2027 QHP Enrollee Survey Instrument: English

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2027 Qualified Health Plan (QHP)
Enrollee Experience Survey
English

OMB No. 0938-1221: Approval Expires XX/XX/XXXX

2027 [QHP ISSUER NAME] 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 2026.
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 10 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 enrolled in
the health plan named on the front page. Is that
right?
1
2

Yes
No

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?

If Yes, go to #3

1
2

2. What is the name of your health plan?

3
4

Please print:

99

Never
Sometimes
Usually
Always
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, did you try to get
information or help from your health plan’s
customer service?

Your Health Plan

1

Yes
No

2

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
2026.

7. How often did your health plan’s customer
service give you the information or help you
needed?
1

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
2
3
4
99

2
3
4

Never
Sometimes
Usually
Always
Not Applicable; did not look for any
information about my health plan

1
2

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?
2
3
4
99

Never
Sometimes
Usually
Always

8. How often did your health plan’s customer
service staff treat you with courtesy and
respect?

3

1

If No, go to #10

4

Never
Sometimes
Usually
Always

9. How often did the time that you waited to talk to
your health plan’s customer service staff take
longer than you expected?

Never
Sometimes
Usually
Always
Not Applicable; did not look for any
information about how much I would
have to pay for services or equipment

1
2
3
4

2

Never
Sometimes
Usually
Always

10. In the last 6 months, did your health plan give
you any forms to fill out?
1

Yes
No

16. 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?

If No, go to #15

1

11. How often were the forms from your health plan
easy to fill out?

3

2

1
2
3
4

2

4

Never
Sometimes
Usually
Always

17. 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

12. How often did the health plan explain the
purpose of a form before you filled it out?
1
2
3
4

2
3

Never
Sometimes
Usually
Always

4

2
3
4

1
2

Never
Sometimes
Usually
Always

3
4

2
3
4
99

1
2
3

Never
Sometimes
Usually
Always
Not Applicable; did not need forms in a
different format

4

2
3
4

Not at all confident
Slightly confident
Moderately confident
Very confident

20. How confident are you that you know most of
the things you need to know about using health
insurance?
1

15. In the last 6 months, how often did your health
plan not pay for care that your doctor said you
needed?
1

Never
Sometimes
Usually
Always

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

14. 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
Sometimes
Usually
Always

18. In the last 6 months, how often did you delay
filling or not fill a prescription because you
were worried about the cost?

13. How often were the forms that you had to fill
out available in the language you prefer?
1

Never
Sometimes
Usually
Always

2
3
4

Never
Sometimes
Usually
Always

3

Not at all confident
Slightly confident
Moderately confident
Very confident

21. 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?

23. How often did you get an appointment in
person, by phone, or by video for a check-up or
routine care at a doctor's office or clinic as
soon as you needed?
1

0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible

2
3
4
99

24. Not counting the times you went to an
emergency room, how many times did you go to
a doctor’s office or clinic in person, by phone,
or by video to get health care for yourself?
None
If None, go to #27
1 time
2
3
4
5 to 9 times
10 or more times

Your Health Care in the Last 6 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. Please answer
the questions based on your experience with the
health plan you had from July through December
2026.

25. How often was it easy to get the care, tests, or
treatment you needed in person, by phone, or by
video?
1
2

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 in
person, by phone, or by video as soon as you
needed?
1
2
3
4
99

Never
Sometimes
Usually
Always
Not Applicable; did not make any
appointments

3
4

Never
Sometimes
Usually
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 in person, phone, or video
appointment at your doctor’s office or clinic,
how often did you get one?

Never
Sometimes
Usually
Always
Not Applicable; did not need care right
away

1
2
3
4
99

4

Never
Sometimes
Usually
Always
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 that you got in
person, by phone, or by video in the last 6
months?

30. How many times did you visit your personal
doctor in person, by phone, or by video to get
care for yourself?
None
If None, go to #44
1 time
2
3
4
5 to 9 times
10 or more times

0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible

31. How often did your personal doctor explain
things in a way that was easy to understand?
1
2
3
4

32. How often did your personal doctor listen
carefully to you?

Your Personal Doctor

1

These questions ask about your personal doctor.
Please answer the questions based on your
experience with the health plan you had from July
through December 2026.

