CMS-10488 QHP Survey (English)

2024 Qualified Health Plan (QHP)
Enrollee Experience Survey
English

OMB No. 0938-1221: Approval Expires XX/XX/XXXX

2024 Qualified Health Plan (QHP)
Enrollee Experience Survey
Introduction
We are asking you to complete this survey about your experiences with [QHP ISSUER NAME]. Please
answer the questions in the survey based on your experience with the health plan you had from July
through December 2023.
Your Privacy is Protected. What you have to say is private and will only be used for this survey.
Your answers will be part of a pool of information. We will not share your name or answers with
anyone, except if required by law.
Your Participation is Voluntary. You do not have to answer any questions that you do not want to
answer. If you choose not to answer, it will not affect the benefits you get.
What To Do When You’re Done. Once you complete the survey, place it in the envelope that was
provided, seal the envelope, and return the envelope to [VENDOR ADDRESS].
What To Do If You Have Questions. [QHP ISSUER NAME] has contracted with [VENDOR
NAME] to conduct this survey. If you have any questions about the survey, call [VENDOR NAME]
toll free at (XXX) [XXX-XXXX] between [XX:XX] a.m. and [XX:XX] p.m. [VENDOR LOCAL
TIME], Monday through Friday (excluding federal holidays) or email [VENDOR EMAIL].

Survey Instructions
Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens, you will see
an arrow with a note that tells you what question to answer next, like this:
Yes
No

If No, go to #1

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this
information collection is 0938-1221; this control number is valid until XX/XX/XXXX. The time required to complete this
information collection is estimated to average 10 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 Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

5. In the last 6 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. Our records show that you are now in the health
plan named on the front page. Is that right?
1
2

If Yes, go to #3

Yes
No

1

2. What is the name of your health plan?

2
3

Please print:

4
99

6. In the last 6 months, how often did your health
plan’s customer service give you the
information or help you needed?

Your Health Plan

1

The next series of questions ask about your
experiences with your health plan. Please answer
the questions based on your experience with the
health plan you had from July through December
2023.

2
3
4
99

3. In the last 6 months, how often did written
materials or the internet provide the information
you needed about how your health plan works?
1
2
3
4
99

2
3
4
99

Never
Sometimes
Usually
Always
Not Applicable; did not contact my
health plan’s customer service for
information or help
If Not
Applicable, go to #9

7. 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
Not Applicable; did not look for any
information about my health plan

1
2
3
4

4. In the last 6 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 before you got it?
1

Never
Sometimes
Usually
Always
Not Applicable; did not look for any
information about how much I would
have to pay for prescription medicines

Never
Sometimes
Usually
Always

8. In the last 6 months, how often did the time that
you waited to talk to your health plan’s
customer service staff take longer than you
expected?

Never
Sometimes
Usually
Always
Not Applicable; did not look for any
information about how much I would
have to pay for services or equipment

1
2
3
4

2

Never
Sometimes
Usually
Always

14. In the last 6 months, how often did you have to
pay out of your own pocket for care that you
thought your health plan would pay for?

9. In the last 6 months, how often were the forms
from your health plan easy to fill out?
1
2
3
4
99

Never
Sometimes
Usually
Always
Not Applicable; health plan did not give
me forms to fill out
If Not
Applicable, go to #13

1
2
3
4

15. In the last 6 months, how often did you delay
visiting or not visit a doctor because you were
worried about the cost? Do not include dental
care.

10. In the last 6 months, how often did the health
plan explain the purpose of a form before you
filled it out?
1
2
3
4

1
2

Never
Sometimes
Usually
Always

3
4

2
3
4

1
2

Never
Sometimes
Usually
Always

3
4

2
3
4
99

1
2

Never
Sometimes
Usually
Always
Not Applicable; did not need forms in a
different format

3
4

2
3
4

Not at all confident
Slightly confident
Moderately confident
Very confident

18. How confident are you that you know most of
the things you need to know about using health
insurance?
1

13. In the last 6 months, how often did your health
plan not pay for care that your doctor said you
needed?
1

Never
Sometimes
Usually
Always

17. How confident are you that you understand
health insurance terms?

12. In the last 6 months, how often were the forms
that you had to fill out available in the format you
needed, such as large print or braille?
1

Never
Sometimes
Usually
Always

16. In the last 6 months, how often did you delay
filling or not fill a prescription because you
were worried about the cost?

11. In the last 6 months, how often were the forms
that you had to fill out available in the language
you prefer?
1

Never
Sometimes
Usually
Always

2
3
4

Never
Sometimes
Usually
Always

3

Not at all confident
Slightly confident
Moderately confident
Very confident

19. 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 in the last 6 months?

