor’s office or
shopping?
Yes
No
10
Never
Sometimes
Usually
Always
I had no in-person, phone, or
video visits in the last 6 months
64. What is the highest grade or level
of school that you have
completed?
68. Do you ever use the internet at
home?
Yes
No
8th grade or less
Some high school, but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college
degree
69. May the Medicare Program follow
up with you to learn more about
your health care, or to invite you to
a group discussion or interview on
topics related to health care?
Yes
No
65. Are you of Hispanic or Latino origin
or descent?
70. Did someone help you complete
this survey?
Yes, Hispanic or Latino
No, not Hispanic or Latino
Yes
No Thank you. Please
return the completed
survey in the postagepaid envelope.
66. What is your race? Please mark
one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific
Islander
American Indian or Alaska Native
71. How did that person help you?
Please 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
67. How many people live in your
household now, including
yourself?
1 person
2 to 3 people
4 or more people
Thank you.
Please return the completed survey in the postage-paid envelope.
[SURVEY VENDOR RETURN ADDRESS FOR MAIL PROCESSING]
11
| File Type | application/pdf |
| File Title | 2022 MA-PD Field Test Survey_1-26-22 |
| Author | Steven D. Kuszmaul |
| File Modified | 2022-01-27 |
| File Created | 2022-01-26 |