CMS-10488 QHP Survey (English)

2021 Qualified Health Plan (QHP)
Enrollee Experience Survey

English

2021 Qualified Health Plan (QHP) Enrollee Experience Survey

Introduction

We are asking you to complete this survey about your experiences with [QHP ISSUER NAME]. Please answer the questions in the survey based on your experience with the health plan you had from July through December 2020.

Your Privacy is Protected. What you have to say is private and will only be used for this survey. 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 [VENDOR ADDRESS].

What To Do If You Have Questions. [QHP ISSUER NAME] has contracted with [VENDOR NAME] to conduct this survey. If you have any questions about the survey, call [VENDOR NAME] toll free at (XXX) [XXX-XXXX] between [XX:XX] a.m. and [XX:XX] p.m. [VENDOR LOCAL TIME], Monday through Friday (excluding federal holidays) or email [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

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; this control number is valid until XX/XX/XXXX. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

1. Our records show that you are now in the health plan named on the front page. 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 Plan

The next series of questions ask about your experiences with your health plan. Please answer the questions based on your experience with the health plan you had from July through December 2020.

3. In the last 6 months, how often did written materials or the Internet provide the information you needed about how your health plan works?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ Not Applicable; did not look for any information about my health plan

4. 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

⁵ Not Applicable; did not look for any information about how much I would have to pay for services or equipment

5. 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

⁵ Not Applicable; did not look for any information about how much I would have to pay for prescription medicines

6. 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

⁵ Not Applicable; did not contact my health plan’s customer service for information or help  If Not Applicable, go to #9

7. 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

8. 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

9. 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

⁵ Not Applicable; health plan did not give me forms to fill out  If Not Applicable, go to #13

10. 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

11. 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

12. 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

⁵ Not Applicable; did not need forms in a different format

13. 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

14. 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

15. 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

16. 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

17. In the last 6 months, how often did you need medical care but could not get it because of a public health emergency (such as the coronavirus outbreak)? Do not include dental care.

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ Not Applicable; did not need medical care

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

¹ Not at all confident

² Slightly confident

³ Moderately confident

⁴ Very confident

19. 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

20. 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

Your Health Care in the Last 6 Months

These questions ask about your own health care. This includes care you got in a clinic, emergency room, doctor’s office, by telephone, or by video appointments. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits. Please answer the questions based on your experience with the health plan you had from July through December 2020.

21. In the last 6 months, did your personal doctor offer telephone or video appointments, so that you did not need to physically visit their office or facility?

¹ Yes

² No

³ Don’t know

⁵ Not Applicable; do not have a personal doctor

22. In the last 6 months, when you needed care right away, in an emergency room, doctor’s office, or clinic, how often did you get care as soon as you needed? Include in-person, telephone, or video appointments.

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ Not Applicable; did not need care right away

23. 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? Include in-person, telephone, or video appointments.

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ Not Applicable; did not make any appointments

24. 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? Include in-person, telephone, or video appointments.

None  If None, go to #28

1 time

2

3

4

5 to 9 times

10 or more times

25. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed? Include in-person, telephone, or video appointments.

¹ Never

² Sometimes

³ Usually

⁴ Always

26. An interpreter is someone who helps you talk with others who do not speak your language. In the last 6 months, when you needed an interpreter at your doctor’s office or clinic, how often did you get one? Include in-person, telephone, or video appointments.

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ Not Applicable; did not need an interpreter

27. 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? Include in-person, telephone, or video appointments.

0 Worst health care possible

1

2

3

4

5

6

7

8

9

10 Best health care possible

Your Personal Doctor

These questions ask about your personal doctor. A personal doctor is the one you would see or talk to if you need a check-up, want advice about a health problem, or get sick or hurt. Please answer the questions based on your experience with the health plan you had from July through December 2020.

28. In the last 6 months, how many times did you visit your personal doctor to get care for yourself? Include in-person, telephone, or video appointments.

None  If None, go to #41

1 time

2

3

4

5 to 9 times

10 or more times

Not Applicable; do not have a personal doctor  If Not Applicable, go to #41

29. 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

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

¹ Never

² Sometimes

³ Usually

⁴ Always

31. 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

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

¹ Never

² Sometimes

³ Usually

⁴ Always

33. 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? Include in-person, telephone, or video appointments.

¹ Never

² Sometimes

³ Usually

⁴ Always

34. 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

⁵ Not Applicable; did not have a blood test, x-ray, or other test  If Not Applicable, go to #36

35. 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

36. 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

⁵ Not Applicable; did not take any prescription medicines

37. 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? Include in-person, telephone, or video appointments.

¹ Yes

² No  If No, go to #40

38. 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 #40

39. 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

40. 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

Getting Health Care from Specialists

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

When you answer the next questions, include care you got in a clinic, emergency room, doctor’s office, by telephone, or by video appointments. Do not include dental visits or care you got when you stayed overnight in a hospital.

41. In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed? Include in-person, telephone, or video appointments.

¹ Never

² Sometimes

³ Usually

⁴ Always

⁵ Not Applicable; I did not need to see a specialist  If Not Applicable,

go to #45

42. How many specialists have you seen in the last 6 months? Include in-person, telephone, or video appointments.

None  If None, go to #45

1 specialist

2

3

4

5 or more specialists

43. 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

⁵ Not Applicable; I do not have a personal doctor

44. 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

About You

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

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

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

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

47. Have you had either a flu shot or flu spray in the nose since July 1, 2020?

¹ Yes

² No

³ Don’t know

48. 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 #52

⁴ Don’t know  If Don’t know,

go to #52

49. 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

50. 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

51. 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

52. 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 #54

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

¹ Yes

² No

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

¹ Yes

² No  If No, go to #56

55. 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

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

¹ Yes

² No

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

¹ Yes

² No

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

¹ Yes

² No

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

¹ Yes

² No

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

¹ Yes

² No

61. 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

62. 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

63. What is your sex?

¹ Male

² Female

64. 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

65. 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

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

¹ Yes, of Hispanic, Latino, or Spanish origin

² No, not of Hispanic, Latino, or Spanish origin  If No, go to #68

67. Which group best describes you?

¹ Mexican, Mexican American, Chicano

² Puerto Rican

³ Cuban

⁴ Another Hispanic, Latino, or Spanish origin

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

¹ White

² Black or African American

³ American Indian or Alaska Native

⁴ Asian

⁵ Native Hawaiian or Pacific Islander

69. Did someone help you complete this survey?

¹ Yes

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

70. 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

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