MA_PD Disenrollment Survey crosswalk

MA_PD Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf

Implementation of the Medicare Prescription Drug Plan (PDP) and Medicare Advantage (MA) Plan Disenrollment Reasons Survey (CMS-10316)

MA_PD Disenrollment Survey crosswalk

OMB: 0938-1113

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Download: pdf | pdf

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
YOUR FORMER HEALTH PLAN
YOUR FORMER HEALTH PLAN
HEADER
Our records show that you used to belong to Our records show that you used to belong to 1
this health plan: [PLACEHOLDER] but that
this health plan: [PLACEHOLDER] but that
you no longer belong to that plan. Is that
you no longer belong to that plan. Is that
correct?
correct?
o Yes, I left the health plan printed above
o Yes, I left the health plan printed above
o No, I left a different health plan
o No, I left a different health plan
o No, I did not switch plans or leave ANY
o No, I did not switch plans or leave ANY
Medicare health plan recently
Medicare health plan recently

Proposed English
Language Survey
Question Number
Item Count=52
HEADER
1

Proposed Spanish
Language Survey
Question Number
Item Count=52
HEADER
1

COMMENTS

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

No change to wording.

GETTING INFORMATION OR HELP FROM
YOUR FORMER HEALTH PLAN

DROPPED

Header has been dropped
because items have been
dropped to reduce burden.

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).

As you answer the questions in this survey, Q3 preamble
please think only of your former health plan
(whose name is printed on the cover of this
survey).

Q3 preamble

No change to wording.

Did you ever try to get information or help
from your former plan’s customer service?
Yes/No -- If no, go to question 5

Item has been dropped

DROPPED

Item has been dropped to
reduce repsondent burden and
streamline survey.

HEADER

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=60
Item has been dropped
4

Proposed English
Language Survey
Question Number
Item Count=52
DROPPED

Proposed Spanish
Language Survey
Question Number
Item Count=52
DROPPED

COMMENTS

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

Deleted

DROPPED

Heading has been dropped to
reduce respondent burden and
streamline survey.

How often was it easy to get the care, tests,
or treatment you needed through your
former plan?
oNever
oSometimes
oUsually
oAlways
oI 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, 5
or treatment you needed through your
former plan?
oNever
oSometimes
oUsually
oAlways
oI did not try to get any kind of care, tests,
or treatment through my former plan

No change to wording.

Did you make an appointment to see a
specialist?
oYes
oNo if no go to question 8
oSomeone else made my specialist
appointments for me

Item has been dropped

DROPPED

DRIP

Item has been dropped to
reduce repsondent burden and
streamline survey.

How often did you get an appointment to
see a specialist as soon as you needed?
oNever
oSometimes
oUsually
oAlways
oI did not make an appointment to see a
specialist

Item has been dropped

DROPPED

Item has been dropped to
reduce repsondent burden and
streamline survey.

How often did your former plan’s customer
service give you the information or help you
needed?
oNever
oSometimes
oUsually
oAlways
oI did not try to get information or help
from my former plan's customer service

HEADER

Item has been dropped to
reduce repsondent burden and
streamline survey.

Current MA-PD Survey/Question Wording

How often was it easy to use your former
plan to get the medicines your doctor
prescribed? oNever
oSometimes
oUsually
oAlways
oI did not use my former plan to get any
prescription medicines

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
How often was it easy to use your former
8
plan to get the medicines your doctor
prescribed? oNever
oSometimes
oUsually
oAlways
oI did not use my former plan to get any
prescription medicines

Proposed English
Language Survey
Question Number
Item Count=52
4

Proposed Spanish
Language Survey
Question Number
Item Count=52
4

COMMENTS

Item has been dropped to
reduce repsondent burden and
streamline survey.
Item has been dropped to
reduce repsondent burden and
streamline survey.

No change to wording.

Did you ever use your former plan to fill a
Item has been dropped
prescription at a pharmacy? Yes/No -- If No,
go to question 11
How often was it easy to use your former
Item has been dropped
plan to fill a prescription at a pharmacy?
oNever
oSometimes
oUsually
oAlways
oI did not have to use my former plan to fill
a prescription at a pharmacy

DROPPED

Did you ever use your former plan to fill any Item has been dropped.
prescriptions by mail? Yes/No -- If no, go to
question 13

DROPPED

Item has been dropped to
reduce repsondent burden and
streamline survey.

