During this period of expanding program services, the Centers for Medicare & Medicaid Services (CMS), the Federal agency that administers the Medicare program is conducting this telephone (or web) survey to help us understand what information you need about Medicare, where you go to find the information, and if you feel we have been effective in getting you the information you need to make informed decisions about Medicare benefits and medical care.
As part of our commitment to enhancing communication to meet your needs, we are asking you to take a few minutes to answer some questions. All information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not have to participate in this survey. Your help is voluntary and your decision to participate or not to participate will not affect your Medicare benefits in any way. This is a legitimate research study sponsored by the Centers for Medicare & Medicaid Services (CMS), which is part of the United States Department of Health & Human Services.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this Publication Use survey is 0938-0892. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review and complete the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
These codes are for control purposes only and will not be visible to the respondent in this form.
IF PUB# = 1, PUB = “Healthcare Coverage Directory for People with Medicare”
IF PUB# = 2, PUB = “Medicare and Home Health Care”
IF PUB# = 9, PUB = “Choosing a Medicare Health Plan”
IF PUB# = 11, PUB = “Medicare & You Handbook”
IF PUB# = 12, PUB = “Medicare Initial Enrollment Period Package”
IF PUB# = 13, PUB = “Your Guide to Medicare Prescription Drug Coverage”
IF PUB# = 14, PUB = “Choosing a Medigap Policy”
IF PUB# = 15, PUB = “Your Medicare Benefits”
IF PUB# = 16, PUB = “Choosing a Nursing Home”
IF PUB# = 17, PUB = “Guide to Medicare's Preventive Services”
(IF PUB = 1, PUBDESCRIP = “ways to pay for health care costs, including federal and state programs, private insurance, and military coverage”)
(IF PUB = 2, PUBDESCRIP = “what home health care services Medicare covers and what kinds of questions to ask when choosing a home health care agency”)
(IF PUB = 9, PUBDESCRIP = “how to choose a Medicare health plan in your area, includes step-by-step instructions”)
(IF PUB = 11, PUBDESCRIP = “your Medicare plans choices such as the Original Medicare Plan, Medicare Advantage Plans, and Medicare drug plans. It provides basic facts about the Medicare Program, Medicare rights, and other insurance and ways to pay health care costs. A revised handbook is mailed every fall to people with Medicare.”)
(IF PUB = 12, PUBDESCRIP = “The booklet in the package discussed the decisions you need to make, including whether to keep or decline Medicare Part B coverage. It also included information about your Medicare plan choices, and other insurance and ways to pay health care costs. Within this package, you also received your Medicare card.”)
(IF PUB = 13, PUBDESCRIP = “introduced Medicare prescription drug coverage, explained how Medicare prescription drug coverage works, how you can get assistance paying for your Medicare prescription drug coverage, what your Medicare prescription drug coverage options are")
(IF PUB = 14, PUBDESCRIP = “what a Medigap policy is, how to choose a Medigap policy, Medigap policies and Medicare prescription drug coverage, and your Medigap protections.”)
(IF PUB = 15, PUBDESCRIP = “introduced Medicare plan choices and explains what services and supplies Medicare covers under the Original Medicare Plan and what you pay for each in a series of charts”)
(IF PUB = 16, PUBDESCRIP = “how to find and choose a nursing home and what your rights are as a nursing home resident. It includes an evaluation checklist and a list of helpful resources for choosing a nursing home.")
(IF PUB = 17, PUBDESCRIP = “what preventive services are and which preventive services are covered by Medicare, such as pneumonia (“knew-mo-nia”) or flu shots,”)
Which best describes you?
A Medicare recipient (currently or shortly).
A relative or friend of a Medicare recipient (currently or shortly).
Medicare Counselor (e.g., SHIP Program).
Social worker, nurse, health professional.
Employee of an insurer, HMO or managed care organization.
Researcher, librarian, student, counselor, employer, or attorney.
A member of a group representing Medicare beneficiaries.
A Medicare Customer Service Representative (CSR) {TERMINATE}.
Another member of the Medicare staff.
