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Supplemental Items for the Adult
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Last updated: December 17, 2008
CAHPS Health Plan Survey 4.0
Supplemental Items for the Adult Questionnaires
TABLE OF CONTENTS
Behavioral Health .......................................................................................................................1
Chronic Conditions .....................................................................................................................2
Measures of Health Status .........................................................................................................4
Claims Processing ......................................................................................................................6
Communication...........................................................................................................................6
Cost Sharing...............................................................................................................................7
Covered By Multiple Plans..........................................................................................................7
Dental Care ................................................................................................................................7
Health Plan .................................................................................................................................8
HEDIS® Set ..............................................................................................................................10
Interpreter .................................................................................................................................14
Medicaid Enrollment .................................................................................................................15
People With Mobility Impairments ............................................................................................16
Your Personal Doctor.....................................................................................................16
Your Health Plan............................................................................................................17
About You ......................................................................................................................19
Personal Doctor........................................................................................................................19
Pregnancy Care........................................................................................................................20
Prescription Medicine ...............................................................................................................20
Quality Improvement ................................................................................................................21
Access to Routine Care .................................................................................................21
Access to Specialist Care ..............................................................................................22
After Hours Care ............................................................................................................23
Calls to Personal Doctor’s Office ...................................................................................24
Coordination of Care from Other Health Providers ........................................................25
Customer Service ..........................................................................................................26
Health Plan Information and Materials ...........................................................................27
Referrals ...................................................................................................................................29
Relation to Policyholder ............................................................................................................29
Transportation ..........................................................................................................................30
Utilization ..................................................................................................................................30
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Supplemental Items for the Adult Questionnaires
Important instructions
Placing Supplemental Items in the Core Questionnaires. After you copy one or more supplemental
items into the core questionnaire:
• Fix the formatting of the items as needed to fit into the two-column format.
• Renumber the supplemental item and ALL subsequent items so that they are consecutive.
• Revise ALL skip instructions in the questionnaire to make sure they point the respondent to the
correct item number.
Definition of Health Providers. If you choose to use one or more supplemental items that refer to other
health providers, please insert this definition before the first of these items: “A health provider could be
a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else
you would see for health care.”
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Supplemental Items for the Adult Questionnaires
Behavioral Health
Insert MH1 – MH4 after core question 8. For Medicaid, reference period should be stated as “In
the last 6 months.”
MH1.
In general, how would your rate your overall mental or emotional health?
1
2
3
4
5
MH2.
In the last 12 months, did you need any treatment or counseling for a personal or family
problem?
1
2
MH3.
Yes
No If No, go to core question 9
In the last 12 months, how often was it easy to get the treatment or counseling you needed
through your health plan?
1
2
3
4
MH4.
Excellent
Very good
Good
Fair
Poor
Never
Sometimes
Usually
Always
Using any number from 0 to 10, where 0 is the worst treatment or counseling possible and 10
is the best treatment or counseling possible, what number would you use to rate all your
treatment or counseling in the last 12 months?
0 Worst treatment or counseling possible
1
2
3
4
5
6
7
8
9
10 Best treatment or counseling possible
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Supplemental Items for the Adult Questionnaires
Chronic Conditions
CC1 – CC23 – For Medicaid, reference period should be stated as “In the last 6 months,” except
for CC21.
Insert CC1 – CC4 after core question 9.
CC1.
Is this person a general doctor or a specialist doctor?
1
2
CC2.
How many months or years have you been going to your personal doctor?
1
2
3
4
5
CC3.
Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 2 years
At least 2 years but less than 5 years
5 years or more
Do you have a physical or medical condition that seriously interferes with your ability to work,
attend school, or manage your day-to-day activities?
1
2
CC4.
General doctor (Family practice or internal medicine)
Specialist doctor
Yes
No If No, go to core question 10
Does your personal doctor understand how any health problems you have affect your day-today life?
1
2
Yes
No
Insert CC5 after core question 18.
