CMS-10450 CAHPS for MIPS CATI Script

CAHPS® Survey for Merit-based Incentive Payment
System (MIPS)
2021 Survey Instructions and CATI Script

Note: The final version of the CAHPS for MIPS survey will be posted
to the QPP website or CMS website.

CAHPS® for MIPS Survey
Survey Instructions and CATI Script
Instructions for Conducting the Survey via CATI
Overview
This telephone interview script is provided to assist interviewers while attempting
to administer the CAHPS for MIPS Survey.
Instructions for Survey Vendors:
•

The scripts provided in this document use the same questions as those
found in the mail version of the CAHPS for MIPS Survey.
• To ensure comparability, neither a group nor a survey vendor may change
the wording of the survey questions, the response categories, or the order
of the questions in any of the surveys.
• The CATI script provided by CMS must be read verbatim.
• The CATI script does not provide scripted language for scheduling a call
back, ending an interview at the request of the beneficiary before the
survey is completed, etc. Survey vendors may use their internal scripting
for such modules.
• All text that appears in lowercase letters must be read out loud.
• For all questions that use “Never/Sometimes/Usually/Always” response
scale, the interviewer should say “Would you say…” before reading the
response options to the respondent.
• Text within a question that is in one of the following styles: underlined, or
bolded, or highlighted, or IN UPPERCASE LETTERING, or italicized must
be emphasized.
Note: Survey vendors are permitted to indicate emphasis of text in a
different manner, such as placing quotes (“”) or asterisks (**) around the
text to be emphasized, if the CATI system does not permit any of the styles
indicated above.
• Words that appear in < > are instructions or for informational purposes
only and must not be read aloud.
• “DON’T KNOW” and “REFUSED” answer categories appear in uppercase
and within < > and should not be read to the respondent, but may be used
for coding a response.
• Text that appears within parentheses and in both (UPPERCASE
LETTERING AND ITALICIZED) indicate instructions for the interviewer
regarding optional items. These instructions are not to be read aloud.
Example: (READ RESPONSE OPTIONS ONLY IF NECESSARY)
• Text that appears within [SQUARE BRACKETS] are used to show
programming instructions that must not actually appear on electronic
telephone interviewing system screens.
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•

Only one language must appear on the electronic interviewing system
screen.
• Some items can and should be skipped by certain beneficiaries.
o Dependent questions that are appropriately skipped should be coded
as “88-NOT APPLICABLE.”
• Skip patterns should be programmed into the electronic telephone
interviewing system. For example, if a beneficiary answers “No” to a
screener question, the program should skip and go to the next screener
question. The dependent questions between the screener questions must
then be coded as “88-NOT APPLICABLE.” Coding may be done
automatically by the telephone interviewing system or later during data
preparation.
• When a response to a screener question is not obtained (“98-DON’T
KNOW” or “99-REFUSED” are considered responses), the screener
question and any questions in the skip pattern should be coded as “MMISSING.” In this case, the telephone interviewing system should be
programmed to skip the dependent question(s) and go to the next screener
question. Coding may be done automatically by the telephone interviewing
system or later during data preparation.
• When a respondent suspends an interview and does not resume, the
unanswered screener questions should be coded “M – Missing.”
• If after starting the survey the interview is disconnected, or the beneficiary
requests a call back at a later date to complete the survey, the survey vendor
may resume the call where the beneficiary left off. Please use the script
provided for “Call Back to Resume a Survey.”
• Survey vendors may not underline or use bold letters to emphasize words
or questions other than what is already included in the final version of the
questionnaires provided by CMS.
• Please note that the telephone script contains two questions from the
questionnaires that ask about receiving assistance (proxy respondent).
The questions “Did someone help you complete this survey?” and “How
did that person help you?” are to be completed by the interviewer based
on the respondent’s (or proxy’s) role during the interview.
o These two questions about proxy respondents may be placed after the
END screen.
• In the event that a beneficiary is unable to complete the interview
himself/herself, a proxy interview may be conducted provided the
telephone interviewer is able to identify a suitable proxy respondent
(someone who knows the beneficiary well and is able to answer health
related questions about the beneficiary accurately). However, the telephone
interviewer must obtain the beneficiary’s permission to have a proxy
respondent assist them with the interview or complete the interview for them.
If the interviewer is unable to speak to the beneficiary directly in order to
identify a proxy respondent and obtain his/her permission to do the
interview for them, they must not proceed with the interview. The CATI
introductory script includes a script for identifying and obtaining consent to
complete a proxy interview, as well as a reminder for the proxy respondent
to answer the survey questions about the beneficiary.
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•

