CMS-10493 CAHPS 5.0H Adult Questionnaire (Medicaid)

CAHPS® 5.0H Adult Questionnaire (Medicaid)
SURVEY INSTRUCTIONS

● Yes

•

Answer each question by filling in the circle to the left of your answer, like this:

•

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 →If Yes, Go to Question 1
○ No
The Centers for Medicare and Medicaid Services is conducting this survey of people with Medicaid to
learn more about the care and services they receive. This survey will ask about your recent experiences
receiving health care and should take about 20 minutes to complete. Your participation is voluntary,
and there is no loss of benefits or penalty of any kind for deciding not to participate. Responding to
the survey does not involve any risks beyond those of daily life. You may skip any questions that you
do not feel comfortable answering. Your participation in this research is confidential, and we will not
share your name or any other identifying information with any outside organization. You may notice a
number on the cover of this survey. This number is ONLY used to let us know if you returned the survey.
Please contact Thoroughbred Research Group toll-free at (XXX) XXX-XXXX or call the NORC Institutional
Review Board toll-free at 1-866-309-0542 with questions about this research.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-New . The time required to complete this information
collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

1. Our records show that in the last six months
you were enrolled in

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.

STATE MEDICAID AGENCY
/ HEALTH PLAN NAME

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?

Is that right?
1
2

○
○

1

Yes →If Yes, Go to Question 3

2

No

○
○

Yes
No →If No, Go to Question 5

2. What is the name of your health plan?
(Please print)

12345678900

______________________________________

THOR_CAHPS_ADULT_MEDICAID

1

11/25/2013

4. In the last 6 months, when you needed care
right away, how often did you get care as
soon as you needed?
1
2
3
4

○
○
○
○

9. What was the main reason for your last
emergency room visit? Choose one.
00

Never

01

Sometimes

02

Usually
Always

5. About how long has it been since you last
visited a doctor for a check-up?
1

○

2

○

3

○

4
5

○
○

W
 ithin the past year
(anytime less than 12 months ago)

2

○
○

W
 ithin the past 2 years
(1 year but less than 2 years ago)
W
 ithin the past 5 years
(2 years but less than 5 years ago)

2
3
4

○
○
○
○

01
02
03
04
05
06

○
○
○
○
○
○
○

04

○

1

5 or more years ago

2

Never

3
4
5
6

Yes

1
2

D
 octor's office or clinic was open,
but could not get an appointment
 roblem was too serious for the
P
doctor’s office or clinic
G
 et most of my care at the
emergency room

○
○
○
○
○
○
○

None → If None, Go to Question 16
1 time
2
3
4
5 to 9
10 or more times

○
○

Yes
No

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

Never
Sometimes
Usually

1

Always

2

○
○

Yes
No → If No, Go to Question 16

13. 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?

None →If None, Go to Question 10
1 time

1

2

2

3

3

4

4

5 to 9
10 or more times

THOR_CAHPS_ADULT_MEDICAID

D
 octor’s office or clinic was not open

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

No → If No, Go to Question 8

8. In the last 6 months, how many times did
you go to an emergency room to get care for
yourself?
00

○

0

7. 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?
1

03

Didn't have a doctor

10. 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?

6. 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

○
○
○

2

○
○
○
○

Not at all
A little
Some
A lot

14. 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?
1
2
3
4

○
○
○
○

19. In the last 6 months, how often was it easy
to get the mental health or behavioral health
services you needed?
1
2

Not at all
A little

3

Some

4

A lot

5

in the last 6 months

15. 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
2

○
○

20. In the last 6 months, how often was it easy
to get the dental services you needed?
1

Yes

2

No

3

16. 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?

