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Form CMS-10793 2022 Medicare Advantage Plan Survey Field Test Version
ICR 202201-0938-021 · OMB 0938-1432 · Object 118269700.
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2022 Medicare Advantage Plan Survey Field Test Version [New items compared to current MA-Only survey highlighted in yellow] 2022 Medicare Experience Survey MEDICARE SURVEY INSTRUCTIONS This survey asks about you and the health care you received in the last six months. Answer each question thinking about yourself and the times you got health care in person, by phone or by video call. Please take the time to complete this survey. Your answers are very important to us. Please return the survey with your answers in the enclosed postage-paid envelope to [Survey Vendor]. If you changed your Medicare plan for 2022, answer the questions thinking about your experiences in the last 6 months of 2021. • Answer all the questions by putting an “X” in the box to the left of your answer, like this: • • • Yes Be sure to read all the answer choices given before marking your answer. You are sometimes told not to answer some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this: [If No, Go to Question 3]. See the example below: EXAMPLE 1. Do you wear a hearing aid now? Yes No If No, Go to Question 3 2. How long have you been wearing a hearing aid? Less than one year 1 to 3 years More than 3 years I don’t wear a hearing aid 3. In the last 6 months, did you have any headaches? Yes No According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. This applies to both mandatory and voluntary collections of information. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average 16 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850. 1 1. 5. Our records show that in 2021 your health services were covered by the plan named on the back page. Is that right? Yes If Yes, Go to Question 3 No 2. Yes No If No, Go to Question 7 6. Please write below the name of the health plan you had in 2021 and complete the rest of the survey based on the experiences you had with that plan. (Please print) 7. In the last 6 months, did you have an illness, injury, or condition that needed care right away? In the last 6 months, when you needed care right away, how often did you get care as soon as you needed? 8. Never Sometimes Usually Always Never Sometimes Usually Always In the last 6 months, not counting the times you went to an emergency room, how many times did you get health care for yourself in person, by phone, or by video? Yes No If No, Go to Question 5 4. In the last 6 months, how often did you get an appointment for a check-up or routine care as soon as you needed? Your Health Care in the Last 6 Months These questions ask about your own health care from a clinic, emergency room, or doctor’s office. This includes care you got in person, by phone, or by video. 3. In the last 6 months, did you make any in-person, phone, or video appointments for a check-up or routine care? None If None, Go to Question 15 1 time 2 3 4 5 to 9 10 or more times In the last 6-months, were any of your visits to doctors, nurses, or other health care providers by phone or video? Yes No If No, Go to Question 14 2 9. 10. 13. In the last 6 months, how often did your in-person, phone, or video visits start on time? In the last 6 months, how often did you get the instructions you needed to use phone or video for your visits? Never Sometimes Usually Always 14. In the last 6 months, when you talked with a doctor, nurse, or other health care provider during a scheduled appointment, how often did they know your health history? In the last 6 months, how often was it easy to have a visit by phone or video? Never Sometimes Usually Always 11. In the last 6 months, how often did the care you got by phone or video meet your needs? Never Sometimes Usually Always 15. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 6 months? Never Sometimes Usually Always 12. In the last 6 months, how often did you feel comfortable talking with your doctor, nurse, or other health care provider by phone or video about your health care concerns and symptoms? Never Sometimes Usually Always Never Sometimes Usually Always 3 0 Worst health care possible 1 2 3 4 5 6 7 8 9 10 Best health care possible 16. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? 20. In the last 6 months, how often did a doctor, nurse, or other health care provider explain the results of your blood test, x-ray, or other test? Never Sometimes Usually Always 17. In the last 6 months, did a doctor, nurse, or other health care provider order a blood test, x-ray, or other test for you? 21. In the last 6 months, how often was the explanation of your test results easy to understand? Yes No If No, Go to Question 23 18. In the last 6 months, when a doctor, nurse, or other health care provider ordered a blood test, x-ray, or other test for you, how often were you told when to expect your test results? Never Sometimes Usually Always Never Sometimes Usually Always 22. In the last 6 months, how often did you get as much information as you needed about your test results? Never Sometimes Usually Always 19. In the last 6 months, when a doctor, nurse, or other health care provider ordered a blood test, x-ray, or other test for you, how often did you get your test results? Never If Never, Go to Question 23 Sometimes Usually Always 4 Never Sometimes Usually Always 27. In the last 6 months, how often did your personal doctor show respect for what you had to say? Your Personal Doctor 23. A personal doctor is the one you would see if you need a check-up, want advice about a health problem, or get sick or hurt. Do you have a personal doctor? Yes No If No, Go to Question 38 28. In the last 6 months, how often did your personal doctor spend enough time with you? 24. In the last 6 months, how many times did you have an in-person, phone, or video visit with your personal doctor about your health? None If None, Go to Question 38 1 time 2 3 4 5 to 9 10 or more times 0 Worst personal doctor possible 1 2 3 4 5 6 7 8 9 10 Best personal doctor possible Never Sometimes Usually Always 26. In the last 6 months, how often did your personal doctor listen carefully to you? Never Sometimes Usually Always 29. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your personal doctor? 