|
BOX_00A
THE SP SECTION IS ASKED IN ROUNDS 2 AND 4 ONLY. IF
IT IS ROUND 1, 3, OR 5, CONTINUE TO THE NEXT
SECTION.
BOX_00
CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME, ESTB.ESTBNAME
PRIVATE INSURANCE AND MEDIGAP SERIES
BOX_01
IF THERE IS AT LEAST ONE ESTABLISHMENT-PERSON-
INSURER-TRIPLE WHERE THE ESTABLISHMENT IS PRIVATE
AND THE INSURER IS FLAGGED AS PROVIDING ‘HOSPITAL
AND PHYSICIAN BENEFITS’ OR IS FLAGGED AS PROVIDING
‘MEDICARE SUPPLEMENT/MEDIGAP BENEFITS’, CONTINUE
WITH LOOP_01
OTHERWISE, GO TO BOX_02
LOOP_01
FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER, ASK NAV_SP01A-END_LP01
LOOP DEFINITION: LOOP_01 COLLECTS SATISFACTION
INFORMATION ON ALL PRIVATE HEALTH INSURANCE PLANS
CURRENTLY HELD BY THE RU THAT PROVIDE HOSPITAL AND
PHYSICIAN BENEFITS OR MEDIGAP BENEFITS. THIS LOOP
CYCLES ON TRIPLES THAT MEET THE FOLLOWING
CONDITIONS:
- ESTABLISHMENT IS PROVIDER OF PRIVATE INSURANCE
WHICH PROVIDES HOSPITAL/PHYSICIAN BENEFITS OR
MEDICARE SUPPLEMENT OR MEDIGAP
AND
- PERSON IS A CURRENT RU MEMBER WHO IS THE
POLICYHOLDER OF THE PRIVATE HEALTH INSURANCE
OBTAINED THROUGH THIS ESTABLISHMENT
AND
- INSURER IS THE SOURCE OF THE BENEFITS PROVIDED
TO PERSON THROUGH THE ESTABLISHMENT (I.E., THE
INSURANCE COMPANY, HMO OR SELF-INSURED COMPANY)
AND IS FLAGGED AS ‘SUPPLYING HOSPITAL/PHYSICIAN
BENEFITS’ OR ‘SUPPLYING MEDICARE SUPPLEMENT/
MEDIGAP BENEFITS’
AND
- PERSON IS CURRENTLY INSURED BY THIS TRIPLE
NOTE: PRIVATE INSURANCE IS DEFINED AS:
- ESTABLISHMENTS FLAGGED AS ‘EMPLOYER’ AND
FLAGGED AS ‘PROVIDES HEALTH INSURANCE’
(ESTABLISHMENTS FLAGGED AS ‘SELF-EMPLOYED’ WITH
A FIRM-SIZE-1 ARE TREATED AS DIRECT PURCHASED,
SEE NOTE BELOW)
- DIRECT PURCHASED INSURANCE, THAT IS,
ESTABLISHMENTS CREATED FROM THE HX23 SERIES
NOTE: HELD ON THE DATE OF THE CURRENT ROUND’S
INTERVIEW DATE:
- FOR PRIVATE SOURCES -- POLICYHOLDER HELD
INSURANCE AT THE TIME OF THE CURRENT ROUND’S
INTERVIEW DATE [HQ01 IS CODED ‘1’ (WHOLE TIME)
OR HQ02 IS CODED ‘1’ (YES, COVERED NOW) FOR THE
POLICYHOLDER] OR [OE01 OR OE12 OR OE26 IS CODED
‘1’ (YES) FOR THE PLAN]
- FOR PRIVATE SOURCES WHERE POLICYHOLDER IS
DECEASED OR THE POLICYHOLDER WAS ORIGINALLY
SELECTED AS ‘POLICYHOLDER NOT IN RU/DU’ -- AT
LEAST ONE DEPENDENT (SELECTED AT HP16) IS
COVERED BY THE INSURANCE AT THE TIME OF THE
CURRENT ROUND’S INTERVIEW DATE [HQ01 IS CODED
‘1’(WHOLE TIME) OR HQ02 IS CODED ‘1’ (YES,
COVERED NOW FOR THE COVERED PERSON] OR [OE01 OR
OE12 OR OE26 IS CODED ‘1’ (YES)] FOR THE PLAN
NOTE: ESTABLISHMENTS WHICH ARE EMPLOYERS AND
PROVIDE HEALTH INSURANCE AND ARE FLAGGED AS
‘SELF-EMPLOYED’ WITH A FIRM-SIZE=1 ARE TREATED AS
DIRECT PURCHASED INSURANCE, THAT IS, LOOP_01 WILL
CYCLE ON THE ESTABLISHMENT PROVIDING THE
INSURANCE, (I.E., CREATED FROM THE HX03 SERIES)
NOT THE EMPLOYER.
NOTE: ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW)
RESPONSES AT ANY QUESTION LISTED ABOVE DOES NOT
MEET THE CRITERIA.
