Form CMS-10493 Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid)

CAHPS^® 5.0H Adult Questionnaire (Medicaid)

2013 English Version

[INTRO] Use English Intro, switch to Spanish language version based on preferred language of respondents CATI Specifications

[Read to each respondent, once reached. Respondent must agree to continue the interview to move forward.]

Hello, I’m calling on behalf of the Centers for Medicare and Medicaid Services, also called CMS, which is the federal agency that administers the Medicaid program. CMS has hired us to conduct an important study of people with Medicaid to learn more about the care and services they receive. Your name was selected at random by CMS from among Medicaid enrollees in your state.

We would greatly appreciate it if you would take about 20 minutes to participate in this survey. Your participation is voluntary, and there is no loss or benefits or penalty for deciding not to participate. Your participation does not involve any risks beyond those of daily life. You may skip any questions you do not want to answer and you may stop at any time. Your participation in this research is completely confidential and your answers will never be attributed to you. We will not share your name or any other identifying information with any outside organization.

For quality assurance, this call may be recorded or monitored. If you have questions, complaints, or concerns about this research, I can provide you with toll-free telephone numbers to call.

Have for reference if needed: please call Thoroughbred Research Group toll-free at (XXX) XXX-XXXX or the NORC Institutional Review Board toll-free at 1-866-309-0542. .

May we begin?

YES: PROCEED WITH INTERVIEW [GO TO Q01]

NO: ANSWER ANY QUESTIONS THE RESPONDENT HAS

IF IT BECOMES CLEAR THAT THE BENEFICIARY CANNOT COMPLETE THE TELEPHONE INTERVIEW HIMSELF/HERSELF (FOR EXAMPLE IF HE/SHE IS HARD OF HEARING, HAS A SPEECH IMPEDIMENT, OR IS TOO ILL OR FRAIL TO DO THE INTERVIEW), OR REQUIRES ASSISTANCE IN COMPLETING THE INTERVIEW, ONLY THE BENEFICIARY CAN GIVE PERMISSION FOR A PROXY TO COMPLETE THE SURVEY.

IF SPEAKING TO THE BENEFICIARY: If you need help in completing this telephone interview or if you feel you are unable to complete the interview by yourself, you can have a family member or close friend help you or do the interview for you. This person needs to be someone who knows you very well and would be able to answer health related questions accurately on your behalf.

THE INTERVIEWER MUST OBTAIN THE BENEFICIARY’S PERMISSION TO HAVE A PROXY RESPONDENT ASSIST HIM/HER IN THE CATI INTERVIEW. IF YOU ARE UNABLE TO SPEAK TO THE BENEFICIARY DIRECTLY IN ORDER TO IDENTIFY A PROXY RESPONDENT AND OBTAIN HIS/HER PERMISSION TO DO THE INTERVIEW FOR THEM, DO NOT PROCEED WITH THE INTERVIEW. CONTINUE TO INTRO Q1.

[INTRO Q1]

Is there someone who could help you do the interview or who could do the interview for you?

1 YES CONTINUE TO INTRO Q2

2 NO THANK THE RESPONDENT AND TERMINATE CALL AND CODE AS MENTALLY/ PHYSICALLY INCAPABLE

[INTRO Q2]

May we have your permission to conduct the telephone interview with this person on your behalf?

1 YES CONTINUE TO INTRO Q3

2 NO THANK THE RESPONDENT AND TERMINATE CALL AND CODE AS MENTALLY/ PHYSICALLY INCAPABLE

[INTRO Q3]

IF NECESSARY: Is this person available to talk to us now?

1 YES GO TO PROXY_INTRO 1

2 NO [COLLECT NAME AND TELEPHONE NUMBER OF PROXY AND SET A CALLBACK, OR IF NO PROXY EXISTS, TERMINATE CALL AND CODE AS MENTALLY/ PHYSICALLY INCAPABLE]

PROXY_INTRO 1

Hello, I’m calling on behalf of [HEALTH PLAN NAME/STATE MEDICAID PROGRAM NAME]. We are conducting an important study to find out how satisfied people are with [HEALTH PLAN NAME/STATE MEDICAID PROGRAM NAME]. The results of the study will help make health care better for everyone. [SAMPLE MEMBER NAME] was selected at random by CMS from among people with Medicare and [SAMPLE MEMBER NAME] has given permission for you to answer the survey on his/her behalf.