CC5.
In the last 12 months, how many times did you go to specialists for care for yourself?
1
2
3
4
5 to 9
10 or more
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Supplemental Items for the Adult Questionnaires
Insert CC6 – CC8 after core question 14. Please refer to instructions at the front of this document
about defining “health providers.”
CC6.
We want to know how you, your doctors, and other health providers make decisions about
your health care.
In the last 12 months, were any decisions made about your health care?
1
2
CC7.
In the last 12 months, how often were you involved as much as you wanted in these decisions
about your health care?
1
2
3
4
CC8.
Yes
No If No, go to core question 15
Never
Sometimes
Usually
Always
In the last 12 months, how often was it easy to get your doctors or other health providers to
agree with you on the best way to manage your health conditions or problems?
1
2
3
4
Never
Sometimes
Usually
Always
Insert CC9 – CC14 after core question 8.
CC9.
In the last 12 months, did you have a health problem for which you needed special medical
equipment, such as a cane, a wheelchair, or oxygen equipment?
1
2
CC10.
Yes
No If No, go to question CC11
In the last 12 months, how often was it easy to get the medical equipment you needed through
your health plan?
1
2
3
4
Never
Sometimes
Usually
Always
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CC11.
In the last 12 months, did you have any health problems that needed special therapy, such as
physical, occupational, or speech therapy?
1
2
CC12.
Yes
No If No, go to question CC13
In the last 12 months, how often was it easy to get the special therapy you needed through your
health plan?
1
2
3
4
CC13.
Supplemental Items for the Adult Questionnaires
Never
Sometimes
Usually
Always
Home health care or assistance means home nursing, help with bathing or dressing, and help
with basic household tasks.
In the last 12 months, did you need someone to come into your home to give you home health
care or assistance?
1
2
CC14.
Yes
No If No, go to core question 9
In the last 12 months, how often was it easy to get home health care or assistance through your
health plan?
1
2
3
4
Never
Sometimes
Usually
Always
Measures of Health Status
Insert CC15 – CC17 after core question 28.
CC15.
Because of any impairment or health problem, do you need the help of other persons with your
personal care needs, such as eating, dressing, or getting around the house?
1
2
Yes
No
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CC16.
Because of any impairment or health problem, do you need help with your routine needs, such
as everyday household chores, doing necessary business, shopping, or getting around for other
purposes?
1
2
CC17.
Supplemental Items for the Adult Questionnaires
Yes
No
Do you have a physical or medical condition that seriously interferes with your independence,
participation in the community, or quality of life?
1
2
Yes
No
Insert CC18 – CC22 after core question 28.
CC18.
In the last 12 months, have you been a patient in a hospital overnight or longer?
1
2
CC19.
In the past 12 months, have you seen a doctor or other health provider 3 or more times for the
same condition or problem?
1
2
CC20.
2
Yes
No
Do you now need to take medicine prescribed by a doctor? Do not include birth control.
1
2
CC22.
Yes
No If No, go to core question 29
Is this condition a problem that has lasted for at least 3 months? Do not include pregnancy.
1
CC21.
Yes
No
Yes
No If No, go to core question 29
Is this to treat a condition that has lasted for at least 3 months? Do not include pregnancy or
menopause.
1
2
Yes
No
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Supplemental Items for the Adult Questionnaires
Claims Processing
Insert CP1 – CP3 before core question 20. For Medicaid, reference period should be stated as “In
the last 6 months.” Please note that CP1 and CP2 repeat questions that appear in the HEDIS® set.
CP1.
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
2
CP2.
In the last 12 months, how often did your health plan handle your claims correctly?
1
2
3
4
CP3.
Yes
No If No, go to core question 20
Don’t know If Don’t know, go to core question 20
Never
Sometimes
Usually
Always
Don’t know
In the last 12 months, before you went for care, how often did your health plan make it clear
how much you would have to pay?
