Form CMS-10450 Attachment B: Mail Survey

CAHPS^® Survey for Merit-based Incentive Payment System (MIPS)

2019 Survey

Note: There may be slight wording changes made to some questions in the 2019 CAHPS for MIPS survey. The final version of the CAHPS for MIPS survey will be posted to the QPP website or CMS website.

Medicare Provider Experience Survey

Survey Instructions

This survey asks about you and the health care you received in the last six months. Answer each question thinking about yourself. Please take the time to complete this survey. Your answers are very important to us. Please return the survey with your answers in the enclosed postage-paid envelope to [VENDOR NAME]

Answer all the questions by putting an “X” in the box to the left of your answer, like this:

 Yes

Be sure to read all the answer choices given before marking your answer.

You are sometimes told not to answer 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:

[ If No, Go to Question 3]. See the example below:

EXAMPLE

1. Do you wear a hearing aid now?

☐ Yes

 No  If No, Go to Question 3

2. How long have you been wearing a hearing aid?

☐ Less than one year

☐ 1 to 3 years

☐ More than 3 years

☐ I don’t wear a hearing aid

3. In the last 6 months, did you have any headaches?

 Yes

☐ No

PRA Disclosure Statement

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 0938-1222 (Expiration date: XX/XX/XXXX).  The time required to complete this information collection is estimated to average 12.9 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. ****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.  Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact [email protected]

_{Your Provider}

1. Our records show that you visited the provider named below in the last 6 months.

Name of provider label goes here

Is that right?

• Yes

• No If No, go to #24

The questions in this survey will refer to the provider named in Question 1 as “this provider.” Please think of that person as you answer the survey.

2. Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

• Yes

• No

3. How long have you been going to this

provider?

• Less than 6 months

• At least 6 months but less than 1 year

• At least 1 year but less than 3 years

• At least 3 years but less than 5 years

• 5 years or more

_{Your Care From This Provider 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.

4. In the last 6 months, how many times did you visit this provider to get care for yourself?

• None If None, go to #24

• 1 time

• 2

• 3

• 4

• 5 to 9

• 10 or more times

5. In the last 6 months, did you contact this provider’s office to get an appointment for an illness, injury or condition that needed care right away?

• Yes

• No If No, go to #7

6. In the last 6 months, when you contacted this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

• Never

• Sometimes

• Usually

• Always

7. In the last 6 months, did you make any appointments for a check-up or routine care with this provider?

• Yes

• No If No, go to #9

8. In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?

• Never

• Sometimes

• Usually

• Always

9. In the last 6 months, did you contact this provider’s office with a medical question during regular office hours?

• Yes

• No If No, go to #11

10. In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

• Never

• Sometimes

• Usually

• Always

11. In the last 6 months, how often did this provider explain things in a way that was easy to understand?

• Never

• Sometimes

• Usually

• Always

12. In the last 6 months, how often did this

provider listen carefully to you?

• Never

• Sometimes

• Usually

• Always

13. In the last 6 months, how often did this provider seem to know the important information about your medical history?

• Never

• Sometimes

• Usually

• Always

14. In the last 6 months, how often did this provider show respect for what you had to say?

• Never

• Sometimes

• Usually

• Always

15. In the last 6 months, how often did this provider spend enough time with you?

• Never

• Sometimes

• Usually

• Always

16. In the last 6 months, did this provider order a blood test, x-ray, or other test for you?

• Yes

• No If No, go to #18

17. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?

• Never

• Sometimes

• Usually

• Always

18. In the last 6 months, did you and this provider talk about starting or stopping a prescription medicine?

• Yes

• No If No, go to #20

19. When you and this provider talked about starting or stopping a prescription medicine, did this provider ask what you thought was best for you?

• Yes

• No

20. In the last 6 months, did you and this provider talk about how much of your personal health information you wanted shared with your family or friends?

• Yes

• No

21. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

• 0 Worst provider possible

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10 Best provider possible

_{Clerks and Receptionists at This Provider’s Office}

22. In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?

• Never

• Sometimes

• Usually

• Always

23. In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?

• Never

• Sometimes

• Usually

• Always

Your Care From Specialists in the Last 6 months

24. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. Is the provider named in Question 1 of this survey a specialist?