[SAMPLE MEMBER NAME]’s participation in this survey is completely voluntary and will not affect [his/her] health care or any benefits [he/she] receives. The interview will take about 20 minutes to complete.

ANSWER ANY QUESTIONS THE PROXY HAS, THEN PROCEED WITH THE INTERVIEW.

PROXY_INTRO 2

As you answer the survey questions, please remember that you are answering the questions for [him/her] and that all survey questions refer to [his/her] experiences with Medicaid. Please do not consider your own experiences or information in the answers you provide.

[Q1]

Our records show that in the last six months you were enrolled in [INSERT STATE MEDICAID AGENCY/HEALTH PLAN NAME]. Is that right?

<1> YES [Q3]

<2> NO [Q2]

<9> NOT ASCERTAINED [Q2]

To be eligible for the survey, the respondent must be currently enrolled in Medicaid. The purpose of questions 1 and 2 is to confirm that this is true. If it is determined the respondent is not currently enrolled in Medicaid, the interview is terminated.

If the respondent provides one of the following responses, the interviewer should select <2> NO.

• I left that plan

• I switched plans

• I am no longer insured by that plan

• I’m not sure

[Q2]

What is the name of your health plan?

{IF NEEDED: Is your coverage provided by [STATE MEDICAID PROGRAM NAME]?}

{FOR OPTIONS B AND D, ENTER THE RESPONDENT’S EXACT RESPONSE}

<a> [HEALTH PLAN NAME)] [Q3]

<b> POSSIBLE MATCH [SPECIFY] [Q3]

<c> RESPONDENT STATES THEY ARE

INSURED BY “MEDICAID” BUT

CANNOT PROVIDE A PLAN NAME [Q3]

<d> NOT A MATCH [SPECIFY] [term]

<e> RESPONDENT NO LONGER INSURED

BY MEDICAID [term]

Sometimes members do not recognize the exact name of their health plan. Sometimes a healthcare organization is known by more than one name. Therefore, a member may answer “No” to question 1 but still be eligible for the survey.

The respondent will provide a health plan name in response to this question. The interviewer must use their judgment to select the option that best corresponds to the respondent’s answer. Sometimes the health plan provides a list of aliases (other names that the health plan is known as). The interviewer will need to refer to the list to select the correct option.

<a> [HEALTH PLAN NAME]: This option represents an exact match. The interviewer selects this option if the respondent gives a name which is exactly the same as the health plan name or which matches a name on a list of aliases provided by the plan.

<b> POSSIBLE MATCH [SPECIFY]: The interviewer selects this option if the respondent gives a name which sounds like it is probably the same as the health plan or which is close to a name on the list of aliases provided by the plan. The interviewer will need to type in the respondent’s exact response.

<c> RESPONDENT STATES THEY ARE INSURED BY “MEDICAID” BUT CANNOT PROVIDE A PLAN NAME: The interviewer selects this option if the respondent says they are covered by Medicaid but are unable to provide the exact name of their health plan.

<d> NOT A MATCH [SPECIFY]: The interviewer selects this option if the respondent gives a name which does not sound like it is the same as the health plan or which does not come close to a name on the list of aliases provided by the plan. The interviewer will need to type in the respondent’s exact response.

<e> RESPONDENT NO LONGER INSURED BY MEDICAID: The interviewer selects this option if the respondent specifically states that s/he is no longer insured by Medicaid.

These options have been set up with the following goals in mind:

Based on responses to questions 1 and 2:

• Members who can be considered enrolled in the health plan are treated as eligible and are interviewed.

• Members whose enrollment status in the health plan is unsure are interviewed. When disposition codes are assigned at a later date, the survey vendor makes eligibility determinations by reviewing the “health plan name” provided by the respondent.

• Members who cannot be considered enrolled in the health plan are not interviewed.

Inappropriate use of these options will result in either too many ineligible people being interviewed, or, too many eligible people not being interviewed. Therefore, CATI supervisors will monitor interviewer’s use of these options for appropriateness and will provide feedback and additional training as necessary.

