CMS-10488 QHP Survey (English)

OMB No. 0938-1221: Approval Expires 02/28/2017

Adult Qualified Health Plan Enrollee
Experience Survey
Language: English
Data Collection: 2016
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
DC=Doctor Communication
CaC=Care Coordination
AI=Access to Information
PA=Plan Administration
CuC=Cultural Competence
CO=Cost
PR=Prevention
GR=Global Ratings
UT=Utilization
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
OMB60-2014 = 2014 OMB 60 Day Comment Period
OMB30-2014 = 2014 OMB 30 Day Comment Period
OMB60-2015 = 2015 OMB 60 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.

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

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OVERVIEW ADULT QHP ENROLLEE SURVEY
DOMAINS
I.

ACCESS TO CARE (*HEALTH PLAN 5.0)


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
II.

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*
CULTURAL COMPETENCE (NEW HP 5.0 SUPP/ C&G SUPPLEMENTAL/NEW QUESTIONS)





III.

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
HOW WELL DOCTORS COMMUNICATE (*HEALTH PLAN 5.0)





IV.

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*
CARE COORDINATION (NEW HEALTH PLAN 5.0 SUPPLEMENTAL QUESTIONS)











V.

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
Got care from provider besides personal doctor
Doctor seemed informed and up-to-date about care from other health providers
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
ACCESS TO INFORMATION (HEALTH PLAN 4.0 SUPPLEMENTAL/HEDIS)




VI.

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
PLAN ADMINISTRATION (*HEALTH PLAN 5.0)



Customer service gave necessary information/help ⃰

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



VII.

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
COST (NEW QUESTIONS)





VIII.











Health plan did not pay for care doctors said you needed
Pay out of pocket for care you thought health plan should pay for
Delay visiting or not visit a doctor because you were worried about cost
Delay filling or not fill prescription because you were worried about cost
PREVENTION (HEDIS)

Flu shot in past year
Frequency of tobacco use
Advised to quit smoking or tobacco use
Medication recommended to quit 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

RESPONDENT CHARACTERISTICS











Rating of overall health
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
Age
Sex
Education status

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
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





Employment status
Ethnicity
Race
Covered by health insurance at any time in 2015
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.

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Introduction
We are asking you to complete this survey about your experiences with [QHP REPORTING UNIT
NAME] in the last 6 months. If you are enrolled in a different health plan for 2016, please answer the
questions in the survey thinking about your experiences in your previous health plan from July through
December 2015.
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. 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 [SURVEY VENDOR ADDRESS].
What To Do If You Have Questions. [QHP ISSUER] contracted with [SURVEY VENDOR
NAME] to conduct this survey. If you have any questions about the survey, call [SURVEY
VENDOR NAME] toll free at (XXX) [XXX-XXXX] between XX:XX a.m. and XX:XX p.m.
[SURVEY VENDOR LOCAL TIME], Monday through Friday or e-mail [SURVEY VENDOR
EMAIL].
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 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.

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

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1. Our records show that you are now in [QHP REPORTING UNIT NAME]. Is that right? (HP5-AM1)
1
2

Yes  If Yes, go to #3
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
2

Yes
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
2
3
4

Never
Sometimes
Usually
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
2

Yes
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
2
3
4

Never
Sometimes
Usually
Always

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7. In the last 6 months, did you need to visit a doctor’s office or clinic after regular office hours?
(AC/OMB60-2014/HP5-AS-AH1)
1
2

Yes
No  If No, go to #9

8. 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/OMB60-2014/HP5-AS-AH2)
1
2
3
4

Never
Sometimes
Usually
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 #14
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

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11. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? (AC/HP5AM-9)
1
2
3
4

Never
Sometimes
Usually
Always

12. 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
2

Yes
No  If No, go to #14

13. 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
2
3
4

Never
Sometimes
Usually
Always

Your Personal Doctor
14. 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
2

Yes
No  If No, go to #32

15. 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 #32
1 time
2
3
4
5 to 9 times
10 or more times

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16. 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
2
3
4

Never
Sometimes
Usually
Always

17. In the last 6 months, how often did your personal doctor listen carefully to you? (DC/HP5-AM-13)
1
2
3
4

Never
Sometimes
Usually
Always

18. In the last 6 months, how often did your personal doctor show respect for what you had to say?
(DC/HP5-AM-14)
1
2
3
4

Never
Sometimes
Usually
Always

19. In the last 6 months, how often did your personal doctor spend enough time with you? (DC/HP5AM-15)
1
2
3
4

Never
Sometimes
Usually
Always

20. 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/ HP5AS-New_Q#)
1
2
3
4

Never
Sometimes
Usually
Always

21. 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
2

Yes
No  If No, go to #24

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22. 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
2
3
4

Never
Sometimes
Usually
Always

23. In the last 6 months, when your personal doctor ordered a blood test, x-ray, or other test for you,
how often did you get those results as soon as you needed them? (CaC/S,F,T/HP5-AS-New_Q#)
1
2
3
4

Never
Sometimes
Usually
Always

24. 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
2

Yes
No  If No, go to #26

25. 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
2
3
4

Never
Sometimes
Usually
Always

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26. 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-AM16)
0 Worst personal doctor possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor possible
27. In the last 6 months, did you take any prescription medicine? (CaC/S,F,T/ HP5-AS-New_Q#)
1
2

Yes
No  If No, go to #29

28. 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
2
3
4

Never
Sometimes
Usually
Always

29. 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
2

Yes
No  If No, go to #32

30. 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
2

Yes
No  If No, go to #32

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31. 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-ASNew_Q#)
1
2
3
4

Never
Sometimes
Usually
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.
32. 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
2

Yes
No  If No, go to #36

33. 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
2
3
4

Never
Sometimes
Usually
Always

34. How many specialists have you seen in the last 6 months? (UT/HP5-AM-19)
None  If None, go to #36
1 specialist
2
3
4
5 or more specialists

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35. 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
36. 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
2

Yes
No  If No, go to #38

37. 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
2
3
4

Never
Sometimes
Usually
Always

38. 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
2

Yes
No  If No, go to #40

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39. 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-ASmH10)
1
2
3
4

Never
Sometimes
Usually
Always

40. 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
2

Yes
No  If No, go to #42

41. 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
2
3
4

Never
Sometimes
Usually
Always

42. In the last 6 months, did you get information or help from your health plan’s customer service?
(PA/HP5-AM-21)
1
2

Yes
No  If No, go to #46

43. 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
2
3
4

Never
Sometimes
Usually
Always

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44. 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
2
3
4

Never
Sometimes
Usually
Always

45. 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
2
3
4

Never
Sometimes
Usually
Always

46. In the last 6 months, did your health plan give you any forms to fill out? (PA/HP5-AM-24)
1
2

Yes
No  If No, go to #52

47. In the last 6 months, how often were the forms from your health plan easy to fill out? (PA/HP5-AM25)
1
2
3
4

Never
Sometimes
Usually
Always

48. In the last 6 months, how often did the health plan explain the purpose of a form before you filled it
out? (PA/OMB30-2014/HP5-AS-New_Q#)
1
2
3
4

Never
Sometimes
Usually
Always

49. 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
2
3
4

Never
Sometimes
Usually
Always

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50. In the last 6 months, did you need the forms in a different format, such as large print or braille?
(CuC/OMB30-2014/HP5-AM-m24)
1
2

Yes
No  If No, go to #52

51. 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/OMB30-2014/CG2-AS-mHL32)
1
2
3
4

Never
Sometimes
Usually
Always

52. 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/HP5AM-26)
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible
53. Using any number from 0 to 10, where 0 is not at all likely and 10 is extremely likely, how likely is
it that you would recommend this health plan to a friend or family member? (GR/OMB302014,OMB60-2015/H-m22)
0 Not at all likely
1
2
3
4
5
6
7
8
9
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10 Extremely likely
54. In the last 6 months, how often did your health plan not pay for care that your doctor said you
needed? (CO/L,S,OMB60-2015)
1
2
3
4

Never
Sometimes
Usually
Always

55. 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
2
3
4

Never
Sometimes
Usually
Always

56. In the last 6 months, how often did you delay visiting or not visit a doctor because you were worried
about the cost? Do not include dental care. (CO/F,T,OMB60-2015)
1
2
3
4

Never
Sometimes
Usually
Always

57. In the last 6 months, how often did you delay filling or not fill a prescription because you were
worried about the cost? (CO/F,T, OMB60-2015)
1
2
3
4

Never
Sometimes
Usually
Always

About You
58. In general, how would you rate your overall health? (RC/HP5-AM-27)
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

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59. In general, how would you rate your overall mental or emotional health? (RC/HP5-AM-28)
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

60. Have you had either a flu shot or flu spray in the nose since July 1, [YYYY FILL THE
MEASUREMENT YEAR (2015 FOR THE SURVEY FIELDED IN 2016)]? (PR/NCQA/ HP5HAC-45)
1
2
3

Yes
No
Don’t know

61. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? (PR/NCQA/
HP5H-AM-38)
1
2
3
4

Every day
Some days
Not at all  If Not at all, go to #65
Don’t know  If Don’t know, go to #65

62. 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
2
3
4

Never
Sometimes
Usually
Always

63. 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
2
3
4

Never
Sometimes
Usually
Always

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64. 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
2
3
4

Never
Sometimes
Usually
Always

65. Do you take aspirin daily or every other day? (PR/NCQA/HP5H-AM-42)
1
2
3

Yes
No
Don’t know

66. Do you have a health problem or take medication that makes taking aspirin unsafe for you?
(PR/NCQA/ HP5H-AM-43)
1
2
3

Yes
No
Don’t know

67. 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
2

Yes
No

68. Are you aware that you have any of the following conditions? Mark one or more. (PR/NCQA/
HP5H-AM-45)
1
2
3

High cholesterol
High blood pressure
Parent or sibling with heart attack before the age of 60

69. Has a doctor ever told you that you have any of the following conditions? Mark one or more.
(PR/NCQA/ HP5H-AM-46)
1
2
3
4

A heart attack
Angina or coronary heart disease
A stroke
Any kind of diabetes or high blood sugar

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70. 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
2

Yes
No  If No, go to #72

71. 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
2

Yes
No

72. Do you now need or take medicine prescribed by a doctor? Do not include birth control. (RC/HP5AM-31)
1
2

Yes
No  If No, go to #74

73. 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
2

Yes
No

74. What is your age? (RC/HP5-AM-33)
1
2
3
4
5
6
7

18 to 24 years
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

75. What is your sex? (RC /OMH-4302-3)
1
2

Male
Female

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76. What is the highest grade or level of school that you have completed? (RC/HP5-AM-35)
1
2
3
4
5
6

8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

77. What best describes your employment status? Mark only ONE. (RC/OMB60-2014/NHBS-DM6)
1
2
3
4
5
6
7
8

Employed full-time
Employed part-time
A homemaker
A full-time student
Retired
Unable to work for health reasons
Unemployed
Other

78. Are you Hispanic, Latino/a, or Spanish origin? (RC/OMB60-2014/M-ACO-77)
1
2

Yes, Hispanic, Latino/a, or Spanish origin
No, not of Hispanic, Latino/a, or Spanish origin  If No, go to #80

79. Which group best describes you? (RC/OMB60-2014/M-ACO-78)
1
Mexican, Mexican American, Chicano/a
2
Puerto Rican
3
Cuban
4
Another Hispanic, Latino/a, or Spanish Origin

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80. What is your race? Mark one or more. (RC /OMH-4302-2)
1
2
3
4
5
6
7
8
9
10
11
12
13
14

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

81. Did you have health insurance in the United States at any time between January 1st and December
31st, 2015? (RC/T,C)
1
2

Yes
No

82. How confident are you that you understand health insurance terms? (RC/OMB30-2014)
1
2
3
4

Not at all confident
Slightly confident
Moderately confident
Very confident

83. How confident are you that you know most of the things you need to know about using health
insurance? (RC/OMB30-2014)
1
2
3
4

Not at all confident
Slightly confident
Moderately confident
Very confident

84. Did someone help you complete this survey? (RC/HP5-AM-38)
1
2

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

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85. How did that person help you? Mark one or more. (RC/HP5-AM-39)
1
2
3
4
5

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

Please Specify: ______________________________________________________________
__________________________________________________________________________

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

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