Our records show that you are now in [QHP ISSUER NAME]. Is that right? 1 Yes If Yes, go to #3 2 No What is the name of your health plan? Please print: would have to pay for services or equipment Your Health Plan In the last 6 months, how often were you The next series of questions ask about your able to find out from your health plan how experiences with your health plan. Please much you would have to pay for specific answer the questions based on your experience prescription medicines? with the health plan you had from July through 1 Never December 2018. 2 Sometimes In the last 6 months, how often did written 3 Usually materials or the Internet provide the 4 Always information you needed about how your 5 Not Applicable; did not look for health plan works? any information about how much I 1 Never would have to pay for prescription 2 Sometimes medicines 3 Usually In the last 6 months, how often did your 4 Always health plan’s customer service give you the 5 Not Applicable; did not look for information or help you needed? any information about my health plan 1 Never In the last 6 months, how were you able 2 Sometimes to find out from your health plan how much 3 Usually you would have to pay for a health care 4 Always service or equipment before you got it? 5 Not Applicable; did not contact 1 Never my health plan’s customer service for 2 Sometimes information or help If Not 3 Usually Applicable, go to #9 4 Always 5 Not Applicable; did not look for any information about how much I
Our records show that you are now in [QHP ISSUER NAME]. Is that right? 1 Yes If Yes, go to #3 2 No What is the name of your health plan? Please print: Your Health Plan 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 2018. 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 Never 2 Sometimes 3 Usually 4 Always 5 Not Applicable; did not look for any information about my health plan In the last 6 months, how 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 2 Sometimes 3 Usually 4 Always 5 Not Applicable; did not look for any information about how much I would have to pay for services or equipment 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 Never 2 Sometimes 3 Usually 4 Always 5 Not Applicable; did not look for any information about how much I would have to pay for prescription medicines In the last 6 months, how often did your health plan’s customer service give you the information or help you needed? 1 Never 2 Sometimes 3 Usually 4 Always 5 Not Applicable; did not contact my health plan’s customer service for information or help If Not Applicable, go to #9
CMS-2019-QHP-Survey-Questionnaire_Eng_FINAL_508.docx