4
5

21. In the last 6 months, were you ever not able
to get medical care, tests, or treatments
you or a doctor believed necessary?
1

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

2

17. In the last 6 months, how often was it easy
to get the care, tests, or treatment you
needed?
1
2
3
4

2
3
4
5

○ Never
○ Sometimes
○ Usually
○ Always

00
01

Yes
No → If No, Go to Question 23

○ Couldn’t afford care
○ My health plan wouldn’t approve,
cover, or pay for care

02
03
04

05

○ Never
○ Sometimes
○ Usually
○ Always
○ D id not need special medical

06
07

equipment in the last 6 months

THOR_CAHPS_ADULT_MEDICAID

○
○

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

18. 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
○ Sometimes
○ Usually
○ Always
○ Did not need these services
in the last 6 months

Worst health
Best health
care possible
care possible
0 1 2 3 4 5 6 7 8 9 10

○ Never
○ Sometimes
○ Usually
○ Always
○ Did not need these services

3

○ Doctor refused to accept my insurance
○ Doctor doesn't speak my language
○ C ouldn't get transportation to
○

doctor's office

 ouldn't take time off work
C
or get child care

○ Didn’t know where to go to get care
○ The wait took too long

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

23. Is there a place that you usually go to when
you are sick or need advice about your
health?
1
2

○
○

Yes →If Yes, Go to Question 25

0

There is NO place

1
2

24. Why don’t you have a usual source of
medical care? Mark one or more.
01
02
03
04

05

○
○
○
○
○

3

Haven't had any problems

4

No doctors take my insurance

5

No doctors speak my language

6

 octor's office is too far away or not
D
convenient

2
3
4
5
6

○
○
○
○
○
○

 on’t plan to see a doctor even
D
when I’m sick

1
2
3

Clinic or health center

4

Doctor's office or HMO
Hospital outpatient department

1

Some other place

2

Don't go to one place most often

3

26. 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?
2

1
2
3

Yes

4

No →If No, Go to Question 35

3
4
5 to 9
10 or more times

○ Never
○ Sometimes
○ Usually
○ Always
○ Never
○ Sometimes
○ Usually
○ Always
○ Never
○ Sometimes
○ Usually
○ Always

31. In the last 6 months, how often did your
personal doctor spend enough time with
you?
1
2
3
4

THOR_CAHPS_ADULT_MEDICAID

2

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

Your Personal Doctor

○
○

1 time

29. In the last 6 months, how often did your
personal doctor listen carefully to you?

Hospital emergency room

4

1

None →If None, Go to Question 34

28. In the last 6 months, how often did your
personal doctor explain things in a way that
was easy to understand?

25. What kind of place do you go to most often
for your medical care? Choose one.
1

○
○
○
○
○
○
○

4

○ Never
○ Sometimes
○ Usually
○ Always

32. In the last 6 months, did you get care from
a doctor or other health provider besides
your personal doctor?
1
2

○
○

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

Yes

1

No →If No, Go to Question 34

2
3

33. In the last 6 months, how often did your
personal doctor seem informed and upto-date about the care you got from these
doctors or other health providers?
1
2
3
4

4

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

○ Never
○ Sometimes
○ Usually
○ Always

0
1
2
3
4

34. 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?

5

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Worst
Best
specialist possible
specialist possible
0 1 2 3 4 5 6 7 8 9 10

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Getting Health Care From Specialists

1
2

Yes

3

No →If No, Go to Question 39

4
5

○ Never
○ Sometimes
○ Usually
○ Always
○ Did not try to get information or help
→ If No, Go to Question 41

THOR_CAHPS_ADULT_MEDICAID

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

In the last 6 months, did you need to make
an appointment to see a specialist?
2

The next questions ask about your experience
with your health plan.

35. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and
other doctors who specialize in one area of
health care.

○
○

Your Health Plan

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

1

○ None →If None, Go to Question 39
○ 1 specialist
○ 2
○ 3
○ 4
○ 5 or more specialists

38. 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?

Worst personal
Best personal
doctor possible
doctor possible
0 1 2 3 4 5 6 7 8 9 10

○ Never
○ Sometimes
○ Usually
○ Always

5

40. In the last 6 months, how often did your
health plan’s customer service staff treat
you with courtesy and respect?
1
2
3
4

44. Has a doctor ever told you that you had any of
the following conditions? Mark 'Yes' or No' for
each
condition.

Yes No

○ Never
○ Sometimes
○ Usually
○ Always

1
2
3
4

41. 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?
Worst health
plan possible
0 1 2 3

4

5

6

5
6

7

Best health
plan possible
7 8 9 10

8

1

42. In general, how would you rate your
overall health?
2
3
4
5

○
○
○
○
○

2

2
3
4
5

○
○
○
○
○

○ ○
○ ○
○ ○
○ ○

○
○

Yes
No

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

Excellent
Very good
Good

1

Fair

2

Poor

○
○

Yes
No

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

43. In general, how would you rate your overall
mental or emotional health?
1

Angina or coronary
heart disease?

