CMS-10488 QHP Survey (English)

2017 Qualified Health Plan (QHP)
Enrollee Experience Survey

English

June 28, 2016

2017 Qualified Health Plan (QHP) Enrollee Experience Survey

Introduction

We are asking you to complete this survey about your experiences with [QHP ISSUER NAME] in the last 6 months. If you changed your health plan for 2017, please answer the questions in the survey based on your experience with the health plan you had from July through December 2016.

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 NAME] has contracted with [SURVEY VENDOR NAME] to conduct this study. 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 (excluding federal holidays) or
e-mail [SURVEY VENDOR EMAIL].

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 [QHP ISSUER NAME]. Is that right?

¹ Yes _→ If Yes, go to #3

² No

2. What is the name of your health plan?

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. If you changed your health plan for 2017, please answer the questions based on your experience with the health plan you had from July through December 2016.

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?

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?

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?

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?

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?

¹ Yes

² 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?

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?

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?

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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Yes

² 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?

None _→ If None, go to #32

1 time

2

3

4

5 to 9 times

10 or more times

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

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ Always

19. In the last 6 months, how often did your personal doctor spend enough time with you?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

21. In the last 6 months, did your personal doctor order a blood test, x-ray, or other test for you?

¹ Yes

² No _→ If No, go to #24

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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

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?

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?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Yes

² 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?

¹ Yes

² No _→ If No, go to #32

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?

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.

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?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

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

None _→ If None, go to #36

1 specialist

2

3

4

5 or more specialists

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?

0 Worst specialist possible

1

2

3

4

5

6

7

8

9

10 Best specialist possible

Your Health Plan

The next series of questions ask about your experiences with your health plan. If you changed your health plan for 2017, please answer the questions based on your experience with the health plan you had from July through December 2016.

36. In the last 6 months, did you look for any information in written materials or on the Internet about your health plan?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Yes

² No _→ If No, go to #40

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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

42. In the last 6 months, did you get information or help from your health plan’s customer service?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

46. In the last 6 months, did your health plan give you any forms to fill out?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

48. In the last 6 months, how often did the health plan explain the purpose of a form before you filled it out?

¹ Never

² Sometimes

³ Usually

⁴ Always

49. In the last 6 months, how often were the forms that you had to fill out available in the language you prefer?

¹ Never

² Sometimes

³ Usually

⁴ Always

50. In the last 6 months, did you need the forms in a different format, such as large print or braille?

¹ Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

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?

0 Not at all likely

1

2

3

4

5

6

7

8

9

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?

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Never

² Sometimes

³ Usually

⁴ 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.

¹ Never

² Sometimes

³ Usually

⁴ 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

About You

58. In general, how would you rate your overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

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

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

60. Have you had either a flu shot or flu spray in the nose since July 1, 2016?

¹ Yes

² No

³ Don’t know

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

¹ Every day

² Some days

³ Not at all _→ If Not at all, go to #65

⁴ Don’t know _→ If Don’t know, go
to question #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?

¹ Never

² Sometimes

³ Usually

⁴ 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.

¹ Never

² Sometimes

³ Usually

⁴ Always

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.

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Yes

² No

³ Don’t know

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

¹ Yes

² No

³ 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?

¹ Yes

² No

68. Are you aware that you have any of the following conditions? Mark one or more.

¹ High cholesterol

² High blood pressure

³ 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.

¹ A heart attack

² Angina or coronary heart disease

³ A stroke

⁴ Any kind of diabetes or high blood sugar

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

¹ Yes

² 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.

¹ Yes

² No

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

¹ Yes

² 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.

¹ Yes

² No

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

¹ Yes

² No

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

¹ Yes

² No

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

¹ Yes

² No

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

¹ Yes

² No

78. Because of a physical, mental, or emotional condition, do you have difficulty dressing or bathing?

¹ Yes

² No

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

¹ Yes

² No

80. What is your age?

¹ 18 to 24

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 or older

81. What is your sex?

¹ Male

² Female

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

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

83. What best describes your employment status? Mark only ONE.

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

84. Are you Hispanic, Latino/a, or Spanish origin?

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

² No, not of Hispanic, Latino/a, or Spanish origin  If No, go to #86

85. Which group best describes you?

¹ Mexican, Mexican American, Chicano/a

² Puerto Rican

³ Cuban

⁴ Another Hispanic, Latino/a, or Spanish Origin

86. What is your race? Mark one or more.

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

87. How confident are you that you understand health insurance terms?

¹ Not at all confident

² Slightly confident

³ Moderately confident

⁴ Very confident

88. How confident are you that you know most of the things you need to know about using health insurance?

¹ Not at all confident

² Slightly confident

³ Moderately confident

⁴ Very confident

89. Did someone help you complete this survey?

¹ Yes

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

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

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