>term<

Today we are only interviewing members of [HEALTH PLAN NAME/STATE MEDICAID PROGRAM NAME], so those are all the questions I have. Thank you very much for your help.

Now I’m going to ask you some questions about your own health care. When you answer these questions, please do not include care you got when you stayed overnight in a hospital.

[Q3]

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?

<1> YES [Q4]

<2> NO [Q5]

<9> NOT ASCERTAINED [Q5]

[Q4]

In the last 6 months, when you needed care right away, how often did you get care as soon as you needed? Would you say…

<1> Never, [Q5]

<2> Sometimes, [Q5]

<3> Usually, or [Q5]

<4> Always? [Q5]

<9> NOT ASCERTAINED [Q5]

[Q5]

About how long has it been since you last visited a doctor for a check-up?

<1> Within the past year (anytime less than 12 months ago) [Q6]

<2> Within the past 2 years (1 year but less than 2 years ago) [Q6]

<3> Within the past 5 years (2 years but less than 5 years ago ) [Q6]

<4> 5 or more years ago [Q6]

<5> Never [Q6]

<9> NOT ASCERTAINED [Q6]

[Q6]

In the last 6 months, did you make any appointments for a check-up or routine care at a doctor’s office or clinic?

<1> YES [Q7]

<2> NO [Q8]

<9> NOT ASCERTAINED [Q8]

[Q7]

In the last 6 months, how often did you get an appointment for a check-up or routine care at a doctor’s office or clinic as soon as you needed? Would you say…

<1> Never, [Q8]

<2> Sometimes, [Q8]

<3> Usually, or [Q8]

<4> Always? [Q8]

<9> NOT ASCERTAINED [Q8]

[Q8]

In the last 6 months, how many times did you go to an emergency room to get care for yourself?

<00> NONE [Q10]

<01> 1 TIME [Q9]

<02> 2 [Q9]

<03> 3 [Q9]

<04> 4 [Q9]

<05> 5-9 [Q9]

<06> 10 OR MORE TIMES [Q9]

<09> NOT ASCERTAINED [Q10]

[Q9]

What was the main reason for your last emergency room visit? Choose one.

<00> Didn’t have a doctor [Q10]

<01> Doctor’s office or clinic was not open [Q10]

<02> The problem was too serious for the doctor’s office or clinic [Q10]

<03> Get most of your case at the emergency room [Q10]

<04> Doctor’s office was open, but could not get an appointment [Q10]

<09> NOT ASCERTAINED [Q10]

[Q10]

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?

<0> NONE [Q16]

<1> 1 TIME [Q11]

<2> 2 [Q11]

<3> 3 [Q11]

<4> 4 [Q11]

<5> 5 TO 9 [Q11]

<6> 10 OR MORE TIMES [Q11]

<9> NOT ASCERTAINED [Q16]

[Q11]

In the last 6 months, did you and a doctor or other health provider talk about specific things you could do to prevent illness?

<1> YES [Q12]

<2> NO [Q12]

<9> NOT ASCERTAINED [Q12]

[Q12]

In the last 6 months, did you and a doctor or other health provider talk about starting or stopping a prescription medicine?

<1> YES [Q13]

<2> NO [Q16]

<9> NOT ASCERTAINED [Q16]

[Q13]

When you talked about starting or stopping a prescription medicine, how much did a doctor or other health provider talk about the reasons you might want to take a medicine? Would you say…

<1> Not at all, [Q14]

<2> A little, [Q14]

<3> Some, or [Q14]

<4> A lot? [Q14]

<9> NOT ASCERTAINED [Q14]

[Q14]

When you talked about starting or stopping a prescription medicine, how much did a doctor or other health provider talk about the reasons you might not want to take a medicine? Would you say…

<1> Not at all, [Q15]

<2> A little, [Q15]

<3> Some, or [Q15]

<4> A lot? [Q15]

<9> NOT ASCERTAINED [Q15]

[Q15]

When you talked about starting or stopping a prescription medicine, did a doctor or other health provider ask you what you thought was best for you?

<1> YES [Q16]

<2> NO [Q16]

<9> NOT ASCERTAINED [Q16]

[Q16]

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?

