MA-ONLY Disenrollment Survey crosswalk

Current MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
YOUR FORMER HEALTH PLAN
HEADER
We are sending you this survey because we believe Introduction to Q1
you recently switched or dropped your Medicare
health plan.

Item Count=45
HEADER
Introduction to Q1

Item Count=45
HEADER
Introduction to Q1

Our records show that you used to belong to the
1
health plan whose name is printed on the cover of
this survey but that you no longer belong to that
plan. Is that right?
o Yes, I switched to a different Medicare health
plan
o I switched health plans but my former plan was
not the plan printed on the cover of this survey
o No, I did not switch plans or drop my Medicare
plan recently
Did you have to change, switch or drop your former Did you have to switch or drop your former
2
Medicare health plan for any of the following
health plan for any of the following reasons?
o I moved outside of the area where the plan was
reasons?
o I moved outside of the area where the plan was
available
available
o I was dropped by the plan
o The plan was cancelled or discontinued in my area o I was dropped by the plan
o The plan was cancelled or discontinued in my
o The plan was changed or discontinued by the
area
organization that provides my insurance (such as a
o The plan was changed or discontinued by the
former employer or a union)
organization that provides my insurance (such as a
o None of the above
former employer or a union)
o None of the above
GETTING INFORMATION OR HELP FROM YOUR
GETTING INFORMATION OR HELP FROM YOUR
HEADER
FORMER HEALTH PLAN
FORMER HEALTH PLAN

1

1

For streamlining and to reduce
fielding costs, the survey no longer
displays customized text with the
prior contract name/number.
Wording to Q1 and response
options changed for new version.

2

2

Re-worded Q2 to improve usability
(changed "did you have to change,
switch or drop" to "did you have to
switch plans or drop").

HEADER

HEADER

No change to wording.

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

Q3 preamble

Q3 preamble

Added reference to the plan name
printed on the cover of the survey.

3

3

3

No change to wording.

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

4

4

No change to wording.

YOUR FORMER HEALTH PLAN
We are sending you this survey because we believe
you recently changed or switched to another health
plan or dropped your Medicare health plan.

Proposed MA-Only Survey/Question Wording

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

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

Did you ever try to get information or help from your Did you ever try to get information or help from
former plan’s customer service?
your former plan’s customer service?
Yes/No
Yes/No
How often did your former plan’s customer service
give you the information or help you needed?
o Never
o Sometimes
o Usually
o Always
o I did not try to get information or help from my
former health plan's customer service

1

Comments

No change to wording.
Minor revisions made to Q1
introduction to improve usability

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

Did you ever need written information from the plan Item has been dropped
in Spanish? Yes/No

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
Item Count=45
5 (SPANISH VERSION NA
ONLY)

Item Count=45
DROPPED

6 (SPANISH VERSION NA
ONLY)

DROPPED

Comments

Spanish language version of the
survey is distributed almost
exclusively in Puerto Rico where
plans customarily provide
information in Spanish. Item
dropped due to low endorsement
and to reduce burden.
Spanish language version of the
survey is distributed almost
exclusively in Puerto Rico where
plans customarily provide
information in Spanish. Item
dropped due to low endorsement
and to reduce burden.
No change to wording.

How often did the plan give you written information
in Spanish?
o Never
o Sometimes
o Usually
o Always
o I did not need written information in Spanish
GETTING HEALTH CARE YOU NEEDED FROM YOUR
FORMER HEALTH PLAN

Item has been dropped

GETTING HEALTH CARE YOU NEEDED FROM YOUR HEADER
FORMER HEALTH PLAN

HEADER

HEADER

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

Item has been dropped.

DROPPED

DROPPED

Equivalent item no longer exists on
the MA & PD CAHPS survey for
comparison of enrollee experiences.

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

How often was it easy to get the care, tests, or
6
treatment you needed through your former plan?
o Never
o Sometimes
o Usually
o Always
o I did not try to get any kind of care, tests, or
treatment through my former plan
In the last 6 months, did you make an appointment NA
to see a specialist?
o Yes
o No if no go to question 8
o Someone else made my specialist appointments
for me

5

5

No change to wording.

6

6

New item enables comparison to
enrollee experiences on MA & PDP
CAHPS survey.

NA

In the last 6 months, how often did you get an
NA
appointment to see a specialist as soon as you
needed?
o Never
o Sometimes
o Usually
o Always
o I did not make an appointment to see a specialist

7

7

New item enables comparison to
enrollee experiences on MA & PDP
CAHPS survey.

2

5

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

Item Count=45
7

Item Count=45
8

Item Count=45
8

No change to wording.

Comments

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?

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 changing, switching or dropping your former
health plan.

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

Q9 preamble

Q9 preamble

Re-worded preamble to improve
usability by revising "changing,
switching or dropping" to "switching
or dropping."

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

Did you leave your former plan because you found 8
out that someone had signed you up for the plan
without your permission? Yes/No

9

9

No change to wording.

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

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

10

10

No change to wording.

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

Did you leave your former plan because the dollar 10
amount you had to pay each time you visited a
doctor went up?
o Yes
o No
o I did not have to pay for doctor visits

11

11

No change to wording.

11

12

12

No change to wording.

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

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

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

Did you leave your former plan because you found 12
a health plan that costs less? Yes/No

13

13

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

14

No change to wording.

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

3

Q8 preamble

9

13

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

Item Count=45
NOT INCLUDED

Item Count=45
15

Item Count=45
15

NOT INCLUDED

16

16

New item added to further assess
possible reasons beneficiaries leave
their former plan.