• YesIf Yes, Please include

this provider as you answer these questions about specialists

• No

25. In the last 6 months, did you try to make any appointments with specialists?

• Yes

• No If No, go to #27

26. In the last 6 months, how often was it easy to get appointments with specialists?

• Never

• Sometimes

• Usually

• Always

_{All Your Care in the Last 6 Months}

These questions ask about all your health care. Include all the providers you saw for health care in the last 6 months. Do not include the times you went for dental care visits.

27. Your health care team includes all the doctors, nurses and other people you see for health care. In the last 6 months, did you and anyone on your health care team talk about a healthy diet and healthy eating habits?

• Yes

• No

28. In the last 6 months, did you and anyone on your health care team talk about the exercise or physical activity you get?

• Yes

• No

29. In the last 6 months, did you take any prescription medicine?

• Yes

• No If No, go to #32

30. In the last 6 months, how often did you and anyone on your health care team talk about all the prescription medicines you were taking?

• Never

• Sometimes

• Usually

• Always

31. In the last 6 months, did you and anyone on your health care team talk about how much your prescription medicines cost?

• Yes

• No

32. In the last 6 months, did anyone on your health care team ask you if there was a period of time when you felt sad, empty, or depressed?

• Yes

• No

33. In the last 6 months, did you and anyone on your health care team talk about things in your life that worry you or cause you stress?

• Yes

• No

_{About You}

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

• Excellent

• Very good

• Good

• Fair

• Poor

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

• Excellent

• Very good

• Good

• Fair

• Poor

36. In the last 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?

• Yes

• No If No, go to #38

37. Is this a condition or problem that has lasted for at least 3 months?

• Yes

• No

38. Do you now need or take medicine prescribed by a doctor?

• Yes

• No If No, go to #40

39. Is this medicine to treat a condition that has lasted for at least 3 months?

• Yes

• No

40. During the last 4 weeks, how much of the time did your physical health interfere with your social activities (like visiting with friends, relatives, etc.)?

• All of the time

• Most of the time

• Some of the time

• A little of the time

• None of the time

41. What is your age?

• 18 to 24

• 25 to 34

• 35 to 44

• 45 to 54

• 55 to 64

• 65 to 69

• 70 to 74

• 75 to 79

• 80 to 84

• 85 or older

42. Are you male or female?

• Male

• Female

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

• 8^th 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

44. How well do you speak English?

• Very well

• Well

• Not well

• Not at all

45. Do you speak a language other than English at home?

• Yes

• No If No, go to #47

46. What is the language you speak at home?

• Spanish

• Chinese

• Korean

• Russian

• Vietnamese

• Some other language



Please print:

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

• Yes

• No

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

• Yes

• No

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

• Yes

• No

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

• Yes

• No

51. Do you have difficulty dressing or bathing?

• Yes

• No

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

• Yes

• No

53. Do you ever use the internet at home?

• Yes

• No

54. Are you of Hispanic, Latino, or Spanish origin?

• Yes, Hispanic, Latino, or Spanish

• No, not Hispanic, Latino, or Spanish If No, go to #56

55. Which group best describes you?

• Mexican, Mexican American, Chicano Go to #56

• Puerto Rican Go to #56

• Cuban Go to #56

• Another Hispanic, Latino, or Spanish origin Go to #56

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

• 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

57. Did someone help you complete this survey?

• Yes

• No Thank you.

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

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

• 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 print:

Thank you

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

[VENDOR NAME AND ADDRESS HERE]

Medicare Provider Experience Survey

Alternative survey instructions for use with a scannable form that uses bubbles rather than boxes for answer choices.

Survey Instructions

This survey asks about you and the health care you received in the last six months. Answer each question thinking about yourself. Please take the time to complete this survey. Your answers are very important to us. Please return the survey with your answers in the enclosed postage-paid envelope to [VENDOR NAME].

Answer all the questions by filling in the circle to the left of your answer, like this:

• Yes

Be sure to read all the answer choices given before marking your answer.

You are sometimes told not to answer 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:

[ If No, Go to Question 3]. See the example below:

EXAMPLE

1. Do you wear a hearing aid now?

• Yes

• No  If No, Go to Question 3

2. How long have you been wearing a hearing aid?

• Less than one year

• 1 to 3 years

• More than 3 years

• I don’t wear a hearing aid

3. In the last 6 months, did you have any headaches?

• Yes

• No

PRA Disclosure Statement

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 0938-1222 (Expiration date: 04/30/2020).  The time required to complete this information collection is estimated to average 13 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. ****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.  Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact [email protected]