OMB No. 0938-1221: Approval Expires 02/28/2017
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 #
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 #
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 #
CG2-AS-mQ# = CAHPS Clinician & Group 2.0, Adult Supplemental, Modified Question #
CG2-PCMH-mQ# = CAHPS Clinician & Group 2.0, Patient-Centered Medical Items, Modified Question #
OMH-4302-Q# = HHS Office of Minority Health ACA Section 4302 Data Collection Standards, Question #
ACS-P-Q# = American Community Survey (ACS) – Person Section - Question #
NHBS-Q# = 2010 National HIV Behavioral Surveillance System – Question #
M-ACO-Q# = 2014 Medicare Provider Satisfaction Survey – Items for ACOs Participating in Medicare Initiatives – Question #
H-mQ = Hospital CAHPS , Modified Question #
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
Have a personal doctor*
How often it was easy to get necessary care, tests, or treatment*
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 hp 5.0 Supp/ C&G Supplemental/new 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.
Introduction
We are asking you to complete this survey about your experiences with the health plan that you got through the Health Insurance Marketplace, also known as Obamacare or Healthcare.gov.
Your Privacy is Protected. What you have to say is private and will only be used for this study. Your answers will be part of a pool of information. We will not share your name or answers with anyone, except if required by law.
Your Participation is Voluntary. Your participation is voluntary. You do not have to answer any questions that you do not want to answer. If you choose not to answer, it will not affect the benefits you get.
What To Do When You’re Done. Once you complete the survey, place it in the envelope that was provided, seal the envelope, and return the envelope to [INSERT VENDOR ADDRESS].
What To Do If You Have Questions. CMS has contracted with the American Institutes for Research (AIR) and Ipsos to conduct this study. If you have any questions, call the Qualified Health Plan Survey Helpdesk at [1-XXX-XXX-XXXX] between 9 a.m. and 8 p.m. Central time, Monday through Friday. If you have questions about your rights as a participant, call the research participants’ protection board at AIR, which approved this study, at [1-XXX-XXX-XXXX]. All calls to these numbers are free.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1221. The time required to complete this information collection is estimated to average 25 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.
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
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, but I am in a different health plan now If No, go to #2
3 No, I am not in a health plan now If No, go to #108
What is the name of your health plan? (HP5-AM-2)
Please print:
______________________________________________________________
_________________________________________________________________________
How many months in a row have you been in this health plan? (HP5-AS-mHP1)
1 Less than 5 months If less than 5 months, go to #108
2 5 months or more
Did you choose this health plan through the Health Insurance Marketplace, also known as Obamacare or Healthcare.gov?
1 Yes
2 No If No, go to #108
3 Not sure
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.
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
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
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
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
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
In the last 6 months, how often were you able to get care you needed from a doctor’s office or clinic after regular office hours? (AC/OMB60/HP5-AS-AH2)
1 Never
2 Sometimes
3 Usually
4 Always
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
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)
1
2
3
4
5
6
7
8
9
10 Best health care possible
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
A health provider could be a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care. 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
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
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
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 #19
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
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
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
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
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
Special therapy includes physical, occupational, or speech therapy. In the last 6 months, did you need any special therapy? (SP/C/HP5-AS-CC11)
1 Yes
2 No If No, go to #23
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
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
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
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
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
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
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
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
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
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
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 #35
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
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
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 see any specialists? (CaC/S,F,T/HP5-AS-New_Q#)
1 Yes
2 No If No, go to #37
In the last 6 months, how often did your personal doctor seem informed and up-to-date about the care you got from specialists? (CaC/S,F,T/HP5-AS-New_Q#)
1 Never
2 Sometimes
3 Usually
4 Always
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
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
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
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
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
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.
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Would you recommend this health plan to your friends and family? (GR/OMB30/H-m22)
1 Yes, definitely
2 Yes, somewhat
3 No
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
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
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
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
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
In general, how would you rate your overall health? (CM/HP5-AM-27)
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor
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
Have you had either a flu shot or flu spray in the nose since July 1, {YYYY FILL THE MEASUREMENT YEAR (2013 FOR THE SURVEY FIELDED IN 2014)}? (PR/NCQA/ HP5H-AC-45)
1 Yes
2 No
3 Don’t know
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
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
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
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
Do you take aspirin daily or every other day? (PR/NCQA/HP5H-AM-42)
1 Yes
2 No
3 Don’t know
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
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
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
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
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
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
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
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
Are you deaf or do you have serious difficulty hearing? (RC/OMB60/ACS-P-17a, OMH-4302-5)
1 Yes
2 No
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
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
Do you have serious difficulty walking or climbing stairs? (RC/OMB60/ACS-P-18b, OMH-4302-5)
1 Yes
2 No
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
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
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
What is your sex? (CM /OMH-4302-3)
1 Male
2 Female
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
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
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
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
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
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
Did you ever get health services from an Indian Health Service, tribal, or urban Indian health program? (RC/OMB30)
1 Yes
2 No
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: _____________________________________________________________
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
Did you have health insurance in the United States at any time between January 1st and December 31st, 2013? (RC/T,C)
1 Yes
2 No
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
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
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.
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 for 2014 Field Test
July
7, 2014 Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CAHPS Health Plan Survey Adult Medicaid Survey 5.0 |
| Subject | Survey of health plan enrollees' experiences with care |
| Author | American Institutes for Research |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |