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pdfMedicare Fee-for-Service CAHPS® Survey
2024 Medicare Experience Survey
MEDICARE 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 and the times you got health care in person, by phone
or by video call. 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: [Survey Organization].
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
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. This applies to both mandatory and voluntary collections of
information. The valid OMB control number for this information collection 0938-0732 (expires 1/31/2025). The time
required to complete this information collection is estimated to average 14.6 minutes, 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 C1-25-05,
Baltimore, Maryland 21244-1850.
1
YOUR HEALTH INSURANCE
COVERAGE
YOUR HEALTH CARE IN THE
LAST 6 MONTHS
Our records show that you are now in Medicare,
the health insurance program for people 65
years old or older or persons with certain
disabilities.
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.
Please answer the following questions in this
survey as fully as possible regardless of
whether you consider yourself in Medicare.
3.
1.
Some people who have Medicare also
have other insurance to help pay for some
of the costs of their health care. Do you
have any other insurance that pays at least
some of the cost of your health care?
Yes
No If No, Go to Question 5
4.
Yes
No If No, Go to Question 3
2.
In the last 6 months, did you have an
illness, injury, or condition that needed
care right away?
In the last 6 months, when you needed
care right away, how often did you get
care as soon as you needed?
Please mark the box below for each type
of health insurance that you have.
Medigap, which may be identified on
the front of your policy as “Medicare
Supplemental Insurance”
Employer, Union, or Retiree Health
Coverage (Insurance)
Veteran’s Benefits, also known as VA
benefits
Military Retiree Benefits, also known
as Tricare
Medicaid, also known as State medical
assistance, which is for some persons
with limited income and resources
Any Prescription Drug Plan
Other (Please write the name of the
other health insurance you currently
have on the line below.)
5.
Never
Sometimes
Usually
Always
In the last 6 months, did you make any inperson, phone, or video appointments for
a check-up or routine care?
Yes
No If No, Go to Question 7
6.
In the last 6 months, how often did you
get an appointment for a check-up or
routine care as soon as you needed?
___________________________
I don’t have health insurance other
than Medicare.
2
Never
Sometimes
Usually
Always
7.
In the last 6 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?
8.
None If None, Go to Question 9
1 time
2
3
4
5 to 9
10 or more times
11. 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?
Yes
No If No, Go to Question 27
Never
Sometimes
Usually
Always
12. In the last 6 months, how many times did
you have an in-person, phone, or video
visit with your personal doctor about your
health?
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?
Never
Sometimes
Usually
Always
YOUR PERSONAL DOCTOR
Wait time includes time spent in the
waiting room and exam room. In the last 6
months, how often did you see the person
you came to see within 15 minutes of your
appointment time?
9.
10. In the last 6 months, how often was it easy
to get the care, tests, or treatment you
needed?
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible
None If None, Go to Question 27
1 time
2
3
4
5 to 9
10 or more times
13. In the last 6 months, how often did your
personal doctor explain things in a way
that was easy to understand?
3
Never
Sometimes
Usually
Always
18. In the last 6 months, when you talked with
your personal doctor during a scheduled
appointment, how often did he or she
have your medical records or other
information about your care?
14. In the last 6 months, how often did your
personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
15. In the last 6 months, how often did your
personal doctor show respect for what you
had to say?
19. In the last 6 months, did your personal
doctor order a blood test, x-ray or other
test for you?
Never
Sometimes
Usually
Always
Yes
No If No, Go to Question 22
16. In the last 6 months, how often did your
personal doctor spend enough time with
you?
20. 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?
Never
Sometimes
Usually
Always
17. 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?
Never
Sometimes
Usually
Always
Never
Sometimes
Usually
Always
21. 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?
0 Worst personal doctor possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor possible
4
Never
Sometimes
Usually
Always
GETTING HEALTH CARE FROM
SPECIALISTS
22. In the last 6 months, did you take any
prescription medicine?
Yes
No If No, Go to Question 24
When you answer the next questions,
include the care you got in person, by phone,
or by video.
23. In the last 6 months, how often did you
and your personal doctor talk about all the
prescription medicines you were taking?
27. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and
other doctors who specialize in one area of
health care. Is your personal doctor a
specialist?
Never
Sometimes
Usually
Always
Yes If Yes, Please include your
personal doctor as you answer
these questions about specialists
No
24. 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?
Yes
No If No, Go to Question 27
28. In the last 6 months, did you make any
appointments with a specialist?
25. 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?
Yes
No If No, Go to Question 33
29. In the last 6 months, how often did you
get an appointment with a specialist as
soon as you needed?
Yes
No If No, Go to Question 27
26. In the last 6 months, did you get the help
you needed from your personal doctor’s
office to manage your care among these
different providers
and services?
Never
Sometimes
Usually
Always
30. How many specialists have you talked to in
the last 6 months?
Yes, definitely
Yes, somewhat
No
5
None If None, Go to Question 33
1 specialist
2
3
4
5 or more specialists
MANAGING YOUR
HEALTH CARE
31. We want to know your rating of the
specialist you talked to 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 that specialist?
33. How likely are you to change doctors if
you are dissatisfied with the way you
and your doctor communicate?
0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible
Very likely
Likely
Unlikely
Very unlikely
34. How likely are you to tell your doctor
when you disagree with him or her?
32. In the last 6 months, how often did your
personal doctor seem informed and up-todate about the care you got from
specialists?