To ensure that proxy respondents answer survey questions about the
beneficiary, all proxy survey questions must be reworded to reference the
selected beneficiary:

EXAMPLES:
Q4

In the last 6 months, how many times did [BENEFICIARY NAME] visit
this provider to get care for [himself/herself]? Would [he/she] say:

Q25

In the last 6 months, did [BENEFICIARY NAME] try to make any
appointments with specialists?

Q34 Intro These next questions are about [BENEFICIARY NAME] and will help us to
describe the people who participate in this survey.
Q34

In general, how would [BENEFICIARY NAME] rate [his/her] overall
health? Would [he/she] say:

Instructions for Telephone Interviewer
•
•
•
•

•
•
•

Interviewers must ask the survey questions and record the respondent’s
responses in a standardized and consistent way, probing as necessary.
Suggested probes are indicated by (PROBE “IF NEEDED: TEXT IS IN ALL
UPPER CASE LETTERING.”).
Characters in < > are instructions or for informational purposes only and must
not be read aloud.
Text that appears within parentheses and in both (UPPERCASE LETTERING
AND ITALICIZED) indicate instructions for the interviewer regarding optional
items. These instructions are not to be read aloud. Example: (READ
RESPONSE OPTIONS ONLY IF NECESSARY)
“DON’T KNOW” and “REFUSED” answer categories appear in uppercase and
within < > and should not be read to the respondent, but may be used for coding
a response.
Interviewers should read aloud all text that appears in lowercase letters.
Text within a question that is in one of the following styles: underlined, or
bolded, or highlighted, or IN UPPER CASE LETTERING, or italicized must
be emphasized by the interviewer.
Note: Survey vendors are permitted to indicate emphasis of text in a different
manner, such as placing quotes (“”) or asterisks (**) around the text to be
emphasized, if the CATI system does not permit any of the styles indicated
above.

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•

•

•
•

4

In situations when a beneficiary says Yes to Q1 (that is, the beneficiary
confirms he/she has seen the provider named in Q1) but begins to refer to a
different provider later in the survey when answering questions about the
named provider, the interviewer should redirect the beneficiary to answer the
questions about the provider named in Q1. If the beneficiary insists he/she has
not seen the named provider in the past 6 months, the interviewer may go
back to Q1 and record a response of No to Q1.
Interviewers must follow basic interviewing conventions such as:
o Conducting the interview in a neutral and unbiased fashion
o Probing for complete answers in a neutral and professional manner
 During the course of the survey, use of neutral acknowledgment words
such as the following is permitted:
 Thank you.
 Okay.
 I understand.
 I see.
 Yes, Ma’am.
 Yes, Sir.
 Let me repeat the question/answer choices for you.
o Reading all questions, transition phrases, and response options
exactly as written
 Reading all response options in lowercase
 In instances when a beneficiary provides a response before the
interviewer completes reading all the response options, the
interviewer must continue to read all the responses. The interviewer
may inform the beneficiary that all response options must be read by
saying “I’m sorry but I have to read you all the answer choices.”
o Maintaining the integrity of the questionnaire content by asking
each question consistently and in the correct order, and without
skipping any questions inappropriately
o Recording responses accurately
o Reading questions at an appropriate speed (at a normal pace,
neither too fast, nor too slow)
o Repeating questions as necessary
Interviewers should avoid assuming answers ahead of time, interpreting
answers provided, or suggesting answers
Interviewers should avoid giving their opinion, even when asked; Interviewers
should provide positive but neutral feedback to maintain cooperation and to
show appreciation for the respondent’s contribution of time and effort.