{READ RESPONSE CHOICES ONLY IF NECESSARY}

<00> 0 [Q17]

<01> 1 [Q17]

<02> 2 [Q17]

<03> 3 [Q17]

<04> 4 [Q17]

<05> 5 [Q17]

<06> 6 [Q17]

<07> 7 [Q17]

<08> 8 [Q17]

<09> 9 [Q17]

<10> 10 [Q17]

<99> NOT ASCERTAINED [Q17]

[Q17]

In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? Would you say…

<1> Never, [Q18]

<2> Sometimes, [Q18]

<3> Usually, or [Q18]

<4> Always? [Q18]

<9> NOT ASCERTAINED [Q18]

[Q18]

In the last 6 months, how often was it easy to get special medical equipment, such as a cane, a wheelchair, diabetic testing supplies, or a nebulizer, you needed?

<1> Never, [Q19]

<2> Sometimes, [Q19]

<3> Usually, or [Q19]

<4> Always? [Q19]

<5> Did not need special medical equipment in the last 6 months [Q19]

<9> NOT ASCERTAINED [Q19]

[Q19]

In the last 6 months, how often was it easy to get the mental health or behavioral health services you needed?

<1> Never, [Q20]

<2> Sometimes, [Q20]

<3> Usually, or [Q20]

<4> Always? [Q20]

<5> Did not need these services in the last 6 months [Q20]

<9> NOT ASCERTAINED [Q20]

[Q20]

In the last 6 months, how often was it easy to get the dental services you needed?

<1> Never, [Q21]

<2> Sometimes, [Q21]

<3> Usually, or [Q21]

<4> Always? [Q21]

<5> Did not need these services in the last 6 months [Q21]

<9> NOT ASCERTAINED [Q21]

[Q21]

In the last 6 months, were you ever not able medical care, tests, or treatment you or a doctor believed necessary?

<1> YES [Q22]

<2> NO [Q23]

<9> NOT ASCERTAINED [Q23]

[Q22]

What is the main reason you were not able to get medical care, tests, or treatment you or a doctor believed necessary? Choose one.

<00> Couldn’t afford care [Q23]

<01> My health plan wouldn’t approve, cover, or pay for care [Q23]

<02> Doctor refused to accept my insurance [Q23]

<03> Doctor doesn’t speak my language [Q23]

<04> Couldn’t get transportation to doctor’s office [Q23]

<05> Couldn’t take time off work or get child care [Q23]

<06> Didn’t know where to go to get care [Q23]

<07> The wait took too long [Q23]

<09> NOT ASCERTAINED [Q23]

[Q23]

Is there a place that you usually go to when you are sick or need advice about your health?

<1> YES [Q25]

<2> NO [Q24]

<9> NOT ASCERTAINED [Q25]

[Q24]

Why don’t you have a usual source of medical care? Is it because…

>Q24_01<

You haven’t had any problems?

<1> YES [Q24_02]

<2> NO [Q24_02]

<9> NOT ASCERTAINED [Q24_02]

>Q24_02<

No doctors take your insurance?

<1> YES [Q24_03]

<2> NO [Q24_03]

<9> NOT ASCERTAINED [Q24_03]

>Q24_03<

No doctors speak your language?

<1> YES [Q24_04]

<2> NO [Q24_04]

<9> NOT ASCERTAINED [Q24_04]

>Q24_04<

The doctor’s office is too far away or not convenient?

<1> YES [Q24_05]

<2> NO [Q24_05]

<9> NOT ASCERTAINED [Q24_05]

>Q24_05<

You don’t plan to see a doctor even when you’re sick?

<1> YES [Q25]

<2> NO [Q25]

<9> NOT ASCERTAINED [Q25]

[Q25]

What kind of place do you go to most often for your medical care? Choose one.

<1> Clinic or health center [Q26]

<2> Doctor’s office or HMO [Q26]

<3> Hospital emergency room [Q26]

<4> Hospital outpatient department [Q26]

<5> Some other place [Q26]

<6> Don’t go to one place most often [Q26]

<9> NOT ASCERTAINED [Q26]

[Q26]

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?

<1> YES [Q27]

<2> NO [Q35]

<9> NOT ASCERTAINED [Q35]

[Q27]

In the last 6 months, how many times did you visit your personal doctor to get care for yourself?