1
2
3
4
Never
Sometimes
Usually
Always
Communication
Insert C1 after core question 12. For Medicaid, reference period should be stated as “In the last 6
months.”
C1.
In the last 12 months, how often did you have a hard time speaking with or understanding your
personal doctor because you spoke different languages?
1
2
3
4
Never
Sometimes
Usually
Always
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Supplemental Items for the Adult Questionnaires
Cost Sharing
Insert CSH1 after core question 27.
CSH1.
People can pay for their health insurance directly or out of their pay check. Do you or your
family pay any part of the cost of your health insurance?
1
2
Yes
No
Covered By Multiple Plans
Insert MP1 after core question 2. If HP1 is included, insert after HP1.
MP1.
Not counting dental insurance, are you covered by any other health plan?
1
2
Yes
No
Dental Care *
Insert D1 – D3 after core question 8. For Medicaid, reference period should be stated as “In the
last 6 months.”
D1.
In the last 12 months, did you get care from a dentist’s office or dental clinic?
1
2
D2.
Yes
No If No, go to core question 9
In the last 12 months, how many times did you go to a dentist’s office or dental clinic for care
for yourself?
None If None, go to core question 9
1
2
3
4
5 to 9
10 or more
*
The CAHPS family of products includes a CAHPS Dental Plan Survey. For more information, go to
https://www.cahps.ahrq.gov/content/products/Dental/PROD_Dental_Intro.asp.
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D3.
Supplemental Items for the Adult Questionnaires
Using any number from 0 to 10, where 0 is the worst dental care possible and 10 is the best
dental care possible, what number would you use to rate all your dental care in the last 12
months?
0 Worst dental care possible
1
2
3
4
5
6
7
8
9
10 Best dental care possible
Health Plan
Insert HP1 after core question 2.
HP1.
How many months or years in a row have you been in this health plan?
1
2
3
4
5
Less than 1 year
At least 1 year but less than 2 years
At least 2 years but less than 5 years
At least 5 years but less than 10 years
10 years or more
Insert HP2 – HP7 after core question 21. For Medicaid, reference period should be stated as “In
the last 6 months.” Please note that HP2 – HP7 repeat questions that appear in the HEDIS set.
HP2.
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
2
Yes
No If No, go to core question 22
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HP3.
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
2
3
4
HP4.
Supplemental Items for the Adult Questionnaires
Never
Sometimes
Usually
Always
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
2
HP5.
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
2
3
4
HP6.
Yes
No If No, go to core question 22
Never
Sometimes
Usually
Always
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
2
HP7.
Yes
No If No, go to core question 22
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
2
3
4
Never
Sometimes
Usually
Always
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Supplemental Items for the Adult Questionnaires
HEDIS® Set
The HEDIS Set is composed of items that the National Committee for Quality Assurance (NCQA)
added to the core questionnaire to create their version of the CAHPS Health Plan Survey, known
as CAHPS 4.0H. Survey sponsors can add these items to their questionnaire whether or not they
are submitting results to NCQA. Please note that some of these items are repeated in other
supplemental sets.
H1 – H20 – For Medicaid, reference period should be stated as “In the last 6 months.” Please refer
to instructions at the front of this document about defining “health providers.”
Insert H1 – H4 after core question 7.
H1.
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
2
3
4
H2.
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
2
H3.
Yes
No If No, go to core question 8
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
2
3
4
H4.
Never
Sometimes
Usually
Always
Definitely yes
Somewhat yes
Somewhat no
Definitely no
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
2
3
4
Definitely yes
Somewhat yes
Somewhat no
Definitely no
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Supplemental Items for the Adult Questionnaires
Insert H5 – H6 after core question 14.
H5.
In the last 12 months, did you get care from a doctor or other health provider besides your
personal doctor?
1
2
H6.
Yes
No If No, go to core question 15
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
2
3
4
Never
Sometimes
Usually
Always
Insert H7 – H12 after core question 21.