Centers for Medicare & Medicaid Services

CATI SCRIPT – CAHPS for MIPS Survey

INTRO1-OUT
Hello, may I please speak to [BENEFICIARY NAME]?
(IF NEEDED:) I’m calling to follow up on a letter from Walter Stone of the Centers for
Medicare and Medicaid Services (CMS).
(IF NEEDED): The letter was sent as part of a CMS survey about care and services
under Medicare.
1
2
3
4
5
6
7
8
9
10
11

YES
SP NOT AVAILABLE RIGHT NOW
REFUSAL
SP NEEDS SPANISH LANGUAGE INTERVIEW
SP NEEDS CANTONESE INTERVIEW
SP NEEDS KOREAN INTERVIEW
SP NEEDS MANDARIN INTERVIEW
SP NEEDS RUSSIAN INTERVIEW
SP NEEDS VIETNAMESE INTERVIEW
SP IS TOO ILL OR FRAIL/PHYSICALLY UNABLE
SP IS DECEASED

12

OTHER NON-INTERVIEW

Centers for Medicare & Medicaid Services

[GO TO INTRO2-OUT]
[GO TO CALLBACK MODULE]
[GO TO REFUSAL MODULE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[GO TO PROXY1]
[GO TO NON-INTERVIEW
SCREEN]
[GO TO NON-INTERVIEW
SCREEN]

5

INTRO1-IN
Hello, am I speaking to [BENEFICIARY NAME]?
1
2
3
4
5
6
7
8
9
10
11
12

YES
[GO TO INTRO2-IN]
SP NOT AVAILABLE RIGHT NOW
[GO TO CALLBACK MODULE]
REFUSAL
[GO TO REFUSAL MODULE]
SP NEEDS SPANISH LANGUAGE INTERVIEW [SET LANGUAGE]
SP NEEDS CANTONESE INTERVIEW
[SET LANGUAGE]
SP NEEDS KOREAN INTERVIEW
[SET LANGUAGE]
SP NEEDS MANDARIN INTERVIEW
[SET LANGUAGE]
SP NEEDS RUSSIAN INTERVIEW
[SET LANGUAGE]
SP NEEDS VIETNAMESE INTERVIEW
[SET LANGUAGE]
SP IS TOO ILL OR FRAIL/PHYSICALLY UNABLE [GO TO PROXY1]
SP IS DECEASED
[GO TO NON-INTERVIEW
SCREEN]
OTHER NON-INTERVIEW
[GO TO NON-INTERVIEW
SCREEN]

PROXY1
I am calling to invite [BENEFICIARY NAME] to take part in an interview about (his/her)
experiences with health care. (He/She) can identify someone to complete the interview
on (his/her) behalf. I would need to speak with (Mr./Ms.) [BENEFICIARY LAST NAME]
briefly about that.
1
2

YES
NO

3

REFUSAL

6

[GO TO PROXY2]
[GO TO NON-INTERVIEW
SCREEN]
[GO TO REFUSAL MODULE]

Centers for Medicare & Medicaid Services

PROXY2
My name is [INTERVIEWER NAME] and I’m calling on behalf of the Centers for
Medicare & Medicaid Services, or CMS, to ask you to take part in an interview about
your visits to doctors and nurses in the last 6 months.
If you need help in completing this interview, you can have a family member or close
friend help you to answer the questions. If you feel you are unable to complete the
interview, you can have a family member or close friend do the interview for you. This
person needs to be someone who knows you very well and would be able to accurately
answer questions about your visits to doctors and nurses in the last 6 months.
Is there someone who could help you answer the interview, or who could do the
interview for you?
1
2
3

YES, HELP WITH INTERVIEW
YES, DO INTERVIEW FOR SP
NO

4

REFUSAL

[GO TO PROXY3]
[GO TO PROXY4]
[GO TO NON-INTERVIEW
SCREEN]
[GO TO REFUSAL MODULE]

PROXY3
What is the first name of the person who can help you to answer the interview?
ENTER NAME:
Is that person there right now?
1
2

YES
NO, CALL BACK

3

SP UNABLE TO CONTINUE

4

REFUSAL

Centers for Medicare & Medicaid Services

[GO TO PROXY6]
[GO TO CALLBACK MODULE]
[NEED TO INDICATE THIS IS
ASSISTED INTERVIEW]
[GO TO NON-INTERVIEW
SCREEN]
[GO TO REFUSAL MODULE]

7

PROXY4
What is the first name of the person who is going to answer the interview on your
behalf?
:
Do I have your permission to conduct the interview with this person on your behalf?
1
2
3
4

YES
NO, CALL BACK
REFUSAL
SP UNABLE TO CONTINUE

[GO TO PROXY5]
[GO TO CALLBACK MODULE]
[GO TO REFUSAL MODULE]
[GO TO NON-INTERVIEW
SCREEN]

PROXY5
Is [FILL NAME FROM PROXY4] available to talk with me now?