Very likely
Likely
Unlikely
Very unlikely
35. In the last 6 months, how often did you
leave your doctor’s office feeling that
all of your concerns or questions were
fully answered?
Never
Sometimes
Usually
Always
I do not have a personal doctor
I have not talked with my personal
doctor in the last 6 months
My personal doctor is a specialist
Never
Sometimes
Usually
Always
36. In the last 6 months, how often did you
make sure you understood the results
of any medical test or procedure such
as x-ray, blood test, or EKG for heart
conditions?
6
Never
Sometimes
Usually
Always
I did not have any medical tests or
procedures in the last 6 months
37. In the last 6 months, did you get
information or help from Medicare’s
customer service?
42. 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
Medicare?
Yes
No If No, Go to Question 40
38. In the last 6 months, how often did
Medicare’s customer service give you the
information or help you needed?
Never
Sometimes
Usually
Always
39. In the last 6 months, how often did
Medicare’s customer service staff treat
you with courtesy and respect?
ABOUT YOU
Never
Sometimes
Usually
Always
43. In general, how would you rate your
overall health?
40. In the last 6 months, did Medicare give
you any forms to fill out?
Yes
No If No, Go to Question 42
Excellent
Very good
Good
Fair
Poor
44. In general, how would you rate your
overall mental or emotional health?
41. In the last 6 months, how often were the
forms from Medicare easy to fill out?
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible
Never
Sometimes
Usually
Always
7
Excellent
Very good
Good
Fair
Poor
45.
What language do you mainly speak at
home?
50.
English
Spanish
Chinese
Korean
Tagalog
Vietnamese
Some other language
a. Health condition
b. Disability
c. Age
d. Culture or religion
e. Language or accent
f. Race or ethnicity
g. Sex (female or male)
h. Sexual orientation
i. Gender or gender
identity
j. Income
↓
Please print:____________
46. In the last 6 months, did you spend one
or more nights in a hospital?
Yes
No
47. In the last 6 months, how often was it
easy to get the medicines your doctor
prescribed?
In the last 6 months, did anyone from a
clinic, emergency room, or doctor’s office
where you got care treat you in an unfair
or insensitive way because of any of the
following things about you?
Yes
No
51. Has a doctor ever told you that you had
any of the following conditions?
Never
Sometimes
Usually
Always
a. A heart attack?
b. Angina or coronary
heart disease?
c. Hypertension
or high blood
pressure?
d. Cancer, other than
skin cancer?
e. Emphysema, asthma,
or COPD (chronic
obstructive pulmonary disease)?
f. Any kind of diabetes
or high blood
sugar?
48. Do you have insurance that pays part
or all of the cost of your prescription
medicines?
Yes
No
Don’t know
49. In the last 6 months, did you delay or
not fill a prescription because you felt
you could not afford it?
Yes
No
52. Have you had a flu shot since July 1, 2023?
Yes
No
My doctor did not prescribe any
medicines for me in the last 6
months
Yes
No
Don’t know
8
53. Have you ever had one or more
pneumonia shots? Two shots are usually
given in a person’s lifetime and these are
different from a flu shot. It is also called
the pneumococcal vaccine.
57. Are you of Hispanic or Latino origin or
descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
58. What is your race? Please mark one or
more.
Yes
No
Don’t know
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or other Pacific
Islander
White
54. Do you now smoke cigarettes or use
tobacco every day, some days, or not at
all?
Every day
Some days
Not at all If Not at all, Go to
Question 56
Don’t know If Don’t know, Go to
Question 56
59. What sex were you assigned at birth,
on your birth certificate?
Female
Male
Prefer not to answer
55. In the last 6 months, how often were
you advised to quit smoking or using
tobacco by a doctor or other health
provider?
60. What is your current gender?
Never
Sometimes
Usually
Always
I had no in-person, phone, or video
visits in the last 6 months
56. What is the highest grade or level of
school that you have completed?
Female
Male
Transgender woman
Transgender man
Non-binary
Gender fluid
I use a different term
Prefer not to answer
61. Which of the following best represents
how you think about yourself?
8th 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
9
Lesbian or gay
Straight, that is, not gay or lesbian
Bisexual
I use a different term
Prefer not to answer
62. How many people live in your
household now, including yourself?
65. Do you ever use the internet at home?
Yes
No
1 person
2 to 3 people
4 or more people
63.
66. May the Medicare Program follow up
with you to learn more about your
health care, or to invite you to a group
discussion or interview on topics related
to health care?
Because of a health or physical problem
are you unable to do or have any difficulty
doing the following activities? (Please
mark one response for each activity.)
a.
b.
c.
d.
e.
f.
Yes
No
I am
unable Yes, I
No, I do
to do this have
not have
activity difficulty difficulty
Bathing
Dressing
Eating
Getting in
or out of
chairs
Walking
Using the
toilet
67. Did someone help you complete this
survey?
Yes
No Thank you. Please
return the completed survey
in the postage-paid envelope.
68. How did that person help you? Please
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
64. 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
THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage-paid envelope to:
[SURVEY ORGANIZATION RETURN ADDRESS FOR MAIL PROCESSING]
Please do not include any other correspondence.
10
| File Type | application/pdf |
| File Title | 2024 FFS Survey |
| Subject | 2024 Medicare FFS CAHPS Survey |
| Author | CMS |
| File Modified | 2023-01-27 |
| File Created | 2023-01-27 |