MA_PD Disenrollment Survey crosswalk

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
YOUR FORMER HEALTH PLAN
HEADER
Drop this Introduction.
Introduction to Q1

Proposed English
Language Survey
Question Number
Item Count=60
HEADER
DROPPED

Proposed Spanish
Language Survey
Question Number
Item Count=60
HEADER
DROPPED

COMMENTS

Our records show that you used to belong to 1
this 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

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 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 plans or drop your
2
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

2

2

No change to wording.

GETTING INFORMATION OR HELP FROM YOUR
FORMER HEALTH PLAN

GETTING INFORMATION OR HELP FROM
YOUR FORMER HEALTH PLAN

HEADER

HEADER

No change to wording.

As you answer the questions in this survey, please
As you answer the questions in this survey, Q3 preamble
think only of your former health plan (whose name is please think only of your former health plan
printed on the cover of this survey).
(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 Did you ever try to get information or help
former plan’s customer service? Yes/No -- If no, go to from your former plan’s customer service?
question 5
Yes/No -- If no, go to question 5

3

3

No change to wording.

YOUR FORMER HEALTH PLAN
We are sending you this survey because we believe
you recently switched or dropped your Medicare
health plan.
Our records show that you used to belong to the
health plan whose name is printed on the cover of
the 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

1

HEADER

3

No change to wording.
Delete this short introduction
to Q1 to streamline

Current MA-PD 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

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
How often did your former plan’s customer 4
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

GETTING HEALTH CARE AND THE PRESCRIPTION
MEDICINES YOU NEEDED FROM YOUR FORMER
HEALTH PLAN
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

GETTING HEALTH CARE AND THE
HEADER
PRESCRIPTION MEDICINES YOU NEEDED
FROM YOUR FORMER HEALTH PLAN
How often was it easy to get the care, tests, 5
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
In the last 6 months, did you make an appointment to Did you make an appointment to see a
6
see a specialist?
specialist?
o Yes
o Yes
o No if no go to question 8
o No if no go to question 8
o Someone else made my specialist appointments for o Someone else made my specialist
appointments for me
me
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

2

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

7

Proposed English
Language Survey
Question Number
Item Count=60
4

Proposed Spanish
Language Survey
Question Number
Item Count=60
4

COMMENTS

HEADER

HEADER

No change to wording.

5

5

No change to wording.

6

6

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

7

7

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

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
How often was it easy to use your former plan to get How often was it easy to use your former
8
plan to get the medicines your doctor
the medicines your doctor prescribed?
prescribed?
o Never
o Never
o Sometimes
o Sometimes
o Usually
o Usually
o Always
o I did not use my former plan to get any prescription o Always
o I did not use my former plan to get any
medicines
prescription medicines
Did you ever use your former plan to fill a
Did you ever use your former plan to fill a
9
prescription at a pharmacy? Yes/No -- If No, go to
prescription at a pharmacy? Yes/No -- If No,
question 11
go to question 11
How often was it easy to use your former plan to fill a How often was it easy to use your former
10
plan to fill a prescription at a pharmacy?
prescription at a pharmacy?
o Never
o Never
o Sometimes
o Sometimes
o Usually
o Usually
o Always
o Always
o I did not have to use my former plan to fill a
o I did not have to use my former plan to fill
a prescription at a pharmacy
prescription at a pharmacy
Did you ever use your former plan to fill any
Did you ever use your former plan to fill any 11
prescriptions by mail? Yes/No -- If no, go to question prescriptions by mail? Yes/No -- If no, go to
13
question 13
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
health plan possible and 10 is the best health plan
possible, what number would you use to rate your
former plan?
REASONS YOU LEFT YOUR FORMER HEALTH PLAN

Using any number from 0 to 10, where 0 is
13
the worst health plan possible and 10 is the
best health plan possible, what number
would you use to rate your former plan?
REASONS YOU LEFT YOUR FORMER HEALTH HEADER
PLAN
The next questions are about reasons you
Q14 preamble
may have had for switching or dropping
your former health plan.

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

3

12

Proposed English
Language Survey
Question Number
Item Count=60
8

Proposed Spanish
Language Survey
Question Number
Item Count=60
8

COMMENTS

9

9

No change to wording.

10

10

No change to wording.

11

11

No change to wording.

12

12

No change to wording.

13

13

No change to wording.

HEADER

HEADER

No change to wording.

Q14 preamble

Q14 preamble

No change to wording.

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
Did you leave your former plan because
14
someone else signed you up for the plan
without your permission? Yes/No

Proposed English
Language Survey
Question Number
Item Count=60
14

Proposed Spanish
Language Survey
Question Number
Item Count=60
14

COMMENTS

Did you leave your former plan because you were
taken off the plan by mistake? Yes/No

Item has been dropped

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 16
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

15

15

Added parenthetical reference
to "copayment" to improve
understanding for some
respondents.