1
2
3
4

8

YES
NO, CALL BACK
REFUSAL
SP UNABLE TO CONTINUE

[GO TO PROXY6]
[GO TO CALLBACK MODULE]
[GO TO REFUSAL MODULE]
[GO TO NON-INTERVIEW
SCREEN]

Centers for Medicare & Medicaid Services

PROXY6
(IF NEEDED: My name is [INTERVIEWER NAME] and I’m calling on behalf of the
Centers for Medicare & Medicaid Services, or CMS, to ask you to take part in an
interview about [BENEFICIARY NAME]’s visits to doctors and nurses in the last 6
months.)
CMS is conducting this study to get direct feedback from Medicare beneficiaries about
their experience with the care and services they receive through Medicare. (Mr./Ms.)
[BENEFICIARY LAST NAME]’s name was selected at random among people who have
visited [PROVIDER NAME]. (He/She) has given permission for you to answer this
interview on (his/her) behalf.
This study is voluntary, and your decision to participate or not to participate will not
affect (Mr./Ms.) [BENEFICIARY LAST NAME]’s Medicare benefits in any way. The
interview will take about 16 minutes to complete [OR VENDOR SPECIFY], depending
on experiences.
[VENDOR NAME] will not share information with anyone other than authorized persons
at CMS, except as required by law. Your individual answers will never be seen by (Mr./
Ms.) [BENEFICIARY LAST NAME]’s doctor or anyone else involved with (his/her) care.
Is this a convenient time to answer a few questions?
USE FAQs TO ANSWER QUESTIONS ABOUT THE SURVEY
1
2
3

YES
NO
REFUSAL

[GO TO REMIND]
[GO TO CALLBACK MODULE]
[GO TO REFUSAL MODULE]

REMIND
As you answer the questions in this interview, please remember that you are answering
the questions for (Mr./Ms.) [BENEFICIARY LAST NAME]. Please answer the questions
based on (his/her) experiences with visits to doctors and nurses.
[GO TO MONITOR]

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INTRO2-OUT
My name is [INTERVIEWER NAME] and I’m calling on behalf of the Centers for
Medicare & Medicaid Services, or CMS, to ask you to take part in an interview about
your visits to doctors and nurses in the last 6 months.
CMS is conducting this study to get direct feedback from Medicare beneficiaries about
their experience with the care and services they receive through Medicare. Your name
was selected at random among people who have visited [PROVIDER NAME].
This study is voluntary, and your decision to participate or not to participate will not
affect your Medicare benefits in any way. The interview will take about 16 minutes to
complete [OR VENDOR SPECIFY], depending on your experiences.
[VENDOR NAME] will not share your information with anyone other than authorized
persons at CMS, except as required by law. Your individual answers will never be seen
by your doctor or anyone else involved with your care.
Is this a convenient time to answer a few questions?
USE FAQs TO ANSWER QUESTIONS ABOUT THE SURVEY
1
2
3
4
5
6
7
8
9
10
11

10

YES
[GO TO MONITOR]
NO, CALL BACK
[GO TO CALLBACK MODULE]
REFUSAL
[GO TO REFUSAL MODULE]
SP NEEDS SPANISH LANGUAGE INTERVIEW [SET LANGUAGE]
SP NEEDS CANTONESE INTERVIEW
[SET LANGUAGE]
SP NEEDS KOREAN INTERVIEW
[SET LANGUAGE]
SP NEEDS MANDARIN INTERVIEW
[SET LANGUAGE]
SP NEEDS RUSSIAN INTERVIEW
[SET LANGUAGE]
SP NEEDS VIETNAMESE INTERVIEW
[SET LANGUAGE]
SP IS TOO ILL OR FRAIL/PHYSICALLY UNABLE [GO TO PROXY1]
OTHER NON-INTERVIEW
[GO TO NON-INTERVIEW
SCREEN]

