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pdf2022 Prescription Drug Plan Survey
Field Test Version
[New items compared to current PDP 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 10 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.
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1.
5.
Our records show that in 2021 your
prescriptions were covered by the
Medicare prescription drug plan
named on the back page.
Is that right?
Yes
No If No, Go to Question 7
Yes If Yes, Go to Question 3
No
2.
3.
7.
No
Never
Sometimes
Usually
Always
In the last 6 months, did you ever
use your prescription drug plan to
fill a prescription by mail?
Yes
No If No, Go to Question 9
8.
In the last 6 months, how often
was it easy to use your
prescription drug plan to get the
medicines your doctor prescribed?
In the last 6 months, how often
was it easy to use your
prescription drug plan to fill a
prescription at your local
pharmacy?
In the last 6 months, did anyone
from a doctor’s office, pharmacy,
or your prescription drug plan
contact you:
a. To make sure you
filled or refilled a
prescription?
b. To make sure you
were taking medicine
as directed?
4.
6.
Please write below the name of
the Medicare prescription drug
plan you had in 2021 and complete
the rest of the survey based on the
experiences you had with that
plan. (Please print)
___________________________
Yes
In the last 6 months, did you ever
use your prescription drug plan to
fill a prescription at your local
pharmacy?
In the last 6 months, how often
was it easy to use your
prescription drug plan to fill a
prescription by mail?
Never
Sometimes
Usually
Always
I did not use my prescription
drug plan to get any medicines
in the last 6 months
2
Never
Sometimes
Usually
Always
9.
12.
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?
0 Worst prescription drug
plan possible
1
2
3
4
5
6
7
8
9
10 Best prescription drug plan
possible
Please print:____________
13. In the last 6 months, did you spend
one or more nights in a hospital?
Yes
No
14. In the last 6 months, did you delay
or not fill a prescription because
you felt you could not afford it?
Yes
No
My doctor did not prescribe
any medicines for me in the
last 6 months
10. In general, how would you rate
your overall health?
Excellent
Very good
Good
Fair
Poor
11. In general, how would you rate
your overall mental or emotional
health?
English
Spanish
Chinese
Korean
Tagalog
Vietnamese
Some other language
↓
About You
What language do you mainly
speak at home?
Excellent
Very good
Good
Fair
Poor
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15. 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 ....
16. Has a doctor ever told you that
you had any of the following
conditions?
Yes
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?
18. Do you have difficulty dressing or
bathing?
Yes
No
19. 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
20. What is the highest grade or level
of school that you have
completed?
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
No
21. Are you of Hispanic or Latino origin
or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
22. 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
17. Do you have serious difficulty
walking or climbing stairs?
Yes
No
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23. How many people live in your
household now, including
yourself?
26. Did someone help you complete
this survey?
Yes
No Thank you. Please
return the completed survey
in the postage-paid
envelope.
1 person
2 to 3 people
4 or more people
24.
Do you ever use the internet at
home?
27. How did that person help you?
Please mark one or more.
Yes
No
25.
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
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
Thank you.
Please return the completed survey in the postage-paid envelope.
[SURVEY VENDOR RETURN ADDRESS FOR MAIL PROCESSING]
Contract Name: ________________
[OPTIONAL]
You may also know your plan by one of the following:
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| File Type | application/pdf |
| File Title | 2022 PDP Field Test Survey_1-26-22 |
| Author | Steven D. Kuszmaul |
| File Modified | 2022-01-27 |
| File Created | 2022-01-26 |