Form CMS-10488 English - Adult Qualified Health Plan Enrollee Experienc

Adult Qualified Health Plan Enrollee Experience Survey

Language: English

Reference Period: 6 months

Each item has been labeled to indicate the domain, construct source, and CAHPS or other survey indicator for this review process; the lists below provide the abbreviations used. For example, the label AC/L/HP5-AM-3 means the survey item came from the Access to Care domain, the construct came from the literature review, and the question wording is the original version of the CAHPS Health Plan 5.0 Adult Medicaid Question #3. The headings in this survey are from the CAHPS Health Plan 5.0 survey and are meant for respondent navigation, not domain headings.

Qualified Health Plan Domain Name

AC=Access to Care

SD=Shared Decision Making

HP=Health Promotion

DC=Doctor Communication

CaC=Care Coordination

AI=Access to Information

PA=Plan Administration

CuC=Cultural Competence

SP=Specialized Services

CO=Cost

PR=Prevention

GR=Global Ratings

UT=Utilization

CM=Case Mix Adjusters

RC=Respondent Characteristics

All the questions have a domain label.

Construct Source

L=Lit Review

F=Focus Groups

S=Stakeholder Interviews

T=Technical Expert Panel

C=Centers for Medicare & Medicaid Services

N=NCQA

OMB60 = OMB 60 Day Comment Period

OMB30 = OMB 30 Day Comment Period

Questions that don’t have a construct source came directly from the original CAHPS Health Plan 5.0 survey, the starting place (core content) for the QHP survey.

Survey Indicator

HP5-AM-Q# = CAHPS Health Plan 5.0, Adult Medicaid, Question #

https://cahps.ahrq.gov/surveys-guidance/docs/2152a_engadultmed_50.pdf

HP5H-AM-Q# = CAHPS Health Plan 5.0 HEDIS, Adult Medicaid, Question #

HEDIS Questionnaires are not publicly available.

HP5H-AC-Q# = CAHPS Health Plan 5.0 HEDIS, Adult Commercial, Question #

HEDIS Questionnaires are not publicly available.

HP4-AS-Q# = CAHPS Health Plan 4.0, Adult Supplemental, Question #

https://cahps.ahrq.gov/surveys-guidance/docs/1157a_engadultsupp_40.pdf

HP5-AS-Q# = CAHPS Health Plan 5.0, Adult Supplemental, Question #

These are new CAHPS questions that are not in public documentation yet.

CG2-AS-Q# = CAHPS Clinician & Group 2.0, Adult Supplemental, Question #

https://cahps.ahrq.gov/surveys-guidance/docs/2312_about_cultural_comp.pdf

CG2-AS-mQ# = CAHPS Clinician & Group 2.0, Adult Supplemental, Modified Question #

https://cahps.ahrq.gov/surveys-guidance/docs/2312_about_cultural_comp.pdf

CG2-PCMH-mQ# = CAHPS Clinician & Group 2.0, Patient-Centered Medical Items, Modified Question #

https://cahps.ahrq.gov/surveys-guidance/docs/1314_About_PCMH.pdf

OMH-4302-Q = HHS Office of Minority Health ACA Section 4302 Data Collection Standards, Question #

http://minorityhealth.hhs.gov/templates/content.aspx?ID=9227&lvl=2&lvlID=208

ACS-P-Q# = 2013 American Community Survey (ACS) – Person Section - Question #

http://www.census.gov/acs/www/Downloads/questionnaires/2013/Quest13.pdf

NHBS-Q# = 2010 National HIV Behavioral Surveillance System – Question #

http://wwwn.cdc.gov/qbank/report/Ridolfo_NCHS_2011_NHBSS%20HIV.pdf

M-ACO-Q# = 2014 Medicare Provider Satisfaction Survey – Items for ACOs Participating in Medicare Initiatives – Question #

http://acocahps.cms.gov/Files/SurveyInstruments/MailSurveyEnglish.pdf

H-mQ# = Hospital CAHPS Survey, Modified Question #

http://www.hcahpsonline.org/files/HCAHPS%20V8.0%20Appendix%20A%20-%20HCAHPS%20Mail%20Survey%20Materials%20(English)%20March%202013.pdf