Centers for Medicare & Medicaid Services

INTRO2-IN
My name is [INTERVIEWER NAME] and CMS is conducting a study to get direct
feedback from Medicare beneficiaries about their experience with the care and services
they receive through Medicare. Your name was selected at random among people who
have visited [PROVIDER NAME].
This study is voluntary, and your decision to participate or not to participate will not
affect your Medicare benefits in any way. The interview will take about 16 minutes to
complete [OR VENDOR SPECIFY], depending on your experiences.
[VENDOR NAME] will not share your information with anyone other than authorized
persons at CMS, except as required by law. Your individual answers will never be seen
by your doctor or anyone else involved with your care.
Is this a convenient time to answer a few questions?
USE FAQs TO ANSWER QUESTIONS ABOUT THE SURVEY
1
2
3
4
5
6
7
8
9
10
11

YES
NO, CALL BACK
REFUSAL
SP NEEDS SPANISH LANGUAGE INTERVIEW
SP NEEDS CANTONESE INTERVIEW
SP NEEDS KOREAN INTERVIEW
SP NEEDS MANDARIN INTERVIEW
SP NEEDS RUSSIAN INTERVIEW
SP NEEDS VIETNAMESE INTERVIEW
SP IS TOO ILL OR FRAIL/PHYSICALLY UNABLE
OTHER NON-INTERVIEW

[GO TO MONITOR]
[GO TO CALLBACK MODULE]
[GO TO REFUSAL MODULE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[GO TO PROXY1]
[GO TO NON-INTERVIEW
SCREEN]

MONITOR
Before we begin, I need to tell you that this call may be monitored for the purposes of
quality control.
[PROGRAMMING SPECIFICATIONS: IF VENDOR RECORDS INTERVIEWS THEN
INTERVIEWER MUST READ THIS VERSION OF MONITOR “Before we begin, I need to tell you that this call may be monitored and/or recorded for
the purposes of quality control.”]

Centers for Medicare & Medicaid Services

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CALL BACK TO RESUME A SURVEY
RESUME1
Hello, may I please speak to [BENEFICIARY NAME]?
(IF NEEDED:) I’m calling on behalf of the Centers for Medicare & Medicaid Services
(CMS) to finish an interview with [BENEFICIARY NAME].
1
2
3

YES
REFUSAL
NO, CALL BACK

[GO TO RESUME2]
[GO TO REFUSAL MODULE]
[GO TO CALLBACK MODULE]

RESUME2
This is [INTERVIEWER NAME] calling from [VENDOR NAME] on behalf of the Centers
for Medicare & Medicaid Services (CMS). I would like to confirm that I am speaking with
[BENEFICIARY NAME]?
I am calling to finish the interview on your visits to doctors and nurses in the last 6
months.
1
2
3
4
5
6
7
8
9
10
11

YES
NO, CALL BACK
REFUSAL
SP NEEDS SPANISH LANGUAGE INTERVIEW
SP NEEDS CANTONESE INTERVIEW
SP NEEDS KOREAN INTERVIEW
SP NEEDS MANDARIN INTERVIEW
SP NEEDS RUSSIAN INTERVIEW
SP NEEDS VIETNAMESE INTERVIEW
SP IS TOO ILL OR FRAIL/PHYSICALLY UNABLE
OTHER NON-INTERVIEW

[GO TO RESUME3]
[GO TO CALLBACK MODULE]
[GO TO REFUSAL MODULE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[SET LANGUAGE]
[GO TO PROXY1]
[GO TO NON-INTERVIEW
SCREEN]

RESUME3
Before we continue, I need to tell you that this call may be monitored for the purposes of
quality control.
[PROGRAMMING SPECIFICATIONS: IF VENDOR RECORDS INTERVIEWS THEN
INTERVIEWER MUST READ THIS VERSION OF RESUME3 “Before we continue, I need to tell you that this call may be monitored and/or recorded
for the purposes of quality control.”]