H7.
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
2
H8.
Yes
No If No, go to question H9
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
2
3
4
Never
Sometimes
Usually
Always
(H9 is the same as HP4)
H9.
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
2
Yes
No If No, go to question H11
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Supplemental Items for the Adult Questionnaires
(H10 is the same as HP5)
H10.
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
2
3
4
Never
Sometimes
Usually
Always
(H11 is the same as HP6)
H11.
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
2
Yes
No If No, go to core question 22
(H12 is the same as HP7)
H12.
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
2
3
4
Never
Sometimes
Usually
Always
Insert H13 – H15 after core question 26.
(H13 is the same as CP1)
H13.
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
2
Yes
No If No, go to core question 27
Don’t know If Don’t know, go to core question 27
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H14.
Supplemental Items for the Adult Questionnaires
In the last 12 months, how often did your health plan handle your claims quickly?
1
2
3
4
Never
Sometimes
Usually
Always
Don’t know
(H15 is the same as CP2)
H15.
In the last 12 months, how often did your health plan handle your claims correctly?
1
2
3
4
Never
Sometimes
Usually
Always
Don’t know
Insert H16 to H20 after core question 28.
H16.
Have you had a flu shot since September 1, 2008?
1
2
H17.
Do you now smoke cigarettes every day, some days, or not at all?
1
2
3
H18.
Yes
No
Don’t know
Every day
Some days
Not at all If Not at all, go to core question 29
Don’t know If Don’t know, go to core question 29
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?
None
1 visit
2 to 4 visits
5 to 9 visits
10 or more visits
I had no visits in the last 12 months
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H19.
Supplemental Items for the Adult Questionnaires
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)?
None
1 visit
2 to 4 visits
5 to 9 visits
10 or more visits
I had no visits in the last 12 months
H20.
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?
None
1 visit
2 to 4 visits
5 to 9 visits
10 or more visits
I had no visits in the last 12 months
Interpreter
Insert I1 – I2 after core question 8. For Medicaid, reference period should be stated as “In the last
6 months.”
I1.
An interpreter is someone who repeats or signs what one person says in a language used by
another person.
In the last 12 months, did you need an interpreter to help you speak with doctors or other
health providers?
1
2
I2.
Yes
No If No, go to core question 9
In the last 12 months, when you needed an interpreter to help you speak with doctors or other
health providers, how often did you get one?
1
2
3
4
Never
Sometimes
Usually
Always
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Supplemental Items for the Adult Questionnaires
Insert I3 after core question 37.
I3.
What language do you mainly speak at home?
1
2
3
4
English
[INSERT LANGUAGE 2]
[INSERT LANGUAGE 3]
[INSERT LANGUAGE 4]
Medicaid Enrollment
Insert ME1 to ME4 before core question 20. If you are including both ME1 and ME3 in your
questionnaire, change the skip instruction for ME1 to “No If No, go to question ME3.”
ME1.
Some states pay health plans to care for people covered by {Medicaid/State name for
Medicaid}. With these health plans, you may have to choose a doctor from the plan list or go
to a clinic or health care center on the plan list.
Are you covered by a health plan like this?
1
2
ME2.
Did you choose your health plan or were you told which plan you were in?
1
2
ME3.
You chose your plan
You were told which plan you were in
You can get information about plan services in writing, by telephone, on the Internet, or inperson. Did you get any information about your health plan before you signed up for it?
1
2
ME4.
Yes
No If No, go to core question 20
Yes
No If No, go to core question 20
How much of the information you were given before you signed up for the plan was correct?
1
2
3
4
All of it
Most of it
Some of it
None of it
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Supplemental Items for the Adult Questionnaires
People With Mobility Impairments
For Medicaid, reference period should be stated as “In the last 6 months.”
Your Personal Doctor
Insert IM1 – IM10 after core question 15.
IM1.
In the last 12 months, did you visit your personal doctor for care?
