OMB 3206-0274 Consumer Assessment of Healthcare Providers and Systems

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 check-up 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. 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

9. 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 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 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 Never

² Sometimes

³ Usually

⁴ 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.