Questions that don’t have a survey indicator are new questions written for the QHP Survey.

overview Adult QHP enrollee survey Domains

I. Access to care (*health plan 5.0)

• Got care for illness/injury as soon as needed*

• Got non-urgent appointment as soon as needed*

• Easy to get care after regular office hours

• How often it was easy to get necessary care, tests, or treatment*

• Have a personal doctor*

• Got appointment with specialists as soon as needed*

II. Shared decision making (Clinician and group-pcmh)

• Provider and patient talked about reasons to take medicine

• Provider and patient talked about reasons not to take medicine

• Provider consulted patient when making decision regarding starting or stopping medicine

Iii. health promotion (Clinician and group-pcmh)

• Provider asked about depression

• Provider asked about sources of worry or stress

• Provider asked about other behavioral health issues

iv. CULTURAL COMPETENCe (New health plan 5.0 Supplemental questions)

• Need interpreter at doctor’s office

• How often got an interpreter

• Forms available in preferred language

• Forms available in preferred format, such as large print or braille

v. specialized services (New health plan 5.0 Supplemental questions)

• Easy to get specialized therapy services you needed

• Easy to get home health care services you needed

Vi. How well doctors communicate (*health plan 5.0)

• Doctor explained things in a way that was easy to understand*

• Doctor listened carefully to enrollee*

• Doctor showed respect for what enrollee had to say*

• Doctor spent enough time with enrollee*

ViI. CARE COORDINATION (New health plan 5.0 Supplemental questions)

• Got care from provider besides personal doctor

• Doctor seemed informed and up-to-date about care from other health providers

• Doctor have your medical records

• Doctor order blood test, x-ray

• Doctor follow up about blood test, x-ray results

• Got blood test, x-ray results as soon as you needed them

• Doctor talk about prescription drugs you are taking

• Got care from more than one kind of provider

• Doctor’s office manage your care among different providers

• Got help you needed from doctor’s office manage your care among different providers

ViiI. aCCESS TO INFORMATION (health plan 4.0 supplemental/hedis)

• Written materials or Internet provided information needed about how plan works

• Found out from health plan about cost for health care service or equipment

• Found out from health plan about cost for specific prescriptions

IX. Plan administration (*health plan 5.0)

• Customer service gave necessary information/help*

• Customer service staff courteous and respectful*

• Wait-time to talk to customer service took longer than expected

• Forms easy to fill out*

• Health plan explain purpose of forms

X. cost (new questions)

• Clear how much you would pay before getting health care

• Health plan did not pay for service doctors said you needed

• Pay out of pocket for care you thought health plan should pay for

• Delay or not visit a doctor because you were worried about cost

• Delay or not fill prescription because you were worried about cost

XI. prevention (hedis)

• Flu shot in past year

• Frequency of tobacco use

• Advised to quit smoking or tobacco use

• Medication recommended to quick smoking

• Other strategies to quit smoking

• Frequency of aspirin use

• Health problem that makes aspirin unsafe

• Risks and benefits of aspirin use

• Health conditions

Global ratings

• Rating of all health care

• Rating of personal doctor

• Rating of specialist

• Rating of health plan

• Recommend health plan to friends and family

Utilization

• Times visited doctor’s office or clinic

• Times visited personal doctor for care

• Number of specialists seen

case mix adjusters

• Rating of overall health

• Age

• Sex

Respondent characteristics

• Rating of overall mental or emotional health

• Got health care 3 or more times for same condition

• Got health care 3 or more times for condition lasted for at least 3 months

• Take medicine prescribed by a doctor

• Take medicine for condition lasted for at least 3 months

• Are you deaf

• Are you blind

• Difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition

• Difficulty walking or climbing stairs

• Difficulty dressing or bathing because of a physical, mental, or emotional condition

