MA Only - Crosswalk

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
HEADER
Introduction to Q1

Item Count=45
HEADER
DROPPED

Item Count=45
HEADER
DROPPED

Comments

YOUR FORMER HEALTH PLAN
We are sending you this survey because we believe
you recently switched or dropped your Medicare
health plan.

YOUR FORMER HEALTH PLAN
Drop this Introduction.

Our records show that you used to belong to the
health plan whose name is printed on the cover of
this 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

Our records show that you used to belong to this 1
health plan: [PLACEHOLDER] but that you no longer
belong to that plan. Is that correct?
o Yes, I left the health plan printed above
o No, I left a different health plan
o No, I did not switch plans or leave ANY Medicare
health plan recently

1

1

Did you have to switch or drop your 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

Did you have to switch or drop your former
2
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

2

2

GETTING INFORMATION OR HELP FROM YOUR
FORMER HEALTH PLAN
As you answer the questions in this survey, please
think only of your former health plan (whose name is
printed on the cover of this survey).

GETTING INFORMATION OR HELP FROM YOUR
HEADER
FORMER HEALTH PLAN
As you answer the questions in this survey, please Q3 preamble
think only of your former health plan (whose name
is printed on the cover of this survey).

HEADER

HEADER

No change to wording.

Q3 preamble

Q3 preamble

No change to wording.

3

3

No change to wording.

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

1

3

No change to wording.
Delete this short introduction to Q1
to streamline
Revised to simplify response option
text; also integrate plan name /
contract# into the Q1.

No change to wording.

Current MA-Only Survey/Question Wording

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

How often did your former plan’s customer service
give you the information or help you needed?
o Never
o Sometimes
o Usually
o Always
o I did not try to get information or help from my
former health plan's customer service

Item Count=45
How often did your former plan’s customer service 4
give you the information or help you needed?
o Never
o Sometimes
o Usually
o Always
o I did not try to get information or help from my
former health plan's customer service

Item Count=45
4

Item Count=45
4

No change to wording.

GETTING HEALTH CARE YOU NEEDED FROM YOUR
FORMER HEALTH PLAN

GETTING HEALTH CARE YOU NEEDED FROM YOUR HEADER
FORMER HEALTH PLAN

HEADER

HEADER

No change to wording.

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, or
5
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

5

5

No change to wording.

In the last 6 months, did you make an appointment to
see a specialist?
o Yes
o No if no go to question 8
o Someone else made my specialist appointments for
me

Did you make an appointment to see a specialist? 6
o Yes
o No if no go to question 8
o Someone else made my specialist appointments
for me

6

6

Deleted the reference to "In the last
6 months" to reduce cognitive
burden.

In the last 6 months, how often did you get 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

How often did you get an appointment to see a
7
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

7

7

Deleted the reference to "In the last
6 months" to reduce cognitive
burden.

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
former plan?

Using any number from 0 to 10, where 0 is the
8
worst health plan possible and 10 is the best health
plan possible, what number would you use to rate
your former plan?

8

8

No change to wording.

REASONS YOU LEFT YOUR FORMER HEALTH PLAN

REASONS YOU LEFT YOUR FORMER HEALTH PLAN HEADER

HEADER

HEADER

No change to wording.

2

Proposed MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

Comments

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

The next questions are about reasons you may have
had for switching or dropping your former health
plan.

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
Q8 preamble

Item Count=45
Q9 preamble

Item Count=45
Q9 preamble

Comments

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 found 9
out that someone had signed you up for the plan
without your permission? Yes/No

9

9

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 you were
taken off the plan by mistake? Yes/No

DROPPED

DROPPED

Item dropped due to low
endorsement and low reliability and
to reduce burden.

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 dollar 11
amount you had to pay each time you visited a
doctor (copayment) went up?
o Yes
o No
o I did not have to pay for doctor visits

10

10

Added parenthetical reference to
"copayment" to improve usability

Not included

Did you leave your former plan because you found Not included
a plan with a lower copayment for doctors' visits?
Yes/No

11

11

Added based on feedback from
consumers and plan representatives
citing this disenrollment reason.