How often was it easy to use your former
plan to fill prescriptions by mail?
oNever
oSometimes
oUsually
oAlways
oI did not use my former plan to fill a
prescription by mail

Item has been dropped

DROPPED

Item has been dropped to
reduce repsondent burden and
streamline survey.

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
The next questions are about reasons you
may have had for switching or dropping
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
HEADER
HEALTH PLAN
The next questions are about reasons you
Q14 preamble
may have had for switching or dropping
your former health plan.

No change to wording.

HEADER

No change to wording.

Q6 preamble

No change to wording.

Current MA-PD Survey/Question Wording

Proposed English
Language Survey
Question Number
Item Count=52
6

Proposed Spanish
Language Survey
Question Number
Item Count=52
6

COMMENTS

Did you leave your former plan because
someone else signed you up for the plan
without your permission? Yes/No

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
Did you leave your former plan because
14
someone else signed you up for the plan
without your permission? Yes/No

Did you leave your former plan because the
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

Did you leave your former plan because the 15
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

No change to wording.

Did you leave your former plan because you Did you leave your former plan because you 16
found a plan with a lower copayment for
found a plan with a lower copayment for
prescription drugs? Yes/No
prescription drugs? Yes/No

No change to wording.

Did you leave your former plan because the
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

No change to wording.

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

Did you leave your former plan because you Did you leave your former plan because you 18
found a plan with a lower copayment for
found a plan with a lower copayment for
doctors' visits? Yes/No
doctors' visits? Yes/No

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
Some people have to pay their health plan a Some people have to pay their health plan a 19
monthly premium (fee) out of their own
monthly premium (fee) out of their own
pocket for health coverage.
pocket for health coverage.

Proposed English
Language Survey
Question Number
Item Count=52
11

Proposed Spanish
Language Survey
Question Number
Item Count=52
11

COMMENTS

No change to wording.

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 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

Did you leave your plan because you found a 20
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

No change to wording.

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 21
medicines they will cover. Did you leave your
former plan because they changed the list of
prescription medicines they cover? Yes/No

No change to wording.

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

No change to wording.

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

No change to wording.

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

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
Did you leave your former plan because the Did you leave your former plan because the 24
plan refused to pay for a medicine your
plan refused to pay for a medicine your
doctor prescribed? Yes/No
doctor prescribed? Yes/No
Did you leave your former plan because you Did you leave your former plan because you 25
had problems getting the medicines your
had problems getting the medicines your
doctor prescribed? Yes/No
doctor prescribed? Yes/No
Did you leave your former plan because it
Did you leave your former plan because it
26
was difficult to get brand name medicines? was difficult to get brand name medicines?
o Yes
o Yes
o No
o No
o I did not try to get brand name medicines o I did not try to get brand name medicines
through my former plan
through my former plan

Proposed English
Language Survey
Question Number
Item Count=52
16

Proposed Spanish
Language Survey
Question Number
Item Count=52
16

COMMENTS

No change to wording.

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

No change to wording.

Did you leave your former plan because you
did not know whom to contact when you had
a problem filling or refilling a prescription?
Yes/No
Did you leave your former plan because it
was hard to get information from the plan
about which prescription medicines were
covered or how much a specific medicine
would cost? Yes/No

Did you leave your former plan because you 28
did not know whom to contact when you had
a problem filling or refilling a prescription?
Yes/No
Did you leave your former plan because it
29
was hard to get information from the plan
about which prescription medicines were
covered or how much a specific medicine
would cost? Yes/No

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

No change to wording.

Current MA-PD Survey/Question Wording

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
Did you leave your former plan because you Did you leave your former plan because you 32
had problems getting the plan to pay a
had problems getting the plan to pay a
claim? Yes/No
claim? Yes/No

Proposed English
Language Survey
Question Number
Item Count=52
24

Proposed Spanish
Language Survey
Question Number
Item Count=52
24

COMMENTS

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

No change to wording.