NAVIGATOR DETAILS: LOOP_01 USES BOTH NAV_SP01A
AND NAV_SP01B TO CONTROL THE FLOW OF THE LOOP.
NAV_SP01A
SERIES: Experience with all of the RU Member’s Private
Health
Insurance Coverage (i.e., happy with provider choices,
ever call
customer service, overall rating of plan)
USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.
WHEN ALL LINKS ARE MARKED "DONE," USE [Continue
Interview] TO GO
PAST THIS SERIES.
IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS
BEFORE THIS
SERIES.
Policyholder
[1. Policyholder’s Name-30] [Status-25]
[2. Policyholder’s Name-30] [Status-25]
[3. Policyholder’s Name-30] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: POLICYHOLDER
INSTRUCTIONS: DISPLAY POLICYHOLDER’S FIRST,
MIDDLE, AND LAST NAMES
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH POLICYHOLDER EACH TIME THE
NAVIGATOR IS PRESENTED
ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER FOR SELECTION.
ROSTER BEHAVIOR:
1. SELECT ALLOWED.
2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.
ROSTER FILTER:
DISPLAY ALL POLICYHOLDERS WHO MEET THE CONDITIONS
STATED AT THE LOOP_01 DEFINITION.
CONTINUE WITH NAV_SP01B FOR SELECTED POLICYHOLDER
NAV_SP01B
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
SERIES: Experience with Private Health Insurance
Coverage
(i.e., happy with provider choices, ever call customer
service,
overall rating of plan)
USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.
WHEN ALL LINKS ARE MARKED "DONE," USE [Continue
Interview] TO GO
PAST THIS SERIES.
IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS
BEFORE THIS
SERIES.
Policyholder...Plan Name
[1. Person’s Name-65]...[Insurer Name-30] [Status-25]
[2. Person’s Name-65]...[Insurer Name-30] [Status-25]
[3. Person’s Name-65]...[Insurer Name-30] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: POLICYHOLDER...PLAN NAME
INSTRUCTIONS: DISPLAY RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-PAIR
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH PAIR EACH TIME THE NAVIGATOR
IS PRESENTED
ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER FOR SELECTION.
ROSTER BEHAVIOR:
1. SELECT ALLOWED.
2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.
ROSTER FILTER:
DISPLAY ALL INSURERS THAT MEET THE CONDITIONS
STATED AT THE LOOP_01 DEFINITION.
CONTINUE WITH SP01 FOR SELECTED PAIR
SP01
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
We are going to ask you to rate
{your/{POLICYHOLDER}’s} (and other
family members’) experience(s) with {NAME OF INSURER
BEING LOOPED ON},
that is, {your/his/her} {hospital and
physician/Medicare Supplement or
Medigap} coverage through {ESTABLISHMENT}
In answering these questions, please think about your
experiences
over the last 12 months.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY ‘hospital and physician’ IF THIS INSURER
IS FLAGGED AS PROVIDING HOSPITAL AND PHYSICIAN
BENEFITS (BUT NOT MEDICARE SUPPLEMENT OR MEDIGAP
BENEFITS). DISPLAY ‘Medicare Supplement or
Medigap’ IF THIS INSURER IS FLAGGED AS PROVIDING
MEDICARE SUPPLEMENT/MEDIGAP BENEFITS OR MEDICARE
SUPPLEMENT/MEDIGAP BENEFITS AND HOSPITAL AND
PHYSICIAN BENEFITS.
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND’S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
SP02
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-1.
Since {you/{POLICYHOLDER}} (and the family) joined
{NAME OF INSURER
BEING LOOPED ON}, how much of a problem, if any, was
it to
get a personal doctor or nurse {you/he/she} (and the
family)
{are/is} happy with?
Would you say ...
a big problem, ......................... 1 {SP03}
a small problem, or .................... 2 {SP03}
not a problem? ......................... 3 {SP03}
IF VOLUNTEERED: DON’T HAVE A PERSONAL
DOCTOR OR NURSE ..................... 95 {SP03}
REF ................................... -7 {SP03}
DK .................................... -8 {SP03}
[Code One]
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND’S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 7
SP03
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
In the last 12 months, did {you/{POLICYHOLDER}} (or
anyone in the
family) need approval from {NAME OF INSURER BEING
LOOPED ON}
for any care, tests, or treatment?
YES .................................... 1 {SP04}
NO ..................................... 2 {SP05}
REF ................................... -7 {SP05}
DK .................................... -8 {SP05}
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND'S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 23
SP04
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
were delays
in health care while {you/{POLICYHOLDER}} (or anyone
in the family)
waited for approval from {NAME OF INSURER BEING LOOPED
ON}?