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Centers for Medicare & Medicaid Services

Q1
Our records show that in the last six months you visited a provider named [PROVIDER
NAME].
Is that right?
1
YES
2
NO
98
99
M [MISSING]

[GO TO Q24 Intro]
[GO TO Q24 Intro]
[GO TO Q24 Intro]

Q2 Intro
The questions in this survey will refer to [PROVIDER NAME] as “this provider.” Please
think of that person as you answer the questions.
Q2
Is this the provider you usually see if you need a check-up, want advice about a health
problem, or get sick or hurt? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q3
How long have you been going to this provider? Would you say:
1
Less than 6 months,
2
At least 6 months but less than 1 year,
3
At least 1 year but less than 3 years,
4
At least 3 years but less than 5 years, or
5
5 years or more
88 [NOT APPLICABLE]
98
99
M [MISSING]

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Q4 Intro
These next questions ask about your own health care during visits that were in-person,
by phone or by video call. Do not include care you got when you stayed overnight in a
hospital. Do not include the times you went for dental care visits.
Q4
In the last 6 months, how many times did you visit this provider to get care for yourself?
Would you say:
(IF NEEDED: “Please include all your care from [PROVIDER NAME] in the last six
months, whether in-person, by video, or by phone, as you answer these questions.”)
0
1
2
3
4
5
6
88
98
99
M

None
1 time,
2,
3,
4,
5 to 9, or
10 or more times
[NOT APPLICABLE]

[MISSING]

[GO TO Q24 Intro]

Q5
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? (READ ANSWER CHOICES
ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q7]
88 [NOT APPLICABLE]
98
[GO TO Q7]
99
[GO TO Q7]
M [MISSING]

14

Centers for Medicare & Medicaid Services

Q6
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? Would you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q7
In the last 6 months, did you make any appointments for a check-up or routine care with
this provider? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q9]
88 [NOT APPLICABLE]
98
[GO TO Q9]
99
[GO TO Q9]
M [MISSING]
Q8
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? Would
you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q9
In the last 6 months, did you contact this provider’s office with a medical question during
regular office hours? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q11]
88 [NOT APPLICABLE]
98
[GO TO Q11]
99
[GO TO Q11]
M [MISSING]

Centers for Medicare & Medicaid Services

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Q10
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?
Would you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q11
In the last 6 months, how often did this provider explain things in a way that was easy to
understand? Would you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q12
In the last 6 months, how often did this provider listen carefully to you? Would you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]

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Centers for Medicare & Medicaid Services

Q13
In the last 6 months, how often did this provider seem to know the important information
about your medical history? Would you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q14
In the last 6 months, how often did this provider show respect for what you had to say?
Would you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q15
In the last 6 months, how often did this provider spend enough time with you? Would
you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q16
In the last 6 months, did this provider order a blood test, x-ray, or other test for you?
(READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q18]
88 [NOT APPLICABLE]
98
[GO TO Q18]
99
[GO TO Q18]
M [MISSING]

Centers for Medicare & Medicaid Services

17

Q17
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?
Would you say:
(IF NEEDED: IF RESPONDENT SAYS “I GOT MY RESULTS ONLINE” OR “I GOT MY
RESULTS BY EMAIL” SAY: “Would you say “Never, Sometimes, Usually or Always?”
IF RESPONDENT IS UNABLE TO CHOOSE ONE OF THOSE OPTIONS, THEN CODE
AS DON’T KNOW)
1
2
3
4
88
98
99
M

Never,
Sometimes,
Usually, or
Always
[NOT APPLICABLE]

[MISSING]

Q18
In the last 6 months, did you and this provider talk about starting or stopping a
prescription medicine? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q20]
88 [NOT APPLICABLE]
98
[GO TO Q20]
99
[GO TO Q20]
M [MISSING]
Q19
When you and this provider talked about starting or stopping a prescription medicine,
did this provider ask what you thought was best for you? (READ ANSWER CHOICES
ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]

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Q20
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? (READ ANSWER
CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q21
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?
ENTER NUMBER:
[0-10 VALID RANGE]
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q22 Intro
These next questions ask about clerks and receptionists in this provider’s office.
Q22
In the last 6 months, how often were clerks and receptionists at this provider’s office as
helpful as you thought they should be? Would you say:
(IF NEEDED: “Please include all your care from [PROVIDER NAME] in the last six
months, whether in-person, by video, or by phone, as you answer these questions.”)
1
2
3
4
88
98
99
M