A member of a Quality Improvement Organization (QIO) or Peer Review Organization
(PRO).
Other (Specify).
Which of the following statements describes your current Medicare situation?
I receive Medicare benefits due to my age.
I receive Medicare benefits due to a disability.
I do not receive Medicare benefits yet but I will in the next few years.
I do not receive Medicare benefits but I am interested in Medicare programs.
Don’t know.
Refused.
Do you have health insurance through?
A current employer.
A former employer.
A Medigap or Medicare supplement insurance policy.
An “H” “M” “O” or managed care plan where you need a referral to see a specialist.
Medicaid, also known as state medical assistance, which is often for people with limited income and resources.
A “P” “P” “O” or preferred provider organization where you pay more if you use a doctor outside of the plan’s network.
Medicare, but no other health insurance.
Other (Specify).
TRICARE.
No health insurance.
Don’t know.
Refused.
Do you or does anyone in your household currently work for a health maintenance organization, a health insurance company, the Social Security Administration, or the Centers for Medicare & Medicaid Services, formerly known as the Health Care Financing Administration?
Yes.
No.
Don’t know.
Refused.
Gender (don’t ask):
Male.
Female.
Just to confirm your age, could you please tell me the month and the year you were born?
Have you recently visited the www.Medicare.gov Website to look up information on (PUBDESCRIP)?
Yes, within the past week.
Yes, one or more weeks ago.
Yes, but don’t know when.
No.
Don’t know.
Refused.
How often do you visit the Medicare Website?
This is my first time.
Less than once a month.
About once or twice a month.
About once a week.
A few times a week.
Once a day.
A few times a day.
How long have you been using the Medicare Website?
Less than one month.
One month to six months.
Six months to a year.
One year or more.
When you just visited www.Medicare.gov were you looking for information for yourself, or did you visit because you were looking for information for someone else?
Self.
Spouse.
Parent.
Other family member.
Friend.
Client/Work.
Other (SPECIFY).
What site were you at when you clicked the link that brought you to the Medicare Website?
Went directly to the Medicare Website.
Linked to Medicare Website from another site (SPECIFY).
Did you know that you could find Medicare publications on the Medicare Website before you visited www.Medicare.gov today?
Yes.
No.
How did you know that you could find Medicare publications on the Medicare Website?
1-800-MEDICARE Representative Told Me.
Newspaper Article.
Newspaper Ad.
Television Ad.
Medicare & You Handbook.
Friend or Family Member.
AARP Publication.
Other (SPECIFY).
Medicare puts booklets on their Website in “P” “D” “F” files that you can download and view. When you click on a title of a booklet on the Medicare Website, the files open up and you can view a booklet by scrolling up and down through the pages. Do you remember looking at a booklet called (PUB)? It was about (PUBDESCRIP).
Yes.
No.
Don’t know.
Refused.
While on the www.Medicare.gov Website, you may have looked at (PUB), a Medicare booklet that provides information on (PUBDESCRIP). Do you recall seeing this publication?
Yes.
No.
Did you read this (PUB) “P” “D” “F” file at your computer?
Yes.
No.
Did you either bookmark the Medicare publication Webpage or save the Medicare publication on your computer?
Yes.
No.
Did you print the booklet, read it off the screen, or save it on your computer? (CHECK ALL THAT APPLY)
Printed it.
Read it from the computer.
Saved it on my computer.
None of the above.
Don’t know.
Have you read the booklet that you printed?
Yes.
No.
Which of the following reasons, if any, describes why you did not save or print the booklet? (CHECK ALL THAT APPLY)
No ability to print.
No ability to save.
It was too big or long.
It was not the information you were looking for.
It looked too confusing.
Don’t know.
How likely is it that you will look at the booklet at some point in the future?
Very Likely.
Likely.
Only somewhat likely.
Not at all likely.
Don’t know.
Would you say it was easy or difficult to access the Medicare booklet through the Internet? OR do you not feel one way or the other about the booklet? (ASK IF EASY OR DIFFICULT) Would you say that it was very (easy/difficult) or only somewhat (easy/difficult)?
