CAHPS Health Plan Survey Version Adult Medicaid Survey 5.0
1. Our records show that you are now in {INSERT HEALTH PLAN NAME}. Is that right?
Yes (If you choose "Yes", you will be directed to question #3)
No
2. What is the name of your health plan?
Please print
Your Health Care in the Last 6 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 6 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?
Yes
No (If you choose "No", you will be directed to question #5)
4. In the last 6 months, when you needed care right away, how often did you get care as soon as you needed?
Never
Sometimes
Usually
Always
5. In the last 6 months, did you make any appointments for a check-up or routine care at a doctor’s office or clinic?
Yes
No (If you choose "No", you will be directed to question #7)
6. In the last 6 months, how often did you get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed?
Never
Sometimes
Usually
Always
7. In the last 6 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?
None (If you choose "None", you will be directed to question #10)
1 time
2
3
4
5 to 9
10 or more times
8. 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 6 months?
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible
9. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed?
Never
Sometimes
Usually
Always
Your Personal Doctor
10. 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?
Yes
No (If you choose "No", you will be directed to question #17)
11. In the last 6 months, how many times did you visit your personal doctor to get care for yourself?
None (If you choose "None", you will be directed to question #16)
1 time
2
3
4
5 to 9
10 or more times
12. In the last 6 months, how often did your personal doctor explain things in a way that was easy to understand?
Never
Sometimes
Usually
Always
13. In the last 6 months, how often did your personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
14. In the last 6 months, how often did your personal doctor show respect for what you had to say?
Never
Sometimes
Usually
Always
15. In the last 6 months, how often did your personal doctor spend enough time with you?
Never
Sometimes
Usually
Always
16. 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?
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care 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.
17. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, did you make any appointments to see a specialist?
Yes
No (If you choose "No", you will be directed to question #21)
18. In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed?
Never
Sometimes
Usually
Always
19. How many specialists have you seen in the last 6 months?
None (If you choose "None", you will be directed to question #21)
1 specialst
2
3
4
5 or more specialists
20. We want to know your rating of the specialist you saw most often in the last 6 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?
0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible
Your Health Plan
The next questions ask about your experience with your health plan.
21. In the last 6 months, did you get information or help from your health plan’s customer service?
Yes
No (If you choose "No", you will be directed to question #24)
22. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed?
Never
Sometimes
Usually
Always
23. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect?
Never
Sometimes
Usually
Always
24. In the last 6 months, did your health plan give you any forms to fill out?
Yes
No (If you choose "No", you will be directed to question #26)
25. In the last 6 months, how often were the forms from your health plan easy to fill out?
Never
Sometimes
Usually
Always
26. 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?
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible
About You
27. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
28. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
29. In the past 6 months, did you get health care 3 or more times for the same condition or problem?
Yes
No (If you choose "No", you will be directed to question #31)
30. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.
Yes
No
31. Do you now need or take medicine prescribed by a doctor? Do not include birth control.
Yes
No (If you choose "No", you will be directed to question #33)
32. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause.
Yes
No
33. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
34. Are you male or female?
Male
Female
35. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
36. Are you Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
37. What is your race? Mark one or more.
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
38. Did someone help you complete this survey?
Yes (If you choose "Yes", you will be directed to question #39)
No
39. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Thank you.
Submit
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