21. In the last 6 months, when you needed care
right away, in an emergency room, doctor’s
office, or clinic, how often did you get care as
soon as you needed? Include in-person,
telephone, or video appointments.

0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible

1
2
3
4
99

22. 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? Include in-person, telephone, or video
appointments.

Your Health Care in the Last 6 Months

1
2
3

These questions ask about your own health care.
This includes care you got in a clinic, emergency
room, doctor’s office, by telephone, or by video
appointments. Do not include care you got when
you stayed overnight in a hospital. Do not include
the times you went for dental care visits. Please
answer the questions based on your experience with
the health plan you had from July through
December 2023.

4
99

2
3
99

Never
Sometimes
Usually
Always
Not Applicable; did not make any
appointments

23. 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? Include in-person,
telephone, or video appointments.

20. In the last 6 months, did your personal doctor
offer telephone or video appointments, so that
you did not need to physically visit their office
or facility?
1

Never
Sometimes
Usually
Always
Not Applicable; did not need care right
away

None
If None, go to #27
1 time
2
3
4
5 to 9 times
10 or more times

Yes
No
Don’t know
Not Applicable; do not have a personal
doctor

24. In the last 6 months, how often was it easy to
get the care, tests, or treatment you needed?
Include in-person, telephone, or video
appointments.
1
2
3
4

4

Never
Sometimes
Usually
Always

27. In the last 6 months, how many times did you
visit your personal doctor to get care for
yourself? Include in-person, telephone, or video
appointments.

25. An interpreter is someone who helps you talk
with others who do not speak your language. In
the last 6 months, when you needed an
interpreter at your doctor’s office or clinic, how
often did you get one? Include in-person,
telephone, or video appointments.
1
2
3
4
99

None
If None, go to #40
1 time
2
3
4
5 to 9 times
10 or more times
Not Applicable; do not have a personal
doctor
If Not Applicable, go to #40

Never
Sometimes
Usually
Always
Not Applicable; did not need an
interpreter

26. 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? Include in-person, telephone, or video
appointments.

28. In the last 6 months, how often did your
personal doctor explain things in a way that was
easy to understand?
1
2

0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible

3
4

Never
Sometimes
Usually
Always

29. In the last 6 months, how often did your
personal doctor listen carefully to you?
1
2
3
4

Never
Sometimes
Usually
Always

30. In the last 6 months, how often did your
personal doctor show respect for what you had
to say?

Your Personal Doctor

1
2

These questions ask about your personal doctor. A
personal doctor is the one you would see or talk to
if you need a check-up, want advice about a health
problem, or get sick or hurt. Please answer the
questions based on your experience with the health
plan you had from July through December 2023.

3
4

Never
Sometimes
Usually
Always

31. In the last 6 months, how often did your
personal doctor spend enough time with you?
1
2
3
4

5

Never
Sometimes
Usually
Always

36. In the last 6 months, did you get care from more
than one kind of health care provider or use
more than one kind of health care service?
Include in-person, telephone, or video
appointments.

32. When you visited your personal doctor for a
scheduled appointment in the last 6 months, how
often did he or she have your medical records or
other information about your care? Include inperson, telephone, or video appointments.
1
2
3
4

1

Never
Sometimes
Usually
Always

2

2
3
4
99

1
2

2
3
4

1
2
3
4

2
3
4
99

If No, go to #39

Never
Sometimes
Usually
Always

39. 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?

Never
Sometimes
Usually
Always

0 Worst personal doctor possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor possible

35. In the last 6 months, how often did you and your
personal doctor talk about all the prescription
medicines you were taking?
1

Yes
No

38. In the last 6 months, how often did you get the
help that you needed from your personal
doctor’s office to manage your care among these
different providers and services?

Never
Sometimes
Usually
Always
Not Applicable; did not have a blood test,
x-ray, or other test
If Not
Applicable, go to #35

34. In the last 6 months, when your personal doctor
ordered a blood test, x-ray, or other test for you,
how often did you get those results as soon as
you needed them?
1

If No, go to #39

37. In the last 6 months, did you need help from
anyone in your personal doctor’s office to
manage your care among these different
providers and services?

33. In the last 6 months, when your personal doctor
ordered a blood test, x-ray, or other test for you,
how often did someone from your personal
doctor’s office follow up to give you those
results?
1

Yes
No

Never
Sometimes
Usually
Always
Not Applicable; did not take any
prescription medicines

6

43. 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?