Did you leave your former plan because the Did you leave your former plan because the 34
clinics or hospitals you wanted to go to were clinics or hospitals you wanted to go to were
not covered by the plan? Yes/No
not covered by the plan? Yes/No

No change to wording.

Did you leave your former plan because it
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

No change to wording.

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 36
were unhappy with how the plan handled a
question or complaint?
Yes/No

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.

No change to wording.

Q31 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 it
39
got a low Medicare star rating? Yes/No
Did you leave your former plan because you 40
found another plan with a higher Medicare
star rating? Yes/No
OTHER REASONS FOR LEAVING YOUR
HEADER
FORMER HEALTH PLAN

No change to wording.

HEADER

No change in wording.

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

No change to wording.

Current MA-PD Survey/Question Wording

Proposed English
Language Survey
Question Number
Item Count=52
33

Proposed Spanish
Language Survey
Question Number
Item Count=52
33

COMMENTS

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

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
Did you leave your former plan because a
41
family member or friend told you about a
better plan? Yes/No
Did you leave your former plan because an 42
insurance agent or broker told you about a
better plan? Yes/No

No change to wording.

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
found another plan that better met your
prescription needs?
Yes/No
Did you leave your former plan because
another plan offered better benefits or
coverage (for example, dental or vision care,
hearing aids, pre-paid cards for medications
and supplies)? Yes/No

Did you leave your former plan because you 43
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 44
found another plan that better met your
prescription needs?
Yes/No
Did you leave your former plan because
45
another plan offered better benefits or
coverage (for example, dental or vision care,
hearing aids, pre-paid cards for medications
and supplies)? Yes/No

No change to wording.

ABOUT YOU
In general, how would you rate your overall
health?
oExcellent
oVery good
oGood
oFair
oPoor

HEADER
38

No change to wording.
No change to wording.

HEADER
46

No change in wording.

Current MA-PD Survey/Question Wording

Proposed English
Language Survey
Question Number
Item Count=52
39

Proposed Spanish
Language Survey
Question Number
Item Count=52
39

COMMENTS

In general, how would you rate your overall
mental or emotional health?
oExcellent
oVery good
oGood
oFair
oPoor

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
In general, how would you rate your overall 47
mental or emotional health?
oExcellent
oVery good
oGood
oFair
oPoor

In the past 12 months, how many different
prescription medicines did you take?
oNone
o1 to 2 medicines
o3 to 5 medicines
o6 or more medicines

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 -- if no, go to question 50

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 43

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 medicine
prescribed by a doctor? Yes/No -- If no, go to
question 52
Is this medicine to treat a condition that has
lasted for at least 3 months? Yes/No
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

Is this a condition or problem that has lasted
for at least 3 months? Yes/No
Do you now need or take medicine
prescribed by a doctor? Yes/No -- If no, go to
question 45
Is this medicine to treat a condition that has
lasted for at least 3 months? Yes/No
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

No change to wording.

Current MA-PD Survey/Question Wording

Proposed English
Language Survey
Question Number
Item Count=52
46

Proposed Spanish
Language Survey
Question Number
Item Count=52
46

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

Proposed MA-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
What is the highest grade or level of school 54
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

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

No change to wording.

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

No change to wording.

Did someone help you complete this survey? Did someone help you complete this survey? 58
Yes/No -- if no, please go to question 60
Yes/No -- if no, please go to question 52

No change to wording.

Current MA-PD 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-PD Survey/Question Wording Current English
Language Survey
Question Number
Item Count=60
How did that person help you? Please mark 59
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)

May we contact you again if we have any
May we contact you again if we have any
60
questions about your survey responses or the questions about your survey responses or the
health care services you received? Yes/No
health care services you received? Yes/No

Proposed English
Language Survey
Question Number
Item Count=52
51

Proposed Spanish
Language Survey
Question Number
Item Count=52
51

COMMENTS

No change to wording.

File Type	application/pdf
File Title	MA and PD Disenrollment Survey crosswalk
Author	CMS
File Modified	2024-03-04
File Created	2024-03-04