1
2
IM2.
When you visited your personal doctor’s office in the last 12 months, how often were you
examined on the examination table?
1
2
3
4
IM3.
2
3
4
Never
Sometimes
Usually
Always
When you visited your personal doctor's office in the last 12 months, did you try to use the
restroom?
1
2
IM5.
Never
Sometimes
Usually
Always
When you visited your personal doctor's office in the last 12 months, how often did someone
weigh you?
1
IM4.
Yes
No If No, go to core question 16
Yes
No If No, go to question IM6
In the last 12 months, how often was it easy to move around the restroom at your personal
doctor’s office?
1
2
3
4
Never
Sometimes
Usually
Always
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IM6.
In the last 12 months, did you and your personal doctor talk about pain?
1
2
IM7.
2
3
4
2
Yes
No
In the last 12 months, how often did fatigue limit your ability to do the things you needed to
do?
1
2
3
4
IM10.
Never If Never, go to question IM9
Sometimes
Usually
Always
In the last 12 months, do you think that your personal doctor understood the impact that pain
has on your life?
1
IM9.
Yes
No
In the last 12 months, how often did pain limit your ability to do the things you needed to do?
1
IM8.
Supplemental Items for the Adult Questionnaires
Never If Never, go to core question 16
Sometimes
Usually
Always
In the last 12 months, do you think that your personal doctor understood the impact that
fatigue has on your life?
1
2
Yes
No
Your Health Plan
Insert IM11 – IM19 after core question 27.
IM11.
In the last 12 months, did you need physical or occupational therapy?
1
2
Yes
No If No, go to question IM13
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IM12.
In the last 12 months, how often was it easy to get this kind of therapy through your health
plan?
1
2
3
4
IM13.
2
2
3
4
2
Yes
No If No, go to core question 28
In the last 12 months, did you try to get your mobility equipment repaired through your health
plan?
1
2
IM17.
Never
Sometimes
Usually
Always
Mobility equipment includes things like a wheelchair, scooter, walker, or cane. In the last 12
months, have you used any mobility equipment to move around your home or community?
1
IM16.
Yes
No If No, go to question IM15
In the last 12 months, how often was it easy to get speech therapy through your health plan?
1
IM15.
Never
Sometimes
Usually
Always
In the last 12 months, did you need speech therapy?
1
IM14.
Supplemental Items for the Adult Questionnaires
Yes
No If No, go to question IM18
In the last 12 months, how often was it easy to get your mobility equipment repaired through
your health plan?
1
2
3
4
Never
Sometimes
Usually
Always
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IM18.
In the last 12 months, did you try to get or replace any mobility equipment through your health
plan?
1
2
IM19.
Supplemental Items for the Adult Questionnaires
Yes
No If No, go to core question 28
In the last 12 months, how often was it easy to get or replace the mobility equipment that you
needed through your health plan?
1
2
3
4
Never
Sometimes
Usually
Always
About You
Insert IM20 – IM21 after core question 32.
IM20.
A quarter mile is about 5 city blocks or 0.4 kilometers. In the last 12 months, were you able to
walk that far?
1
2
IM21.
Yes
No If No, go to core question 33
In the last 12 months, did you have difficulty or need assistance to walk that far?
1
2
Yes
No
Personal Doctor
Insert PD1 – PD2 after core question 15.
PD1.
Did you have the same personal doctor before you joined this health plan?
1
2
Yes If Yes, go to core question 16
No
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PD2.
Supplemental Items for the Adult Questionnaires
Since you joined your health plan, how often was it easy to get a personal doctor you are
happy with?
1
2
3
4
Never
Sometimes
Usually
Always
Pregnancy Care
Insert P1 – P3 after core question 14. Remove core question 34 from the Adult Questionnaire, as it
is duplicated in P1.
P1.
Are you male or female?
1
2
P2.
Are you pregnant now?
1
2
P3.