Very easy.
Somewhat easy.
Neither easy nor difficult.
Somewhat difficult.
Very difficult.
Don’t know.
Refused.
As far as the information you were looking for when you visited www.Medicare.gov, have you tried to find that information anywhere other than through www.Medicare.gov?
Yes.
No.
Don’t know.
Refused.
Where else have you tried to find the information you were looking for?
Internet.
1-800-Medicare.
Health fair.
Senior Center.
Other (Specify).
Don’t know.
Refused.
As a result of visiting www.Medicare.gov and viewing (PUB), would you say your overall opinion of Medicare is more favorable, less favorable, or is your opinion of Medicare about the same as it was before you received the booklet? (IF MORE/LESS FAVORABLE, ASK) Would you say that your opinion of Medicare is much (more/less) favorable or somewhat (more/less) favorable?
Much more favorable.
Somewhat more favorable.
About the same.
Somewhat less favorable.
Much less favorable.
Don’t know.
Refused.
This last question is used for classification purposes. As a reminder, your individual responses are kept private.
From where did you access www.Medicare.gov?
Home (yours or another).
Office (yours or another).
Library.
Senior or Community Center.
School.
Medical office, clinic or facility.
Other (Specify).
Refused.
Have you received a Medicare booklet titled (PUB) recently?
Yes.
No.
Ordered it but hasn’t received it.
Don’t know.
Refused.
The Medicare booklet I’m referring to provides information on (PUBDESCRIP) – do you recall receiving a booklet with this information from Medicare?
Yes.
No.
Don’t know.
Refused.
Have you recently called 1-800-MEDICARE? (IF YES, ASK) Did you call 1-800-MEDICARE in the last two weeks, or was it more than two weeks ago?
Yes, within the last two weeks.
Yes, over two weeks ago.
Yes, but don’t know when.
No.
Don’t know .
Refused.
Did you call 1-800-MEDICARE for information for yourself, or did you call because you were looking for information for someone else?
Self.
Spouse.
Parent.
Other Family member .
Friend.
Client/Work.
Other (SPECIFY).
Don’t know.
Refused.
During your call to 1-800-MEDICARE, did you request that the booklet (PUB) be sent to you, did the Customer Service Representative suggest it to you, or do you not recall discussing that booklet during your call to 1-800-MEDICARE?
Requested it.
Customer Service suggestion.
Does not recall discussing booklet.
Other (SPECIFY).
Don’t know.
Refused.
As far as the information you were looking for when you called 1-800-MEDICARE, have you tried to find that information anywhere other than through 1-800-Medicare?
Yes.
No.
Don’t know.
Refused.
Are you familiar with “w” “w” “w” dot medicare dot gov, which is the official Medicare Website where you can get information about the products, services or programs offered by Medicare? (IF YES, ASK) Have you visited “w” “w” “w” dot medicare dot gov, the Medicare Web site?
Yes familiar, Visited.
Yes familiar, Not visited.
Not familiar.
Don’t know.
Refused.
At the Medicare Website, you can download and print booklets such as (PUB). How likely are you to use a Medicare website to download and print booklets?
Very likely.
Likely.
Only somewhat likely .
Not at all likely.
Don’t know.
Refused.
Have you had a chance to look at the booklet, or have you not had a chance to look at the booklet? (IF YES, ASK) Would you say you skimmed through the booklet, did you read certain sections of the booklet, or did you read the booklet thoroughly?
Looked at it, read it thoroughly.
Looked at it, read certain sections.
Looked at it, skimmed through it.
No, haven’t looked at it.
Don’t know.
Refused (TERMINATE).
Would you say that you are satisfied or dissatisfied with the booklet (PUB), OR do you not feel one way or the other about the booklet? (ASK IF SATISFIED OR DISSATISFIED) Would you say that you are very (satisfied/dissatisfied), or only somewhat (satisfied/dissatisfied)?
Very satisfied.
Only somewhat satisfied.
Do not feel one way or the other.
Only somewhat dissatisfied.
Very dissatisfied.
Don’t know.
Refused.
The following are statements about your overall experience with the booklet (PUB), please tell us how much you agree with each statement.
The information I received from the booklet (PUB) grabbed my attention.
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Strongly disagree.
Don’t know.
Refused.
The information I received from the booklet (PUB) did not tell me what to do to find out if I am eligible for the benefit I was interested in finding out about.
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Strongly disagree.
Don’t know.
Refused.
The information I received from the booklet (PUB) was for people like me.
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Strongly disagree.
Don’t know.
Refused.
I learned something I did not know before from the booklet (PUB).
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Strongly disagree.
Don’t know.
Refused.
The booklet (PUB) did not give me a good reason to apply for the benefit.
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Strongly disagree.
Don’t know.
Refused.
I was interested in what the booklet (PUB) said.
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Strongly disagree.
Don’t know.
Refused.
The booklet (PUB) helped me understand my benefits.
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Strongly disagree.
Don’t know.
Refused.
The booklet (PUB) looked like other material from the government.
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Don’t know.
Refused.
The booklet (PUB) was easy to understand.
Strongly agree.
Agree.
No opinion.
Disagree.
Strongly disagree.
Don’t know.
Refused.
The booklet was easy to read.
Very much disagree.
Neither agree or disagree/Neutral.
Very much agree.
Don’t know.
The booklet had the information I needed.
Very much disagree.
Neither agree or disagree/Neutral.
Very much agree.
Don’t know.
I would recommend this booklet to others.
Very much disagree.
Neither agree or disagree/Neutral.
Very much agree.
Don’t know.
The booklet was written for someone like me.
Very much disagree.
Neither agree or disagree/Neutral.
Very much agree.
Don’t know.
What about the length of the booklet?
Too long.
Too short.
About the right length.
Don’t know.
Did you refer to the booklet/hope to use the booklet to help you make a specific decision?
Yes.
No.
Could you briefly describe the decision you needed to make?
_____________________________________________________________
How helpful was the booklet with that decision?
Very helpful.
Helpful.
Only somewhat helpful.
Not at all helpful.
Don’t know.
Which of the following reasons, if any, describe why the booklet has not been more helpful? (READ AND RANDOMIZE, RECORD ALL THAT APPLY).
You haven’t needed to use the information in the booklet.
You needed more information than the booklet provided.
You already knew most of the information provided by the booklet .
You found the information confusing or hard to use.
The booklet arrived too late to be helpful.
The booklet did not provide the needed information.
Other (SPECIFY).
Don’t know.
Refused.
What did you do with the booklet?
Saved it.
Discarded it.
Gave it to someone else.
Don’t know.
After receiving (or accessing) the booklet, did you talk to someone about it?
Yes.
No.
If so, who? (CHECK ALL THAT APPLY)
Spouse.
Child.
Other relative.
Friend.
Health care provider.
Pharmacist.
Social worker.
SHIP representative/local counselor?
With whom have you shared the booklet?
Spouse.
Parent.
Other family member.
Friend.
Doctor or Nurse.
Client/Work
No one.
Don’t know.
With whom do you intend to share it?
Spouse.
Parent.
Other family member.
Friend.
Doctor or Nurse.
Client/Work.
No one.
Don’t know.
Have you called any of the telephone numbers listed in the booklet, or not?
Yes.
No.
Don’t know.
Refused.
Have you visited any of the Websites listed in the booklet, or not?
Yes.
No.
Don’t know.
Refused.
How many times would you say you have referred to the booklet (PUB)?
Never.
Just once.
Two to three times.
Four or more times.
Don’t know.
Refused.
Which of the following reasons, if any, describe why you didn’t look at the booklet when you received it? (READ AND RANDOMIZE, RECORD ALL RESPONSES)
It did not arrive in time for you to use it.
You haven’t had time to read it.
It looked too big and long to read.
It wasn’t what you expected.
It looked too confusing.
It turned out that you didn’t need the information.
You ordered it to give to someone else.
Other (SPECIFY).
Don’t know.
Refused.
How likely is it that you’ll look at the booklet at some point in the future?
Very likely.