Would you say ...
a big problem, ......................... 1 {SP05}
a small problem, or .................... 2 {SP05}
not a problem? ......................... 3 {SP05}
IF VOLUNTEERED: NO VISITS IN LAST
12 MONTHS ........................... 95 {SP05}
REF ................................... -7 {SP05}
DK .................................... -8 {SP05}
[Code One]
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND'S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 24
SP05
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
In the last 12 months, did {you/{POLICYHOLDER}} (or
anyone in the
family) look for any information about how
{NAME OF INSURER
BEING LOOPED ON} works in written material or on
the Internet?
YES .................................... 1 {SP06}
NO ..................................... 2 {SP07}
REF ................................... -7 {SP07}
DK .................................... -8 {SP07}
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND'S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 33
SP06
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
PLAN NAME: {NAME OF INSURER BEING LOOPED ON}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
was it to
find or understand this information?
Would you say ...
a big problem, ......................... 1 {SP07}
a small problem, or .................... 2 {SP07}
not a problem? ......................... 3 {SP07}
REF ................................... -7 {SP07}
DK .................................... -8 {SP07}
[Code One]
DISPLAY THE NAME OF THIS POLICYHOLDER'S CURRENT
ROUND'S PRIVATE OR MEDIGAP INSURER FOR PLAN NAME.
THAT IS, DISPLAY THE NAME OF THE PLAN (PROVIDING
MEDICARE SUPPLEMENT / MEDIGAP BENEFITS OR
HOSPITAL/PHYSICIAN BENEFITS) ENTERED AT HX49,
HX51, OE11, OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 34
SP07
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
In the last 12 months, did {you/{POLICYHOLDER}} (or
anyone in the
family) call {NAME OF INSURER BEING LOOPED ON}’s customer
service to get information or help?
YES .................................... 1 {SP08}
NO ..................................... 2 {SP09}
REF ................................... -7 {SP09}
DK .................................... -8 {SP09}
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND'S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 35
SP08
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
was it to
get the help {you/{POLICYHOLDER}} (or anyone in the
family) needed when
{you/he/she} called {NAME OF INSURER BEING LOOPED
ON}’s customer
service?
Would you say ...
a big problem, ......................... 1 {SP09}
a small problem, or .................... 2 {SP09}
not a problem? ......................... 3 {SP09}
REF ................................... -7 {SP09}
DK .................................... -8 {SP09}
[Code One]
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND'S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 36
SP09
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
In the last 12 months, did {you/{POLICYHOLDER}} (or
anyone in the
family) have to fill out any paperwork for {NAME OF
INSURER
BEING LOOPED ON}?
YES .................................... 1 {SP10}
NO ..................................... 2 {SP11}
REF ................................... -7 {SP11}
DK .................................... -8 {SP11}
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND'S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 37
SP10
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
did
{you/{POLICYHOLDER}} (or anyone in the family) have
with paperwork
for {NAME OF INSURER BEING LOOPED ON}?
Would you say ...
a big problem, ......................... 1 {SP11}
a small problem, or .................... 2 {SP11}
not a problem? ......................... 3 {SP11}
REF ................................... -7 {SP11}
DK .................................... -8 {SP11}
[Code One]
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND'S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
NOTE: CAHPS 3.0 ADULT CORE ITEM 38
SP11
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-2.
We want to know your rating of all
{your/{POLICYHOLDER}’s} (and the
family’s) experience with {NAME OF INSURER BEING
LOOPED ON}.
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 {NAME OF INSURER BEING LOOPED
ON}?
ENTER RATING FROM 0-10:
[Enter Small Number] ...................
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}
FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND'S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.
HARD CHECK: ACCEPTABLE RANGE FOR THIS RESPONSE IS
0-10.
NOTE: CAHPS 3.0 ADULT CORE ITEM 39
END_LP01
CYCLE ON NEXT TRIPLE ON RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION
IF NO MORE TRIPLES MEET THE STATED CONDITIONS,
END LOOP_01 AND CONTINUE WITH BOX_02
MEDICARE MANAGED CARE SERIES
BOX_02
IF THERE IS AT LEAST ONE ESTABLISHMENT-PERSON PAIR
WHERE THE ESTABLISHMENT IS MEDICARE AND THE
MEDICARE BENEFITS ARE THROUGH A MANAGED CARE PLAN,
CONTINUE WITH LOOP_02
OTHERWISE, GO TO BOX_03
LOOP_02
FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS ROSTER, ASK SP12-END_LP02
LOOP DEFINITION: LOOP_02 COLLECTS SATISFACTION
INFORMATION ON ALL PERSONS WITH MEDICARE MANAGED