25. In the last 6 months, how often did your personal doctor explain things in a way that was easy to understand? Never Sometimes Usually Always Never Sometimes Usually Always 5 30. In the last 6 months, when you talked with your personal doctor during a scheduled appointment, how often did he or she have your medical records or other information about your care? 34. In the last 6 months, did you get care from more than one kind of health care provider or use more than one kind of health care service? Yes No If No, Go to Question 38 Never Sometimes Usually Always 35. In the last 6 months, did you need help from anyone in your personal doctor’s office to manage your care among these different providers and services? 31. In the last 6 months, how often did your personal doctor dismiss symptoms that were important to you? Yes No If No, Go to Question 38 36. In the last 6 months, did you get the help you needed from your personal doctor’s office to manage your care among these different providers and services? Never Sometimes Usually Always 32. In the last 6 months, did you take any prescription medicine? Yes, definitely Yes, somewhat No Yes No If No, Go to Question 34 37. In the last 6 months, did anyone from your personal doctor’s office follow up to ask if you had any questions about your care from these different providers and services? 33. In the last 6 months, how often did you and your personal doctor talk about all the prescription medicines you were taking? Never Sometimes Usually Always Yes No 6 42. We want to know your rating of the specialist you talked to most often in the last 6 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist? Getting Health Care From Specialists When you answer the next questions, include the care you got in person, by phone, or by video. 38. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. Is your personal doctor a specialist? Yes If Yes, Please include your personal doctor as you answer these questions about specialists No 39. In the last 6 months, did you make any appointments with a specialist? 43. In the last 6 months, how often did your personal doctor seem informed and up-to-date about the care you got from specialists? Yes No If No, Go to Question 44 40. In the last 6 months, how often did you get an appointment with a specialist as soon as you needed? 0 Worst specialist possible 1 2 3 4 5 6 7 8 9 10 Best specialist possible Never Sometimes Usually Always I do not have a personal doctor I have not talked with my personal doctor in the last 6 months My personal doctor is a specialist Never Sometimes Usually Always 41. How many specialists have you talked to in the last 6 months? None If None, Go to Question 44 1 specialist 2 3 4 5 or more specialists 7 47. 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 health plan? Your Health Plan 44. In the last 6 months, did you get information or help from your health plan’s customer service? Yes No If No, Go to Question 47 45. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed? Never Sometimes Usually Always About You 46. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect? 0 Worst health plan possible 1 2 3 4 5 6 7 8 9 10 Best health plan possible 48. In general, how would you rate your overall health? Never Sometimes Usually Always Excellent Very good Good Fair Poor 49. In general, how would you rate your overall mental or emotional health? 8 Excellent Very good Good Fair Poor 50. 54. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it? What language do you mainly speak at home? English Spanish Chinese Korean Tagalog Vietnamese Some other language Yes No My doctor did not prescribe any medicines for me in the last 6 months 55. In the last 6 months, did anyone from a clinic, emergency room, or doctor’s office where you got care treat you in an unfair or insensitive way because of any of the following things about you? Yes No a. Medical history......... b. Disability ................... c. Age ............................ d. Culture or religion .... e. Language or accent .. f. Race or ethnicity ....... g. Gender or gender identity ..................... h. Sexual orientation .... ↓ Please print:____________ 51. In the last 6 months, did you spend one or more nights in a hospital? Yes No 52. In the last 6 months, how often was it easy to get the medicines your doctor prescribed? Never Sometimes Usually Always My doctor did not prescribe any medicines for me in the last 6 months 53. Do you have insurance that pays part or all of the cost of your prescription medicines? Yes No Don’t know 9 56. Has a doctor ever told you that you had any of the following conditions? a. A heart attack? b. Angina or coronary heart disease? c. Hypertension or high blood pressure? d. Cancer, other than skin cancer? e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? f. Any kind of diabetes or high blood sugar? Yes No 60. Have you had a flu shot since July 1, 2021? Yes No Don’t know 61. Have you ever had one or more pneumonia shots? Two shots are usually given in a person’s lifetime and these are different from a flu shot. It is also called the pneumococcal vaccine. Yes No Don’t know 62. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? 57. Do you have serious difficulty walking or climbing stairs? Every day Some days Not at all If Not at all, Go to Question 64 Don’t know If Don’t know, Go to Question 64 Yes No 58. Do you have difficulty dressing or bathing? 63. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider? Yes No 59. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? Yes No 10 Never Sometimes Usually Always I had no in-person, phone, or video visits in the last 6 months 64. What is the highest grade or level of school that you have completed? 68. Do you ever use the internet at home? Yes No 8th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree 69. May the Medicare Program follow up with you to learn more about your health care, or to invite you to a group discussion or interview on topics related to health care? Yes No 65. Are you of Hispanic or Latino origin or descent? 70. Did someone help you complete this survey? Yes, Hispanic or Latino No, not Hispanic or Latino Yes No Thank you. Please return the completed survey in the postagepaid envelope. 66. What is your race? Please mark one or more. White Black or African-American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native 71. 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 67. How many people live in your household now, including yourself? 1 person 2 to 3 people 4 or more people Thank you. Please return the completed survey in the postage-paid envelope. [SURVEY VENDOR RETURN ADDRESS FOR MAIL PROCESSING] 11
| File Type | application/pdf |
| File Title | 2022 MA-Only Field Test Survey_1-26-22 |
| Author | Steven D. Kuszmaul |
| File Modified | 2022-01-27 |
| File Created | 2022-01-26 |