Medicare Health Outcomes Survey

Survey Instrument


HOS Instrument

The Medicare HOS 2.5 questionnaire consists of the following major components: the Veterans RAND 12-Item Health Survey (VR-12); questions to gather information for case-mix and risk-adjustment; questions to collect results for four HEDIS® Effectiveness of Care measures; revisions to existing questions on race, ethnicity, sex and disability and new questions on disability and primary language, as part of Section 4302 of the Affordable Care Act; and additional health questions. Physical and mental health functioning are the primary outcome measures which are derived from the core health status component. Further details about the development of the survey instrument can be found in the Program Overview section.

Three instrument versions (HOS 2.5 [2013], HOS 2.0 [2012], and HOS 1.0 [2005]) are available for use with permission. Those interested in using the Health Outcomes Survey Instrument must complete the Medicare Health Outcomes Survey Use Application and read the Permission to Use and Terms of Use information. Instructions for completing the application form are included in the downloadable file. All requests are subject to approval by NCQA and CMS.

The following Medicare HOS Instruments are available for informational purposes only:

HOS-M Instrument

The HOS-M questionnaire is a modified version of the Medicare Health Outcomes Survey. The instrument contains 6 Activity of Daily Living (ADL) items as the core items used to calculate the frailty adjustment factor. The survey also includes 12 physical and mental health status questions, one question about memory loss interfering with daily activities, and one question about urinary incontinence. If the participant received assistance completing the questionnaire, the respondent was asked why a proxy was needed, how the proxy assisted the participant and the staff position of the proxy.

The following Medicare HOS Instruments are available for informational purposes only:
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