Likely.
Only somewhat likely .
Not at all likely.
Don’t know.
Refused.
After receiving (or accessing) the booklet did you apply for the benefit?
Yes.
No.
After receiving (or accessing) the booklet did you request additional information?
Yes.
No.
After receiving (or accessing) the booklet did you engage in a specific behavior that the booklet suggested?
Yes. (Specify)
No.
After receiving (or accessing) the booklet did you return a business reply card?
Yes.
No.
As far as the information that you were looking for when you visited www.Medicare.gov (or called 1-800-Medicare), have you tried to find that information anywhere else?
The Medicare Website.
Yes.
No.
Don’t know.
1-800-MEDICARE.
Yes.
No.
Don’t know.
Your health insurance company, HMO, PPO.
Yes.
No.
Don’t know.
Social Security.
Yes.
No.
Don’t know.
Your Medicare Part D prescription drug provider.
Yes.
No.
Don’t know.
AARP or other senior citizen's group.
Yes.
No.
Don’t know.
Your doctor or another health care provider.
Yes.
No.
Don’t know.
Family or friends.
Yes.
No.
Don’t know.
A senior center, library or other community organization.
Yes.
No.
Don’t know.
Your employer or former employer.
Yes.
No.
Don’t know.
A Medicare counseling program.
Yes.
No.
Don’t know.
In thinking about the sources of information that you use when you have a question about Medicare, which of the following do you use?
The Medicare Website.
Often.
Occasionally.
Rarely.
Never.
Don’t know.
1-800-MEDICARE.
Often.
Occasionally.
Rarely.
Never.
Don’t know.
Your health insurance company, HMO, PPO.
Often.
Occasionally.
Rarely.
Never.
Don’t know.
Social Security.
Often .
Occasionally.
Rarely.
Never.
Don’t know.
Your Medicare Part D prescription drug provider.
Often .
Occasionally.
Rarely.
Never.
Don’t know.
AARP or other senior citizen's group.
Often .
Occasionally.
Rarely.
Never.
Don’t know.
Your doctor or another health care provider.
Often .
Occasionally.
Rarely.
Never.
Don’t know.
Family or friends.
Often .
Occasionally.
Rarely.
Never.
Don’t know.
A senior center, library or other community organization.
Often .
Occasionally.
Rarely.
Never.
Don’t know.
Your employer or former employer.
Often .
Occasionally.
Rarely.
Never.
Don’t know.
A Medicare counseling program.
Often .
Occasionally.
Rarely.
Never.
Don’t know.
At any time over the past couple of months, have you needed information on (PUBDESCRIP)? (IF YES, ASK) Did the booklet (PUB) provide you with that information, did it not provide you with that information, or do you not recall?
Needed, booklet provided.
Needed, booklet did not provide.
Needed, Do not recall whether booklet had information.
Did not need.
Don’t know.
Refused.
ASK IF PUB = 1
Federal and state health programs such as Medicare Savings Programs, PACE, or Federally Qualified Health Centers
Private insurance such as Medigap or Medicare supplement insurance policies, employee or retiree coverage, long-term care insurance, or COBRA
Military coverage such as TRICARE
ASK IF PUB = 2
Who qualifies for Medicare home health care
What Medicare pays for as far as home health care
Finding a home health care agency
ASK IF PUB = 9
What to do if you lose coverage because your plan leaves Medicare
Choosing a Medicare health plan if you are new to Medicare or you are dissatisfied and want to switch plans
Medigap or Medicare supplement insurance policies
Medicare plus choice plans such as a Medicare managed care plan from an “H “M” “O” or a Medicare preferred provider organization plan or a Medicare private fee-for-service plan
ASK IF PUB = 11
Changes in Medicare or What's New
Your Medicare coverage options
Medicare prescription drug coverage
Medicare rights and protections
ASK IF PUB = 12
Deciding if you want to keep Medicare Part B
Deciding what Medicare health plan you want
Deciding if you want Medicare prescription drug coverage
Deciding if you want a Medigap policy (Medicare Supplemental Insurance)
ASK IF PUB = 13
Medicare drug plan costs
Assistance with drug plan costs
How to choose a Medicare drug plan
How to join a Medicare drug plan
ASK IF PUB = 14
What is a Medigap policy
Choosing a Medigap policy
Medigap rights and protections
ASK IF PUB = 15
Medicare coverage options
Assistance with health care costs
What benefits the original Medicare plan covers
Coverage of a specific benefit
ASK IF PUB = 16
Comparing nursing homes
Choosing a nursing home
Paying for nursing home care
Your rights as a nursing home resident
ASK IF PUB = 17
What preventive services Medicare covers
Specific information about a particular preventive service
What you and Medicare pay for preventive services
What other comments do you have that will help us improve the publication?