CARE PLANS. THIS LOOP CYCLES ON PAIRS THAT MEET
THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS MEDICARE
AND
- MEDICARE COVERAGE IS THROUGH A MANAGED CARE PLAN
AND
- PERSON IS CURRENTLY COVERED BY THE MEDICARE
MANAGED CARE PLAN
NOTE: MEDICARE MANAGED CARE COVERAGE IS DEFINED
AS:
- IF MEDICARE CREATED IN CURRENT ROUND, THEN HX31
OR HX32 OR HX32A IS CODED ‘1’ (YES)
- IF MEDICARE CREATED IN A PREVIOUS ROUND AND
THERE HAS BEEN NO CHANGE IN MEDICARE COVERAGE
(PR01 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’
(DON’T KNOW)), THEN HX31 OR HX32 OR HX32A WAS
CODED ‘1’ (YES) WHEN THE INSURANCE WAS CREATED
OR PR02 OR PR03 OR PR03A WAS CODED ‘1’ (YES) IN
A PREVIOUS ROUND
- IF MEDICARE CREATED IN A PREVIOUS ROUND AND
THERE HAS BEEN A CHANGE IN MEDICARE COVERAGE
(PR01 IS CODED ‘1’ (YES)), THEN PR02 OR PR03 OR
PR03A IS CODED ‘1’ (YES) DURING THE CURRENT
ROUND
SP12
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
The next questions ask about {your/{PERSON}’s}
experience with {NAME
OF CURRENT ROUND MEDICARE MANAGED CARE PLAN}, that is,
{your/his/her}
coverage through Medicare.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
FOR ‘NAME OF CURRENT ROUND MEDICARE MANAGED CARE
PLAN’, DISPLAY THE NAME OF THIS PERSON’S CURRENT
ROUND’S MEDICARE INSURER. THAT IS, DISPLAY THE
NAME OF THE PLAN SELECTED AT HX31OV OR ENTERED AT
HX33 (IF MEDICARE CREATED THIS ROUND OR IF
UNCHANGED FROM A PREVIOUS ROUND) OR THE PLAN
SELECTED AT PR02OV OR ENTERED AT PR04 (IF
MEDICARE CREATED IN A PREVIOUS ROUND AND COVERAGE
HAS CHANGED OR IT IS THE MOST RECENT INSURER
ENTERED).
SP13
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-1.
Since {you/{PERSON}} joined {NAME OF CURRENT ROUND
MEDICARE MANAGED
CARE PLAN}, that is, {your/his/her} coverage through
Medicare, how
much of a problem, if any, was it to get a personal
doctor or
nurse {you/he/she} {are/is} happy with?
Would you say ...
a big problem, ......................... 1 {SP14}
a small problem, or .................... 2 {SP14}
not a problem? ......................... 3 {SP14}
IF VOLUNTEERED: DON’T HAVE A PERSONAL
DOCTOR OR NURSE ..................... 95 {SP14}
REF ................................... -7 {SP14}
DK .................................... -8 {SP14}
[Code One]
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 7
SP14
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
In the last 12 months, did {you/{PERSON}} need
approval from
{NAME OF CURRENT ROUND MEDICARE MANAGED CARE PLAN},
that is,
{your/his/her} coverage through Medicare, for any
care, tests or
treatment?
YES .................................... 1 {SP15}
NO ..................................... 2 {SP16}
REF ................................... -7 {SP16}
DK .................................... -8 {SP16}
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 23
SP15
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
were delays
in health care while {you/{PERSON}} waited for
approval from {NAME OF
CURRENT ROUND MEDICARE MANAGED CARE PLAN}, that is,
{your/his/her}
coverage through Medicare?
Would you say ...
a big problem, ......................... 1 {SP16}
a small problem, or .................... 2 {SP16}
not a problem? ......................... 3 {SP16}
IF VOLUNTEERED: NO VISITS IN LAST
12 MONTHS ........................... 95 {SP16}
REF ................................... -7 {SP16}
DK .................................... -8 {SP16}
[Code One]
SEE FILL SPECIFICATIONS FOR SP12
SP16
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
In the last 12 months, did {you/{PERSON}} look for any information
about how {NAME OF CURRENT ROUND MEDICARE MANAGED CARE PLAN},
that is, {your/his/her} coverage through Medicare, works in written
material or on the Internet?
YES .................................... 1 {SP17}
NO ..................................... 2 {SP18}
REF ................................... -7 {SP18}
DK .................................... -8 {SP18}
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 33
SP17
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
PLAN NAME: {NAME OF CURRENT ROUND MEDICARE MANAGED
CARE PLAN}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
was it to
find or understand this information?
Would you say ...
a big problem, ......................... 1 {SP18}
a small problem, or .................... 2 {SP18}
not a problem? ......................... 3 {SP18}
REF ................................... -7 {SP18}
DK .................................... -8 {SP18}
[Code One]
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 34
SP18
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
In the last 12 months, did {you/{PERSON}} call {NAME
OF CURRENT ROUND
MEDICARE MANAGED CARE PLAN}’s, that is, {your/his/her}
coverage through
Medicare, customer service to get information
or help?
YES .................................... 1 {SP19}
NO ..................................... 2 {SP20}
REF ................................... -7 {SP20}
DK .................................... -8 {SP20}
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 35
SP19
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
was it to
get the help {you/{PERSON}} needed when {you/he/she}
called {NAME OF
CURRENT ROUND MEDICARE MANAGED CARE PLAN}’s, that is,
{your/his/her}
coverage through Medicare, customer service?
