PDP Disenrollment Survey Crosswalk_

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

YOUR FORMER PRESCRIPTION DRUG PLAN

YOUR FORMER PRESCRIPTION DRUG PLAN

Our records show that you used to belong to
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

Item count=49
HEADER

Item Count=43
HEADER

Item Count=43
HEADER

No change to wording.

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

No change to wording.

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 FORMER PRESCRIPTION DRUG PLAN

DROPPED

DROPPED

Header has been dropped
because items have been
dropped.

1

HEADER

Comments

Current PDP Survey/Question Wording

Proposed PDP Survey/Question 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).

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item count=49
As you answer the questions in this survey,
Q3 preamble
please think only of your former prescription
drug plan (whose name is printed on the cover
of this survey).

Item Count=43
Q3 preamble

Item Count=43
Q3 preamble

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

Item has been dropped

3

DROPPED

DROPPED

Item dropped to reduce
respondent burden and to
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

Item has been dropped

4

DROPPED

DROPPED

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

HEADER

DROPPED

DROPPED

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

GETTING THE PRESCRIPTION MEDICINES YOU Dropped
NEEDED FROM YOUR FORMER PRESCRIPTION
DRUG PLAN

2

Current English
Language Survey
Question Number

Comments

No change to wording.

Current PDP Survey/Question Wording

Proposed PDP Survey/Question Wording

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

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item count=49
How often was it easy to use your former plan 5
to get the medicines your doctor prescribed?
oNever
oSometimes
oUsually
oAlways
o I did not use my former plan to get any
prescription medicines.

Item Count=43
3

Item Count=43
3

Item has been dropped

6

DROPPED

DROPPED

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

How often was it easy to use your former plan Item has been dropped
to fill a prescription at a pharmacy?
oNever
oSometimes
oUsually
oAlways
o I did not have to use my former plan to fill a
prescription at a pharmacy

7

DROPPED

DROPPED

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

Did you ever use your former plan to fill any
prescriptions by mail? Yes/No

8

DROPPED

DROPPED

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

Did you ever use your former plan to fill a
prescription at a pharmacy? Yes/No

3

Item has been dropped

Current English
Language Survey
Question Number

Comments

No change to wording.

Current PDP Survey/Question Wording

Proposed PDP Survey/Question Wording

How often was it easy to use your former plan Item has been dropped
to fill prescriptions by mail?
oNever
oSometimes
oUsually
oAlways
o I did not use my former plan to fill a
prescription by mail

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item count=49
9

Item Count=43
DROPPED

Item Count=43
DROPPED

Comments

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

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 10
worst prescription drug plan possible and 10 is
the best prescription drug plan possible, what
number would you use to rate your former
plan?

4

4

No change to wording.

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.

HEADER

HEADER

No change to wording.

Q5 preamble

Q5 preamble

No change to wording.

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

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

5

5

No change to wording.

4

11

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

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
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 you
found a plan with a lower copayment for
prescription drugs? Yes/No

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

Item count=49
12

Item Count=43
6

Item Count=43
6

No change to wording.

13

7

7

No change to wording.

Some people have to pay their prescription
Some people have to pay their prescription
14
drug plan a monthly premium (fee) out of their drug plan a monthly premium (fee) out of their
own pocket for prescription drug coverage.
own pocket for prescription drug coverage.

8

8

No change to wording.

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

5

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

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

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

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

Item count=49
15

Item Count=43
9

Item Count=43
9

No change to wording.

Prescription drug plans have a list of the
16
prescription medicines they will cover. Did you
leave your former plan because they changed
the list of prescription medicines they cover?
Yes/No

10

10

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

17

11

11

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 the
plan refused to pay for a medicine your doctor
prescribed? Yes/No

Did you leave your former plan because it
18
turned out to be more expensive than you
expected? Yes/No
Did you leave your former plan because the
19
plan refused to pay for a medicine your doctor
prescribed? Yes/No

12

12

No change to wording.

13

13

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 problems getting the medicines your
doctor prescribed? Yes/No

14

14

No change to wording.

