MA-ONLY Disenrollment Survey crosswalk

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

YOUR FORMER HEALTH PLAN
Our records show that you used to belong to 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

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=46
YOUR FORMER HEALTH PLAN
HEADER
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

Item Count=42
HEADER
1

Item Count=42
HEADER
1

No change to wording.
No change to wording.

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

No change to wording.

GETTING INFORMATION OR HELP FROM YOUR
FORMER HEALTH PLAN

GETTING INFORMATION OR HELP FROM YOUR
FORMER HEALTH PLAN

DROPPED

DROPPED

Header has been dropped because
items have been dropped.

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

HEADER

Comments

Item has been dropped

3

DROPPED

DROPPED

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

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

4

DROPPED

DROPPED

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

GETTING HEALTH CARE YOU NEEDED FROM
YOUR FORMER HEALTH PLAN

HEADER

DROPPED

DROPPED

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

1

Dropped

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

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, 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

Item Count=46
5

Item Count=42
3

Item Count=42
3

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

6

DROPPED

DROPPED

Item has been dropped to reduce
respondent 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

7

DROPPED

DROPPED

Item has been dropped to reduce
respondent 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?

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?

8

4

4

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.

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

Q5 preamble

Q5 preamble

No change to wording.

5

5

No change to wording.

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

Q9 preamble

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

2

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

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

Item Count=46
Did you leave your former plan because the dollar 10
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

Comments

Item Count=42
6

Item Count=42
6

No change to wording.

Did you leave your former plan because you found Did you leave your former plan because you found 11
a plan with a lower copayment for doctors' visits? a plan with a lower copayment for doctors' visits?
Yes/No
Yes/No

7

7

No change to wording.

Some people have to pay their health plan a
Some people have to pay their health plan a
12
monthly premium (fee) out of their own pocket for monthly premium (fee) out of their own pocket for
health coverage.
health coverage.

8

8

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 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 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

13

9

9

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

14

10

10

No change to wording.

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

15

11

11

No change to wording.

16

12

12

No change to wording.

Did you leave your former plan because you had
Did you leave your former plan because you had
17
problems getting the care, tests, or treatment you problems getting the care, tests, or treatment you
needed? Yes/No
needed? Yes/No

13

13

No change to wording.

3

Current MA-Only Survey/Question Wording

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=46
Did you leave your former plan because you had
Did you leave your former plan because you had
18
problems getting the plan to pay a claim? Yes/No problems getting the plan to pay a claim? Yes/No

Item Count=42
14

Item Count=42
14

No change to wording.

Did you leave your former plan because the
Did you leave your former plan because the
19
doctors or other health care providers you wanted doctors or other health care providers you wanted
to see did not belong to the plan? Yes/No
to see did not belong to the plan? Yes/No

15

15

No change to wording.

Did you leave your former plan because the clinics Did you leave your former plan because the clinics 20
or hospitals you wanted to go to were not covered or hospitals you wanted to go to were not covered
by the plan? Yes/No
by the plan? Yes/No

16

16

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

Did you leave your former plan because it was
21
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

17

17

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

22

18

18

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

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

23

19

19

No change to wording.

24

20

20

No change to wording.

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

Q21 preamble

Q21 preamble

No change to wording.

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

25

21

21

No change to wording.

Did you leave your former plan because you found Did you leave your former plan because you found 26
another plan with a higher Medicare star rating? another plan with a higher Medicare star rating?
Yes/No
Yes/No

22

22

No change to wording.

OTHER REASONS FOR LEAVING YOUR FORMER
HEALTH PLAN

HEADER

HEADER

No change to wording.

4

Proposed MA-Only Survey/Question Wording

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

OTHER REASONS FOR LEAVING YOUR FORMER
HEALTH PLAN

Current English
Language Survey
Question Number

HEADER

Comments

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

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

Did you leave your former plan because an
insurance agent or broker 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

Item Count=46
27

Item Count=42
23

Item Count=42
23

No change to wording.

28

24

24

No change to wording.

Did you leave your former plan because you saw a Did you leave your former plan because you saw a 29
commercial or advertisement for a health plan you commercial or advertisement for a health plan you
thought you would like better? Yes/No
thought you would like better? Yes/No

25

25

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

26

26

No change to wording.

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

Did you leave your former plan because another
31
plan offered better benefits or coverage (for
example, dental or vision care, hearing aids, prepaid cards for medications and supplies)? Yes/No

27

27

No change to wording.

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

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

HEADER
28

HEADER
28

No change to wording.
No change to wording.

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

In general, how would you rate your overall mental 33
or emotional health?
oExcellent
oVery good
oGood
oFair
oPoor

29

29

No change to wording.

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

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

30

30

No change to wording.

5

HEADER
32

34

Comments

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

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 33

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 33

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

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

Item Count=46
35

Item Count=42
31

Item Count=42
31

No change to wording.

36

32

32

No change to wording.

Do you now need or take medicine prescribed by a Do you now need or take medicine prescribed by a 37
doctor? Yes/No -- If no, go to question 39
doctor? Yes/No -- If no, go to question 35

33

33

No change to wording.

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

34

34

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

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

35

35

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

36

36

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

37

37

No change to wording.

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

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

38

38

No change to wording.

6

Comments

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

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)

Did someone help you complete this survey?
Yes/No If no, go to question 46

Did someone help you complete this survey?
Yes/No If no, go to question 42

Item Count=46
43

Item Count=42
39

Item Count=42
39

No change to wording.

44

40

40

No change to 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 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)

41

41

No change to wording.

May we contact you again if we have any
questions about your survey responses or the
health care services 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

42

42

No change to wording.

7

46

Comments