Would you say ...
a big problem, ......................... 1 {SP20}
a small problem, or .................... 2 {SP20}
not a problem? ......................... 3 {SP20}
REF ................................... -7 {SP20}
DK .................................... -8 {SP20}
[Code One]
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 36
SP20
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
In the last 12 months, did {you/{PERSON}} have to fill
out any
paperwork for {NAME OF CURRENT ROUND MEDICARE MANAGED
CARE PLAN},
that is, {your/his/her} coverage through Medicare?
YES .................................... 1 {SP21}
NO ..................................... 2 {SP22}
REF ................................... -7 {SP22}
DK .................................... -8 {SP22}
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 37
SP21
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
did
{you/{PERSON}} have with paperwork for {NAME OF
CURRENT ROUND MEDICARE
MANAGED CARE PLAN}, that is, {your/his/her} coverage
through Medicare?
Would you say ...
a big problem, ......................... 1 {SP22}
a small problem, or .................... 2 {SP22}
not a problem? ......................... 3 {SP22}
REF ................................... -7 {SP22}
DK .................................... -8 {SP22}
[Code One]
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 38
SP22
{PERSON FIRST MIDDLE LAST NAME......} {NAME OF
ESTABLISHMENT.........}
SHOW CARD SP-2.
We want to know your rating of all {your/{PERSON}’s}
experience with
{NAME OF CURRENT ROUND MEDICARE MANAGED CARE PLAN}, that is,
{your/his/her} coverage through Medicare.
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 {NAME OF CURRENT ROUND MEDICARE
MANAGED
CARE PLAN}?
ENTER RATING FROM 0-10:
[Enter Small Number] ...................
REF ................................... -7
DK .................................... -8
HARD CHECK: ACCEPTABLE RANGE FOR THIS RESPONSE IS
0-10
SEE FILL SPECIFICATIONS FOR SP12
NOTE: CAHPS 3.0 ADULT CORE ITEM 39
END_LP02
CYCLE ON NEXT PAIR ON THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION
IF NO MORE PAIRS MEET THE STATED CONDITIONS, END
LOOP_02 AND CONTINUE WITH BOX_03
MEDICAID/SCHIP AND HOSPITAL/PHYSICIAN SERIES
BOX_03
IF AT LEAST ONE CURRENT RU MEMBER IS COVERED BY
MEDICAID/SCHIP OR GOVT-HOSPITAL/PHYSICIAN DURING
THE CURRENT ROUND, CONTINUE WITH SP23
OTHERWISE, GO TO BOX_04
SP23
{NAME OF ESTABLISHMENT.........}
The next questions ask about the family’s experience
with
{{NAME OF CURRENT ROUND MEDICAID/SCHIP/GOVT-H/P
INSURER}, that is,
their coverage through} {{Medicaid/{STATE NAME FOR
MEDICAID}} or
{STATE CHIP NAME}/the program sponsored by a state or
local
government agency which provides hospital and
physician benefits}.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY ‘{NAME OF CURRENT ... through’ IF THERE IS
AN INSURER ASSOCIATED WITH THE FAMILY’S MEDICAID/
SCHIP OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE DURING
THE CURRENT ROUND. OTHERWISE, USE A NULL DISPLAY.
FOR ‘NAME OF ... INSURER’, DISPLAY THE NAME OF THE
CURRENT ROUND’S INSURER FOR THE FAMILY’S MEDICAID\
SCHIP OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE.
DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}/or
{STATE CHIP NAME}}’ IF FAMILY HAS MEDICAID/SCHIP.
OTHERWISE, DISPLAY ‘the program ... benefits’.
DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL
STATE NAME FOR PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
DISPLAY ‘or STATE CHIP NAME’ (SUBSTITUTING THE
REAL STATE NAME FOR PROGRAM). FOR THE SPECIFIC
NAME TO USE BY STATE, SEE BOX ON HX06.
SP24
{NAME OF ESTABLISHMENT.........}
SHOW CARD SP-1.
Since the family joined {{NAME OF CURRENT ROUND
MEDICAID/SCHIP/
GOVT-H/P INSURER}/the coverage through}
{{Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME}} {the program
sponsored by a
state or local government agency which provides
hospital and physician
benefits}, how much of a problem, if any, was it to
get a personal
doctor or nurse the family is happy with?
Would you say ...
a big problem, ......................... 1 {SP25}
a small problem, or .................... 2 {SP25}
not a problem? ......................... 3 {SP25}
IF VOLUNTEERED: DON’T HAVE A PERSONAL
DOCTOR OR NURSE ..................... 95 {SP25}
REF ................................... -7 {SP25}
DK .................................... -8 {SP25}
[Code One]
DISPLAY ‘{NAME OF CURRENT ... INSURER}’ IF THERE IS
AN INSURER ASSOCIATED WITH THE FAMILY’S MEDICAID/
SCHIP OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE DURING
THE CURRENT ROUND. OTHERWISE, DISPLAY ‘the
coverage through’.
