Survey Instrument
HOS Instrument
The Medicare HOS questionnaire consists of four components: physical and mental
health status questions; questions for case mix and risk adjustment purposes; questions
added to collect results for select HEDIS Effectiveness of Care measures, and questions
added by CMS as required by the 1997 Balanced Budget Act. 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.
Two instrument versions (HOS 2.0, 2006; 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. Instructions for completing the 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:
- 2010 Medicare Health Outcomes Survey Instrument 2.0 (PDF, 1.4 MB)
-
2009 Medicare Health Outcomes Survey Instrument 2.0 (PDF, 1.4 MB)
-
2008 Medicare Health Outcomes Survey Instrument 2.0 (PDF, 1.5 MB)
-
2007 Medicare Health Outcomes Survey Instrument 2.0 (PDF, 1.3 MB)
-
2006 Medicare Health Outcomes Survey Instrument 2.0 (PDF, 346 KB)
-
2005 Medicare Health Outcomes Survey Instrument (PDF, 312 KB)
-
2004 Medicare Health Outcomes Survey Instrument (PDF, 199 KB)
-
2003 Medicare Health Outcomes Survey Instrument (PDF, 701 KB)
-
2002 Medicare Health Outcomes Survey Instrument (PDF, 140 KB)
-
2001 Medicare Health Outcomes Survey Instrument (PDF, 546 KB)
-
2000 Medicare Health Outcomes Survey Instrument (PDF, 46 KB)
-
1999 Medicare Health Outcomes Survey Instrument (PDF, 44 KB)
-
1998 Medicare Health Outcomes Survey Instrument (PDF, 44 KB)
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: