Medicare Advantage and Medicare Fee-For-Service CAHPS Survey: MA & PDP Plan Burden

2011 MA PD Survey (April)	2011 MA PD Survey Revised
1. Our records show that in 2010 your health services were covered by the plan named on the back cover. Is that right?  Yes If Yes, Go to Question 3  No	1. Our records show that in 2010 your health services were covered by the plan named on the back cover. Is that right?  Yes If Yes, Go to Question 3  No
2. Please write below the name of the health plan you had in 2010 and complete the rest of the survey based on the experiences you had with that plan. (Please print)	2. Please write below the name of the health plan you had in 2010 and complete the rest of the survey based on the experiences you had with that plan. (Please print)
YOUR HEALTH CARE IN THE LAST 6 MONTHS	YOUR HEALTH CARE IN THE LAST 6 MONTHS
3. In the last 6 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?  Yes  No → If No, Go to Question 5	3. In the last 6 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?  Yes  No → If No, Go to Question 5
4. In the last 6 months, when you needed care right away, how often did you get care as soon as you thought you needed?  Never  Sometimes  Usually  Always	4. In the last 6 months, when you needed care right away, how often did you get care as soon as you thought you needed?  Never  Sometimes  Usually  Always
5. In the last 6 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic?  Yes  No → If No, Go to Question 7	5. In the last 6 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic?  Yes  No → If No, Go to Question 7
6. In the last 6 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor’s office or clinic as soon as you thought you needed?  Never  Sometimes  Usually  Always	6. In the last 6 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor’s office or clinic as soon as you thought you needed?  Never  Sometimes  Usually  Always
7. In the last 6 months, not counting the times you went to an emergency room, how many times did you go to a doctor’s office or clinic to get health care for yourself?  None →If None, Go to Question 13  1  2  3  4  5 to 9  10 or more	7. In the last 6 months, not counting the times you went to an emergency room, how many times did you go to a doctor’s office or clinic to get health care for yourself?  None →If None, Go to Question 13  1  2  3  4  5 to 9  10 or more
8. In the last 6 months, did you phone a doctor’s office or clinic with a medical question after regular office hours?  Yes  No → If No, Go to Question 11 9. In the last 6 months, when you phoned a doctor’s office or clinic after regular office hours, how often did you get an answer to your medical question as soon as you needed?  Never  Sometimes  Usually  Always	8. In the last 6 months, did you phone a doctor’s office or clinic with a medical question after regular office hours?  Yes  No →If No, Go to Question 11 9. In the last 6 months, when you phoned a doctor’s office or clinic after regular office hours, how often did you get an answer to your medical question as soon as you needed?  Never  Sometimes  Usually  Always
10. In the last 6 months, when you phone a doctor’s office or clinic after regular office hours, how long did it take for someone to call you back?  Less than 1 hour  1 to 3 hours  More than 3 hours but less than 6 hours  More than 6 hours  I did not ask for a return call  I did not get a return call  I was told to go to the Emergency Room	10. In the last 6 months, when you phone a doctor’s office or clinic after regular office hours, how long did it take for someone to call you back?  Less than 1 hour  1 to 3 hours  More than 3 hours but less than 6 hours  More than 6 hours  I did not ask for a return call  I did not get a return call  I was told to go to the Emergency Room
11. Wait time includes time spent in the waiting room and exam room. In the last 6 months, how often did you see the person you came to see within 15 minutes of your appointment time?  Never  Sometimes  Usually  Always	11. Wait time includes time spent in the waiting room and exam room. In the last 6 months, how often did you see the person you came to see within 15 minutes of your appointment time?  Never  Sometimes  Usually  Always
12. 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?  0 Worst health care possible  1  2  3  4  5  6  7  8  9  10 Best health care possible	12. 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?  0 Worst health care possible  1  2  3  4  5  6  7  8  9  10 Best health care possible
13. In the last 6 months, did you have a health problem for which you needed special medical equipment, such as a cane, a wheelchair, oxygen equipment, or diabetic supplies and equipment?  Yes  No If No, Go to Question 15	13. In the last 6 months, did you have a health problem for which you needed special medical equipment, such as a cane, a wheelchair, oxygen equipment, or diabetic supplies and equipment?  Yes  No → If No, Go to Question 15
14. In the last 6 months, how often was it easy to get the medical equipment you needed through your health plan?  Never  Sometimes  Usually  Always	14. In the last 6 months, how often was it easy to get the medical equipment you needed through your health plan?  Never  Sometimes  Usually  Always
Your Personal Doctor	Your Personal Doctor
15. 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 24	15. 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 24
16. In the last 6 months, how many times did you visit your personal doctor to get care for yourself?  None →If None, Go to Question 24  1  2  3  4  5 to 9  10 or more	16. In the last 6 months, how many times did you visit your personal doctor to get care for yourself?  None →If None, Go to Question 24  1  2  3  4  5 to 9  10 or more
17. 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	17. 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
18. In the last 6 months, how often did your personal doctor listen carefully to you?  Never  Sometimes  Usually  Always	18. In the last 6 months, how often did your personal doctor listen carefully to you?  Never  Sometimes  Usually  Always
19. In the last 6 months, how often did your personal doctor show respect for what you had to say?  Never  Sometimes  Usually  Always	19. In the last 6 months, how often did your personal doctor show respect for what you had to say?  Never  Sometimes  Usually  Always
20. In the last 6 months, how often did your personal doctor spend enough time with you?  Never  Sometimes  Usually  Always	20. In the last 6 months, how often did your personal doctor spend enough time with you?  Never  Sometimes  Usually  Always
PPO a. Does <NAME OF YOUR HEALTH PLAN’S> network have enough doctors to choose from?  Yes  No	This question is used in PPO MA PD surveys only
PPO b. In the last 6 months, did you try to find out if a doctor was part of <NAME OF YOUR HEALTH PLAN’S> network?  Yes  No	This question is used in PPO MA PD surveys only
PPO c. Was the information you found on whether a doctor was part of <NAME OF YOUR HEALTH PLAN’S> network accurate?  Yes  No  I did not find the information	This question is used in PPO MA PD surveys only
21. 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?  0 Worst personal doctor possible  1  2  3  4  5  6  7  8  9  10 Best personal doctor possible	21. 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?  0 Worst personal doctor possible  1  2  3  4  5  6  7  8  9  10 Best personal doctor possible
22. In the last 6 months, did your personal doctor order a blood test, x-ray or other test for you?  Yes  No →If No, Go to Question 24	22. In the last 6 months, did your personal doctor order a blood test, x-ray or other test for you?  Yes  No →If No, Go to Question 24
23. In the last 6 months, when your personal doctor ordered a blood test, x-ray or other test for you, how often did someone from your doctor’s office follow up to give you those results?  Never  Sometimes  Usually  Always	23. In the last 6 months, when your personal doctor ordered a blood test, x-ray or other test for you, how often did someone from your doctor’s office follow up to give you those results?  Never  Sometimes  Usually  Always
This question was moved from Specialist section to Personal Doctor Session	24. How satisfied are you with the help you received to coordinate your care in the last 6 months?  Very dissatisfied  Somewhat dissatisfied  Neither dissatisfied nor satisfied  Somewhat satisfied  Very satisfied
Getting Health Care From Specialists	Getting Health Care From Specialists
25. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, did you try to make any appointments to see a specialist?  Yes  No → If No, Go to Question 31	25. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, did you try to make any appointments to see a specialist?  Yes  No → If No, Go to Question 32
26. In the last 6 months, how often was it easy to get appointments with specialists?  Never  Sometimes  Usually  Always	26. In the last 6 months, how often was it easy to get appointments with specialists?  Never  Sometimes  Usually  Always
27. How many specialists have you seen in the last 6 months?  None →If None, Go to Question 31  1 specialist  2  3  4  5 or more specialists	27. How many specialists have you seen in the last 6 months?  None →If None, Go to Question 32  1 2pecialist  2  3  4  5 or more specialists
PPO d. Some insurance plans have a network or group of doctors who belong to the plan. You pay less if you use doctors who belong to the network, and more if you use doctors who are not part of the network. In the last 6 months, did you visit any specialists who were not part of <NAME OF YOUR HEALTH PLAN> network?  Yes  No  I don’t know	This question is used in PPO MA PD surveys only
28. We want to know your rating of the specialist you saw 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?  0 Worst specialist possible  1  2  3  4  5  6  7  8  9  10 Best specialist possible	28. We want to know your rating of the specialist you saw 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?  0 Worst specialist possible  1  2  3  4  5  6  7  8  9  10 Best specialist possible
29. In the last 6 months, how often did your personal doctor seem informed and up-to-date about the care you got from specialists?  Never  Sometimes  Usually  Always I do not have a personal doctor I did not visit my personal doctor in the last 6 months	29. In the last 6 months, how often did your personal doctor seem informed and up-to-date about the care you got from specialists?  Never  Sometimes  Usually  Always  I do not have a personal doctor  I did not visit my personal doctor in the last 6 months
30. How satisfied are you with the help you received to coordinate your care in the last 6 months?  Very dissatisfied  Somewhat dissatisfied  Neither dissatisfied nor satisfied  Somewhat satisfied  Very satisfied	This question was moved to the Personal doctor section of the survey.
Your Health Plan	Your Health Plan
30. In the last 6 months, did you try to get any kind of care, tests, or treatment through your health plan?  Yes  No → If No, Go to Question 33	30. In the last 6 months, did you try to get any kind of care, tests, or treatment through your health plan?  Yes  No → If No, Go to Question 33
31. In the last 6 months, how often was it easy to get the care, tests, or treatment you thought you needed through your health plan?  Never  Sometimes  Usually  Always	31. In the last 6 months, how often was it easy to get the care, tests, or treatment you thought you needed through your health plan?  Never  Sometimes  Usually  Always
32. In the last 6 months, did you try to get information or help from your health plan’s customer service?  Yes  No → If No, Go to Question 36	32. In the last 6 months, did you try to get information or help from your health plan’s customer service?  Yes  No → If No, Go to Question 35
33. 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	33. 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
34. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect?  Never  Sometimes  Usually  Always	34. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect?  Never  Sometimes  Usually  Always
35. In the last 6 months, did your health plan give you any forms to fill out?  Yes  No → If No, Go to Question 38	35. In the last 6 months, did your health plan give you any forms to fill out?  Yes  No → If No, Go to Question 38
36. In the last 6 months, how often were the forms from your health plan easy to fill out?  Never  Sometimes  Usually  Always	36. In the last 6 months, how often were the forms from your health plan easy to fill out?  Never  Sometimes  Usually  Always
37. 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?  0 Worst health plan possible  1  2  3  4  5  6  7  8  9  10 Best health plan possible	37. 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?  0 Worst health plan possible  1  2  3  4  5  6  7  8  9  10 Best health plan possible
38. Each fall your health plan sends you a notice that describes any changes in covered services. Since September 2010, has your health plan sent you this kind of notice?  Yes  No  Don’t know	This question was dropped in revised survey
40. When you sign up for a health plan, you are given a document that describes your specific benefits under the plan. This document also describes whether there are any limits on how much or what type of care you can have in a year, what care or treatment is included in your health plan, and your rights as a plan member. Has your health plan ever given you a document with this kind of information?  Yes  No  Don’t know	This question was dropped in revised survey
41. An insurance agent or broker sells insurance for your health, your home, or your car. Did an insurance agent or broker ever call you without your asking them to, to tell you about insurance for health care or prescription medicines?  Yes  No	This question was dropped in revised survey
42. Did an insurance agent or broker ever visit your home you without your asking them to, to tell you about insurance for health care or prescription medicines?  Yes  No	This question was dropped in revised survey
43. Did an insurance agent or broker ever switch you to a different health care plan without your permission?  Yes  No	This question was dropped in revised survey
Your Medicare Rights	Your Medicare Rights