FOR ‘NAME OF ... INSURER’, DISPLAY THE NAME OF THE
CURRENT ROUND’S INSURER FOR THE FAMILY’S MEDICAID/
SCHIP OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE.
DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID} or
{STATE CHIP NAME}}’ IF FAMILY HAS MEDICAID/SCHIP
AND THERE IS NO INSURER ASSOCIATED WITH THE
FAMILY’S MEDICAID/SCHIP INSURANCE DURING THE
CURRENT ROUND. IF THERE IS AN INSURER, USE A NULL
DISPLAY.
DISPLAY ‘the program ... benefits’ IF THE FAMILY
HAS GOVT-HOSPITAL/PHYSICIAN AND THERE IS NO
INSURER ASSOCIATED WITH THE FAMILY’S GOVT-HOSPITAL/
PHYSICIAN INSURANCE DURING THE CURRENT ROUND. IF
THERE IS AN INSURER, USE A NULL DISPLAY.
DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL
STATE NAME FOR PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID’. FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
DISPLAY ‘or STATE CHIP NAME’ (SUBSTITUTING THE
REAL STATE NAME FOR PROGRAM UNDER ALL CONDITIONS).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON
HX06.
NOTE: CAHPS 3.0 ADULT CORE ITEM 7
SP25
{NAME OF ESTABLISHMENT.........}
In the last 12 months, did anyone in the family need
approval from
{{NAME OF CURRENT ROUND MEDICAID/SCHIP/GOVT-H/P
INSURER}/the coverage
through} {{Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}}
{the program sponsored by a state or local government
agency which
provides hospital and physician benefits} for any
care, tests or
treatment?
YES .................................... 1 {SP26}
NO ..................................... 2 {SP27}
REF ................................... -7 {SP27}
DK .................................... -8 {SP27}
SEE FILL SPECIFICATIONS FROM SP24
NOTE: CAHPS 3.0 ADULT CORE ITEM 23
SP26
{NAME OF ESTABLISHMENT.........}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
were delays
in health care while the family waited for approval
from {{NAME
OF CURRENT ROUND MEDICAID/SCHIP/GOVT-H/P INSURER}/the
coverage
through} {{Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}}
{the program sponsored by a state or local government
agency which
provides hospital and physician benefits}?
Would you say ...
a big problem, ......................... 1 {SP27}
a small problem, or .................... 2 {SP27}
not a problem? ......................... 3 {SP27}
IF VOLUNTEERED: NO VISITS IN LAST
12 MONTHS ........................... 95 {SP27}
REF ................................... -7 {SP27}
DK .................................... -8 {SP27}
[Code One]
SEE FILL SPECIFICATIONS FROM SP24.
NOTE: CAHPS 3.0 ADULT CORE ITEM 24
SP27
{NAME OF ESTABLISHMENT.........}
In the last 12 months, did anyone in the family look
for any
information about how {{NAME OF CURRENT
ROUND MEDICAID/SCHIP/
GOVT-H/P INSURER}/the coverage through}
{{Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME}} {the program
sponsored by
a state or local government agency which provides
hospital and
physician benefits} works in written material or on
the Internet?
YES .................................... 1 {SP28}
NO ..................................... 2 {SP29}
REF ................................... -7 {SP29}
DK .................................... -8 {SP29}
SEE FILL SPECIFICATIONS FROM SP24
NOTE: CAHPS 3.0 ADULT CORE ITEM 33
SP28
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND
MEDICAID/SCHIP/GOVT-H/P INSURER}}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
was it to
find or understand this information?
Would you say ...
a big problem, ......................... 1 {SP29}
a small problem, or .................... 2 {SP29}
not a problem? ......................... 3 {SP29}
REF ................................... -7 {SP29}
DK .................................... -8 {SP29}
[Code One]
DISPLAY ‘PLAN NAME: ... INSURER}’ IF THERE IS AN
INSURER ASSOCIATED WITH THE FAMILY’S MEDICAID/
SCHIP OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE DURING
THE CURRENT ROUND. OTHERWISE, USE A NULL DISPLAY.
FOR ‘NAME OF ... INSURER’, DISPLAY THE NAME OF THE
CURRENT ROUND’S INSURER FOR THE FAMILY’S MEDICAID/
SCHIP OR GOV’T HOSPITAL/PHYSICIAN INSURANCE.
NOTE: CAHPS 3.0 ADULT CORE ITEM 34
SP29
{NAME OF ESTABLISHMENT.........}
In the last 12 months, did anyone in the family call
{{NAME OF
CURRENT ROUND MEDICAID/SCHIP/GOVT-H/P INSURER}’s/the
coverage through}
{{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP
NAME}} {the program
sponsored by a state or local government agency which
provides hospital
and physician benefits} customer service to get
information or help?
