Crosswalk - MAPD Only

Current MA-PD Survey Item
Number and Text

Proposed MA-PD Survey Item
Number and Text/English

Proposed MA-PD Survey Item
Number and Text/Spanish

Item Count=74
1. Our records show that you used to
belong to [PLAN NAME], but no longer
belong to that plan. Is that right?
Yes  If Yes, go to Question 2
I left or was dropped by a plan but it
was not [HEALTH PLAN] Go to Question
2
No, I did not belong to [HEALTH PLAN]
No, I still belong to [HEALTH PLAN]
If you answered No to Question 1,
please stop and return the survey. You
DO NOT have to complete the survey.

Item Count=63
1. Our records show that you used
to belong to [MARKETING]
(Contract Number [PREV_PLAN])
but no longer belong to that plan.
Is that right?
RESPONSES: Yes, I changed or
switched health plans; I changed or
switched health plans but my
former plan was not [PLAN NAME];
No, I did not change, switch or
drop health plans recently

Item Count=65
1. Our records show that you used
to belong to [MARKETING]
(Contract Number [PREV_PLAN])
but no longer belong to that plan.
Is that right?
RESPONSES: Yes, I changed or
switched health plans; I changed or
switched health plans but my
former plan was not [PLAN NAME];
No, I did not change, switch or
drop health plans recently

2. Did you have to leave or switch [PLAN
NAME] for any of the following reasons?
I moved outside of the area where the
plan was available
I was dropped by the plan
The plan was cancelled or
discontinued in my area
The plan was changed by the
organization that provides my insurance
(such as an employer or a union)
PLEASE READ: If you checked any of the
reasons above, please stop and return
the survey. You DO NOT have to
complete the survey.
None of the above  If you did not
choose any of the reasons in Question 2
please continue to Question 3

2. Did you have to change, switch
or drop your former health plan for
any of the following reasons?
o I moved outside of the area
where the plan was available
I was dropped by the plan
The plan was cancelled or
discontinued in my area
The plan was changed or
discontinued by the organization
that provides my insurance (such
as a former employer or a union)
None of the above --> Continue
survey, go to Question 3

2. Did you have to change, switch
or drop your former health plan for
any of the following reasons?
o I moved outside of the area
where the plan was available
I was dropped by the plan
The plan was cancelled or
discontinued in my area
The plan was changed or
discontinued by the organization
that provides my insurance (such
as a former employer or a union)
None of the above --> Continue
survey, go to Question 3

Comments

Revised response
option #2.

Revised intro and
added response
option to make item
easier to navigate
and to better screen
out beneficiaries
who did not
disenroll
voluntarily.

(PREAMBLE) These questions ask about
your experience with your former health
plan. As you answer the rest of the
questions in this survey, please think
only of your former plan.
3. Customer service is information you
get from staff about what is covered and
how to use the plan. Did you ever try to
get information or help from [PLAN
NAME]’s customer service?
Yes
No  If No, go to #5
4. How often did the plan’s customer
service give you the information or help
you needed?
Never
Sometimes
Usually
Always
I did not try to get information or help
from the plan’s customer service
5. Did you ever try to get information
from the plan about which prescription
medicines were covered?
Yes
No  If No, go to #7
6. How often did the plan give you all
the information you needed about
which prescription medicines were
covered?
Never
Sometimes
Usually
Always
I did not try to get information about
which prescription medicines were

(PREAMBLE) As you answer the
questions in this survey, please
think only of your former health
plan.

(PREAMBLE) As you answer the
questions in this survey, please
think only of your former health
plan.

Revised preamble.

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

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

Deleted first
sentence to make
item easier to
understand.

4. How often did your former
plan’s customer service give you
the information or help you
needed?
Never/Sometimes/Usually/Always/
I did not try to get information or
help from my former health plan's
customer service

4. How often did your former
plan’s customer service give you
the information or help you
needed?
Never/Sometimes/Usually/Always/
I did not try to get information or
help from my former health plan's
customer service

Changed "the plan's
customer service"
to "your former
plan's customer
service."