44. Was there ever a time when you believed you needed care or services that your health plan decided not to give you?  Yes  No → If No, Go to Question 44	38. In the last 6 months was there a time when you believed you needed care or services that your health plan decided not to give you?  Yes  No → If No, Go to Question 44
45. Have you ever asked anyone at your health plan to reconsider a decision not to provide or pay for health care or services?  Yes  No → If No, Go to Question 46  Don’t know → If Don't know, Go to Question 46	39. In the last 6 months have you ever asked anyone at your health plan to reconsider a decision not to provide or pay for health care or services?  Yes  No → If No, Go to Question 41  Don’t know →If Don't know, Go to Question 41
46. When you spoke to your health plan about the decision not to provide care or services, did they… Please mark one or more.  Tell you that you can file an appeal  Offer to send you forms that you need to file an appeal  Suggest how to resolve your complaint  Listen to your complaint but did not help resolve it  Discourage you from taking action  Do none of these things	40. When you spoke to your health plan about the decision not to provide care or services, did they… Please mark one or more.  Tell you that you can file an appeal  Offer to send you forms that you need to file an appeal  Suggest how to resolve your complaint  Listen to your complaint but did not help resolve it  Discourage you from taking action  Do none of these things
47. In the last 6 months, have you called or written your health plan with a complaint or problem?  Yes  No → If No, Go to Question 44	41. In the last 6 months, have you called or written your health plan with a complaint or problem?  Yes  No →If No, Go to Question 43
48. How long did it take for your health plan to resolve your complaint?  Same day  1 week  2 weeks  3 weeks  4 or more weeks  I am still waiting for it to be settled	42. How long did it take for your health plan to settle your complaint?  Same day  1 week  2 weeks  3 weeks  4 or more weeks  I am still waiting for it to be settled
49. Was your complaint or problem settled to your satisfaction?  Yes  No  I am still waiting for it to be settled	43. Was your complaint or problem settled to your satisfaction?  Yes  No  I am still waiting for it to be settled
Your Prescription Drug Plan	Your Prescription Drug Plan
Now we would like to ask you some questions about the prescription drug coverage you get through your prescription drug plan.	Now we would like to ask you some questions about the prescription drug coverage you get through your prescription drug plan.
50. Customer service is information you get from staff about what is covered and how to use the plan. In the last 6 months, did you try to get information or help from your prescription drug plan’s customer service about prescription drugs?  Yes  No If No, Go to Question 52	44. Customer service is information you get from staff about what is covered and how to use the plan. In the last 6 months, did you try to get information or help from your prescription drug plan’s customer service about prescription drugs?  Yes  No If No, Go to Question 46
51. In the last 6 months, how often did your prescription drug plan’s customer service give you the information or help you needed about prescription drugs?  Never  Sometimes  Usually  Always	45. In the last 6 months, how often did your prescription drug plan’s customer service give you the information or help you needed about prescription drugs?  Never  Sometimes  Usually  Always
52. In the last 6 months, how often did your prescription drug plan’s customer service treat you with courtesy and respect when you tried to get information or help about prescription drugs?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.	46. In the last 6 months, how often did your prescription drug plan’s customer service treat you with courtesy and respect when you tried to get information or help about prescription drugs?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.
53. In the last 6 months, did you try to get information from your prescription drug plan about which prescription medicines were covered?  Yes  No →If No, Go to Question 55	47. In the last 6 months, did you try to get information from your prescription drug plan about which prescription medicines were covered?  Yes  No →If No, Go to Question 49
54. In the last 6 months, how often did your prescription drug plan’s customer service give you all the information you needed about which prescription medicines were covered?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months	48. In the last 6 months, how often did your prescription drug plan’s customer service give you all the information you needed about which prescription medicines were covered?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.