YES .................................... 1 {SP30}
NO ..................................... 2 {SP31}
REF ................................... -7 {SP31}
DK .................................... -8 {SP31}
SEE FILL SPECIFICATIONS FROM SP24
NOTE: CAHPS 3.0 ADULT CORE ITEM 35
SP30
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND
MEDICAID/SCHIP/GOVT-H/P INSURER}}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
was it to
get the help the family needed when they called this
health
plan’s customer service?
Would you say ...
a big problem, ......................... 1 {SP31}
a small problem, or .................... 2 {SP31}
not a problem? ......................... 3 {SP31}
REF ................................... -7 {SP31}
DK .................................... -8 {SP31}
[Code One]
DISPLAY ‘PLAN NAME: ... INSURER}’ IF THERE IS AN
INSURER ASSOCIATED WITH THE FAMILY’S MEDICAID/
SCHIP OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE DURING
THE CURRENT ROUND. OTHERWISE, USE A NULL DISPLAY.
FOR ‘NAME OF ... INSURER’, DISPLAY THE NAME OF THE
CURRENT ROUND’S INSURER FOR THE FAMILY’S MEDICAID/
SCHIP OR GOV’T HOSPITAL/PHYSICIAN INSURANCE.
NOTE: CAHPS 3.0 ADULT CORE ITEM 36
SP31
{NAME OF ESTABLISHMENT.........}
In the last 12 months, did anyone in the family have
to fill
out any paperwork for {{NAME OF CURRENT ROUND
MEDICAID/SCHIP/
GOVT-H/P INSURER}/the coverage through}
{{Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME}} {the program
sponsored by
a state or local government agency which provides
hospital and
physician benefits}?
YES .................................... 1 {SP32}
NO ..................................... 2 {SP33}
REF ................................... -7 {SP33}
DK .................................... -8 {SP33}
SEE FILL SPECIFICATIONS FROM SP24
NOTE: CAHPS 3.0 ADULT CORE ITEM 37
SP32
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND
MEDICAID/SCHIP/GOVT-H/P INSURER}}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
did the
family have with paperwork for this health plan?
Would you say ...
a big problem, ......................... 1 {SP33}
a small problem, or .................... 2 {SP33}
not a problem? ......................... 3 {SP33}
REF ................................... -7 {SP33}
DK .................................... -8 {SP33}
[Code One]
DISPLAY ‘PLAN NAME: ... INSURER}’ IF THERE IS AN
INSURER ASSOCIATED WITH THE FAMILY’S MEDICAID/SHIP
OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE DURING THE
CURRENT ROUND. OTHERWISE, USE A NULL DISPLAY.
FOR ‘NAME OF ... INSURER’, DISPLAY THE NAME OF THE
CURRENT ROUND’S INSURER FOR THE FAMILY’S MEDICAID/
SCHIP OR GOV’T HOSPITAL/PHYSICIAN INSURANCE.
NOTE: CAHPS 3.0 ADULT CORE ITEM 38
SP33
{NAME OF ESTABLISHMENT.........}
SHOW CARD SP-2.
We want to know your rating of all the family’s experience with
{{NAME OF CURRENT ROUND MEDICAID/SCHIP/GOVT-H/P INSURER}/the
coverage through} {{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE
CHIP NAME}} {the program sponsored by a state or local government
agency which provides hospital and physician benefits}.
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 this health plan?
ENTER RATING FROM 0-10:
[Enter Small Number] ...................
REF ................................... -7
DK .................................... -8
HARD CHECK: ACCEPTABLE RANGE FOR THIS RESPONSE
IS 0-10.
SEE FILL SPECIFICATIONS FROM SP24
NOTE: CAHPS 3.0 ADULT CORE ITEM 39
TRICARE/CHAMPVA SERIES
BOX_04
IF AT LEAST ONE CURRENT RU MEMBER IS COVERED BY
TRICARE/CHAMPVA DURING THE CURRENT ROUND, CONTINUE
WITH SP34
OTHERWISE, GO TO BOX_05
SP34
{NAME OF ESTABLISHMENT.........}
The next questions ask about the family’s experience
with {{NAME OF
CURRENT ROUND TRICARE/CHAMPVA INSURER(S)}, that is,}
their coverage
through TRICARE or CHAMPVA.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
FOR’ NAME OF ESTABLISHMENT...’, DISPLAY ‘TRICARE/
CHAMPVA’.
DISPLAY ‘{NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}, that is,’ IF THERE IS A TRICARE/
CHAMPVA INSURER ASSOCIATED WITH THE FAMILY’S
TRICARE/CHAMPVA INSURANCE (CHECK HX12A, PR19A,
OR PR21A).
OTHERWISE, USE A NULL DISPLAY.
FOR ‘NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)’, DISPLAY THE NAME(S) OF THE CURRENT
ROUND’S INSURER(S) FOR THE FAMILY’S TRICARE/
CHAMPVA INSURANCE.
NOTE: IF MULTIPLE INSURERS ARE SELECTED AT HX12A,
PR19A, OR PR21A, SEPARATE THE INSURER NAMES WITH
A ‘/’.
SP35
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
SHOW CARD SP-1.