Never,
Sometimes,
Usually, or
Always
[NOT APPLICABLE]

[MISSING]

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19

Q23
In the last 6 months, how often did clerks and receptionists at this provider’s office treat
you with courtesy and respect? Would you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q24 Intro
These next questions ask about your care from specialists in the last 6 months.
Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and
other doctors who specialize in one area of health care.
Q24
Is [PROVIDER NAME] a specialist? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
[PROGRAMMING SPECIFICATIONS:
IF Q24 IS ASSIGNED ANSWER “1 – YES” THE INTERVIEWER MUST READ THE
FOLLOWING SENTENCE BEFORE Q25 “Please include this provider as you answer these questions about specialists.”]
Q25
In the last 6 months, did you try to make any appointments with specialists? (READ
ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q27 Intro]
98
[GO TO Q27 Intro]
99
[GO TO Q27 Intro]
M [MISSING]

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Centers for Medicare & Medicaid Services

Q26
In the last 6 months, how often was it easy to get appointments with specialists? Would
you say:
(IF NEEDED: “Please include all your care from specialists in the last six months,
whether in-person, by video, or by phone, as you answer these questions.”)
1
2
3
4
88
98
99
M

Never,
Sometimes,
Usually, or
Always
[NOT APPLICABLE]

[MISSING]

Q27 Intro
These next 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.
Q27
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? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q28
In the last 6 months, did you and anyone on your health care team talk about the
exercise or physical activity you get? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]

Centers for Medicare & Medicaid Services

21

Q29
In the last 6 months, did you take any prescription medicine? (READ ANSWER
CHOICES ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q32]
98
[GO TO Q32]
99
[GO TO Q32]
M [MISSING]
Q30
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? Would you say:
1
Never,
2
Sometimes,
3
Usually, or
4
Always
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q31
In the last 6 months, did you and anyone on your health care team talk about how much
your prescription medicines cost?
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q32
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? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES
2
NO
98
99
M [MISSING]

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Centers for Medicare & Medicaid Services

Q33
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? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q34 Intro
These next questions are about you and will help us to describe the people who
participate in this survey.
Q34
In general, how would you rate your overall health? Would you say:
1
Excellent,
2
Very good,
3
Good,
4
Fair, or
5
Poor
98
99
M [MISSING]
Q35
In general, how would you rate your overall mental or emotional health? Would you say:
1
Excellent,
2
Very good,
3
Good,
4
Fair, or
5
Poor
98
99
M [MISSING]

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23

Q36
In the last 12 months, have you seen a doctor or other health provider 3 or more times
for the same condition or problem? (READ ANSWER CHOICES ONLY IF NEEDED)
(IF NEEDED: “Please include all your care from doctors or other health providers in the
last 12 months, whether in-person, by video, or by phone, as you answer these
questions.”)
1
2
98
99
M

YES
NO

[MISSING]

[GO TO Q38]
[GO TO Q38]
[GO TO Q38]

Q37
Is this a condition or problem that has lasted for at least 3 months? (READ ANSWER
CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q38
Do you now need or take medicine prescribed by a doctor? (READ ANSWER
CHOICES ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q40]
98
[GO TO Q40]
99
[GO TO Q40]
M [MISSING]
Q39
Is this medicine to treat a condition that has lasted for at least 3 months? (READ
ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]

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Centers for Medicare & Medicaid Services

Q40a
In the last 6 months, were any of your visits for your own health care in-person? (READ
ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q40b
In the last 6 months, were any of your visits for your own health care by phone? (READ
ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q40c
In the last 6 months, were any of your visits for your own health care by video call?
(READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q41
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.? Would you say:
1
All of the time,
2
Most of the time,
3
Some of the time,
4
A little of the time, or
5
None of the time
98
99
M [MISSING]

