Veterans Millennium Act Emergency Care Benefit Satisfaction Survey

Veterans Millennium Act Emergency Care
Benefit Satisfaction Survey
OMB No. 2900-0770
Estimated Burden: 7 minutes
Expiration Date: 08/31/2017

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the
Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who complete this survey will average 7 minutes. This includes the time it will take
to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is
used to gauge customer perceptions of Department of Veterans Affairs (VA) services as well as customer
expectations and desires. The results of this online/mail survey will help VA to more effectively tailor education
efforts and service delivery processes in order to increase yours and other Veterans’ satisfaction with
emergency treatment received in the community and knowledge regarding eligibility for the Veterans
Millennium Health Care and Benefits Act (Millennium Act) emergency care benefit. Participation in this survey
is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Privacy Act Statement: This survey is not a collection of personal information; please do not enter any
personal information in the open text fields. By voluntarily providing information on
www.va.gov/purchasedcare/programs/provider info, you are consenting to VA’s use and disclosure of
that information in the manner described in this limited policy. The VA general Web privacy policy is
available at www.va.gov/privacy.
The Veterans Millennium Health Care and Benefits Act (Millennium Act) authorizes VA to cover
emergency care for conditions not related to Veterans' service-connected disabilities when eligible
Veterans who have no other health plan coverage receive care at a community medical facility because
their local VA Medical Center cannot readily provide the needed care.

The statements and questions in this survey are regarding your experience with the
emergency treatment you received in a community medical facility under the Millennium
Act emergency care benefit.
Unique Identifier Code (UIC)
Please enter the Unique Identifier Code (UIC) that is printed under your name on the survey invitation
letter (7-8 characters): _________________________________
Any reference to your emergency treatment in this survey will refer to the emergency treatment
you sought and received in a community medical facility under the Millennium Act benefit in the
last 3 months.
For each question, please check the box that best matches your experience.

Your Emergency Treatment
Have you received emergency treatment in a community medical facility in the last 3 months?
Ο Yes
Ο No (Thank you for completing this survey)

Seeking Emergency Treatment
Did VA provide you with the information necessary to receive emergency treatment
prior to your admission?
Ο Yes
Ο No
If your answer was no, what information was lacking?
________________________________________________________________________________
How satisfied are you with the information provided to you by VA in order to receive emergency
treatment?
Ο Very
Ο Satisfied
Ο Somewhat
Ο Somewhat
Ο Dissatisfied
Ο Very
Satisfied
Satisfied
Dissatisfied
Dissatisfied
I understand the process for seeking emergency treatment.
Ο Strongly
Ο Agree
Ο Somewhat
Ο
Somewhat
Agree
Agree
Disagree
2

Ο Disagree

Ο Strongly

Disagree

Experience with VA Staff Regarding Emergency Treatment
Courteous
Ο Strongly
Agree

Ο Agree

Ο Somewhat

Ο

Agree

Adequately accessible for advice and assistance
Ο Strongly
Ο Agree
Ο Somewhat
Ο
Agree
Agree

Somewhat
Disagree

Ο Disagree

Somewhat
Disagree

Ο Disagree

Ο Strongly

Disagree
Ο Strongly

Disagree

Keep me informed of conditions and changes that affect me
Ο Strongly
Ο Agree
Ο Somewhat
Ο Somewhat
Agree
Agree
Disagree

Ο

Disagree

Ο

Strongly
Disagree

Able to answer my questions
Ο Strongly
Ο Agree
Agree

Ο

Somewhat
Agree

Ο

Somewhat
Disagree

Ο

Disagree

Ο

Strongly
Disagree

Able to resolve my issues
Ο Strongly
Ο Agree
Agree

Ο

Somewhat
Agree

Ο

Somewhat
Disagree

Ο

Disagree

Ο

Strongly
Disagree

Claim for Reimbursement of Emergency Treatment
Submission of a Claim
VA provided me with the necessary resources to submit my claim for reimbursement.
Ο Strongly
Ο Agree
Ο Somewhat
Ο Somewhat
Ο Disagree
Ο Strongly
Agree
Agree
Disagree
Disagree
I understand the process to submit a claim for reimbursement.
Ο Strongly
Ο Agree
Ο Somewhat
Ο Somewhat
Agree
Agree
Disagree