• Education status

• Employment status

• Ethnicity

• Race

• Eligibility to get health services from Indian Health Service

• Received care at an Indian Health Service facility

• Preferred Language

• Rating of English language skills

• Covered by health insurance at any time in 2013

• Knowledge of health insurance terms

• Knowledge of how health plan works

• Someone help you complete this survey

• How did someone help you complete this survey

Domain Overview Note: The Domain Overview is meant to provide a quick overview of what is measured in this survey. It is NOT meant to list hypothesized composite items. There are a mix of screener, assessment/composite, and single items listed under each domain. It also does NOT list out every item but rather is meant to cover unique constructs. For example, if there is a screener item and an assessment item that measure the same construct, then the assessment item is listed.

Survey Instructions

Answer each question by marking the box to the left of your answer.

You are sometimes told to skip over 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:

Yes

No  If No, go to #1

1. Our records show that you are now in {INSERT HEALTH PLAN NAME}. Is that right? (HP5-AM-1)

¹ Yes  If Yes, go to #3

² No

2. What is the name of your health plan? (HP5-AM-2)

Please print: ______________________________________________________________
_________________________________________________________________________

Your Health Care in the Last 6 Months

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

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? (AC/HP5-AM-3)

¹ Yes

² No  If No, go to #5

4. In the last 6 months, when you needed care right away, how often did you get care as soon as you needed? (AC/HP5-AM-4)

¹ Never

² Sometimes

³ Usually

⁴ Always

5. In the last 6 months, did you make any appointments for a check-up or routine care at a doctor’s office or clinic? (AC/HP5-AM-5)

¹ Yes

² No  If No, go to #7

6. 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? (AC/HP5-AM-6)

¹ Never

² Sometimes

³ Usually

⁴ Always

7. In the last 6 months, did you need to visit a doctor’s office or clinic after regular office hours? (AC/OMB60/HP5-AS-AH1)

¹ Yes

² No  If No, go to #9

8. In the last 6 months, how often was it easy to get care after regular office hours? (AC/OMB60/HP5-AS-AH2)

¹ Never

² Sometimes

³ Usually

⁴ Always

9. 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? (UT/HP5-AM-7)

None  If None, go to #21

1 time

2

3

4

5 to 9 times

10 or more times

10. 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? (GR/HP5-AM-8)

0 Worst health care possible

1

2

3

4

5

6

7

8

9

10 Best health care possible

11. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? (AC/HP5-AM-9)

¹ Never

² Sometimes

³ Usually

⁴ Always

12. In the last 6 months, did you and a health provider talk about starting or stopping a prescription medicine? (SD/ OMB60/CG2-PCMH-m6)

¹ Yes

² No  If No, go to #16

13. Did you and a health provider talk about the reasons you might want to take a medicine? (SD/ OMB60/CG2-PCMH-m7)

¹ Yes

² No

14. Did you and a health provider talk about the reasons you might not want to take a medicine? (SD/OMB60/CG2-PCMH-m8)

¹ Yes

² No

15. When you and a health provider talked about starting or stopping a prescription medicine, did the health provider ask what you thought was best for you? (SD/ OMB60/CG2-PCMH-m9)

¹ Yes

² No

16. In the last 6 months, did a health provider ask you if there was a period of time when you felt sad, empty, or depressed? (HP/ OMB60/CG2-PCMH-m16)

¹ Yes

² No

17. In the last 6 months, did you and your health provider talk about things in your life that worry you or cause you stress? (HP/ OMB60/CG2-PCMH-m17)

¹ Yes

² No

18. In the last 6 months, did you and your health provider talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional illness? (HP/OMB60/CG2-PCMH-m18)

¹ Yes

² No

19. An interpreter is someone who helps you talk with others who do not speak your language. In the last 6 months, did you need an interpreter to help you speak with anyone at your doctor’s office or clinic? (CuC/S,T/ HP5-AS-New_Q#)

¹ Yes

² No  If No, go to #21

20. In the last 6 months, when you needed an interpreter at your doctor’s office or clinic, how often did you get one?(CuC/S,T/ HP5-AS-New_Q#)

