Two survey instruments are used for the Medicare HOS program. The HOS questionnaire is the longer form developed for use with participating Medicare Advantage Organizations (MAOs), and the HOS-Modified (HOS-M) questionnaire is the shorter form developed for participating Program of All-Inclusive Care for the Elderly (PACE) organizations. Details about the instruments and downloadable versions are provided below.
In the Spring of 2015, CMS implemented the Medicare HOS 3.0; the latest version of the HOS questionnaire. Like the HOS 2.5, the Medicare HOS 3.0 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; updated questions on race, ethnicity, sex, primary language, and disability status as part of Section 4302 of the Affordable Care Act; and additional health questions, including new and revised 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 About HOS section under the Program page.
The VR-12 is a generic patient reported outcome measure (PROM) used to measure health-related quality of life, and is one of the components of the Medicare HOS. Other VR assessments include the VR-36 long-form counterpart and the VR-6D derived from the VR-12. The VR-36, VR-12 and VR-6D questionnaires, scoring algorithms, and documentation are available on request. For detailed information about the VR measures and to request permission to use, see the measure developer’s website.
Medicare HOS Instruments are available to download for informational purposes only:
-Select HOS Instrument-
2019 HOS Instrument 3.0
2018 HOS Instrument 3.0
2017 HOS Instrument 3.0
2016 HOS Instrument 3.0
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 relationship or staff position of the proxy.
Medicare HOS-M Instruments are available to download for informational purposes only:
-Select HOS-M Instrument-
2019 HOS-M Instrument
2018 HOS-M Instrument
2017 HOS-M Instrument
2016 HOS-M Instrument
This page was last modified on 11/01/2019