Form OMB 3206-0274 OMB 3206-0274 Consumer Assessment of Healthcare Providers and Systems

HEDIS MY 2021 CAHPS Health Plan
Survey 5.1H Adult Questionnaire
(Commercial)

CAHPS® 5.1H Adult Questionnaire (Commercial)
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

If Yes, Go to Question 1

No

{This box should be placed on the Cover Page}
Personally identifiable information will not be made public and will only be released
in accordance with federal laws and regulations.
You may choose to answer this survey or not. If you choose not to, this will not
affect the benefits you get. You may notice a number on the cover of this survey.
This number is ONLY used to let us know if you returned your survey so we don’t
have to send you reminders.
If you want to know more about this study, please call
{SURVEY VENDOR TOLL-FREE TELEPHONE NUMBER}.

1. Our records show that you are now
in {INSERT HEALTH PLAN NAME}.
Is that right?
1
 Yes If Yes, Go to Question 3
2
 No
2. What is the name of your health
plan? (Please print)
_______________________________

YOUR HEALTH CARE IN
THE LAST 12 MONTHS
These questions ask about your own
health care from a clinic, emergency
room, or doctor’s office. This includes
care you got in person, by phone, or by
video. 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 12 months, did you have
an illness, injury, or condition that
needed care right away?
1
 Yes
2
 No If No, Go to Question 5
4. In the last 12 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 12 months, did you make
any in person, phone, or video
appointments for a check-up or
routine care?
1
 Yes
2
 No  If No, Go to Question 7
6. In the last 12 months, how often did
you get an appointment for a checkup or routine care as soon as you
needed?
1
 Never
2
 Sometimes
3
 Usually
4
 Always

7. In the last 12 months, not counting
the times you went to an emergency
room, how many times did you get
health care for yourself in person,
by phone, or by video?
0
 None  If None, Go to
Question 10
1
 1 time
2
2
3
3
4
4
5
 5 to 9
6
 10 or more times
8.

9.

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 12 months?
00
 0 Worst health care possible
01
1
02
2
03
3
04
4
05
5
06
6
07
7
08
8
09
9
10
 10 Best health care possible
In the last 12 months, how often
was it easy to get the care, tests,
or treatment you needed?
1
 Never
2
 Sometimes
3
 Usually
4
 Always

YOUR PERSONAL DOCTOR
10. A personal doctor is the one you
would talk to if you need a checkup, 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 Question 19
11. In the last 12 months, how many
times did you have an in person,
phone, or video visit with your
personal doctor about your health?
0
 None If None, Go to
Question 18
1
 1 time
2
2
3
3
4
4
5
 5 to 9
6
 10 or more times
12. In the last 12 months, how often
did your personal doctor explain
things in a way that was easy to
understand?
1



3

4

2

Never
Sometimes
Usually
Always

13. In the last 12 months, how often
did your personal doctor listen
carefully to you?
1
 Never
2
 Sometimes
3
 Usually
4
 Always

14. In the last 12 months, how often
did your personal doctor show
respect for what you had to say?
1
 Never
2
 Sometimes
3
 Usually
4
 Always
15. In the last 12 months, how often
did your personal doctor spend
enough time with you?
1
 Never
2
 Sometimes
3
 Usually
4
 Always
16. In the last 12 months, did you get
care from a doctor or other health
provider besides your personal
doctor?
1
 Yes
2
 No If No, Go to Question 18
17. In the last 12 months, how often
did your personal doctor seem
informed and up-to-date about the
care you got from these doctors or
other health providers?
1
 Never
2
 Sometimes
3
 Usually
4
 Always

18. 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?
00
 0 Worst personal doctor possible
01
1
02
2
03
3
04
4
05
5
06
6
07
7
08
8
09
9
10
 10 Best personal doctor possible

GETTING HEALTH CARE FROM
SPECIALISTS
When you answer the next questions,
include the care you got in person, by
phone, or by video. Do not include
dental visits or care you got when you
stayed overnight in a hospital.
19. 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 12
months, did you make any
appointments with a specialist?
1
 Yes
2
 No If No, Go to Question 23
20. In the last 12 months, how often
did you get an appointment with a
specialist as soon as you needed?
1
 Never
2
 Sometimes
3
 Usually
4
 Always
21. How many specialists have you
talked to in the last 12 months?
0
 None If None, Go to
Question 23
1
 1 specialist
2
2
3
3
4
4
5
 5 or more specialists

22. We want to know your rating of the
specialist you talked to most often
in the last 12 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 that
specialist?
00
 0 Worst specialist possible
01
1
02
2
03
3
04
4
05
5
06
6
07
7
08
8
09
9
10
 10 Best specialist possible

YOUR HEALTH PLAN
The next questions ask about your
experience with your health plan.
23. In the last 12 months, did you get
information or help from your
health plan’s customer service?
1
 Yes
2
 No If No, Go to Question 26
24. In the last 12 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
25. In the last 12 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
26. In the last 12 months, did your
health plan give you any forms to
fill out?
1
 Yes
2
 No If No, Go to Question 28
27. In the last 12 months, how often
were the forms from your health
plan easy to fill out?
1
 Never
2
 Sometimes
3
 Usually
4
 Always

28. Claims are sent to a health plan for
payment. You may send in the
claims yourself, or doctors,
hospitals, or others may do this for
you. In the last 12 months, did you
or anyone else send in any claims
for your care to your health plan?
1
 Yes
2
 No If No, Go to Question 31
3
 Don’t know If Don’t know, Go
to Question 31
29. In the last 12 months, how often
did your health plan handle your
claims quickly?
1
 Never
2
 Sometimes
3
 Usually
4
 Always
5
 Don’t know
30. In the last 12 months, how often
did your health plan handle your
claims correctly?
1
 Never
2
 Sometimes
3
 Usually
4
 Always
5
 Don’t know

31. 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?
00
 0 Worst health plan possible
01
1
02
2
03
3
04
4
05
5
06
6
07
7
08
8
09
9
10
 10 Best health plan possible

ABOUT YOU
32. In general, how would you rate
your overall health?
1
 Excellent
2
 Very Good
3
 Good
4
 Fair
5
 Poor
33. In general, how would you rate
your overall mental or emotional
health?
1
 Excellent
2
 Very Good
3
 Good
4
 Fair
5
 Poor
34. Have you had either a flu shot or
flu spray in the nose since July 1,
2021?
1
 Yes
2
 No
3
 Don’t know
35. 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 Question 39
4
 Don’t know If Don’t know,
Go to Question 39

36. In the last 12 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
37. In the last 12 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
38. In the last 12 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

39. 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
40. Are you male or female?
1
 Male
2
 Female
41. 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

42. Are you of Hispanic or Latino
origin or descent?
1
 Yes, Hispanic or Latino
2
 No, Not Hispanic or Latino
43. What is your race? Mark one or
more.
a
 White
b
 Black or African-American
c
 Asian
d
 Native Hawaiian or other
Pacific Islander
e
 American Indian or Alaska
Native
f
 Other

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