¹ Never

² Sometimes

³ Usually

⁴ Always

21. In the last 6 months, did you have any health problems that needed special therapy, such as physical, occupational, or speech therapy? (SP/C/HP5-AS-CC11)

¹ Yes

² No  If No, go to #23

22. In the last 6 months, how often was it easy to get the special therapy you needed? (SP/C/ HP5-AS-CC12)

¹ Never

² Sometimes

³ Usually

⁴ Always

23. Home health care or assistance means home nursing, help with bathing or dressing, and help with basic household tasks. In the last 6 months, did you need someone to come into your home to give you home health care or assistance? (SP/C/HP5-AS-CC13)

¹ Yes

² No  If No, go to #25

24. In the last 6 months, how often was it easy to get home health care or assistance? (SP/C/HP5-AS-CC14)

¹ Never

² Sometimes

³ Usually

⁴ Always

Your Personal Doctor

25. 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? (AC/HP5-AM-10)

¹ Yes

² No  If No, go to #43

26. In the last 6 months, how many times did you visit your personal doctor to get care for yourself? (UT/HP5-AM-11)

None  If None, go to #43

1 time

2

3

4

5 to 9 times

10 or more times

27. In the last 6 months, how often did your personal doctor explain things in a way that was easy to understand? (DC/HP5-AM-12)

¹ Never

² Sometimes

³ Usually

⁴ Always

28. In the last 6 months, how often did your personal doctor listen carefully to you? (DC/HP5-AM-13)

¹ Never

² Sometimes

³ Usually

⁴ Always

29. In the last 6 months, how often did your personal doctor show respect for what you had to say? (DC/HP5-AM-14)

¹ Never

² Sometimes

³ Usually

⁴ Always

30. In the last 6 months, how often did your personal doctor spend enough time with you? (DC/HP5-AM-15)

¹ Never

² Sometimes

³ Usually

⁴ Always

31. In the last 6 months, did you get care from a doctor or other health provider besides your personal doctor? (CaC/S,F,T/HP4-AS-OHP1)

¹ Yes

² No  If No, go to #33

32. 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? (CaC/S,F,T/HP4-AS-OHP2)

¹ Never

² Sometimes

³ Usually

⁴ Always

33. 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? (GR/HP5-AM-16)

0 Worst personal doctor possible

1

2

3

4

5

6

7

8

9

10 Best personal doctor possible

34. When you visited your personal doctor for a scheduled appointment in the last 6 months, how often did he or she have your medical records or other information about your care? (CaC/S,F,T/ HP5-AS-New_Q#)

¹ Never

² Sometimes

³ Usually

⁴ Always

35. In the last 6 months, did your personal doctor order a blood test, x-ray, or other test for you? (CaC/S,F,T/ HP5-AS-New_Q#)

¹ Yes

² No  If No, go to #38

36. 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 personal doctor’s office follow up to give you those results? (CaC/S,F,T/ HP5-AS-New_Q#)

¹ Never

² Sometimes

³ Usually

⁴ Always

37. In the last 6 months, when your personal doctor ordered a blood test, x-ray, or other test for you, how often did you get those results as soon as you needed them? (CaC/S,F,T/ HP5-AS-New_Q#)

¹ Never

² Sometimes

³ Usually

⁴ Always

38. In the last 6 months, did you take any prescription medicine? (CaC/S,F,T/ HP5-AS-New_Q#)

¹ Yes

² No  If No, go to #40

39. In the last 6 months, how often did you and your personal doctor talk about all the prescription medicines you were taking? (CaC/S,F,T/ HP5-AS-New_Q#)

¹ Never

² Sometimes

³ Usually

⁴ Always

40. 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? (CaC/S,F,T/HP5-AS-New_Q#)

¹ Yes

² No  If No, go to #43

41. 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? (CaC/S,F,T/HP5-AS-New_Q#)

¹ Yes

² No  If No, go to #43

42. In the last 6 months, how often did you get the help that you needed from your personal doctor’s office to manage your care among these different providers and services? (CaC/S,F,T/HP5-AS-New_Q#)

¹ Never

² Sometimes

³ Usually

⁴ Always

Getting Health Care From Specialists

When you answer the next questions, do not include dental visits or care you got when you stayed overnight in a hospital.