Not included

Did you leave your former plan because you Not included
found a plan with a lower copayment for
prescription drugs? Yes/No

16

16

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

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 17
dollar 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

17

17

Added parenthetical reference
to "copayment" to improve
usability.

Not included

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

18

18

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

Did you leave your former plan because you found
out that someone had signed you up for the plan
without your permission? Yes/No

4

15

Streamlined wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
Some people have to pay their health plan a monthly Some people have to pay their health plan a 18
monthly premium (fee) out of their own
fee (called a premium) out of their own pocket for
pocket for health coverage.
health coverage.

Proposed English
Language Survey
Question Number
Item Count=60
19

Proposed Spanish
Language Survey
Question Number
Item Count=60
19

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 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

Not included

Did you leave your plan because you found a Not included
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

20

20

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

Health 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

Health plans have a list of the prescription 19
medicines they will cover. Did you leave your
former plan because they changed the list of
prescription medicines they cover? Yes/No

21

21

No change to wording.

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

Item has been dropped

DROPPED

DROPPED

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

Did you leave your former plan because a
21
change in your personal finances meant you
could no longer afford the plan? Yes/No
Item has been dropped
22

22

22

New items 16, 18, and 20 ask
about costs specifically to be
more useful to CMS, plans, and
consumers.
No change to wording.

DROPPED

DROPPED

Did you leave your former plan because it
23
turned out to be more expensive than you
expected? Yes/No
Did you leave your former plan because the plan
Did you leave your former plan because the 24
refused to pay for a medicine your doctor prescribed? plan refused to pay for a medicine your
Yes/No
doctor prescribed? Yes/No
Did you leave your former plan because you had
Did you leave your former plan because you 25
problems getting the medicines your doctor
had problems getting the medicines your
prescribed? Yes/No
doctor prescribed? Yes/No

23

23

Item dropped due to low
reliability and to reduce
respondent burden.
No change to wording.

24

24

No change to wording.

25

25

No change to wording.

5

20

Current MA-PD Survey/Question 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

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
Did you leave your former plan because it
26
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 you were
frustrated by the plan’s approval process for
medicines your doctor prescribed?
Yes/No

Did you leave your former plan because you 27
were frustrated by the plan’s approval
process for medicines your doctor
prescribed?
Yes/No
Did you leave your former plan because you did not Did you leave your former plan because you 28
know whom to contact when you had a problem
did not know whom to contact when you
filling or refilling a prescription? Yes/No
had a problem filling or refilling a
prescription? Yes/No
Did you leave your former plan because it was hard to Did you leave your former plan because it
29
get information from the plan
was hard to get information from the plan
-- like which prescription medicines were covered or about which prescription medicines were
how much a specific medicine would cost? Yes/No
covered or how much a specific medicine
would cost? Yes/No

Proposed English
Language Survey
Question Number
Item Count=60
26

Proposed Spanish
Language Survey
Question Number
Item Count=60
26

COMMENTS

27

27

No change to wording.

28

28

No change to wording.

29

29

Small wording change
specifying type of information
sought.

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 30
were frustrated by the plan’s approval
process for care, tests, or treatment? Yes/No

30

30

No change to wording.

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

Did you leave your former plan because you 31
had problems getting the care, tests, or
treatment you needed? Yes/No
Did you leave your former plan because you 32
had problems getting the plan to pay a
claim? Yes/No

31

31

No change to wording.

32

32

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 33
or other health care providers you wanted to see did doctors or other health care providers you
not belong to the plan? Yes/No
wanted to see did not belong to the plan?
Yes/No

33

33

No change to wording.

6

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
Did you leave your former plan because the clinics or Did you leave your former plan because the 34
clinics or hospitals you wanted to go to were
hospitals you wanted to go to for care were not
not covered by the plan? Yes/No
covered by the plan? Yes/No

Proposed English
Language Survey
Question Number
Item Count=60
34

Proposed Spanish
Language Survey
Question Number
Item Count=60
34

COMMENTS

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

35

35

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 it
35
was hard 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
Did you leave your former plan because you 36
were unhappy with how the plan handled a
question or complaint?
Yes/No

36

36

No change to wording.

Did you leave your former plan because you could not
get the information or help you needed from the
plan? Yes/No
Did you leave your former plan because their
customer service staff did not treat you with courtesy
and respect? Yes/No
Every year Medicare evaluates all health plans and
gives them a star rating.

Did you leave your former plan because you 37
could not get the information or help you
needed from the plan? Yes/No
Did you leave your former plan because their 38
customer service staff did not treat you with
courtesy and respect? Yes/No
Every year Medicare evaluates all health
Q39 preamble
plans and gives them a star rating.