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25

Q42
What is your age? (READ ANSWER CHOICES ONLY IF NEEDED)
1
18 to 24
2
25 to 34
3
35 to 44
4
45 to 54
5
55 to 64
6
65 to 69
7
70 to 74
8
75 to 79
9
80 to 84
10 85 or older
98
99
M [MISSING]
Q43
(INTERVIEWER: ASK ONLY IF NEEDED: Are you male or female?)
1
MALE
2
FEMALE
98
99
M [MISSING]
Q44
What is the highest grade or level of school that you have completed? (READ ANSWER
CHOICES ONLY IF NEEDED)
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
98
99
M [MISSING]
Q45
How well do you speak English? Would you say:
1
Very well,
2
Well,
3
Not well, or
4
Not at all
98
99
M [MISSING]

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Q46
Do you speak a language other than English at home? (READ ANSWER CHOICES
ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q48]
98
[GO TO Q48]
99
[GO TO Q48]
M [MISSING]
Q47
What is the language you speak at home? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
SPANISH
2
CHINESE
3
KOREAN
4
RUSSIAN
5
VIETNAMESE
6
SOME OTHER LANGUAGE [SPECIFY]
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q48
Are you deaf or do you have serious difficulty hearing? (READ ANSWER CHOICES
ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q49
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
(READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]

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27

Q50
Because of a physical, mental, or emotional condition, do you have serious difficulty
concentrating, remembering, or making decisions? (READ ANSWER CHOICES ONLY
IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q51
Do you have serious difficulty walking or climbing stairs? (READ ANSWER CHOICES
ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q52
Do you have difficulty dressing or bathing? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q53
Because of a physical, mental, or emotional condition, do you have difficulty doing
errands alone such as visiting a doctor’s office or shopping? (READ ANSWER
CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q54
Do you ever use the internet at home? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]

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Q55
Are you of Hispanic, Latino, or Spanish origin? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES, HISPANIC, LATINO, OR SPANISH
2
NO, NOT HISPANIC, LATINO, OR SPANISH
[GO TO Q57 Intro]
98
[GO TO Q57 Intro]
99
[GO TO Q57 Intro]
M [MISSING]
Q56
Which group best describes you? Would you say:
1
Mexican, Mexican American, Chicano,
2
Puerto Rican,
3
Cuban, or
4
Another Hispanic, Latino, or Spanish origin
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57 Intro
I am going to read a list of race categories. For each category, please say yes or no if it
describes your race. I must ask you about all categories in case more than one applies.
(IF THE RESPONDENT WANTS TO KNOW WHY YOU ARE ASKING WHAT RACE
THEY ARE, SAY: “We ask about your race for demographic purposes only.")
Q57a
Are you White? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q57b
(Are you) Black or African American? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
98
99
M [MISSING]

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29

Q57c
(Are you) American Indian or Alaskan Native? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES
2
NO
98
99
M [MISSING]
Q57d
(Are you) Asian? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
[GO TO Q57e]
98
[GO TO Q57e]
99
[GO TO Q57e]
M [MISSING]
Q57d1
(Are you) Asian Indian? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57d2
(Are you) Chinese? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57d3
(Are you) Filipino? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]

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Centers for Medicare & Medicaid Services

Q57d4
(Are you) Japanese? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57d5
(Are you) Korean? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57d6
(Are you) Vietnamese? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57d7
(Are you) another Asian race? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57e
(Are you) Native Hawaiian or Pacific Islander? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES
2
NO
[GO TO Q58]
98
[GO TO Q58]
99
[GO TO Q58]
M [MISSING]

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31

Q57e1
(Are you) Native Hawaiian? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57e2
(Are you) Guamanian or Chamorro? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57e3
(Are you) Samoan? (READ ANSWER CHOICES ONLY IF NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q57e4
(Are you) Other Pacific Islander? (READ ANSWER CHOICES ONLY IF
NEEDED)
1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]

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Q58

1
YES
2
NO
[GO TO END]
98
[GO TO END]
99
[GO TO END]
M [MISSING]
Q59a

1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q59b

1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q59c

1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
Q59d

1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]

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33

Q59e

1
YES
2
NO
88 [NOT APPLICABLE]
98
99
M [MISSING]
END. Those are all the questions I have for you. Thank you for your time and have a
nice day.

PRA Disclosure Statement
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: 01/31/2022). 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
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do not send applications, claims, payments, medical records or any documents containing sensitive
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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 QPP@cms.hhs.gov.

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Centers for Medicare & Medicaid Services