43. 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 make any appointments to see a specialist? (AC/HP5-AM-17)

¹ Yes

² No  If No, go to #47

44. In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed? (AC/HP5-AM-18)

¹ Never

² Sometimes

³ Usually

⁴ Always

45. How many specialists have you seen in the last 6 months? (UT/HP5-AM-19)

None  If None, go to #47

1 specialist

2

3

4

5 or more specialists

46. 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 the specialist? (GR/HP5-AM-20)

0 Worst specialist possible

1

2

3

4

5

6

7

8

9

10 Best specialist possible

Your Health Plan

47. In the last 6 months, did you look for any information in written materials or on the Internet about your health plan? (AI/L,F/HP4-AS-mH7)

¹ Yes

² No  If No, go to #49

48. In the last 6 months, how often did the written materials or the Internet provide the information you needed about how your health plan works? (AI/L,F/HP4-AS-H8)

¹ Never

² Sometimes

³ Usually

⁴ Always

49. Sometimes people need services or equipment beyond what is provided in a regular or routine office visit, such as care from a specialist, physical therapy, a hearing aid, or oxygen. In the last 6 months, did you look for information from your health plan on how much you would have to pay for a health care service or equipment? (AI/L,F/HP4-AS-H9)

¹ Yes

² No  If No, go to #51

50. In the last 6 months, how often were you able to find out from your health plan how much you would have to pay for a health care service or equipment before you got it? (AI/L,F/HP4-AS-mH10)

¹ Never

² Sometimes

³ Usually

⁴ Always

51. In some health plans the amount you pay for a prescription medicine can be different for different medicines, or can be different for prescriptions filled by mail instead of at the pharmacy. In the last 6 months, did you look for information from your health plan on how much you would have to pay for specific prescription medicines before you got them? (AI/L,F/HP4-AS-mH11)

¹ Yes

² No  If No, go to #53

52. In the last 6 months, how often were you able to find out from your health plan how much you would have to pay for specific prescription medicines? (AI/L,F/HP4-AS-H12)

¹ Never

² Sometimes

³ Usually

⁴ Always

53. In the last 6 months, did you get information or help from your health plan’s customer service? (PA/HP5-AM-21)

¹ Yes

² No  If No, go to #57

54. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed? (PA/HP5-AM-22)

¹ Never

² Sometimes

³ Usually

⁴ Always

55. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect? (PA/HP5-AM-23)

¹ Never

² Sometimes

³ Usually

⁴ Always

56. In the last 6 months, how often did the time that you waited to talk to your health plan’s customer service staff take longer than you expected?(PA/C)

¹ Never

² Sometimes

³ Usually

⁴ Always

57. In the last 6 months, did your health plan give you any forms to fill out? (PA/HP5-AM-24)

¹ Yes

² No  If No, go to #63

58. In the last 6 months, how often were the forms from your health plan easy to fill out? (PA/HP5-AM-25)

¹ Never

² Sometimes

³ Usually

⁴ Always

59. In the last 6 months, how often did the health plan explain the purpose of a form before you filled it out? (PA/OMB30/HP5-AS-New_Q#)

 

¹ Never

² Sometimes

³ Usually

⁴ Always

60. In the last 6 months, how often were the forms that you had to fill out available in the language you prefer? (CuC/S,T/CG2-AS-mHL32)

¹ Never

² Sometimes

³ Usually

⁴ Always

61. In the last 6 months, did you need the forms in a different format, such as large print or braille? (CuC/OMB30/HP5-AM-m24)

¹ Yes

² No  If No, go to #63

62. In the last 6 months, how often were the forms that you had to fill out available in the format you needed, such as large print or braille? (CuC/OMB30/CG2-AS-mHL32)