12

12

Minor wording changes around
"premium" and "fee" to increase
usability.

10

Some people have to pay their health plan a monthly Some people have to pay their health plan a
12
fee (called a premium) out of their own pocket for
monthly premium (fee) out of their own pocket for
health coverage.
health coverage.
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 the
monthly premium went up?
o Yes
o No
o I did not have to pay my former plan a monthly
premium out of my own pocket

Did you leave your former plan because you found a
health plan that costs less? Yes/No

Item has been dropped

13

DROPPED

DROPPED

New items 11 and 13 ask about
costs specifically to be more useful
to CMS, plans, and consumers.

Not included

Did you leave your plan because you found a plan
with a lower monthly premium?
o Yes
o No
o I did not have to pay my former plan a monthly
premium out of my own pocket

Not included

13

13

Added based on feedback from
consumers and plan representatives
citing this disenrollment reason.

3

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
14

Item Count=45
14

Item Count=45
14

15

DROPPED

DROPPED

Item dropped due to low reliability
and to reduce respondent burden.

16

15

15

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 were 17
frustrated by the plan’s approval process for care,
tests, or treatment? Yes/No

16

16

No change to wording.

Did you leave your former plan because you had
problems getting the care, tests, or treatment you
needed? Yes/No

Did you leave your former plan because you had
18
problems getting the care, tests, or treatment you
needed? Yes/No

17

17

No change to wording.

19

18

18

Streamlined this item by removing
the preamble to reduce burden and
preserve usability.

Did you leave your former plan because the doctors Did you leave your former plan because the
20
or other health care providers you wanted to see did doctors or other health care providers you wanted
not belong to the plan? Yes/No
to see did not belong to the plan? Yes/No

19

19

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 the clinics 21
or hospitals you wanted to go to were not covered
by the plan? Yes/No

20

20

Removed "for care" from the item
to streamline.

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 it was hard 22
to get information from the plan about which
health care services were covered or how much a
specific test or treatment would cost? Yes/No

21

21

Small wording change specifying
type of information sought.

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

Did you leave your former plan because you were 23
unhappy with how the plan handled a question or
complaint?
Yes/No

22

22

No change to wording.

Did you leave your former plan because a change in
your personal finances meant you could no longer
afford the plan? 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

Did you leave your former plan because a change in
your health meant the plan no longer met your
needs? Yes/No

Item has been dropped

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

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

4

Comments

No change to wording.

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
Did you leave your former plan because you could not Did you leave your former plan because you could 24
get the information or help you needed from the
not get the information or help you needed from
plan? Yes/No
the plan?
Yes/No

Item Count=45
23

Item Count=45
23

No change to wording.

Did you leave your former plan because their
Did you leave your former plan because their
customer service staff did not treat you with courtesy customer service staff did not treat you with
and respect? Yes/No
courtesy and respect? Yes/No

24

24

No change to wording.

25

Comments

Every year Medicare evaluates all health plans and
gives them a star rating.

Every year Medicare evaluates all health plans and Q26 preamble
gives them a star rating.

Q25 preamble

Q25 preamble

No change to wording.

Did you leave your former plan because it got a low
Medicare star rating? Yes/No

Did you leave your former plan because it got a low 26
Medicare star rating? Yes/No

25

25

No change to wording.

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

Did you leave your former plan because you found 27
another plan with a higher Medicare star rating?
Yes/No

26

26

No change to wording.

OTHER REASONS FOR LEAVING YOUR FORMER
HEALTH PLAN

OTHER REASONS FOR LEAVING YOUR FORMER
HEALTH PLAN

HEADER

HEADER

HEADER

No change to wording.

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 a family
member or friend told you about a better plan?
Yes/No

28

27

27

No change to wording.