55. In the last 6 months, did you try to get information from your prescription drug plan about how much you would have to pay for your prescription medicines?  Yes  No →If No, Go to Question 57	49. In the last 6 months, did you try to get information from your prescription drug plan about how much you would have to pay for your prescription medicines?  Yes  No →If No, Go to Question 51
56. In the last 6 months, how often did your prescription drug plan’s customer service give you all the information you needed about how much you would have to pay for your prescription medicine?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.	50. In the last 6 months, how often did your prescription drug plan’s customer service give you all the information you needed about how much you would have to pay for your prescription medicine?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.
51. In the last 6 months, how many different prescription medicines did you fill or have refilled?  None  1 to 2 medicines  3 to 5 medicines  6 or more medicines	51. In the last 6 months, how many different prescription medicines did you fill or have refilled?  None  1 to 2 medicines  3 to 5 medicines  6 or more medicines
58. In the last 6 months, did a doctor prescribe a medicine for you that your prescription drug plan did not cover?  Yes  No →If No, Go to Question 55	52. In the last 6 months, did a doctor prescribe a medicine for you that your prescription drug plan did not cover?  Yes  No →If No, Go to Question 55
59. When this happened, did you contact your prescription drug plan to ask them to cover the medicine your doctor prescribed?  Yes  No →If No, Go to Question 61  All my prescribed medicines were covered.	53. When this happened, did you contact your prescription drug plan to ask them to cover the medicine your doctor prescribed?  Yes  No →If No, Go to Question 55  All my prescribed medicines were covered.
60. When you contacted your prescription drug plan about the decision not to cover a prescription medicine did they … Please mark one or more.  Tell you that you can file an appeal  Offer to send you forms that you need to file an appeal  Suggest how to resolve your complaint  Listen to your complaint but did not help to resolve it  Discourage you from taking action  Do none of the above  All my prescribed medicines were covered	54. When you contacted your prescription drug plan about the decision not to cover a prescription medicine did they … Please mark one or more.  Tell you that you can file an appeal  Offer to send you forms that you need to file an appeal  Suggest how to resolve your complaint  Listen to your complaint but did not help to resolve it  Discourage you from taking action  Do none of the above  All my prescribed medicines were covered
61. In the last 6 months, how often was it easy to use you prescription drug plan to get the medicines your doctor prescribed?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to get any medicines in the last 6 months.	55. In the last 6 months, how often was it easy to use you prescription drug plan to get the medicines your doctor prescribed?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to get any medicines in the last 6 months.
62. In the last 6 months, did you ever use you prescription drug plan to fill a prescription at your local pharmacy?  Yes  No →If No, Go to Question 64	56. In the last 6 months, did you ever use you prescription drug plan to fill a prescription at your local pharmacy?  Yes  No →If No, Go to Question 58
63. In the last 6 months, how often was it easy to use you prescription drug plan to fill a prescription at your local pharmacy?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months.	57. In the last 6 months, how often was it easy to use you prescription drug plan to fill a prescription at your local pharmacy?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months.
64. In the last 6 months, did you ever use you prescription drug plan to fill any prescription by mail?  Yes  No →If No, Go to Question 66	58. In the last 6 months, did you ever use you prescription drug plan to fill any prescription by mail?  Yes  No →If No, Go to Question 60  I am not sure if my drug plan offers prescriptions by mail.
65. In the last 6 months, how often was it easy to use you prescription drug plan to fill a prescription by mail?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months.	59. In the last 6 months, how often was it easy to use you prescription drug plan to fill a prescription by mail?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months.  I am not sure if my drug plan offers prescriptions by mail.