¹ Never

² Sometimes

³ Usually

⁴ Always

63. 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 in the last 6 months? (GR/HP5-AM-26)

0 Worst health plan possible

1

2

3

4

5

6

7

8

9

10 Best health plan possible

64. Would you recommend this health plan to your friends and family? (GR/OMB30/H-m22)

¹ Yes, definitely

² Yes, somewhat

³ No

65. In the last 6 months, before you went for care, how often did your health plan make it clear how much you would have to pay? (CO/L,S/HP4-AS-CP3)

¹ Never

² Sometimes

³ Usually

⁴ Always

66. In the last 6 months, how often did your health plan not pay for a service that your doctor said you needed? (CO/L,S)

¹ Never

² Sometimes

³ Usually

⁴ Always

67. In the last 6 months, how often did you have to pay out of your own pocket for care that you thought your health plan would pay for? (CO/F,T)

¹ Never

² Sometimes

³ Usually

⁴ Always

68. In the last 6 months, how often did you delay or not visit a doctor because you were worried about the cost? Do not include dental care. (CO/F,T)

¹ Never

² Sometimes

³ Usually

⁴ Always

69. In the last 6 months, how often did you delay or not fill a prescription because you were worried about the cost? (CO/F,T)

¹ Never

² Sometimes

³ Usually

⁴ Always

About You

70. In general, how would you rate your overall health? (CM/HP5-AM-27)

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

71. In general, how would you rate your overall mental or emotional health? (RC/HP5-AM-28)

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

72. Have you had a flu shot since July 1, {YYYY FILL THE MEASUREMENT YEAR (2012 FOR THE SURVEY FIELDED IN 2013)}? (PR/NCQA/ HP5H-AC-45)

¹ Yes

² No

³ Don’t know

73. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? (PR/NCQA/ HP5H-AM-38)

¹ Every day

² Some days

³ Not at all  If Not at all, Go to Question 77

⁴ Don’t know ® If Don’t know, Go to question 77

74. 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? (PR/NCQA/ HP5H-AM-39)

¹ Never

² Sometimes

³ Usually

⁴ Always

75. 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. (PR/NCQA/HP5H-AM-40)

¹ Never

² Sometimes

³ Usually

⁴ Always

76. 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. (PR/NCQA/HP5H-AM-41)

¹ Never

² Sometimes

³ Usually

⁴ Always

77. Do you take aspirin daily or every other day? (PR/NCQA/HP5H-AM-42)

¹ Yes

² No

³ Don’t know

78. Do you have a health problem or take medication that makes taking aspirin unsafe for you? (PR/NCQA/ HP5H-AM-43)

¹ Yes

² No

³ Don’t know

79. Has a doctor or health provider ever discussed with you the risks and benefits of aspirin to prevent heart attack or stroke? (PR/NCQA/ HP5H-AM-44)

¹ Yes

² No

80. Are you aware that you have any of the following conditions? Mark one or more. (PR/NCQA/ HP5H-AM-45)

¹ High cholesterol

² High blood pressure

³ Parent or sibling with heart attack before the age of 60

81. Has a doctor ever told you that you have any of the following conditions? Mark one or more.. (PR/NCQA/ HP5H-AM-46)

¹ A heart attack

² Angina or coronary heart disease

³ A stroke

⁴ Any kind of diabetes or high blood sugar

82. In the past 6 months, did you get health care 3 or more times for the same condition or problem? (RC/HP5-AM-29)

¹ Yes

² No  If No, go to #84

83. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause. (RC/HP5-AM-30)

¹ Yes

² No

84. Do you now need or take medicine prescribed by a doctor? Do not include birth control. (RC/HP5-AM-31)

¹ Yes

² No  If No, go to #86

85. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause. (RC/HP5-AM-32)

¹ Yes

² No

86. Are you deaf or do you have serious difficulty hearing? (RC/OMB60/ACS-P-17a, OMH-4302-5)

¹ Yes

² No

87. Are you blind or do you have serious difficulty seeing, even when wearing glasses? (RC/OMB60/ACS-P-17b, OMH-4302-5)

¹ Yes

² No

88. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (RC/OMB60/ACS-P-18a, OMH-4302-5)