<0> NONE [Q34]

<1> 1 TIME [Q28]

<2> 2 [Q28]

<3> 3 [Q28]

<4> 4 [Q28]

<5> 5 TO 9 [Q28]

<6> 10 OR MORE TIMES [Q28]

<9> NOT ASCERTAINED [Q34]

[Q28]

In the last 6 months, how often did your personal doctor explain things in a way that was easy to understand? Would you say…

<1> Never, [Q29]

<2> Sometimes, [Q29]

<3> Usually, or [Q29]

<4> Always? [Q29]

<9> NOT ASCERTAINED [Q29]

[Q29]

In the last 6 months, how often did your personal doctor listen carefully to you? Would you say…

<1> Never, [Q30]

<2> Sometimes, [Q30]

<3> Usually, or [Q30]

<4> Always? [Q30]

<9> NOT ASCERTAINED [Q30]

[Q30]

In the last 6 months, how often did your personal doctor show respect for what you had to say? Would you say…

<1> Never, [Q31]

<2> Sometimes, [Q31]

<3> Usually, or [Q31]

<4> Always? [Q31]

<9> NOT ASCERTAINED [Q31]

[Q31]

In the last 6 months, how often did your personal doctor spend enough time with you? Would you say…

<1> Never, [Q32]

<2> Sometimes, [Q32]

<3> Usually, or [Q32]

<4> Always? [Q32]

<9> NOT ASCERTAINED [Q32]

[Q32]

In the last 6 months, did you get care from a doctor or other health provider besides your personal doctor?

<1> YES [Q33]

<2> NO [Q34]

<9> NOT ASCERTAINED [Q34]

[Q33]

In the last 6 months, how often did your personal doctor seem informed and up-to-date about the care you got from these doctors or other health providers?

<1> Never, [Q34]

<2> Sometimes, [Q34]

<3> Usually, or [Q34]

<4> Always? [Q34]

<9> NOT ASCERTAINED [Q34]

[Q34]

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?

{READ RESPONSE CHOICES ONLY IF NECESSARY}

<00> 0 [Q35]

<01> 1 [Q35]

<02> 2 [Q35]

<03> 3 [Q35]

<04> 4 [Q35]

<05> 5 [Q35]

<06> 6 [Q35]

<07> 7 [Q35]

<08> 8 [Q35]

<09> 9 [Q35]

<10> 10 [Q35]

<99> NOT ASCERTAINED [Q35]

[Q35]

Now I’m going to ask you some questions about specialists. When you answer these questions, do not include dental visits or care you got when you stayed overnight in a hospital.

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 need to make an appointment to see a specialist?

<1> YES [Q36]

<2> NO [Q39]

<9> NOT ASCERTAINED [Q39]

Respondents may ask whether or not to include specialties that are not listed, such as OB/GYNs. Do not interpret for the respondent. Interviewers may provide a neutral response such as:

• Specialists are doctors who specialize in one area of health care. Please include all doctors you consider to be specialists but do not include any dental visits.

• I don’t have any information about that, so please just interpret it however it seems best to you.

• You can interpret this question however it seems best to you.

[Q36]

In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed? Would you say…

<1> Never, [Q37]

<2> Sometimes, [Q37]

<3> Usually, or [Q37]

<4> Always? [Q37]

<9> NOT ASCERTAINED [Q37]

[Q37]

How many specialists have you seen in the last 6 months?

{IF NEEDED: Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. Would you say you’ve seen… THEN READ RESPONSE CHOICES}

<0> NONE [Q39]

<1> 1 SPECIALIST [Q38]

<2> 2 [Q38]

<3> 3 [Q38]

<4> 4 [Q38]

<5> 5 OR MORE SPECIALISTS [Q38]

<9> NOT ASCERTAINED [Q39]

[Q38]

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?

{IF NEEDED: Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care.}

{READ RESPONSE CHOICES ONLY IF NECESSARY}

<00> 0 [Q39]

<01> 1 [Q39]

<02> 2 [Q39]

<03> 3 [Q39]

<04> 4 [Q39]

<05> 5 [Q39]

<06> 6 [Q39]

<07> 7 [Q39]

<08> 8 [Q39]

<09> 9 [Q39]

<10> 10 [Q39]

<99> NOT ASCERTAINED [Q39]

Now I’m going to ask you some questions about your experience with your health plan.