Male If Male, go to core question 15
Female
Yes
No If No, go to core question 15
A health provider could be a general doctor, a specialist doctor, a nurse practitioner, a
physician assistant, a nurse, a mid-wife, or anyone else you would see for health care when
you are pregnant.
Have you been to a doctor or other health provider for a pregnancy care check-up for this
pregnancy?
1
2
Yes
No
Prescription Medicine
Insert PM1 – PM3 after core question 27. For Medicaid, reference period should be stated as “In
the last 6 months.”
PM1.
In the last 12 months, did you get any new prescription medicines or refill a prescription?
1
2
Yes
No If No, go to core question 28
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PM2.
In the last 12 months, how often was it easy to get your prescription medicine from your health
plan?
1
2
3
4
PM3.
Supplemental Items for the Adult Questionnaires
Never
Sometimes
Usually
Always
In the last 12 months, how often did you get the prescription medicine you needed through
your health plan?
1
2
3
4
Never
Sometimes
Usually
Always
Quality Improvement
For Medicaid, reference period should be stated as “In the last 6 months.”
Access to Routine Care
Insert AR1 – AR2 after core question 6. Please refer to instructions at the front of this document
about defining “health providers.”
AR1.
In the last 12 months, not counting the times you needed health care right away, how many
days did you usually have to wait between making an appointment and actually seeing a health
provider?
1
2
3
4
5
6
7
8
9
Same day
1 day
2 to 3 days
4 to 7 days
8 to 14 days
15 to 30 days
31 to 60 days
61 to 90 days
91 days or longer
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AR2.
Supplemental Items for the Adult Questionnaires
In the last 12 months, how often did you have to wait for an appointment because the health
provider you wanted to see worked limited hours or had few available appointments?
1
2
3
4
Never
Sometimes
Usually
Always
Access to Specialist Care
Insert AS1 after core question 17, which should be modified to include the skip instructions
presented below.
17.
In the last 12 months, how often was it easy to get appointments with specialists?
1
2
3
4
Never
Sometimes
Usually
Always If Always, go to core question 18
AS1 was designed for and tested with a commercial population using primarily a selfadministered format. Item wording and format may not be appropriate for other modes of
administration or other populations (e.g., Medicaid, Medicare, low literacy).
AS1.
Were any of the following a reason it was not easy to get an appointment with a specialist?
a) Your doctor did not think you needed to see a specialist
b) Your health plan approval or authorization was delayed
c) You weren’t sure where to find a list of specialists in your
health plan or network
d) The specialists you had to choose from were too far away
e) You did not have enough specialists to choose from
f) The specialist you wanted did not belong to your health
plan or network
g) You could not get an appointment at a time that was
convenient
h) Some other reason
Yes
No
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
Please specify: ____________________________________
________________________________________________
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Supplemental Items for the Adult Questionnaires
After Hours Care
Insert AH1 – AH3 after core question 8.
AH1.
After hours care is health care when your usual doctor’s office or clinic is closed. In the last 12
months, did you need to visit a doctor’s office or clinic for after hours care?
1
2
AH2.
Yes
No If No, go to core question 9
In the last 12 months, how often was it easy to get the after hours care you thought you
needed?
1
2
3
4
Never
Sometimes
Usually
Always If No, go to core question 9
AH3 was designed for and tested with a commercial population using primarily a selfadministered format. Item wording and format may not be appropriate for other modes of
administration or other populations (e.g., Medicaid, Medicare, low literacy).
AH3.
Were any of the following a reason it was not easy to get the after hours care you thought you
needed?
a) You did not know where to go for after hours care
b) You weren’t sure where to find a list of doctor’s offices
or clinics in your health plan or network that are open
for after hours care
c) The doctor’s office or clinic that had after hours care
was too far away
d) Office or clinic hours for after hours care did not meet
your needs
e) Some other reason
Yes
No
1
2
1
2
1
2
1
2
1
2
Please specify: ____________________________________
________________________________________________
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Supplemental Items for the Adult Questionnaires
Calls to Personal Doctor’s Office
Insert C1 – C5 after core question 14.