5. Did you ever try to get
information from your former plan
about which prescription
medicines were covered? Yes/No

5. Did you ever try to get
information from your former plan
about which prescription
medicines were covered? Yes/No

Changed "the plan"
to "your former
plan."

6. How often did your former plan
give you all the information you
needed about which prescription
medicines were covered?
Never/Sometimes/Usually/Always/
I did not try to get information
from my former plan about which
prescription medicines were
covered

6. How often did your former plan
give you all the information you
needed about which prescription
medicines were covered?
Never/Sometimes/Usually/Always/
I did not try to get information
from my former plan about which
prescription medicines were
covered

Changed "the plan"
to "your former
plan."

7. Did you ever try to get information
from the plan about how much you
would have to pay for a prescription
medicine?
Yes
No  If No, go to #9

7. Did you ever try to get
information from your former plan
about how much you would have
to pay for a prescription medicine?
Yes/No

7. Did you ever try to get
information from your former plan
about how much you would have
to pay for a prescription medicine?
Yes/No

Changed "the plan"
to "your former
plan."

8. How often did the plan give you all the
information you needed about how
much you would have to pay for a
prescription medicine?
Never
Sometimes
Usually
Always
I did not try to get information about
how much I would have to pay for a
prescription medicine

8. How often did your former plan
give you information about how
much you would have to pay for a
prescription medicine?
RESPONSES:
Never/Sometimes/Usually/Always/
I did not try to get information
from my former plan about how
much I would have to pay for a
prescription medicine

8. How often did your former plan
give you information about how
much you would have to pay for a
prescription medicine?
RESPONSES:
Never/Sometimes/Usually/Always/
I did not try to get information
from my former plan about how
much I would have to pay for a
prescription medicine

Changed "the plan"
to "your former
plan."

9. Did you ever need written information
from the plan in a language other than
English?
Yes
No  If No, go to #11

N/A

9. Did you ever need written
information from the plan in
Spanish?
Yes
No  If No, go to #11

Simplified question
for Spanish only.
Removed item from
English version.

10. How often did the plan give you
written information in a language other
than English?
Never
Sometimes
Usually
Always
I did not need written information in a
language other than English

N/A

10. How often did the plan give you
written information in Spanish?
Never
Sometimes
Usually
Always
I did not need written
information in a language other
than English

Simplified question
for Spanish only.
Removed item from
English question.

11. Did you ever try to get any kind of
care, tests, or treatment through the
plan?
Yes
No  If No, go to #13
12. How often was it easy to get the
care, tests, or treatment you thought
you needed through the plan?
Never
Sometimes
Usually
Always

9. Did you ever try to get any kind
of care, tests, or treatment through
your former plan? Yes/No

11. Did you ever try to get any kind Simplified question
of care, tests, or treatment through for Spanish only.
your former plan? Yes/No
Removed from
English version.

10. How often was it easy to get
the care, tests, or treatment you
needed through your former
plan?Never/Sometimes/Usually/
Always/I did not try to get any
kind of care, tests, or treatment
through my former plan

12. How often was it easy to get
the care, tests, or treatment you
needed through your former
plan?Never/Sometimes/Usually/
Always/I did not try to get any
kind of care, tests, or treatment
through my former plan

Changed "the plan"
to "your former
plan." Added N/A
response category.

13. Did a doctor ever prescribe a
medicine for you that the plan did not
cover?
Yes
No

11. Did a doctor ever prescribe a
medicine for you that your former
plan did not cover? Yes/No

13. Did a doctor ever prescribe a
medicine for you that your former
plan did not cover? Yes/No

Changed "the plan"
to "your former
plan."

14. How often was it easy to use the plan
to get the medicines your doctor
prescribed?
Never
Sometimes
Usually
Always
I did not use the plan to get any
prescription medicines

12. How often was it easy to use
your former plan to get the
medicines your doctor prescribed?
Never/Sometimes/Usually/Always/
I did not use my former plan to get
any prescription medicines

14. How often was it easy to use
your former plan to get the
medicines your doctor
prescribed?
Never/Sometimes/Usually/Always/
I did not use my former plan to get
any prescription medicines

Changed "the plan"
to "your former
plan."