[Q39]

In the last 6 months, how often did your health plan’s customer service give you the information or help you needed? Would you say…

<1> Never, [Q40]

<2> Sometimes, [Q40]

<3> Usually, or [Q40]

<4> Always? [Q40]

<5> Did not try to get information or help [Q41]

<9> NOT ASCERTAINED [Q40]

[Q40]

In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect? Would you say…

<1> Never, [Q41]

<2> Sometimes, [Q41]

<3> Usually, or [Q41]

<4> Always? [Q41]

<9> NOT ASCERTAINED [Q41]

[Q41]

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?

{READ RESPONSE CHOICES ONLY IF NECESSARY}

<00> 0 [Q42]

<01> 1 [Q42]

<02> 2 [Q42]

<03> 3 [Q42]

<04> 4 [Q42]

<05> 5 [Q42]

<06> 6 [Q42]

<07> 7 [Q42]

<08> 8 [Q42]

<09> 9 [Q42]

<10> 10 [Q42]

<99> NOT ASCERTAINED [Q42]

I have just a few more questions.

[Q42]

In general, how would you rate your overall health? Would you say it is…

<1> Excellent, [Q43]

<2> Very good, [Q43]

<3> Good, [Q43]

<4> Fair, or [Q43]

<5> Poor? [Q43]

<9> NOT ASCERTAINED [Q43]

[Q43]

In general, how would you rate your overall mental or emotional health? Would you say it is…

<1> Excellent, [Q44a]

<2> Very good, [Q44a]

<3> Good, [Q44a]

<4> Fair, or [Q44a]

<5> Poor? [Q44a]

<9> NOT ASCERTAINED [Q44a]

[Q44]

Has a doctor ever told you that you had any of the following conditions?

>44a<

High cholesterol?

<1> YES [Q44b]

<2> NO [Q44b]

<9> NOT ASCERTAINED [Q44b]

>44b<

High blood pressure?

<1> YES [Q44c]

<2> NO [Q44c]

<9> NOT ASCERTAINED [Q44c]

>44c<

A heart attack?

<1> YES [Q44d]

<2> NO [Q44d]

<9> NOT ASCERTAINED [Q44d]

>44d<

Angina or coronary heart disease?

<1> YES [Q44e]

<2> NO [Q44e]

<9> NOT ASCERTAINED [Q44e]

>44e<

A stroke?

<1> YES [Q44f]

<2> NO [Q44f]

<9> NOT ASCERTAINED [Q44f]

>44f<

Any kind of diabetes or high blood sugar?

<1> YES [Q44g]

<2> NO [Q44g]

<9> NOT ASCERTAINED [Q44g]

>44g<

Cancer, other than skin cancer?

<1> YES [Q44h]

<2> NO [Q44h]

<9> NOT ASCERTAINED [Q44h]

>44h<

Emphysema, asthma or COPD (chronic obstructive pulmonary disease)?

<1> YES [Q44i]

<2> NO [Q44i]

<9> NOT ASCERTAINED [Q44i]

[Q45]

Are you deaf or do you have serious difficulty hearing?

<1> Yes [Q46]

<2> No [Q46]

<9> NOT ASCERTAINED [Q46]

[Q46]

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

<1> Yes [Q47]

<2> No [Q47]

<9> NOT ASCERTAINED [Q47]

[Q47]

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

<1> Yes [Q48]

<2> No [Q48]

<9> NOT ASCERTAINED [Q48]

[Q48]

Do you have serious difficulty walking or climbing stairs?

<1> Yes [Q49]

<2> No [Q49]

<9> NOT ASCERTAINED [Q49]

[Q49]

Do you have difficulty dressing or bathing?

<1> Yes [Q50]

<2> No [Q51]

<9> NOT ASCERTAINED [Q50]

[Q50]

In the last month, did you ever go without showering/ taking a bath/ washing up because no one was there to help?

<1> Yes [Q51]

<2> No [Q51]

<9> NOT ASCERTAINED [Q51]

[Q51]

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

<1> Yes [Q52]

<2> No [Q53]

<9> NOT ASCERTAINED [Q52]

[Q52]

In the last month, did you ever have to stay home because you had difficulty going out by yourself?

