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pdfCurrent PDP Survey/Question Wording
Proposed PDP Survey/Question Wording
Current English
Language Survey
Question Number
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
Comments
Item Count=54
HEADER
Item Count=54
HEADER
DROPPED
DROPPED
Delete this short introduction to
Q1 to streamline
YOUR FORMER PRESCRIPTION DRUG PLAN
YOUR FORMER PRESCRIPTION DRUG PLAN
Item count=54
HEADER
We are sending you this survey because we believe
you recently switched or dropped your Medicare
prescription drug plan.
Drop this Introduction.
Introduction to Q1
Our records show that you used to belong to
prescription drug 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 prescription
drug plan
o I switched prescription drug 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
prescription drug plan recently
Our records show that you used to belong to
1
this prescription durg plan: [PLACEHOLDER] but
that you no longer belong to that plan. Is that
correct?
o Yes, I left the prescription drug plan printed
above
o No, I left a different prescription drug plan
o No, I did not switch plans or leave ANY
prescription drug plan recently
1
1
Revised to simplify response
option text; also integrate plan
name / contract# into the Q1.
Did you have to switch plans or drop your former
Medicare prescription drug 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 plans or drop your
2
former Medicare prescription drug 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
No change to wording.
GETTING INFORMATION OR HELP FROM YOUR
FORMER PRESCRIPTION DRUG PLAN
GETTING INFORMATION OR HELP FROM YOUR HEADER
FORMER PRESCRIPTION DRUG PLAN
HEADER
HEADER
No change to wording.
As you answer the questions in this survey, please
think only of your former prescription drug plan
(whose name is printed on the cover of this
survey).
As you answer the questions in this survey,
please think only of your former prescription
drug plan (whose name is printed on the
cover of this survey).
Q3 preamble
Q3 preamble
No change to wording.
Did you ever try to get information or help from your
former plan’s customer service?
Yes/No
Did you ever try to get information or help from 3
your former plan’s customer service?
Yes/No
3
3
No change to wording.
1
Q3 preamble
No change to wording.
Current PDP Survey/Question Wording
Current English
Language Survey
Question Number
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
Item count=54
4
Item Count=54
4
Item Count=54
4
No change to wording.
GETTING THE PRESCRIPTION MEDICINES YOU
GETTING THE PRESCRIPTION MEDICINES YOU
NEEDED FROM YOUR FORMER PRESCRIPTION DRUG NEEDED FROM YOUR FORMER PRESCRIPTION
PLAN
DRUG PLAN
HEADER
HEADER
HEADER
No change in wording.
How often was it easy to use your former plan to get
the medicines your doctor prescribed?
o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to get any prescription
medicines.
5
5
5
No change to wording.
Did you ever use your former plan to fill a prescription Did you ever use your former plan to fill a
at a pharmacy? Yes/No
prescription at a pharmacy? Yes/No
6
6
6
No change to wording.
How often was it easy to use your former plan to fill a
prescription at a pharmacy?
o Never
o Sometimes
o Usually
o Always
o I did not have to use my former plan to fill a
prescription at a pharmacy
How often was it easy to use your former plan
to fill a prescription at a pharmacy?
o Never
o Sometimes
o Usually
o Always
o I did not have to use my former plan to fill a
prescription at a pharmacy
7
7
7
No change to wording.
Did you ever use your former plan to fill any
prescriptions by mail? Yes/No
Did you ever use your former plan to fill any
prescriptions by mail? Yes/No
8
8
8
No change to wording.
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 plan's customer service
2
Proposed PDP Survey/Question Wording
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 plan's customer service
How often was it easy to use your former plan
to get the medicines your doctor prescribed?
o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to get any
prescription medicines.
Comments
Current PDP Survey/Question Wording
Proposed PDP Survey/Question Wording
Current English
Language Survey
Question Number
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
Item count=54
9
Item Count=54
9
Item Count=54
9
No change to wording.
10
10
10
No change to wording.
HEADER
HEADER
No change to wording.
Q11 preamble
Q11 preamble
No change to wording.
How often was it easy to use your former plan to fill
prescriptions by mail?
o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to fill a prescription by
mail
How often was it easy to use your former plan
to fill prescriptions by mail?
o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to fill a
prescription by mail
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 former plan?
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 former
plan?
REASONS YOU LEFT YOUR FORMER PRESCRIPTION
DRUG PLAN
The next questions are about reasons you may have
had for switching or dropping your former prescription
drug plan.
REASONS YOU LEFT YOUR FORMER
HEADER
PRESCRIPTION DRUG PLAN
The next questions are about reasons you may Q11 preamble
have had for switching or dropping your former
prescription drug plan.