Ο

Disagree

Ο

Strongly
Disagree

Reimbursement of my claim was paid to the provider in a timely manner.
Ο Strongly
Ο Agree
Ο Somewhat
Ο Somewhat
Ο Disagree
Agree
Agree
Disagree

Ο

Strongly
Disagree

Approval and Reimbursement

Did you experience a problem(s) regarding your claim for reimbursement?
Ο Yes
Ο No
If yes, in which of the following areas was your problem(s)?
Mark all that apply.
□ Service Connected Condition
□ Non-Emergent
□ No Treatment in the past 24 months

□ Other Health Insurance
□ Timely Filing
□ Other – please specify__________________
3

Inquiries to VA
Did you place any inquiries to VA concerning your claim?
Ο Yes
Ο No (Please skip to the next section – Overall Satisfaction)
How satisfied are you with the timeliness in which VA contacted you regarding your inquiry(s)?
Ο Very
Ο Satisfied
Ο Somewhat
Ο Somewhat
Ο Dissatisfied
Ο Very
Satisfied
Satisfied
Dissatisfied
Dissatisfied
How satisfied are you with the resolution of your inquiry(s)?
Ο Very
Ο Satisfied
Ο Somewhat
Ο Somewhat
Satisfied
Satisfied
Dissatisfied

Ο

Ο

Dissatisfied

Very
Dissatisfied

Overall Satisfaction with VA Regarding Emergency Treatment
Overall, how satisfied are you with the level of service you received from VA in regard to
seeking emergency treatment?
Ο Very
Ο Satisfied
Ο Somewhat
Ο Somewhat
Ο Dissatisfied
Ο Very
Satisfied
Satisfied
Dissatisfied
Dissatisfied
Overall, how satisfied are you with the level of service you received from VA regarding
reimbursement of your claim?
Ο Very
Ο Satisfied
Ο Somewhat
Ο Somewhat
Ο Dissatisfied
Ο Very
Satisfied
Satisfied
Dissatisfied
Dissatisfied
Overall, how satisfied are you with your interaction with VA?
Ο Very
Ο Satisfied
Ο Somewhat
Ο Somewhat
Satisfied
Satisfied
Dissatisfied

Ο

Ο

Dissatisfied

Very
Dissatisfied

Is there anything you would like to share regarding your emergency treatment at the community
medical facility under the Millennium Act benefit?
_______________________________________________________________________________
_______________________________________________________________________________
What could VA do to improve the process of receiving emergency treatment at a community medical
facility under the Millennium Act benefit?
_______________________________________________________________________________
_______________________________________________________________________________

Overall Experience with all Services Provided by VA
Now think about your experiences with all the services provided by the VA (which includes healthcare,
benefits programs or memorial services).
Please tell us how you feel about the following statements:
I got the service I needed.
Ο Strongly
Ο Agree
Agree

Ο

Neither Agree
nor Disagree
4

Ο

Disagree

Ο

Strongly
Disagree

It was easy to get the service I needed.
Ο Strongly
Ο Agree
Ο Neither Agree
Agree
nor Disagree

Ο

Disagree

Ο

Strongly
Disagree

I felt like a valued customer.
Ο Strongly
Ο Agree
Agree

Ο

Disagree

Ο

Strongly
Disagree

Ο

Disagree

Ο

Strongly
Disagree

Ο

Neither Agree
nor Disagree

I trust VA to fulfill our country’s commitment to Veterans.
Ο Strongly
Ο Agree
Ο Neither Agree
Agree
nor Disagree

END OF SURVEY

Thank you for your time!

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