<1> Yes [Q53]

<2> No [Q53]

<9> NOT ASCERTAINED [Q53]

[Q53]

Have you had a flu shot since September 1, 2013?

<1> YES [Q54]

<2> NO [Q54]

<3> DON’T KNOW [Q54]

<9> NOT ASCERTAINED [Q54]

[Q54]

Do you now smoke cigarettes or use tobacco every day, some days, or not at all?

<1> EVERY DAY [Q55]

<2> SOME DAYS [Q55]

<3> NOT AT ALL [Q58]

<4> DON’T KNOW [Q58]

<9> NOT ASCERTAINED [Q58]

[Q55]

In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan? Would you say…

<1> Never, [Q56]

<2> Sometimes, [Q56]

<3> Usually, or [Q56]

<4> Always? [Q56]

<9> NOT ASCERTAINED [Q56]

[Q56]

In the last 6 months, how often was medication recommended or discussed by a doctor or health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication. Would you say…

<1> Never, [Q57]

<2> Sometimes, [Q57]

<3> Usually, or [Q57]

<4> Always? [Q57]

<9> NOT ASCERTAINED [Q57]

[Q57]

In the last 6 months, how often did your doctor or health provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program. Would you say…

<1> Never, [Q58]

<2> Sometimes, [Q58]

<3> Usually, or [Q58]

<4> Always? [Q58]

<9> NOT ASCERTAINED [Q58]

[Q58]

Do you take aspirin daily or every other day?

{IF NECESSARY: “Would you say yes or no?”}

<1> YES [Q59]

<2> NO [Q59]

<3> DON’T KNOW [Q59]

<9> NOT ASCERTAINED [Q59]

The interviewer should pay attention to intonation with this question so that respondent replies “yes” or “no” to the question. If the respondent does not reply “yes” or “no”, a probe is provided.

If the respondent asks about whether a particular medication or Brand name is considered aspirin, the interviewer may provide the following clarification:

Aspirin: Bayer and Bufferin.

Not Aspirin: Tylenol, Motrin, Aleve, Advil, ibuprofen and acetaminophen.

[Q59]

Do you have a health problem or take medication that makes taking aspirin unsafe for you?

{IF NECESSARY: “Would you say yes or no?”}

<1> YES [Q60]

<2> NO [Q60]

<3> DON’T KNOW [Q60]

<9> NOT ASCERTAINED [Q60]

[Q60]

Has a doctor or health provider ever discussed with you the risks and benefits of aspirin to prevent heart attack or stroke?

<1> YES [Q61a]

<2> NO [Q61a]

<9> NOT ASCERTAINED [Q61a]

[Q61]

In the last 6 months, did you get health care 3 or more times for the same condition or problem?

<1> YES [Q62]

<2> NO [Q63]

<9> NOT ASCERTAINED [Q63]

[Q62]

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

{READ IF RESPONDENT IS FEMALE: When answering this question do not include pregnancy or menopause.}

<1> YES [Q63]

<2> NO [Q63]

<9> NOT ASCERTAINED [Q63]

Menopause (men ne paws) is the time in a woman’s life when she stops having menstrual periods. It is sometimes called “the change of life” or “the change”.

[Q63]

Do you now need or take medicine prescribed by a doctor?

{READ IF RESPONDENT IS FEMALE: When answering this question do not include birth control.}

<1> YES [Q64]

<2> NO [Q65]

<9> NOT ASCERTAINED [Q65]

[Q64]

Is this medicine to treat a condition that has lasted for at least 3 months?

{READ IF RESPONDENT IS FEMALE: When answering this question do not include pregnancy or menopause.}

<1> YES [Q65]

<2> NO [Q65]

<9> NOT ASCERTAINED [Q65]

[Q65]

What is your age?

{IF NECESSARY: “Are you…” THEN READ RESPONSE CHOICES}

<1> 18 to 24, [Q66]

<2> 25 to 34, [Q66]

<3> 35 to 44, [Q66]

<4> 45 to 54, [Q66]

<5> 55 to 64, [Q66]

<6> 65 to 74, or [Q66]

<7> 75 or older? [Q66]

<9> NOT ASCERTAINED [Q66]

The respondent should report their age as of their last birthday. Do not round. Reading response choices is optional.