Comments
Did you leave your former plan because you found out Did you leave your former plan because
that someone had signed you up for the plan without someone else signed you up for the plan
your permission? Yes/No
without your permission? Yes/No
11
11
11
Streamlined wording.
Did you leave your former plan because you were
taken off the plan by mistake? Yes/No
Item has been dropped
12
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 filled or refilled
a prescription went up?
o Yes
o No
o I did not have to pay for my prescription medicines
Did you leave your former plan because the
13
dollar amount you had to pay each time you
filled or refilled a prescription (copayment) went
up?
o Yes
o No
o I did not have to pay for my prescription
medicines
12
12
Added parenthetical reference
to "copayment" to improve
understanding for some
respondents.
Not included
Did you leave your former plan because you
found a plan with a lower copayment for
prescription drugs? Yes/No
13
13
Added based on feedback from
consumers and plan
representatives citing this
disenrollment reason.
3
Not included
Current PDP Survey/Question Wording
Proposed PDP Survey/Question Wording
Current English
Language Survey
Question Number
Item count=54
Some people have to pay their prescription drug plan a Some people have to pay their prescription drug 14
plan a monthly premium (fee) out of their own
monthly fee (called a premium) out of their own
pocket for prescription drug coverage.
pocket for prescription drug coverage.
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
Item Count=54
14
Item Count=54
14
Comments
Minor wording changes around
"premium" and "fee" to
increase usability.
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 this
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
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
15
15
Added based on feedback from
consumers and plan
representatives citing this
disenrollment reason.
Prescription drug plans have a list of the prescription
medicines they will cover. Did you leave your former
plan because they changed the list of prescription
medicines they cover? Yes/No
Prescription drug plans have a list of the
prescription medicines they will cover. Did you
leave your former plan because they changed
the list of prescription medicines they cover?
Yes/No
15
16
16
No change to wording.
Did you leave your former plan because you found a
prescription drug plan that costs less? Yes/No
Item has been dropped
16
DROPPED
DROPPED
New items 13 and 15 ask about
costs specifically to be more
useful to CMS, plans, and
consumers.
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
17
17
17
No change to wording.
Did you leave your former plan because a change in
DROPPED
your health meant the plan no longer met your needs?
Yes/No
18
DROPPED
DROPPED
Item dropped due to low
reliability and to reduce
respondent burden.
Did you leave your former plan because it turned out
to be more expensive than you expected? Yes/No
19
18
18
No change to wording.
4
Did you leave your former plan because it
turned out to be more expensive than you
expected? Yes/No
Current PDP Survey/Question Wording
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
Item count=54
Did you leave your former plan because the plan
Did you leave your former plan because the plan 20
refused to pay for a medicine your doctor prescribed? refused to pay for a medicine your doctor
prescribed? Yes/No
Yes/No
Item Count=54
19
Item Count=54
19
No change to wording.
Did you leave your former plan because you had
problems getting the medicines your doctor
prescribed? Yes/No
Did you leave your former plan because you had 21
problems getting the medicines your doctor
prescribed? Yes/No
20
20
No change to wording.
Did you leave your former plan because it was difficult
to get brand name medicines?
o Yes
o No
o I did not try to get brand name medicines through
my former plan
Did you leave your former plan because it was
difficult to get brand name medicines?
o Yes
o No
o I did not try to get brand name medicines
through my former plan
22
21
21
No change to wording.
Did you leave your former plan because you were
Did you leave your former plan because you
frustrated by the plan’s approval process for medicines were frustrated by the plan’s approval process
for medicines your doctor prescribed? Yes/No
your doctor prescribed? Yes/No
23
22
22
No change to wording.
Did you leave your former plan because you did not
Did you leave your former plan because you did 24
know whom to contact when you had a problem filling not know whom to contact when you had a
or refilling a prescription?
problem filling or refilling a prescription? Yes/No
Yes/No
23
23
No change to wording.
Did you leave your former plan because it was hard to
get information from the plan
-- like which prescription medicines were covered or
how much a specific medicine would cost?
Yes/No
Did you leave your former plan because it was 25
hard to get information from the plan
about which prescription medicines were
covered or how much a specific medicine would
cost? Yes/No
24
24
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 unhappy with how the plan handled a
question or complaint?
Yes/No
26
25
25
No change to wording.
Did you leave your former plan because you could not Did you leave your former plan because you
get the information or help you needed from the plan? could not get the information or help you
needed from the plan? Yes/No
Yes/No
27
26
26
No change to wording.
Did you leave your former plan because their customer Did you leave your former plan because their
service staff did not treat you with courtesy and
customer service staff did not treat you with
respect? Yes/No
courtesy and respect? Yes/No
28
27
27
No change to wording.