66. 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 prescription drug plan?  0 Worst health plan possible  1  2  3  4  5  6  7  8  9  10 Best health plan possible	60. 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 prescription drug plan?  0 Worst health plan possible  1  2  3  4  5  6  7  8  9  10 Best health plan possible
67. Would you recommend your prescription drug plan for coverage of prescription drugs to other people like yourself?  Definitely yes  Somewhat yes  Somewhat no  Definitely no	61. Would you recommend your prescription drug plan for coverage of prescription drugs to other people like yourself?  Definitely yes  Somewhat yes  Somewhat no  Definitely no
About You	About You
68. In general, how would you rate your overall health?  Excellent  Very good  Good  Fair  Poor	62. In general, how would you rate your overall health?  Excellent  Very good  Good  Fair  Poor
69. In general, how would you rate your overall mental health?  Excellent  Very good  Good  Fair  Poor	63. In general, how would you rate your overall mental health?  Excellent  Very good  Good  Fair  Poor
70. 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 72	64. 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 66
71. Is this a condition or problem that has lasted for at least 3 months?  Yes  No	65. Is this a condition or problem that has lasted for at least 3 months?  Yes  No
72. Do you now need or take medicine prescribed by a doctor?  Yes  No → If No, Go to Question 51	66. Do you now need or take medicine prescribed by a doctor?  Yes  No → If No, Go to Question 68
73. Is this to treat a condition that has lasted for at least 3 months?  Yes  No	67. Is this to treat a condition that has lasted for at least 3 months?  Yes  No
74. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it?  Yes  No  My doctor did not prescribe any medicines for me in the last 6 months 75. How confident are you that you can identify when it is necessary for you to get medical care?  Very confident  Confident  Somewhat confident  Not at all confident	68. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it?  Yes  No  My doctor did not prescribe any medicines for me in the last 6 months This question was dropped in revised survey
76. Because of any impairment or health problem, do you need help of other persons with your personal care needs, such as eating, dressing, or getting around the house?  Yes  No	This question was dropped in revised survey
77. Because of any impairment or health problem, do you need help with your routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?  Yes  No	This question was dropped in revised survey
78. Do you have a physical or medical condition that seriously interferes with your independence, participation in the community, or quality of life?  Yes  No	This question was dropped in revised survey
79. Has a doctor ever told you that you had any of the following conditions? Yes No a. A heart attack? b. Angina or coronary heart disease? c. A stroke? d. Cancer, other than skin cancer? e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? f. Any kind of diabetes or high blood sugar?	69. Has a doctor ever told you that you had any of the following conditions? Yes No a. A heart attack? b. Angina or coronary heart disease? c. A stroke? d. Cancer, other than skin cancer? e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? f. Any kind of diabetes or high blood sugar?
80. Did you get a flu shot since September 1, 2010?  Yes  No  Don’t know	70. Have you had a flu shot since September 1, 2010?  Yes  No  Don’t know
81. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.  Yes  No  Don’t know	71. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.  Yes  No  Don’t know
82. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?  Every day  Some days  Not at all → If No, Go to Question 68  Don’t know → If Don’t know, Go to Question 68	72. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?  Every day  Some days  Not at all → If No, Go to Question 59  Don’t know → If Don’t know, Go to Question 59
83. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider?  Never  Sometimes  Usually  Always  I had no visits in the last 6 months.	73. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider?  Never  Sometimes  Usually  Always  I had no visits in the last 6 months.
84. What is your age?  18 to 24  25 to 34  35 to 44  45 to 54  55 to 64  65 to 69  70 to 74  75 to 79  80 to 84  85 or older	74. What is your age?  18 to 24  25 to 34  35 to 44  45 to 54  55 to 64  65 to 69  70 to 74  75 to 79  80 to 84  85 or older
85. Are you male or female?  Male  Female	75. Are you male or female?  Male  Female
86. What is the highest grade or level of school that you have completed?  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	76. What is the highest grade or level of school that you have completed?  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
87. Are you of Hispanic or Latino origin or descent?  Yes, Hispanic or Latino  No, not Hispanic or Latino	77. Are you of Hispanic or Latino origin or descent?  Yes, Hispanic or Latino  No, not Hispanic or Latino
88. 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	78. 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
89. Did someone help you complete this survey?  Yes  No → If No, Go to Question 75	70. Did someone help you complete this survey?  Yes  No → If No, Go to Question 72
90. 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	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
91. Do you live alone?  Yes, I live alone  No, I live with others	72. Do you live alone?  Yes, I live alone  No, I live with others
92. 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	73. 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

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