Comments

NOT INCLUDED

Did you leave your former plan because a change
in your health meant the plan no longer met your
needs? Yes/No

NOT INCLUDED

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 you were 14
frustrated by the plan’s approval process for care,
tests, or treatment? Yes/No

17

17

No change to wording.

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 had
15
problems getting the care, tests, or treatment you
needed? Yes/No

18

18

No change to wording.

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

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

16

19

19

No change to wording.

Did you leave your former plan because the doctors Did you leave your former plan because the
17
or other health care providers you wanted to see did doctors or other health care providers you wanted
not belong to the plan? Yes/No
to see did not belong to the plan? Yes/No

20

20

No change to wording.

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

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

18

21

21

No change to wording.

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

Did you leave your former plan because it was hard 19
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

22

22

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 20
unhappy with how the plan handled a question or
complaint?
Yes/No

23

23

No change to wording.

Did you leave your former plan because you could not Did you leave your former plan because you could 21
get the information or help you needed from the
not get the information or help you needed from
plan? Yes/No
the plan?
Yes/No

24

24

No change to wording.

4

New item added to further assess
possible reasons beneficiaries leave
their former plan.

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

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

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
22

Item Count=45
25

Item Count=45
25

Comments

No change to wording.

Every year Medicare evaluates all health plans and
gives them a star rating that gives information on
health plan quality.

Every year Medicare evaluates all health plans and Q23 preamble
gives them a star rating.

Q26 preamble

Q26 preamble

Re-worded the preamble to improve
usability.

Have you ever seen the Medicare Star Rating for any
health plan? Yes/No

Item has been dropped

DROPPED

DROPPED

Low endorsement; removed to
reduce respondent burden

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

Did you leave your former plan because it got a low 24
Medicare star rating? Yes/No

26

26

Inserted "Medicare" before "star
rating" for added clarity.

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

Did you leave your former plan because you found 25
another plan with a higher Medicare star rating?
Yes/No

27

27

Inserted "Medicare" before "star
rating" for added clarity.

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

Item has been dropped

26

DROPPED

DROPPED

Low endorsement; removed to
reduce respondent burden

OTHER REASONS FOR LEAVING YOUR FORMER
HEALTH PLAN

OTHER REASONS FOR LEAVING YOUR FORMER
HEALTH PLAN

HEADER

HEADER

HEADER

No change to 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

27

28

28

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 saw a 28
commercial or advertisement for a health plan you
thought you would like better? Yes/No

29

29

No change to wording.

Did you leave your former plan because you found
Did you leave your former plan because you found 29
another plan that better met your prescription needs? another plan that better met your prescription
Yes/No
needs? Yes/No

30

30

No change to wording.

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

30

31

31

No change to wording.

ABOUT YOU

HEADER

HEADER

HEADER

No change to wording.

5

ABOUT YOU

23

Current MA-Only Survey/Question Wording

Proposed MA-Only Survey/Question Wording

In general, how would you rate your overall health?
o Excellent
o Very good
o Good
o Fair
o Poor

Current English
Language Survey
Question Number

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

Item Count=45
31

Item Count=45
32

Item Count=45
32

No change to wording.

33

33

No change to wording.

In general, how would you rate your overall
health?
o Excellent
o Very good
o Good
o Fair
o Poor
In general, how would you rate your overall mental or In general, how would you rate your overall mental 32
emotional health?
or emotional health?
o Excellent
o Excellent
o Very good
o Very good
o Good
o Good
o Fair
o Fair
o Poor
o Poor

Comments

In the past 12 months, how many different
prescription medicines did you take?
o None
o 1 to 2 medicines
o 3 to 5 medicines
o 6 or more medicines

In the past 12 months, how many different
prescription medicines did you take?
o None
o 1 to 2 medicines
o 3 to 5 medicines
o 6 or more medicines

33

34

34

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

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

35

35

No change to wording.

35

36

36

No change to wording.

Do you now need or take any medicine prescribed by Do you now need or take any medicine prescribed 36
a doctor for any condition? Yes/No
by a doctor for any condition? Yes/No

37

37

No change to wording.

Is this medicine to treat a condition that has lasted for Is this medicine to treat a condition that has lasted 37
at least 3 months
for at least 3 months
Yes/No
Yes/No

38

38

No change to wording.

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

6

Current MA-Only Survey/Question Wording

Proposed English
Language Survey
Question Number

Proposed Spanish
Language Survey
Question Number

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

Item Count=45
Has a doctor ever told you that you have any of the 38
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

Item Count=45
39

Item Count=45
39

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

39

40

40

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

40

41

41

No change to wording.

What is your race? Please mark one or more.
o White
o Black or African-American
o Asian
o Native Hawaiian or other Pacific Islander
o American Indian or Alaska Native

What is your race? Please mark one or more.
o White
o Black or African-American
o Asian
o Native Hawaiian or other Pacific Islander
o American Indian or Alaska Native

41

42

42

No change to wording.

7

Proposed MA-Only Survey/Question Wording

Current English
Language Survey
Question Number

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

Item Count=45
42

Item Count=45
43

Item Count=45
43

No change to wording.

Comments

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

44

44

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)

Did someone help you complete this survey?
43
Yes/No
How did that person help you? Please mark one or 44
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)

45

45

No change to wording.

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

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

46

46

No change to wording.

8

45