5
Proposed PDP Survey/Question Wording
Current English
Language Survey
Question Number
Comments
Current PDP Survey/Question Wording
Proposed PDP Survey/Question Wording
Current English
Language Survey
Question Number
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
Comments
Item count=54
Q29 preamble
Item Count=54
Q28 preamble
Item Count=54
Q28 preamble
No change to wording.
Every year Medicare evaluates all prescription drug
plans and gives them a star rating.
Every year Medicare evaluates all prescription
drug plans and gives them a star rating.
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 29
low Medicare star rating? Yes/No
28
28
No change in 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
30
found another plan with a higher Medicare star
rating? Yes/No
29
29
No change in wording.
OTHER REASONS FOR LEAVING YOUR FORMER
PRESCRIPTION DRUG PLAN
OTHER REASONS FOR LEAVING YOUR FORMER HEADER
PRESCRIPTION DRUG PLAN
HEADER
HEADER
No change in 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 31
member or friend told you about a better plan?
Yes/No
30
30
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
31
31
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 32
a commercial or advertisement for a health plan
you thought you would like better? Yes/No
32
32
No change to wording.
Not included
Did you leave your former plan because you found
Did you leave your former plan because you
another plan that better met your prescription needs? found another plan that better met your
Yes/No
prescription needs? Yes/No
33
33
33
No change to wording.
Did you leave your former plan because you take very
few prescription medicines and don’t need a
prescription drug plan?
Yes/No
Did you leave your former plan because you
take very few prescription medicines and don’t
need a prescription drug plan?
Yes/No
34
34
34
No change in wording.
ABOUT YOU
In general, how would you rate your overall health?
o Excellent
o Very good
o Good
o Fair
o Poor
ABOUT YOU
In general, how would you rate your overall
health?
o Excellent
o Very good
o Good
o Fair
o Poor
HEADER
35
HEADER
35
HEADER
35
No change in wording.
No change in wording.
6
Current PDP Survey/Question Wording
Proposed PDP Survey/Question Wording
Current English
Language Survey
Question Number
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
Item count=54
36
Item Count=54
36
Item Count=54
36
No change to wording.
37
37
37
No change to wording.
In the past 12 months, have you seen a doctor or other In the past 12 months, have you seen a doctor 38
health provider 3 or more times for the same condition or other health provider 3 or more times for the
same condition or problem? Yes/No -- If No, go
or problem? Yes/No -- If No, go to Question 40
to Question 40
38
38
No change to wording.
Is this a condition or problem that has lasted for at
least 3 months? Yes/No
39
39
No change to wording.
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 or emotional health?
o Excellent
o Very good
o Good
o Fair
o Poor
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
Is this a condition or problem that has lasted for 39
at least 3 months? Yes/No
Comments
Do you now need or take any medicine prescribed by a Do you now need or take medicine prescribed
doctor for any condition? Yes/No -- If No, go to
by a doctor? Yes/No -- If No, go to question 42
Question 42
40
40
40
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
at least 3 months? Yes/No
lasted for at least 3 months? Yes/No
41
41
41
No change to wording.
Has a doctor ever told you that you have any of 42
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
42
42
No change to wording.
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
7
Current PDP Survey/Question Wording
Proposed PDP Survey/Question Wording
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
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
Item count=54
What is the highest grade or level of school that 43
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
Item Count=54
43
Item Count=54
43
No change in 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? 44
o Yes, Hispanic or Latino
o No, not Hispanic or Latino
44
44
No change in 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
45
45
45
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)
46
46
46
No change in wording.
Did someone help you complete this survey?
Yes/No -- If No, go to Question 49
Did someone help you complete this survey?
Yes/No -- If No, go to Question 49
47
47
47
No change in 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) _____________________________
How did that person help you? Please mark one 48
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) _____________________________
48
48
No change to wording.
8
Current English
Language Survey
Question Number
Comments
Current PDP Survey/Question Wording
Proposed PDP Survey/Question Wording
May we contact you again if we have questions about May we contact you again if we have any
questions about your survey responses or the
your survey responses or if we have other questions
health care services you received? Yes/No
about the health care services that you received?
Yes/No
9
Current English
Language Survey
Question Number
Proposed English
Language Survey
Question Number
Proposed Spanish
Language Survey
Question Number
Item count=54
49
Item Count=54
49
Item Count=54
49
Comments
Streamlined this item to reduce
burden and preserve usability.
| File Type | application/pdf |
| File Title | PDP Disenrollment Survey Crosswalk_OMB |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2023-02-08 |
| File Created | 2023-02-07 |