Since the family joined TRICARE or CHAMPVA, how much
of a problem,
if any, was it to get a personal doctor or nurse the
family is happy
with?
Would you say ...
a big problem, ......................... 1 {SP36}
a small problem, or .................... 2 {SP36}
not a problem? ......................... 3 {SP36}
IF VOLUNTEERED: DON’T HAVE A PERSONAL
DOCTOR OR NURSE ..................... 95 {SP36}
REF ................................... -7 {SP36}
DK .................................... -8 {SP36}
[Code One]
FOR’ NAME OF ESTABLISHMENT...’, DISPLAY ‘TRICARE
OR CHAMPVA’.
DISPLAY ‘PLAN NAME: ... INSURER(S)}’ IF THERE IS A
TRICARE/CHAMPVA INSURER ASSOCIATED WITH THE
FAMILY’S TRICARE/CHAMPVA INSURANCE (CHECK HX12A,
PR19A, OR PR21A). OTHERWISE, USE A NULL DISPLAY.
FOR ‘NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)’, DISPLAY THE NAME(S) OF THE CURRENT
ROUND’S INSURER(S) FOR THE FAMILY’S TRICARE/
CHAMPVA INSURANCE.
NOTE: IF MULTIPLE INSURERS ARE SELECTED AT HX12A,
PR19A, OR PR21A, SEPARATE THE INSURER NAMES WITH
A ‘/’.
NOTE: CAHPS 3.0 ADULT CORE ITEM 7
SP36
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
In the last 12 months, did anyone in the family need
approval
from TRICARE or CHAMPVA for any care, tests or
treatment?
YES .................................... 1 {SP37}
NO ..................................... 2 {SP38}
REF ................................... -7 {SP38}
DK .................................... -8 {SP38}
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 23
SP37
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
were delays
in health care while the family waited for approval
from TRICARE or
CHAMPVA?
Would you say ...
a big problem, ......................... 1 {SP38}
a small problem, or .................... 2 {SP38}
not a problem? ......................... 3 {SP38}
IF VOLUNTEERED: NO VISITS IN LAST
12 MONTHS ........................... 95 {SP38}
REF ................................... -7 {SP38}
DK .................................... -8 {SP38}
[Code One]
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 24
SP38
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
In the last 12 months, did anyone in the family look
for any
information about how their coverage through TRICARE or CHAMPVA works
in written material or on the Internet?
YES .................................... 1 {SP39}
NO ..................................... 2 {SP40}
REF ................................... -7 {SP40}
DK .................................... -8 {SP40}
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 33
SP39
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
was it to
find or understand this information?
Would you say ...
a big problem, ......................... 1 {SP40}
a small problem, or .................... 2 {SP40}
not a problem? ......................... 3 {SP40}
REF ................................... -7 {SP40}
DK .................................... -8 {SP40}
[Code One]
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 34
SP40
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
In the last 12 months, did anyone in the family call
TRICARE’s
or CHAMPVA’S customer service to get
information or help?
YES .................................... 1 {SP41}
NO ..................................... 2 {SP42}
REF ................................... -7 {SP42}
DK .................................... -8 {SP42}
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 35
SP41
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
was it to
get the help the family needed when they called
TRICARE’s or
CHAMPVA’S customer service?
Would you say ...
a big problem, ......................... 1 {SP42}
a small problem, or .................... 2 {SP42}
not a problem? ......................... 3 {SP42}
REF ................................... -7 {SP42}
DK .................................... -8 {SP42}
[Code One]
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 36
SP42
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
In the last 12 months, did anyone in the family have
to fill out
any paperwork for their coverage through TRICARE or
CHAMPVA?
YES .................................... 1 {SP43}
NO ..................................... 2 {SP44}
REF ................................... -7 {SP44}
DK .................................... -8 {SP44}
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 37
SP43
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
SHOW CARD SP-1.
In the last 12 months, how much of a problem, if any,
did the
family have with paperwork for their coverage through
TRICARE
or CHAMPVA?
Would you say ...
a big problem, ......................... 1 {SP44}
a small problem, or .................... 2 {SP44}
not a problem? ......................... 3 {SP44}
REF ................................... -7 {SP44}
DK .................................... -8 {SP44}
[Code One]
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 38
SP44
{NAME OF ESTABLISHMENT.........}
{PLAN NAME: {NAME OF CURRENT ROUND TRICARE/CHAMPVA
INSURER(S)}}
SHOW CARD SP-2.
We want to know your rating of all the family’s
experience with
their coverage through TRICARE or CHAMPVA.
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 the coverage through TRICARE or
CHAMPVA?
ENTER RATING FROM 0-10:
[Enter Small Number] ...................
REF ................................... -7
DK .................................... -8
HARD CHECK: ACCEPTABLE RANGE FOR THIS RESPONSE
IS 0-10
SEE FILL SPECIFICATIONS FROM SP35
NOTE: CAHPS 3.0 ADULT CORE ITEM 39
BOX_05
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