CO1.
In the last 12 months, did you phone your personal doctor’s office during regular office hours
to get help or advice for yourself?
1
2
CO2.
In the last 12 months, when you phoned during regular office hours, how often did you get the
help or advice you needed?
1
2
3
4
CO3.
Never
Sometimes
Usually
Always
In the last 12 months, did you phone your personal doctor’s office after regular office hours to
get help or advice for yourself?
1
2
CO4.
Yes
No If No, go to question CO3
Yes
No If No, go to core question 15
In the last 12 months, when you phoned after regular office hours, how often did you get the
help or advice you needed?
1
2
3
4
Never
Sometimes
Usually
Always If Always, go to core question 15
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Supplemental Items for the Adult Questionnaires
CO5 was designed for and tested with a commercial population using primarily a selfadministered format. Item wording and format may not be appropriate for other modes of
administration or other populations (e.g., Medicaid, Medicare, low literacy).
CO5.
Were any of the following a reason you did not get the help or advice you thought you needed
when you phoned after regular office hours?
a)
b)
c)
d)
e)
You did not know what number to call
You left a message but no one returned your call
You could not leave a message at the number you phoned
Another doctor was covering for your personal doctor
Some other reason
Yes
No
1
2
1
2
1
2
1
2
1
2
Please specify: ____________________________________
________________________________________________
Coordination of Care from Other Health Providers
Insert OHP1 – OHP5 after core question 14. Please note that OHP1 – OHP2 repeat questions that
appear in the HEDIS set. Please refer to instructions at the front of this document about defining
“health providers.”
OHP1. In the last 12 months, did you get care from a doctor or other health provider besides your
personal doctor?
1
2
Yes
No If No, go to core question 15
OHP2. 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
2
3
4
Never
Sometimes
Usually
Always
OHP3. In the last 12 months, did anyone from your health plan, doctor’s office, or clinic help
coordinate your care among these doctors or other health providers?
1
2
Yes
No If No, go to core question 15
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Supplemental Items for the Adult Questionnaires
OHP4. In the last 12 months, who helped to coordinate your care?
1
2
3
4
5
Someone from your health plan
Someone from your doctor’s office or clinic
Someone from another organization
A friend or family member
You
OHP5. How satisfied are you with the help you received to coordinate your care in the last 12
months?
1
2
3
4
5
Very dissatisfied
Dissatisfied
Neither dissatisfied nor satisfied
Satisfied
Very satisfied
Customer Service
Insert CS1 – CS2 after core question 23, which should be modified to include the skip instructions
presented below. Core question 24 also provides useful drill-down data on consumer encounters
with customer service.
23.
In the last 12 months, how often did your health plan’s customer service give you the
information or help you needed?
1
2
3
4
Never
Sometimes
Usually
Always If Always, go to question CS2
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Supplemental Items for the Adult Questionnaires
CS1 was designed for and tested with a commercial population using primarily a selfadministered format. Item wording and format may not be appropriate for other modes of
administration or other populations (e.g., Medicaid, Medicare, low literacy).
CS1.
Were any of the following a reason you did not get the information or help you needed from
your health plan’s customer service?
a)
You had to call several times before you could speak
with someone
b) The information customer service gave you was not correct
c) Customer service did not have the information you needed
d) You waited too long for someone to call you back
e) No one called you back
f) Some other reason
Yes
No
1
2
1
2
1
2
1
2
1
2
1
2
Please specify: ____________________________________
________________________________________________
CS2.
How many calls did it take for you to get the help or information you needed from your health
plan’s customer service?
1
2
3
4
5
6
1 call
2
3
4
5 or more calls
You are still waiting for help
Health Plan Information and Materials
Insert PW1 – PW8 after core question 21. Please note that PW1 – PW2 repeat questions that
appear in the HEDIS set. If you use PW4 or PW8, please refer to instructions at the front of this
document about defining “health providers.”