15. Did you ever use the plan to fill a
prescription at a local pharmacy?
Yes
No  If No, go to #17

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

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

Changed "the plan"
to "your former
plan" and removed
reference to "local."

16. How often was it easy to use the plan
to fill a prescription at a local pharmacy?
Never
Sometimes
Usually
Always
I did not use the plan to fill a
prescription at a local pharmacy

14. How often was it easy to use
your former plan to fill a
prescription at a pharmacy?
RESPONSES:
Never/Sometimes/Usually/Always/
I did not have to use my former
plan to fill a prescription at a
pharmacy

16. How often was it easy to use
your former plan to fill a
prescription at a pharmacy?
RESPONSES:
Never/Sometimes/Usually/Always/
I did not have to use my former
plan to fill a prescription at a
pharmacy

Changed "the plan"
to "your former
plan" and removed
reference to "local."

17. Did you ever use the plan to fill any
prescriptions by mail?
Yes No  If No, go to #19
18. How often was it easy to use the plan
to fill prescriptions by mail?
Never
Sometimes
Usually
Always
I did not use the plan to fill a
prescription by mail

15. Did you ever use your former
plan to fill any prescriptions by
mail? Yes/No
16. How often was it easy to use
your former plan to fill
prescriptions by mail?
Never/Sometimes/Usually/Always/
I did not use my former plan to fill
a prescription by mail

17. Did you ever use your former
plan to fill any prescriptions by
mail? Yes/No
18. How often was it easy to use
your former plan to fill
prescriptions by mail?
Never/Sometimes/Usually/Always/
I did not use my former plan to fill
a prescription by mail

Changed "the plan"
to "your former
plan."
Changed "the plan"
to "your former
plan."

19. 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 the
plan?
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible

17. 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?

19. 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?

Changed "the plan"
to "your former
plan."

(Preamble) People leave, drop, or switch
health plans for different reasons. These
questions are about reasons you may
have had for switching, leaving, or
dropping [PLAN NAME].
20. Did you leave the plan because you
found out that someone had signed you
up for the plan without your permission?
Yes
No

(Preamble) The next questions are
about reasons you may have had
for changing, switching or dropping
your former health plan.

(Preamble) The next questions are
about reasons you may have had
for changing, switching or dropping
your former health plan.

Deleted the first
sentence; revised
second sentence.

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

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

Changed "the plan"
to "your former
plan."

21. Did you leave the plan because you
were accidentally taken off the plan (or
because of some other paperwork or
clerical error)?
Yes
No
22. Some Medicare beneficiaries have to
pay their health plan a monthly fee out
of their own pocket for coverage for
health and prescription medicines.
Did you leave the plan because the
monthly fee that the health plan charges
to provide coverage for health care and
prescription medicines went up?
Yes
No

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

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

Simplified question
and changed "the
plan" to "your
former plan."

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

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

Shortened question
and changed "the
plan" to "your
former plan."

Did you leave your former plan
because this monthly fee went up?
Yes
No
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 fee went up?
Yes
No
I did not have to pay my former
plan a monthly fee out of my own
pocket

23. Did you leave the plan because you
stopped paying the monthly fee for
coverage for health care and
prescription medicines?
Yes
No  If No, go to #25

N/A

N/A

Removed question.

24. Why did you stop paying the plan’s
monthly fee?
I stopped paying the monthly fee
because I could not afford it
I stopped paying the monthly fee
because I was unhappy with the plan
I stopped paying the monthly fee for
some other reason

N/A

N/A

Removed question.

25. Health plans have a list of the
prescription medicines that the plan will
cover. Did you leave the plan because
they changed the list of prescription
medicines they cover?
Yes
No

23. 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

25. 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

Changed "the plan
will cover" to "they
will cover."

26. Did you leave the plan because the
dollar amount you had to pay each time
you filled or refilled a prescription went
up?
Yes
No

20. Did you leave your former plan
because the dollar amount you had
to pay each time you filled or
refilled a prescription went up?
Yes
No
I did not have to pay for my
prescription medicines

22. Did you leave your former plan
because the dollar amount you had
to pay each time you filled or
refilled a prescription went up?
Yes
No
I did not have to pay for my
prescription medicines

Changed "the plan"
to "your former
plan."