_____________________________________________________________
Compared to reading the booklet online, would calling 1-800-MEDICARE and requesting a copy of this booklet by mail be:
Strongly preferred.
Somewhat preferred.
No difference.
Somewhat less preferred.
Much less preferred.
Why?
_____________________________________________________________
As far as the mail that is delivered to your household, who usually sorts through your mail when it arrives?
Respondent.
Other Household member.
Everyone.
Nurse or home health aide.
Family member that stops by.
Don’t know.
Refused.
People have different ways of handling their mail. Which of the following best describes how you handle the mail:
I open almost all of the mail before I throw anything away, including the mail I don’t recognize and the junk mail.
I open some of the mail that I don’t recognize but throw away anything that looks like junk mail.
I only open the mail that I recognize and I throw away everything else
Don’t know.
Refused.
How comfortable are you with the Internet?
I am very comfortable using the Internet.
I am somewhat comfortable using the Internet.
I am somewhat uncomfortable using the Internet.
I am very uncomfortable using the Internet.
Refused.
In general, do you personally use the Internet? (IF NO, ASK) Is there someone that helps you to use the Internet? Is there someone that searches the Internet for you?
Yes.
No, there is someone who helps me.
No, there is someone who searches for me.
No .
Don’t know.
Refused.
As a result of having received (PUB), would you say your overall opinion of Medicare is more favorable, less favorable, or is your opinion of Medicare about the same as it was before you received the booklet?
Much more favorable.
Somewhat more favorable.
About the same.
Somewhat less favorable.
Much less favorable.
Don’t know.
Refused.
How likely are you to request a booklet from Medicare in the future?
Very likely.
Likely.
Only somewhat likely .
Not at all likely.
Don’t know.
Refused.
How likely are you to go on the Web and look for a Medicare publication on www.Medicare.gov in the future?
Very likely.
Likely.
Only somewhat likely .
Not at all likely.
Don’t know.
Refused.
What is your marital status? {Read only if necessary.}
Single.
Married.
Unmarried but in committed relationship.
Separated.
Divorced.
Widowed.
What is the highest grade you completed in school? {Read if necessary.}
8th Grade or Less.
Some High School, but Did Not Graduate.
High School Graduate or GED.
Vocational or Trade School.
Some College or 2-Year Degree.
4-Year College Graduate.
More than 4-Year College Degree.
Don’t know.
Are you Hispanic or Latino?
Yes.
No.
Refuse.
Don’t know.
What is your racial or ethnic background? (Select one or more.)
White.
Black.
Asian.
American Indian.
Other (Specify)______________________.
Don’t know.
Refuse.
What is the annual income of your household? Is it …? [Read. If needed, clarify “income” as “income before taxes and deductions.”]
Under $10,000 ($0-$14,999).
$10,000-$20,000 ($24,999).
$20,000-$30,000 ($34,999).
$30,000-$,40000 ($49,999).
$40,000-$50,000 ($74,999).
$50,000-$75,000.
$75,000-$100,000.
$100,000 and over.
Refuse.
Don’t know.
| File Type | application/msword |
| File Title | Publication Usage Collection Instrument |
| Subject | Publication Usage Survey Information Clearance |
| Author | CMS/OEA/SRCMG/DR |
| Last Modified By | CMS |
| File Modified | 2009-08-28 |
| File Created | 2009-08-28 |