(PWI is the same as HP2)
PW1.
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
2
Yes
No If No, go to core question 22
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PW2.
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
2
3
4
PW3.
Supplemental Items for the Adult Questionnaires
Never
Sometimes
Usually
Always
In the last 12 months, how often was it easy to use the information on how your health plan
works?
1
2
3
4
Never
Sometimes
Usually
Always If Always, go to question PW6
PW4 and PW5 were designed for and tested with a commercial population using primarily a selfadministered format. Item wording and format may not be appropriate for other modes of
administration or other populations (e.g., Medicaid, Medicare, low literacy).
PW4.
What kind of information was not easy to use?
a)
b)
c)
d)
e)
f)
g)
Benefits and coverage for doctor or specialist visits
Benefits and coverage for pharmacy
Getting a referral to a specialist
After hours or urgent care
Choosing a health provider
Getting care outside your network
Something else
Yes
No
1
2
1
2
1
2
1
2
1
2
1
2
1
2
Please specify: ____________________________________
________________________________________________
PW5.
Where did you get that information? Mark one or more.
a)
b)
c)
d)
e)
From your health plan
From your employer
From your doctor’s office
From some other source
Not sure where you got it
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Yes
No
1
2
1
2
1
2
1
2
1
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PW6.
When you looked for information in the last 12 months, did you go to your health plan’s
Internet site?
1
2
PW7.
Yes
No If No, go to core question 22
How useful was the information you found on your health plan’s Internet site?
1
2
3
4
PW8.
Supplemental Items for the Adult Questionnaires
Not at all useful
A little useful
Somewhat useful
Very useful
In the last 12 months, did you use information on your health plan’s Internet site to choose a
doctor, specialist, or group of health providers?
1
2
Yes
No
Referrals
Insert R1 before core question 17. For Medicaid, reference period should be stated as “In the last
6 months.”
R1.
In the last 12 months, how often was it easy to get a referral to a specialist that you needed to
see?
1
2
3
4
Never
Sometimes
Usually
Always
Relation to Policyholder
Insert RP1 after core question 37.
RP1.
Health insurance plans are usually in one person’s name, the policyholder. Are you the
policyholder?
1
2
Yes
No
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Supplemental Items for the Adult Questionnaires
Transportation
Insert T1 – T3 after core question 27. For Medicaid, reference period should be stated as “In the
last 6 months.”
T1.
Some health plans help with transportation to doctors’ offices or clinics. This help can be a
shuttle bus, tokens or vouchers for a bus or taxi, or payments for mileage.
In the last 12 months, did you phone your health plan to get help with transportation?
1
2
T2.
In the last 12 months, when you phoned to get help with transportation from your health plan,
how often did you get it?
1
2
3
4
T3.
Yes
No If No, go to core question 28
Never If Never, go to core question 28
Sometimes
Usually
Always
In the last 12 months, how often did the help with transportation meet your needs?
1
2
3
4
Never
Sometimes
Usually
Always
Utilization
Insert UT1 after core question 6. For Medicaid, reference period should be stated as “In the last 6
months.”
UT1.
In the last 12 months, how many times did you go to an emergency room to get care for
yourself?
None
1
2
3
4
5 to 9
10 or more
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Supplemental Items for the Adult Questionnaires
Insert UT2 after core question 19. For Medicaid, reference period should be stated as “In the last
6 months.”
UT2.
In the last 12 months, was the specialist you saw most often the same doctor as your personal
doctor?
1
2
Yes
No
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| File Type | application/pdf |
| File Title | CAHPS Health Plan Survey 4.0: Supplemental Items for the Adult Questionnaires |
| Subject | Survey of health plan enrollees’ experiences with care |
| Author | CAHPS Consortium |
| File Modified | 2011-02-08 |
| File Created | 2008-12-18 |