1. Our records show that you are now in {INSERT HEALTH PLAN NAME}. Is that right?
2. What is the name of your health plan?
3. In the last 12 months, did you have an illness, injury, or condition that needed care right away?
4. In the last 12 months, when you needed care right away, how often did you get care as soon as you needed?
5. In the last 12 months, did you make any in-person, phone, or video appointments for a check-up or routine care?
6. In the last 12 months, how often did you get an appointment for a check-up or routine care as soon as you needed?
7. In the last 12 months, not counting the times you went to an emergency room, how many times did you get health care for yourself in person, by phone, or by video?
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 12 months?
9. In the last 12 months, how often was it easy to get the care, tests, or treatment you needed?
10. A personal doctor is the one you would talk to if you need a check-up, want advice about a health problem, or get sick or hurt. Do you have a personal doctor?
11. In the last 12 months, how many times did you have an in-person, phone, or video visit with your personal doctor about your health?
12. In the last 12 months, how often did your personal doctor explain things in a way that was easy to understand?
13. In the last 12 months, how often did your personal doctor listen carefully to you?
14. In the last 12 months, how often did your personal doctor show respect for what you had to say?
15. In the last 12 months, how often did your personal doctor spend enough time with you?
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?
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 12 months, did you make any appointments with a specialist?
18. In the last 12 months, how often did you get an appointment with a specialist as soon as you needed?
19. How many specialists have you talked to in the last 12 months?
20. We want to know your rating of the specialist you talked to most often in the last 12 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?
21. In the last 12 months, did you get information or help from your health plan's customer service?
22. In the last 12 months, how often did your health plan's customer service give you the information or help you needed?
23. In the last 12 months, how often did your health plan's customer service staff treat you with courtesy and respect?
24. In the last 12 months, did your health plan give you any forms to fill out?
25. In the last 12 months, how often were the forms from your health plan easy to fill out?
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?
27. In general, how would you rate your overall health?
28. In general, how would you rate your overall mental or emotional health?
29. In the past 12 months, did you get health care 3 or more times for the same condition or problem?
30. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.
31. Do you now need or take medicine prescribed by a doctor? Do not include birth control.
32. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause.
33. What is your age?
34. Are you male or female?
35. What is the highest grade or level of school that you have completed?
36. Are you of Hispanic or Latino origin or descent?
37. What is your race? Mark one or more.
38. Did someone help you complete this survey?
39. How did that person help you? Mark one or more.
