Form 0 Cahps Adult Questionnaire

Form Approved
OMB No. 3206-0236

CAHPS^® 4.0H Adult Questionnaire (Commercial)

SURVEY INSTRUCTIONS

Public Burden Statement

We estimate this survey takes an average of 20 minutes to complete including the time for reviewing both the instructions and completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Insurance Services Programs, Angela Calarco (3206-0236), 1900 E. Street N.W., Washington, DC 20415-7900. The OMB Number 3206-0236 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

SURVEY INSTRUCTIONS

• Answer all the questions by checking 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 Go to Question 1

 No

{This box should be placed on the Cover Page}

All information that would let someone identify you or your family will be kept private. {SURVEY VENDOR NAME} will not share your personal information with anyone without your OK. 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. 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 in a clinic, emergency room, or doctor’s office?

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 thought you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

5. In the last 12 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic?

¹ Yes

² No  If No, Go to Question 7

6. In the last 12 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor's office or clinic as soon as you thought 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 go to a doctor’s office or clinic to get health care for yourself?

⁰ None If None, Go to
Question 13

¹ 1

² 2

³ 3

⁴ 4

⁵ 5 to 9

⁶ 10 or more

8. In the last 12 months, how often did you and a doctor or other health provider talk about specific things you could do to prevent illness?

¹ Never

² Sometimes

³ Usually

⁴ Always

9. Choices for your treatment or health care can include choices about medicine, surgery, or other treatment. In the last 12 months, did a doctor or other health provider tell you there was more than one choice for your treatment or health care?

¹ Yes

² No  If No, Go to Question 12

10. In the last 12 months, did a doctor or other health provider talk with you about the pros and cons of each choice for your treatment or health care?

¹ Definitely yes

² Somewhat yes

³ Somewhat no

⁴ Definitely no

11. In the last 12 months, when there was more than one choice for your treatment or health care, did a doctor or other health provider ask which choice you thought was best for you?

¹ Definitely yes

² Somewhat yes

³ Somewhat no

⁴ Definitely no

12. 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

YOUR PERSONAL DOCTOR

13. A personal doctor is the one you would see 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 22

14. In the last 12 months, how many times did you visit your personal doctor to get care for yourself?

⁰ None If None, Go to
Question 21

¹ 1

² 2

³ 3

⁴ 4

⁵ 5 to 9

⁶ 10 or more

15. 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

16. In the last 12 months, how often did your personal doctor listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

17. 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

18. In the last 12 months, how often did your personal doctor spend enough time with you?

¹ Never

² Sometimes

³ Usually

⁴ Always

19. 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 21

20. 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

21. 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, do not include dental visits or care you got when you stayed overnight in a hospital.

22. 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 try to make any appointments to see a specialist?

¹ Yes

² No If No, Go to Question 26

23. In the last 12 months, how often was it easy to get appointments with specialists?

¹ Never

² Sometimes

³ Usually

⁴ Always

24. How many specialists have you seen in the last 12 months?

⁰ None If None, Go to
Question 26

¹ 1 specialist

² 2

³ 3

⁴ 4

⁵ 5 or more specialists

25. We want to know your rating of the specialist you saw 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.

26. In the last 12 months, did you try to get any kind of care, tests, or treatment through your health plan?

¹ Yes

² No If No, Go to Question 28

27. In the last 12 months, how often was it easy to get the care, tests, or treatment you thought you needed through your health plan?

¹ Never

² Sometimes

³ Usually

⁴ Always

28. In the last 12 months, did you look for any information in written materials or on the Internet about how your health plan works?

¹ Yes

² No If No, Go to Question 30

29. In the last 12 months, how often did the written materials or the Internet provide the information you needed about how your health plan works?

¹ Never

² Sometimes

³ Usually

⁴ Always

30. Sometimes people need services or equipment beyond what is provided in a regular or routine office visit, such as care from a specialist, physical therapy, a hearing aid, or oxygen.

In the last 12 months, did you look for information from your health plan on how much you would have to pay for a health care service or equipment?

¹ Yes

² No If No, Go to Question 32

31. In the last 12 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

32. In some health plans the amount you pay for a prescription medicine can be different for different medicines, or can be different for prescriptions filled by mail instead of at the pharmacy.

In the last 12 months, did you look for information from your health plan on how much you would have to pay for specific prescription medicines?

¹ Yes

² No If No, Go to Question 34

33. In the last 12 months, how often were you able to find out from your health plan how much you would have to pay for specific prescription medicines?

¹ Never

² Sometimes

³ Usually

⁴ Always

34. In the last 12 months, did you try to get information or help from your health plan’s customer service?

¹ Yes

² No If No, Go to Question 37

35. 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

36. 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

37. 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 39

38. 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

39. 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 42

³ Don’t know If Don’t know, Go
to Question 42

40. 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

41. 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

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 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

43. In general, how would you rate your overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

44. Have you had a flu shot since September 1, 2008?

¹ Yes

² No

³ Don’t know

45. Do you now smoke cigarettes 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 49

⁴ Don’t know If Don’t know, Go
to Question 49

46. In the last 12 months, on how many visits were you advised to quit smoking by a doctor or other health provider in your plan?

⁰ None

¹ 1 visit

² 2 to 4 visits

³ 5 to 9 visits

⁴ 10 or more visits

⁵ I had no visits in the last 12 months

47. On how many visits was medication recommended or discussed to assist you with quitting smoking (for example: nicotine gum, patch, nasal spray, inhaler, prescription medication)?

⁰ None

¹ 1 visit

² 2 to 4 visits

³ 5 to 9 visits

⁴ 10 or more visits

⁵ I had no visits in the last 12 months

48. On how many visits did your doctor or health provider recommend or discuss methods and strategies (other than medication) to assist you with quitting smoking?

⁰ None

¹ 1 visit

² 2 to 4 visits

³ 5 to 9 visits

⁴ 10 or more visits

⁵ I had no visits in the last 12 months

49. In the last 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?

¹ Yes

² No If No, Go to Question 51

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

¹ Yes

² No

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

¹ Yes

² No If No, Go to Question 53

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

¹ Yes

² No

53. 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

54. Are you male or female?

¹ Male

² Female

55. 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

56. Are you of Hispanic or Latino origin or descent?

¹ Yes, Hispanic or Latino

² No, Not Hispanic or Latino

57. What is your race? Please 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

58. Did someone help you complete this survey?

¹ Yes If Yes, Go to Question 59

² No Thank you.

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

59. How did that person help you? Check all that apply.

^a Read the questions to me

^b Wrote down the answers I gave

^c Answered the questions for me

^d Translated the questions into my
language

^e Helped in some other way

THANK YOU

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