2
3
4

28. A personal doctor is the provider 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
2

Yes
No

2
3

Never
Sometimes
Usually
Always

33. How often did your personal doctor show
respect for what you had to say?
1
2
3

If No, go to #44

4

29. 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

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

34. How often did your personal doctor spend
enough time with you?
1
2

Yes
No
Don’t know

3
4

5

Never
Sometimes
Usually
Always

35. When you visited your personal doctor for a
scheduled in person, phone, or video
appointment, how often did he or she have your
medical records or other information about your
care?
1
2
3
4

40. In the last 6 months, did you get care in person,
by phone, or by video from more than one kind
of health care provider or use more than one
kind of health care service?
1

Never
Sometimes
Usually
Always

2

2

Yes
No

1
2

2
3
4

1
2
3

Never
Sometimes
Usually
Always

4

2
3
4

2
3
4
99

Never
Sometimes
Usually
Always

0 Worst personal doctor possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor possible

Never
Sometimes
Usually
Always

39. In the last 6 months, how often did you and your
personal doctor talk about all the prescription
medicines you were taking?
1

If No, go to #43

43. 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?

38. 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

Yes
No

42. 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?

If No, go to #39

37. 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

If No, go to #43

41. Did you need help from anyone in your personal
doctor’s office to manage your care among
these different providers and services?

36. In the last 6 months, did your personal doctor
order a blood test, x-ray, or other test for you?
1

Yes
No

Never
Sometimes
Usually
Always
Not Applicable; did not take any
prescription medicines

6

48. 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?

Getting Health Care from Specialists
When you answer the next questions, include care
you got in person, by phone, or by video in a clinic,
emergency room, or doctor’s office from July
through December of 2026. Do not include dental
visits or care you got when you stayed overnight in
a hospital.

0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible

44. 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 6 months, did you try to make
any appointments to see a specialist?
1
2

Yes
No

If No, go to #49

45. How often did you get an in person, phone, or
video appointment to see a specialist as soon as
you needed?
1
2
3
4

About You

Never
Sometimes
Usually
Always

49. In general, how would you rate your overall
health?
1
2
3

46. How many specialists have you seen in person,
by phone, or by video in the last 6 months?

4
5

None
If None, go to #49
1 specialist
2
3
4
5 or more specialists

50. In general, how would you rate your overall
mental or emotional health?
1
2
3
4

47. How often did your personal doctor seem
informed and up-to-date about the care you got
from specialists?
1
2
3
4
99

Excellent
Very good
Good
Fair
Poor

5

Excellent
Very good
Good
Fair
Poor

51. In the last 6 months, did you get health care 3 or
more times for the same condition or problem?

Never
Sometimes
Usually
Always
Not Applicable; I do not have a personal
doctor

1
2

7

Yes
No

If No, go to #53

52. Is this a condition or problem that has lasted for
at least 3 months? Do not include pregnancy or
menopause.
1
2

60. 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

1
2

53. Do you now need or take medicine prescribed
by a doctor? Do not include birth control.
1
2

Yes
No

61. What is your age?
1
2

If No, go to #55

3

54. Is this medicine to treat a condition that has
lasted for at least 3 months? Do not include
pregnancy or menopause.
1
2

4
5
6

Yes
No

7

2

1
2

Yes
No

2

1
2

Yes
No

3
4
5

57. Because of a physical, mental, or emotional
condition, do you have serious difficulty
concentrating, remembering, or making
decisions?
1
2

6

2

Yes
No

1
2
3
4
5

Yes
No

6
7

59. Because of a physical, mental, or emotional
condition, do you have difficulty dressing or
bathing?
1
2

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

64. What best describes your employment status?
Mark only ONE.

58. Do you have serious difficulty walking or
climbing stairs?
1

Male
Female

63. What is the highest grade or level of school that
you have completed?

56. Are you blind or do you have serious difficulty
seeing, even when wearing glasses?
1

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

62. What is your sex?

55. Are you deaf or do you have serious difficulty
hearing?
1

Yes
No

8

Yes
No
8

Employed full-time
Employed part-time
A homemaker
A full-time student
Retired
Unable to work for health reasons
Unemployed
Other

65. What is your race and/or ethnicity? Mark one or
more.
1
2
3
4
5
6
7

67. How did that person help you? Mark one or
more.
1

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White

2
3
4

5

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

66. Did someone help you complete this survey?
1
2

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

9

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will get extra time to take any action if there’s a delay in fulfilling your request.
To request Medicare or Marketplace information in an accessible format you can:
1. Call us:
• For Medicare: 1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
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TTY: 1-855-889-4325
2. Email us: [email protected]
3. Send us a fax: 1-844-530-3676
4. Send us a letter:
Centers for Medicare & Medicaid Services Offices of Hearings and Inquiries (OHI)
7500 Security Boulevard, Mail Stop DO-01-20 Baltimore, MD 21244-1850
Attn: Customer Accessibility Resource Staff (CARS)
Your request should include your name, phone number, type of information you need (if known), and the
mailing address where we should send the materials. We may contact you for additional information.
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You can contact CMS in any of the ways included in this notice if you have any concerns about getting
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