6

20

Comments

Current PDP Survey/Question Wording

Proposed PDP Survey/Question Wording

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

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

Item count=49
Did you leave your former plan because it was 21
difficult to get brand name medicines?
o Yes
o No
o I did not try to get brand name medicines
through my former plan

Item Count=43
15

Item Count=43
15

No change to wording.

Did you leave your former plan because you
Did you leave your former plan because you
22
were frustrated by the plan’s approval process were frustrated by the plan’s approval process
for medicines your doctor prescribed? Yes/No for medicines your doctor prescribed? Yes/No

16

16

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 you did 23
not know whom to contact when you had a
problem filling or refilling a prescription?
Yes/No

17

17

No change to wording.

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 it was 24
hard to get information from the plan
about which prescription medicines were
covered or how much a specific medicine
would cost? Yes/No

18

18

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

25

19

19

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 you
could not get the information or help you
needed from the plan? Yes/No

26

20

20

No change to wording.

7

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

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 their
customer service staff did not treat you with
courtesy and respect? Yes/No

Item count=49
27

Item Count=43
21

Item Count=43
21

No change to wording.

Every year Medicare evaluates all prescription Every year Medicare evaluates all prescription Q29 preamble
drug plans and gives them a star rating.
drug plans and gives them a star rating.

Q22 preamble

Q22 preamble

No change to wording.

Did you leave your former plan because it got a Did you leave your former plan because it got a 28
low Medicare star rating? Yes/No
low Medicare star rating? Yes/No

22

22

No change in wording.

Did you leave your former plan because you
Did you leave your former plan because you
29
found another plan with a higher Medicare star found another plan with a higher Medicare star
rating? Yes/No
rating? Yes/No

23

23

No change in wording.

OTHER REASONS FOR LEAVING YOUR
FORMER PRESCRIPTION DRUG PLAN

OTHER REASONS FOR LEAVING YOUR
FORMER PRESCRIPTION DRUG PLAN

HEADER

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

30

24

24

No change to wording.

8

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

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

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

Item count=49
31

Item Count=43
25

Item Count=43
25

No change to wording.

Did you leave your former plan because you
32
saw a commercial or advertisement for a
health plan you thought you would like better?
Yes/No

26

26

No change to wording.

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

27

27

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

Did you leave your former plan because you
34
take very few prescription medicines and don’t
need a prescription drug plan?
Yes/No
ABOUT YOU
HEADER
In general, how would you rate your overall
35
health?
oExcellent
oVery good
oGood
oFair
oPoor

28

28

No change in wording.

HEADER
29

HEADER
29

No change in wording.
No change in wording.

9

33

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

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 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

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

Item count=49
36

Item Count=43
30

Item Count=43
30

No change to wording.

37

31

31

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 40

In the past 12 months, have you seen a doctor 38
or other health provider 3 or more times for
the same condition or problem? Yes/No -- If
No, go to Question 34

32

32

No change to wording.

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

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

39

33

33

No change to wording.

Do you now need or take medicine prescribed Do you now need or take medicine prescribed 40
by a doctor? Yes/No -- If No, go to question 42 by a doctor? Yes/No -- If No, go to question 36

34

34

No change to wording.

10

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

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

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
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=49
41

Item Count=43
35

Item Count=43
35

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

36

36

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

43

37

37

No change in wording.

Are you of Hispanic or Latino origin or descent? Are you of Hispanic or Latino origin or descent? 44
o Yes, Hispanic or Latino
o Yes, Hispanic or Latino
o No, not Hispanic or Latino
o No, not Hispanic or Latino

38

38

No change in 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

39

39

No change to wording.

11

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

Comments

Current PDP Survey/Question Wording

Proposed PDP Survey/Question 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)

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item count=49
What language do you mainly speak at home? 46
o Chinese
o English
o Russian
o Spanish
o Vietnamese
o Some other language (please print)

Item Count=43
40

Item Count=43
40

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 43

47

41

41

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 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

42

42

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

49

43

43

No change to wording.

12

Current English
Language Survey
Question Number

Comments