[Q66]

{ASK IF NECESSARY: “Are you male or female?”}

<1> MALE [Q67]

<2> FEMALE [Q67]

<9> NOT ASCERTAINED [Q67]

[Q67]

What is the highest grade or level of school that you have completed? Did you complete…

<1> 8th grade or less, [Q68]

<2> Some high school, but did not graduate, [Q68]

<3> High school graduate or GED, [Q68]

<4> Some college or 2-year degree, [Q68]

<5> 4-year college graduate, or [Q68]

<6> More than 4-year college degree? [Q68]

<9> NOT ASCERTAINED [Q68]

Code academic training beyond a high school diploma that does not lead to a bachelor’s degree as 4. This includes business school training or a three-year nursing degree.

If the respondent describes non-academic training, such as trade school, probe to find out if s/he has a high school diploma and code 2 or 3, as appropriate.

[Q68]

Are you of Hispanic or Latino origin or descent?

{RESPONDENT MAY SELECT MORE THAN ONE}

<1> No, not of Hispanic, Latino/a, or Spanish origin [Q69a]

<2> Yes, Mexican, Mexican American, Chicano/a [Q69a]

<3> Yes, Puerto Rican [Q69a]

<4> Yes, Cuban [Q69a]

<5> Yes, another Hispanic, Latino, or Spanish origin [Q69a]

<9> NOT ASCERTAINED [Q69a]

[FOR TELEPHONE INTERVIEWING THIS QUESTION IS BROKEN INTO PARTS A-O]

>69a<

I am going to read a list of race categories. For each category, please say yes or no if it describes your race. I must ask you about all categories in case more than one applies.

Are you White?

<0> NO OR NOT ASCERTAINED [Q69b]

<1> YES [Q69b]

If the respondent replies “Why are you asking my race?” say: “We ask about your race for demographic purposes only. We want to be sure that the people we survey accurately represent the racial diversity of managed care enrollees in this country.”

If the respondent answers with a category not listed here, such as “Hispanic” or “American” or “Mixed race”, the interviewer can probe using the category “Other.”

>69b<

Black or African-American?

<0> NO OR NOT ASCERTAINED [Q69c]

<1> YES [Q69c]

>69c<

American Indian or Alaska Native?

<0> NO OR NOT ASCERTAINED [Q69d]

<1> YES [Q69d]

>69d<

Asian Indian?

<0> NO OR NOT ASCERTAINED [Q69e]

<1> YES [Q69e]

>69e<

Chinese?

<0> NO OR NOT ASCERTAINED [Q69f]

<1> YES [Q69f]

>69f<

Filipino?

<0> NO OR NOT ASCERTAINED [Q69g]

<1> YES [Q69g]

>69g<

Japanese?

<0> NO OR NOT ASCERTAINED [Q69h]

<1> YES [Q69h]

>69h<

Korean?

<0> NO OR NOT ASCERTAINED [Q69i]

<1> YES [Q69i]

>69i<

Vietnamese?

<0> NO OR NOT ASCERTAINED [Q69j]

<1> YES [Q69j]

>69j<

Other Asian?

<0> NO OR NOT ASCERTAINED [Q69k]

<1> YES [Q69k]

>69k<

Native Hawaiian?

<0> NO OR NOT ASCERTAINED [Q69l]

<1> YES [Q69l]

>69l<

Guamanian or Chamorro?

<0> NO OR NOT ASCERTAINED [Q69m]

<1> YES [Q69m]

>69m<

Samoan?

<0> NO OR NOT ASCERTAINED [Q69n]

<1> YES [Q69n]

>69n<

Other Pacific Islander?

<0> NO OR NOT ASCERTAINED [Q69o]

<1> YES [Q69o]

>69o<

Some other race?

<0> NO OR NOT ASCERTAINED [close]

<1> YES [close]

>close<

Those are all the questions I have. Thank you for taking part in this important interview. If you want to know more about this study, please call Thoroughbred 1-800-xxx-xxxx, the NORC Institutional Review Board toll-free at 1-866-309-0542, OR write CMS, 7500 Security Blvd, Att: Mail Stop C-4-26-05, Baltimore, MD 21244-1850.

1/28/2021 11:20 a1/p1 CMS Nationwide Adult Medicaid CATI Script (English) 50