27. Did you leave the plan because the
dollar amount you had to pay each time
you visited a doctor went up?
Yes
No

21. Did you leave your former plan
because the dollar amount you had
to pay each time you visited a
doctor went up?
Yes
No
I did not have to pay for doctor
visits

23. Did you leave your former plan
because the dollar amount you had
to pay each time you visited a
doctor went up?
Yes
No
I did not have to pay for doctor
visits

Changed "the plan"
to "your former
plan."

28. Did you leave the plan because you
found a health plan that costs less?
Yes
No

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

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

Changed "the plan"
to "your former
plan."

29. Did you leave the plan because a
change in your personal finances meant
you could no longer afford the plan?
Yes
No

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

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

Changed "the plan"
to "your former
plan."

30. Did you leave the plan because the
plan refused to pay for a medicine your
doctor prescribed?
Yes
No

26. Did you leave your former plan
because the plan refused to pay for
a medicine your doctor prescribed?
Yes/No

28. Did you leave your former plan
because the plan refused to pay for
a medicine your doctor prescribed?
Yes/No

Changed "the plan"
to "your former
plan."

31. Did you leave the plan because you
had problems getting the medicines your
doctor prescribed?
Yes
No

27. Did you leave your former plan
because you had problems getting
the medicines your doctor
prescribed? Yes/No

29. Did you leave your former plan
because you had problems getting
the medicines your doctor
prescribed? Yes/No

Changed "the plan"
to "your former
plan."

32. Did you leave the plan because it was
difficult to get brand name medicines?
Yes
No

28. Did you leave your former plan
because it was difficult to get
brand name medicines?
Yes
No
I did not try to get brand name
medicines through my former plan
29. Did you leave your former plan
because you were frustrated by the
plan’s approval process for
medicines your doctor prescribed?
Yes/No

30. Did you leave your former plan
because it was difficult to get
brand name medicines?
Yes
No
I did not try to get brand name
medicines through my former plan
31. Did you leave your former plan
because you were frustrated by the
plan’s approval process for
medicines your doctor prescribed?
Yes/No

Changed "the plan"
to "your former
plan."

33. Did you leave the plan because you
were frustrated by the plan’s approval
process for medicines your doctor
prescribed that were not on the plan’s
list of medicines that the plan covers?
Yes
No

Simplified question
and changed "the
plan" to "your
former plan."

34. Did you leave the plan because you
did not know whom to contact when you
had a problem filling or refilling a
prescription?
Yes
No
35. Did you leave the 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
36. Did you leave the plan because you
were frustrated by the plan’s approval
process for care, tests, or treatment?
Yes
No

30. 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

32. 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

Changed "the plan"
to "your former
plan."

31. 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
32. Did you leave your former plan
because you were frustrated by the
plan’s approval process for care,
tests, or treatment? Yes/No

33. 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
34. Did you leave your former plan
because you were frustrated by the
plan’s approval process for care,
tests, or treatment? Yes/No

Changed "the plan"
to "your former
plan."

37. Did you leave the plan because you
had problems getting the care, tests, or
treatment you needed?
Yes
No

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

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

Changed "the plan"
to "your former
plan."

38. 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 the plan because you had
problems getting the plan to pay a
claim?
Yes
No

34. 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

36. 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

Changed "the plan"
to "your former
plan."

Changed "the plan"
to "your former
plan."

39. Did you leave the plan because the
doctors or other health care providers
you wanted to see did not belong to the
plan?
Yes
No

35. 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

37. 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

Changed "the plan"
to "your former
plan."

40. Did you leave the plan because
clinics or hospitals you wanted to go to
for care were not covered by the plan?
Yes
No
41. Did you leave the 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

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

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

Changed "the plan"
to "your former
plan."

37. 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

39. 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

Changed "the plan"
to "your former
plan."

42. Did you leave the plan because you
were unhappy with how the plan
handled a question or complaint?
Yes
No

38. Did you leave your former plan
because you were unhappy with
how the plan handled a question or
complaint?

40. Did you leave your former plan Changed "the plan"
because you were unhappy with
to "your former
how the plan handled a question or plan."
complaint?