37

37

No change to wording.

38

38

No change to wording.

Q39 preamble

Q39 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 you found
another plan with a higher Medicare star rating?
Yes/No
OTHER REASONS FOR LEAVING YOUR FORMER
HEALTH PLAN
Did you leave your former plan because a family
member or friend told you about a better plan?
Yes/No
Not included

Did you leave your former plan because it
got a low Medicare star rating? Yes/No
Did you leave your former plan because you
found another plan with a higher Medicare
star rating? Yes/No
OTHER REASONS FOR LEAVING YOUR
FORMER HEALTH PLAN
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 an
insurance agent or broker told you about a
better plan? Yes/No

39

39

39

No change to wording.

40

40

40

No change to wording.

HEADER

HEADER

HEADER

No change in wording.

41

41

41

No change in wording.

Not included

42

42

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 42
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 43
found another plan that better met your
prescription needs?
Yes/No

43

43

No change to wording.

44

44

No change to wording.

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

7

Removed "for care" from the
item to streamline.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
Did you leave your former plan because another plan Did you leave your former plan because
44
another plan offered better benefits or
offered better benefits or coverage (for example,
coverage (for example, dental or vision care,
dental or vision care)? Yes/No
hearing aids, pre-paid cards for medications
and supplies)? Yes/No
ABOUT YOU
ABOUT YOU
HEADER
In general, how would you rate your overall health? In general, how would you rate your overall 45
o Excellent
health?
o Very good
o Excellent
o Good
o Very good
o Fair
o Good
o Poor
o Fair
o Poor
In general, how would you rate your overall mental or In general, how would you rate your overall 46
emotional health?
mental or emotional health?
o Excellent
o Excellent
o Very good
o Very good
o Good
o Good
o Fair
o Fair
o Poor
o Poor

Proposed English
Language Survey
Question Number
Item Count=60
45

Proposed Spanish
Language Survey
Question Number
Item Count=60
45

COMMENTS

HEADER
46

HEADER
46

No change to wording.
No change to wording.

47

47

No change to wording.

47

48

48

No change to wording.

Added additional examples of
benefits and coverage to
improve understanding.

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, have you seen a doctor or
other health provider 3 or more times for the same
condition or problem?
Yes/No -- If no, go to question 49

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, have you seen a
doctor or other health provider 3 or more
times for the same condition or problem?
Yes/No -- if no, go to question 50

48

49

49

No change to wording.

Is this a condition or problem that has lasted for at
least 3 months? Yes/No
Do you now need or take any medicine prescribed by
a doctor for any condition? Yes/No -- If no, go to
question 51

Is this a condition or problem that has lasted 49
for at least 3 months? Yes/No
Do you now need or take medicine
50
prescribed by a doctor? Yes/No -- If no, go to
question 52

50

50

No change to wording.

51

51

Is this medicine to treat a condition that has lasted for Is this medicine to treat a condition that has 51
at least 3 months? Yes/No
lasted for at least 3 months? Yes/No

52

52

Deleted "any" before
"medicine" and "for any
condition" to reduce item
length.
No change to wording.

8

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
Has a doctor ever told you that you have any of the Has a doctor ever told you that you have any 52
of the following conditions?
following conditions?
o A heart attack
o A heart attack
o Angina or coronary heart disease
o Angina or coronary heart disease
o High blood pressure or hypertension
o High blood pressure or hypertension
o Cancer, other than skin cancer
o Cancer, other than skin cancer
o Emphysema, asthma or COPD (chronic obstructive o Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)
pulmonary disease)
o Any kind of diabetes or high blood sugar
o Any kind of diabetes or high blood sugar

Proposed English
Language Survey
Question Number
Item Count=60
53

Proposed Spanish
Language Survey
Question Number
Item Count=60
53

COMMENTS

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

53

54

54

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
54
descent?
o Yes, Hispanic or Latino
o No, not Hispanic or Latino
What is your race? Please mark one or more. 55
o American Indian or Alaska Native
o Asian
o Black or African-American
o Native Hawaiian or other Pacific Islander
o White

55

55

No change to wording.

56

56

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)

57

57

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

9

56

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=59
Did someone help you complete this survey? Yes/No -- Did someone help you complete this survey? 57
Yes/No -- if no, please go to question 60
if no, please go to question 59

Proposed English
Language Survey
Question Number
Item Count=60
58

Proposed Spanish
Language Survey
Question Number
Item Count=60
58

COMMENTS

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 58
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)

59

59

No change to wording.

May we contact you again if we have questions about
your survey responses or if we have other questions
about the health care services that you received?
Yes/No

May we contact you again if we have any
questions about your survey responses or
the health care services you received?
Yes/No

60

60

Streamlined this item to reduce
burden and preserve usability.

10

59

No change to wording.