¹ Yes

² No

89. Do you have serious difficulty walking or climbing stairs? (RC/OMB60/ACS-P-18b, OMH-4302-5)

¹ Yes

² No

90. Because of a physical, mental, or emotional condition, do you have difficulty dressing or bathing? (RC/OMB60/ACS-P-18c, OMH-4302-5)

¹ Yes

² No

91. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (RC/OMB60/ACS-P-19, OMH-4302-5)

¹ Yes

² No

92. What is your age? (RC/HP5-AM-33)

¹ 18 to 24 years

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 or older

93. What is your sex? (CM /OMH-4302-3)

¹ Male

² Female

94. What is the highest grade or level of school that you have completed? (CM/HP5-AM-35)

¹ 8th grade or less

² Some high school, but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

95. What best describes your employment status? Mark only ONE. (RC/OMB60/NHBS-DM6)

¹ Employed full-time

² Employed part-time

³ A homemaker

⁴ A full-time student

⁵ Retired

⁶ Unable to work for health reasons

⁷ Unemployed

⁸ Other

96. Are you Hispanic, Latino/a, or Spanish origin? (RC/OMB60/M-ACO-77)

¹ Yes, Hispanic, Latino/a, or Spanish origin

² No, not of Hispanic, Latino/a, or Spanish origin  If No, go to #98

97. Which group best describes you? (RC/OMB60/M-ACO-78)

¹ Mexican, Mexican American, Chicano

² Puerto Rican

³ Cuban

⁴ Another Hispanic, Latino, or Spanish Origin

98. What is your race? Mark one or more. (RC /OMH-4302-2)

¹ White

² Black or African American

³ American Indian or Alaska Native

⁴ Asian Indian

⁵ Chinese

⁶ Filipino

⁷ Japanese

⁸ Korean

⁹ Vietnamese

¹⁰ Other Asian

¹¹ Native Hawaiian

¹² Guamanian or Chamorro

¹³ Samoan

¹⁴ Other Pacific Islander

99. Are you eligible to get health services from an Indian Health Service, tribal, or urban Indian health program? (RC/OMB30)

¹ Yes

² No  If No, go to #101

³ Don’t Know  If Don’t Know, go to #101

100. Did you ever get health services from an Indian Health Service, tribal, or urban Indian health program? (RC/OMB30)

¹ Yes

² No

101. What is your preferred language? (RC,CuC/T,C,OMB60/CG2-AS-CU22)

¹ English  If English, go to #103

² Spanish

³ Chinese

⁴ Other

Please specify: _____________________________________________________________

102. How well do you speak English? (RC,CuC /T,C,OMB60/OMH-4302-4)

¹ Very Well

² Well

³ Not well

⁴ Not at all

103. Did you have health insurance in the United States at any time between January 1^st and December 31^st, 2013? (RC/T,C)

¹ Yes

² No

104. How confident are you that you understand health insurance terms? (RC/OMB30)

¹ Not at all confident

² Slightly confident

³ Moderately confident

³ Very confident

105. How confident are you that you know most of the things you need to know about using health insurance? (RC/OMB30)

¹ Not at all confident

² Slightly confident

³ Moderately confident

³ Very confident

106. Did someone help you complete this survey? (RC/HP5-AM-38)

¹ Yes

² No  Thank you. Please return the completed survey in the postage-paid envelope.

107. How did that person help you? Mark one or more. (RC/HP5-AM-39)

¹ Read the questions to me

² Wrote down the answers I gave

³ Answered the questions for me

⁴ Translated the questions into my language

⁵ Helped in some other way

Please Specify: ______________________________________________________________
__________________________________________________________________________

Thank you.
Please return the completed survey in the postage-paid envelope.

English Adult QHP Enrollee Experience Survey After OMB/NCHS review 2-5-14 Page 10 of 41