CAHPS for MIPS Web Survey

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2027 CAHPS for MIPS Survey
Web Specifications
ENGLISH VERSION
GENERAL PROGRAMMING SPECIFICATIONS:

o Display only one survey item per screen
o When displayed, “BACK” button appears in the lower left of each
screen

o When displayed, “NEXT” button appears in the lower right of each
screen

o Every question has a color or shaded header
o All questions can be paged through without requiring a response
o When survey is submitted sample member should be re-directed to
Medicare home page https://www.medicare.gov/

o Starting at Q1 display a progress bar at the top left or right of each
screen

MEDICARE PROVIDER EXPERIENCE SURVEY

o Welcome, continue in English
o Bienvenidos continuar en español
NEXT / SIGUIENTE
[PROGRAMMING SPECIFICATIONS:
• ALL SAMPLED PATIENTS START AT THE LANGUAGE SELECTION SCREEN
• ONLY THE LANGUAGES OFFERED BY THE GROUP OR ACO ARE
DISPLAYED ON THIS SCREEN
• “Welcome, continue in English” SHOULD BE IN BOLD
• INCLUDE A LINE BREAK BETWEEN EACH LANGUAGE
• A RESPONSE OF “Bienvenidos continuar en español” AT THIS SCREEN
SKIPS TO THE SPANISH VERSION OF THE SURVEY]

1

WELCOME TO THE MEDICARE PROVIDER EXPERIENCE SURVEY

Please type in the survey code that is printed on the letter you received, and click NEXT
below.
Survey code from letter:_____________
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• ONLY SAMPLED PATIENTS WHO ENTER THE URL FROM LETTER
RECEIVE THIS SCREEN
• SCREEN DISPLAYS SELECTED LANGUAGE FROM LANGUAGE
SELECTION SCREEN]

2

WELCOME TO THE MEDICARE PROVIDER EXPERIENCE SURVEY
This survey asks about you and the health care you received in the last 6 months during
visits that were in-person, by phone or by video call. Answer each question thinking
about yourself. Please take the time to complete this survey. Your answers are very
important to us.
• You will need about 13 minutes to answer the survey questions
• Your participation in the survey is voluntary
• You may skip any question(s) you do not wish to answer
• You may exit the survey at any time
• Your answers will be kept confidential
If you have any questions about this survey, please email us at [VENDOR EMAIL] or call
us toll-free at [VENDOR PHONE]. Thank you.
Click START to begin the survey.
START
[PROGRAMMING SPECIFICATION:
• START BUTTON MUST APPEAR ON THE RIGHT SIDE OF THE SCREEN]
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: TBD). The time
required to complete this information collection is estimated to average 13.1 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].

3

Your Provider
1. Our records show that you visited the provider named below in the last 6 months.
[PRFNAME] [PRLNAME]
Is that right?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q1 SKIPS TO Q24]

Your Provider
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?

o Yes
o No
BACK

NEXT
Your Provider

3. How long have you been going to this provider?

o Less than 6 months
o At least 6 months but less than 1 year
o At least 1 year but less than 3 years
o At least 3 years but less than 5 years
o 5 years or more
BACK

NEXT

4

Your Care From This Provider in the Last 6 Months
These questions ask about your own health care. Don’t include care you got when you
stayed overnight in a hospital. Don’t 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?

o None
o 1 time
o2
o3
o4
o 5 to 9
o 10 or more times
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NONE” AT Q4 SKIPS TO Q24]

Your Care From This Provider in the Last 6 Months
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?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q5 SKIPS TO Q7]

5

Your Care From This Provider in the Last 6 Months
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?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

Your Care From This Provider in the Last 6 Months
7. In the last 6 months, did you make any appointments for a check-up or routine
care with this provider?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q7 SKIPS TO Q9]

Your Care From This Provider in the Last 6 Months
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?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

6

Your Care From This Provider in the Last 6 Months
9. In the last 6 months, did you contact this provider’s office with a medical question
during regular office hours?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q9 SKIPS TO Q11]

Your Care From This Provider in the Last 6 Months
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?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

Your Care From This Provider in the Last 6 Months
11. In the last 6 months, how often did this provider explain things in a way that was
easy to understand?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

7

Your Care From This Provider in the Last 6 Months
12. In the last 6 months, how often did this provider listen carefully to you?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

Your Care From This Provider in the Last 6 Months
13. In the last 6 months, how often did this provider seem to know the important
information about your medical history?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

Your Care From This Provider in the Last 6 Months
14. In the last 6 months, how often did this provider show respect for what you had to
say?

o Never
o Sometimes
o Usually
o Always

BACK

NEXT

8

Your Care From This Provider in the Last 6 Months
15. In the last 6 months, how often did this provider spend enough time with you?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

Your Care From This Provider in the Last 6 Months
16. In the last 6 months, did this provider order a blood test, x-ray, or other test for
you?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q16 SKIPS TO Q18]

Your Care From This Provider in the Last 6 Months
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?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

9

Your Care From This Provider in the Last 6 Months
18. In the last 6 months, did you and this provider talk about starting or stopping a
prescription medicine?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q18 SKIPS TO Q20]

Your Care From This Provider in the Last 6 Months
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?

o Yes
o No
BACK

NEXT

Your Care From This Provider in the Last 6 Months
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?