Not included

Did you leave your former plan because an
insurance agent or broker told you about a better
plan? Yes/No

Not included

28

28

Added based on feedback from
consumers and plan representatives
citing this disenrollment reason.

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 saw a 29
commercial or advertisement for a health plan you
thought you would like better? Yes/No

29

29

No change to wording.

Did you leave your former plan because you found
Did you leave your former plan because you found 30
another plan that better met your prescription needs? another plan that better met your prescription
Yes/No
needs? Yes/No

30

30

No change to wording.

Did you leave your former plan because another plan Did you leave your former plan because another
offered better benefits or coverage (for example,
plan offered better benefits or coverage (for
dental or vision care)? Yes/No
example, dental or vision care, hearing aids, prepaid cards for medications and supplies)? Yes/No

31

31

31

Added additional examples of
benefits and coverage to improve
understanding

ABOUT YOU

HEADER

HEADER

HEADER

No change to wording.

5

ABOUT YOU

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
32

Item Count=45
32

Item Count=45
32

No change to wording.

Comments

In general, how would you rate your overall health?
o Excellent
o Very good
o Good
o Fair
o Poor

In general, how would you rate your overall
health?
o Excellent
o Very good
o Good
o Fair
o Poor

In general, how would you rate your overall mental or
emotional health?
o Excellent
o Very good
o Good
o Fair
o Poor

In general, how would you rate your overall mental 33
or emotional health?
o Excellent
o Very good
o Good
o Fair
o Poor

33

33

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, 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

34

34

34

No change to wording.

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, have you seen a doctor or 35
other health provider 3 or more times for the same
condition or problem?
Yes/No

35

35

No change to wording.

36

36

36

No change to wording.

Do you now need or take any medicine prescribed by Do you now need or take medicine prescribed by a 37
a doctor for any condition? Yes/No
doctor? Yes/No -- If no, go to question 52

37

37

Deleted "any" before "medicine"
and "for any condition" to reduce
item length.

Is this medicine to treat a condition that has lasted for Is this medicine to treat a condition that has lasted 38
at least 3 months
for at least 3 months
Yes/No
Yes/No

38

38

No change to wording.

Is this a condition or problem that has lasted at least 3 Is this a condition or problem that has lasted at
months?
least 3 months?
Yes/No
Yes/No

6

Current MA-Only Survey/Question Wording

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

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

Item Count=45
Has a doctor ever told you that you have any of the 39
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

Item Count=45
39

Item Count=45
39

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

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

40

40

40

No change to wording.

Are you of Hispanic or Latino origin or descent?
o Yes, Hispanic or Latino
o No, not Hispanic or Latino

Are you of Hispanic or Latino origin or descent?
o Yes, Hispanic or Latino
o No, not Hispanic or Latino

41

41

41

No change to wording.

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 is your race? Please mark one or more.
o American Indian or Alaska Native
o Asian
o Black or African-American
o Native Hawaiian or other Pacific Islander
o White

42

42

42

Changed order of the response
options to alphabetical.

What language do you mainly speak at home?
o Chinese
o English
o Russian
o Spanish
o Vietnamese
o Some other language (please print)

What language do you mainly speak at home?
o Chinese
o English
o Russian
o Spanish
o Vietnamese
o Some other language (please print)

43

43

43

No change to wording.

Did someone help you complete this survey? Yes/No

Did someone help you complete this survey?
Yes/No

44

44

44

No change to wording.

7

Proposed MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

Comments

Current MA-Only Survey/Question 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)

Proposed MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

Item Count=45
How did that person help you? Please mark one or 45
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 May we contact you again if we have any questions 46
your survey responses or if we have other questions about your survey responses or the health care
about the health care services that you received?
services you received? Yes/No
Yes/No

8

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
45

Item Count=45
45

46

46

Comments

No change to wording.

Streamlined this item to reduce
burden and preserve usability.