43. Did you leave the plan because you
could not get the information or help
you needed from the plan?
Yes
No

39. Did you leave your former plan
because you could not get the
information or help you needed
from the plan? Yes/No

41. Did you leave your former plan
because you could not get the
information or help you needed
from the plan? Yes/No

Changed "the plan"
to "your former
plan."

44. Did you leave the plan because their
customer service staff did not treat you
with courtesy and respect?
Yes
No

40. Did you leave your former plan
because their customer service
staff did not treat you with
courtesy and respect? Yes/No

42. Did you leave your former plan
because their customer service
staff did not treat you with
courtesy and respect? Yes/No

Changed "the plan"
to "your former
plan."

(PREAMBLE) Every year Medicare
evaluates all Medicare health and
prescription drug plans and gives each
plan a quality rating. The ratings are
referred to as the Medicare Star or Plan
Ratings. The ratings provide Medicare
beneficiaries information on the quality
of services a plan provides.

41. Every year Medicare evaluates
all health plans and gives them a
star rating that gives information
on health plan quality.
Have you ever seen the Medicare
Star Rating for any health plan?
Yes/No

43. Every year Medicare evaluates
all health plans and gives them a
star rating that gives information
on health plan quality.
Have you ever seen the Medicare
Star Rating for any health plan?
Yes/No

New question.

45. Did you leave the plan because it got
a low Medicare Star Rating? Yes/no

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

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

Added new
question (above);
made this a
separate question.

46. Did you leave the plan because you
found another plan with a higher
Medicare Star Rating?
Yes
No

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

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

Changed "the plan"
to "your former
plan."

47. In the past year, did you think about
the Medicare Star or Plan ratings when
making a decision about enrolling in a
health plan?
Yes
No

44. In the past year, did you
consider Medicare Star Ratings
when trying to choose a plan?
Yes/No

46. In the past year, did you
consider Medicare Star Ratings
when trying to choose a plan?
Yes/No

Revised question
for clarity.

48. Did you leave the plan because a
family member or friend told you that
another health plan was a better plan?
Yes
No

45. Did you leave your former plan
because a family member or friend
told you about a better plan?
Yes/No

47. Did you leave your former plan
because a family member or friend
told you about a better plan?
Yes/No

Changed "the plan"
to "former plan"
and underlined
"family member or
friend."

49. Did you leave the plan because you
saw a commercial or advertisement for a
health plan you thought you would like
better?
Yes
No

46. 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

48. 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

Changed "the plan"
to "former plan."

50. Did you leave the plan because you
found another plan that better met your
prescription needs?
Yes
No
51. Did you leave the plan because
another plan offered better benefits or
coverage for some types of care,
treatment, or services (for example,
dental or vision care)?
Yes
No

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

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

Changed "the plan"
to "former plan."

48. Did you leave your former plan
because another plan offered
better benefits or coverage (for
example, dental or vision care)?
Yes/No

50. Did you leave your former plan
because another plan offered
better benefits or coverage (for
example, dental or vision care)?
Yes/No

Shortened question
and changed "the
plan" to "former
plan."

52. What was the one most important
reason you left [PLAN NAME]? (Check
one)
Financial or cost reasons
Problems getting prescription drugs
through the plan
Problems getting the care, tests, or
treatment you needed through the plan
Problems with plan not covering
doctors or hospitals you wanted to see
Problems getting information from the
plan about prescription drugs
Switched to another plan that offers
better benefits or coverage
Another reason. Please specify:

N/A

N/A

Removed question.

(HEADER) YOUR EXPERIENCE WITH
INSURANCE AGENTS, BROKERS, OR
PLAN REPRESENTATIVES

N/A

N/A

Removed item.

53. Different kinds of people sell health
insurance. Insurance may be sold by
independent insurance agents or
brokers who don’t work for the health
plan OR by plan representatives who
work directly for the plan.
Did an insurance agent, broker, or plan
representative ever call you without
your asking them to, to tell you about
insurance for health care or prescription
medicines?
Yes
No

N/A

N/A

Removed question.