o Yes
o No
BACK

NEXT

10

Your Care From This Provider in the Last 6 Months
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?

o 0 Worst provider possible
o1
o2
o3
o4
o5
o6
o7
o8
o9
o 10 Best provider possible
BACK

NEXT

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?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

11

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

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

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 [PRFNAME]
[PRLNAME] a specialist?

o Yes
o No
BACK

NEXT

Your Care From Specialists in the Last 6 Months
[PROGRAMMING SPECIFICATION:
• IF THE RESPONSE TO Q24 IS “YES” THE FOLLOWING TEXT SHOULD BE
DISPLAYED BEFORE Q25: Please include [PRFNAME PRLNAME] as you
answer these questions about specialists]
25. In the last 6 months, did you try to make any appointments with specialists?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q25 SKIPS TO Q27]

12

Your Care From Specialists in the Last 6 Months
26. In the last 6 months, how often was it easy to get appointments with specialists?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

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?

o Yes
o No
BACK

NEXT

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

o Yes
o No
BACK

NEXT

13

All Your Care in the Last 6 Months
29. In the last 6 months, did you take any prescription medicine?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q29 SKIPS TO Q32]

All Your Care in the Last 6 Months
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?

o Never
o Sometimes
o Usually
o Always
BACK

NEXT

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

o Yes
o No
BACK

NEXT

14

All Your Care in the Last 6 Months
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?

o Yes
o No
BACK

NEXT

All Your Care in the Last 6 Months
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?

o Yes
o No
BACK

NEXT

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

o Excellent
o Very good
o Good
o Fair
o Poor
BACK

NEXT

15

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

o Excellent
o Very good
o Good
o Fair
o Poor
BACK

NEXT

About You
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?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q36 SKIPS TO Q38]

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

o Yes
o No
BACK

NEXT

16

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

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q38 SKIPS TO Q40]

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

o Yes
o No
BACK

NEXT

About You
40. In the last 6 months, were any of your visits for your own health care…
Yes
a. In person?
b. By phone?
c. By video call?
BACK

o
o
o

No

o
o
o

NEXT

17

About You
41. 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.)?

o All of the time
o Most of the time
o Some of the time
o A little of the time
o None of the time
BACK

NEXT

About You
42. What is your age?

o 18 to 24
o 25 to 34
o 35 to 44
o 45 to 54
o 55 to 64
o 65 to 69
o 70 to 74
o 75 to 79
o 80 to 84
o 85 or older
BACK

NEXT

18

About You
43. Are you male or female?

o Male
o Female
BACK

NEXT

About You
44. What is the highest grade or level of school that you have completed?

o 8th grade or less
o Some high school, but did not graduate
o High school graduate or GED
o Some college or 2-year degree
o 4-year college graduate
o More than 4-year college degree
BACK

NEXT

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

o Yes
o No
[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q45 SKIPS TO Q47]
BACK

NEXT

19

About You
46. What is the language you speak at home?

o Spanish
o Chinese
o Korean
o Russian
o Vietnamese
o Some other language
BACK

NEXT

About You
47. How well do you speak English?

o Very well
o Well
o Not well
o Not at all
BACK

NEXT

About You
48. Are you deaf or do you have serious difficulty hearing?

o Yes
o No
BACK

NEXT

20

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

o Yes
o No
BACK

NEXT

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

o Yes
o No
BACK

NEXT

About You
51. Do you have serious difficulty walking or climbing stairs?

o Yes
o No
BACK

NEXT

About You
52. Do you have difficulty dressing or bathing?

o Yes
o No
BACK

NEXT
21

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

o Yes
o No
BACK

NEXT

About You
54. Do you ever use the internet at home?

o Yes
o No
BACK

NEXT
About You

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

o Yes, Hispanic, Latino, or Spanish
o No, not Hispanic, Latino, or Spanish
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO, NOT HISPANIC, LATINO, OR SPANISH” AT Q55
SKIPS TO Q57]

22

About You
56.

Which group best describes you?

o Mexican, Mexican American, Chicano
o Puerto Rican
o Cuban
o Another Hispanic, Latino, or Spanish origin
BACK

NEXT

About You
57. What is your race? Mark one or more.

o American Indian or Alaska Native
o Black or African American
o Asian Indian
o Chinese
o Filipino
o Japanese
o Korean
o Vietnamese
o Other Asian
o Guamanian or Chamorro
o Native Hawaiian
o Samoan
o Other Pacific Islander
o White
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• Q57 IS MULTI-RESPONSE; ALLOW SELECTION OF ALL THAT APPLY]

23

About You
58. Did someone help you complete this survey?

o Yes
o No
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• A RESPONSE OF “NO” AT Q58 SKIPS TO Thank You]

About You
59. How did that person help you? Mark one or more.

o Read the questions to me
o Wrote down the answers I gave
o Answered the questions for me
o Translated the questions into my language
o Helped in some other way
BACK

NEXT

[PROGRAMMING SPECIFICATION:
• 59 IS MULTI-RESPONSE; ALLOW SELECTION OF ALL THAT APPLY

Thank You
You have reached the end of the survey. If you are finished answering the questions,
please click SUBMIT to close out the survey. Thank you for your time.
SUBMIT
[PROGRAMMING SPECIFICATION:
• SUBMIT BUTTON MUST APPEAR ON THE RIGHT SIDE OF THE SCREEN]

24