A stroke?

Any
kind of diabetes
or high blood sugar?


Cancer, other than
skin cancer?
Emphysema, asthma
or COPD (chronic obstructive
pulmonary disease)?

45. Are you deaf or do you have serious
difficulty hearing?

About You

1

○ ○
○ ○
○ ○

○ ○

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

High cholesterol?
High blood pressure?
A heart attack?

Excellent

1

Very good

2

Good

○
○

Yes
No

48. Do you have serious difficulty walking or
climbing stairs?

Fair
Poor

1
2

○
○

Yes
No

49. Do you have difficulty dressing or bathing?
1
2

○
○

Yes
No→If No, Go to Question 51

50. In the last month, did you ever go without
showering/ taking a bath/ washing up
because no one was there to help?
1
2

THOR_CAHPS_ADULT_MEDICAID

6

○
○

Yes
No

51. 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
2

○
○

57. 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.

Yes
No→If No, Go to Question 53

52. In the last month, did you ever have to stay
home because you had difficulty going out
by yourself?
1
2

○
○

1
2

Yes

3

No

4

58. Do you take aspirin daily or every other day?

53. Have you had a flu shot since
September 1, 2013?
1
2
3

○
○
○

1

Yes

2

No

3

Don’t know

2
3

4

○
○
○
○

Every day

1

Some days

2

Not at all → If Not at all, Go to
Question 58

3

2
3
4

1
2

○ Never
○ Sometimes
○ Usually
○ Always

2
3
4

1
2

Don’t know

○
○
○

Yes
No
Don’t know

○
○

Yes
No

○
○

Yes
No →If No, Go to Question 63

62. Is this a condition or problem that has
lasted for at least 3 months?
Do not include pregnancy or menopause.
1
2

○ Never
○ Sometimes
○ Usually
○ Always

THOR_CAHPS_ADULT_MEDICAID

No

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

56. 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.
1

Yes

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

Don’t know → If Don’t know,
Go to Question 58

55. 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?
1

○
○
○

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

54. Do you now smoke cigarettes or use
tobacco every day, some days, or not at all?
1

○ Never
○ Sometimes
○ Usually
○ Always

7

○
○

Yes
No

63. Do you now need or take medicine
prescribed by a doctor? Do not include
birth control.
1
2

○
○

69. What is your race? Mark one or more.
a
b

Yes

c

No →If No, Go to Question 65

d

64. Is this medicine to treat a condition that has
lasted for at least 3 months? Do not include
pregnancy or menopause.
1
2

○
○

e
f

Yes

g

No

h
i

65. What is your age?
1
2
3
4
5
6
7

○
○
○
○
○
○
○

j

18 to 24

k

25 to 34

l

35 to 44

m

45 to 54

n

55 to 64

o

65 to 74

2

○
○

1
2

Male

2
3
4
5
6

○
○
○
○
○
○

○
○

Female

67. What is the highest grade or level of school
that you have completed?
1

White
Black or African-American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Some other race

70. Did someone help you complete this survey?

75 or older

66. Are you male or female?
1

○
○
○
○
○
○
○
○
○
○
○
○
○
○
○

Yes →If Yes, Go to Question 71
N
 o →Thank you. Please
return the completed
survey in the postage-
paid envelope.

71. How did that person help you?
Mark one or more.

8th grade or less

a

S
 ome high school, but did not graduate

b

High school graduate or GED

c

Some college or 2-year degree

d

4-year college graduate
More than 4-year college degree

e

○
○
○
○
○

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

68. Are you of Hispanic or Latino origin or descent?
(One or more categories may be selected.)
1

○

2

○

3
4
5

○
○
○

N
 o, not of Hispanic, Latino/a,
or Spanish origin
Y
 es, Mexican, Mexican American,
Chicano/a

THANK YOU

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

Yes, Puerto Rican
Yes, Cuban

THOROUGHBRED RESEARCH GROUP
2074 East Park Drive, NE
Conyers, GA 30013

Y
 es, another Hispanic, Latino,
or Spanish origin

THOR_CAHPS_ADULT_MEDICAID

8