54. Did an insurance agent, broker, or
plan representative ever visit your home
without your asking them to, to tell you
about insurance for health care or
prescription medicines?
Yes
No

N/A

N/A

Removed question.

55. Did you decide to leave [PLAN
NAME] because of information you got
from an insurance agent, broker, or plan
representative?
Yes
No

N/A

N/A

Removed question.

56. Did an insurance agent, broker, or
plan representative give you any
information that was not correct?
Yes
No  If No, go to #58

N/A

N/A

Removed question.

57. What kind of information was not
correct? Please check all that apply.
What the plan covered
What the plan would cost you
Which doctors belong to the plan
Which pharmacies are covered by the
plan
Which hospitals are covered by the
plan
Some other information
(please print)

N/A

N/A

Removed question.

59. In general, how would you rate your
overall mental health?
Excellent
Very good
Good
Fair
Poor

50. In general, how would you rate
your overall mental or emotional
health?

52. In general, how would you rate
your overall mental or emotional
health?

Underlined "mental
or emotional."

60. In the last 12 months, how many
different prescription medicines did you
fill? (Don’t count the same prescriptions
twice)
None
1 to 2 medicines
3 to 5 medicines
6 or more medicines
62. Is this a condition or problem that
has lasted for at least 3 months?
Yes
No

51. In the past 12 months, how
many different prescription
medicines did you take?

53. In the past 12 months, how
many different prescription
medicines did you take?

Revised question
for clarity.

52. In the past 12 months, have
you seen a doctor or other health
provider 3 or more times for the
same condition or problem?

54. In the past 12 months, have
you seen a doctor or other health
provider 3 or more times for the
same condition or problem?

Revised for
consistency across
surveys. Also
changed question
order.

61. 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 #63
63. Do you now need or take medicine
prescribed by a doctor?
Yes
No  If No, go to #65
64. Is this to treat a condition that has
lasted for at least 3 months?
Yes No
65. Has a doctor ever told you that you
had any of the following conditions?
a. A heart attack?
Yes
No
b. Angina or coronary heart disease?
Yes
No
c. Hypertension or high blood pressure?
Yes
No
d. Cancer, other than skin cancer?
Yes
No
e. Emphysema, asthma or COPD
(chronic obstructive pulmonary
disease)?
Yes
No
f. Any kind of diabetes or high blood
sugar?
Yes
No

53. Is this a condition or problem
that has lasted at least 3 months?

55. Is this a condition or problem
that has lasted at least 3 months?

Revised for
consistency across
surveys. Also
changed question
order.

54. Do you now need or take any
medicine prescribed by a doctor
for any condition?

56. Do you now need or take any
medicine prescribed by a doctor
for any condition?

Revised question
for clarity.

55. Is this medicine to treat a
condition that has lasted for at
least 3 months?
56. Has a doctor ever told you that
you have any of the following
conditions?
a heart attack
Angina or coronary heart disease
High blood pressure or
hypertension
Cancer, other than skin cancer
Emphysema, asthma or COPD
(chronic obstructive pulmonary
disease)
Any kind of diabetes or high
blood sugar

57. is this medicine to treat a
condition that has lasted for at
least 3 months?
58. Has a doctor ever told you that
you have any of the following
conditions?
a heart attack
Angina or coronary heart disease
High blood pressure or
hypertension
Cancer, other than skin cancer
Emphysema, asthma or COPD
(chronic obstructive pulmonary
disease)
Any kind of diabetes or high
blood sugar

Revised question
for clarity.
Revised question
and response
option #3.

66. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 79
80 to 84
85 or older

N/A

N/A

Removed question.

67. Are you male or female?
Male
Female

N/A

N/A

Removed question.

73. How did that person help you?
Please mark one or more.
Read the questions to me
Entered the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way (please
print)

62. How did that person help you?
Please mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way
(please
print)

64. How did that person help you?
Please mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way
(please
print)

Revised response
option 2.

74. The Medicare Program is trying to
learn more about the health care or
services provided to people with
Medicare. May we contact you again
about the health care services that you
received?
Yes
No

63. 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?

65. 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?

Deleted first
sentence; revised
second sentence.