Getting Health Care from Specialists
Specialists are doctors like surgeons, heart doctors,
allergy doctors, skin doctors, and other doctors who
specialize in one area of health care.
When you answer the next questions, include care
you got in a clinic, emergency room, doctor’s
office, by telephone, or by video appointments. Do
not include dental visits or care you got when you
stayed overnight in a hospital.

0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible

40. In the last 6 months, how often did you get an
appointment to see a specialist as soon as you
needed? Include in-person, telephone, or video
appointments.
1
2
3
4
99

Never
Sometimes
Usually
Always
Not Applicable; I did not need to see a
specialist
If Not Applicable,
go to #44

About You
44. In general, how would you rate your overall
health?

41. How many specialists have you seen in the last
6 months? Include in-person, telephone, or
video appointments.

1
2
3

None
If None, go to #44
1 specialist
2
3
4
5 or more specialists

4
5

45. In general, how would you rate your overall
mental or emotional health?
1
2

42. In the last 6 months, how often did your
personal doctor seem informed and up-to-date
about the care you got from specialists?
1
2
3
4
99

Excellent
Very good
Good
Fair
Poor

3
4
5

Never
Sometimes
Usually
Always
Not Applicable; I do not have a personal
doctor

Excellent
Very good
Good
Fair
Poor

46. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
1
2
3
4

7

Every day
Some days
Not at all
Don’t know
go to #50

If Not at all, go to #50
If Don’t know,

47. In the last 6 months, how often were you
advised to quit smoking or using tobacco by a
doctor or other health provider in your plan?
1
2
3
4

52. Do you now need or take medicine prescribed
by a doctor? Do not include birth control.
1

Never
Sometimes
Usually
Always

2

2
3
4

1
2

2
3
4

1

Never
Sometimes
Usually
Always

2

1
2

2

1
2

2

Yes
No

57. Do you have serious difficulty walking or
climbing stairs?
1
2

Yes
No

58. Because of a physical, mental, or emotional
condition, do you have difficulty dressing or
bathing?

If No, go to #52

1

51. Is this a condition or problem that has lasted for
at least 3 months? Do not include pregnancy or
menopause.
1

Yes
No

56. Because of a physical, mental, or emotional
condition, do you have serious difficulty
concentrating, remembering, or making
decisions?

Never
Sometimes
Usually
Always

Yes
No

Yes
No

55. Are you blind or do you have serious difficulty
seeing, even when wearing glasses?

50. In the past 6 months, did you get health care 3
or more times for the same condition or
problem?
1

Yes
No

54. Are you deaf or do you have serious difficulty
hearing?

49. In the last 6 months, how often did your doctor
or health provider discuss or provide methods
and strategies other than medication to assist
you with quitting smoking or using tobacco?
Examples of methods and strategies are:
telephone helpline, individual or group
counseling, or cessation program.
1

If No, go to #54

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

48. In the last 6 months, how often was medication
recommended or discussed by a doctor or health
provider to assist you with quitting smoking or
using tobacco? Examples of medication are:
nicotine gum, patch, nasal spray, inhaler, or
prescription medication.
1

Yes
No

2

Yes
No

59. Because of a physical, mental, or emotional
condition, do you have difficulty doing errands
alone such as visiting a doctor’s office or
shopping?

Yes
No

1
2

8

Yes
No

60. What is your age?
1
2
3
4
5
6
7

64. Are you of Hispanic, Latino/a, or Spanish
origin? Mark one or more.

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

1

2

3
4
5

61. What is your sex?
1
2

Male
Female

65. What is your race? Mark one or more.
1

62. What is the highest grade or level of school that
you have completed?
1
2
3
4
5
6

2
3
4

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

5
6
7
8
9
10

63. What best describes your employment status?
Mark only ONE.
1
2
3
4
5
6
7
8

No, not of Hispanic, Latino/a, or Spanish
origin
Yes, Mexican, Mexican American, or
Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or
Spanish origin

11
12

Employed full-time
Employed part-time
A homemaker
A full-time student
Retired
Unable to work for health reasons
Unemployed
Other

13
14

American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Black or African American
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
White

66. Did someone help you complete this survey?
1
2

Yes
No
Thank you. Please return the
completed survey in the postage-paid
envelope.

67. How did that person help you? Mark one or
more.
1
2
3
4

5

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.
Please return the completed survey in the postage-paid envelope.
9

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1. Call us:
• For Medicare: 1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
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Centers for Medicare & Medicaid Services Offices of Hearings and Inquiries (OHI)
7500 Security Boulevard, Mail Stop DO-01-20 Baltimore, MD 21244-1850
Attn: Customer Accessibility Resource Staff (CARS)
Your request should include your name, phone number, type of information you need (if known), and the
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10