New Enrollee Survey – Updated 4/21/09
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 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 New Enrollee survey is 0938-0869. 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(s) 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.
Screening Questions:
Just to confirm your age, could you please tell me the month and the year you were born?
Are you currently enrolled in Medicare?
Yes.
No.
Don’t know.
Refused.
How long have you been enrolled in Medicare?
< 3 months.
3-6 months.
6-12 months.
1-2 years.
2+ years.
I’m currently not enrolled in Medicare.
If not in Medicare: When will you be enrolled in Medicare?
3-6 months.
2-3 months.
<2 months.
Do you currently receive Medicaid (describe Medicaid)?
Yes.
No.
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.
Enrolling in Medicare:
Which of the following best describes your current work situation?
I am currently working full time.
I am currently working part time.
I am retired.
I am retired and working part time.
I am unemployed/looking for work.
I am a homemaker.
Disabled/unable to work due to injury.
Other.
At what age did you start collecting Social Security Benefits?
<62.
62-65.
67.
>67.
Don’t know.
I’m not collecting Social Security.
At what age can you enroll in Medicare?
62.
65.
67.
Other age _____.
When you retire.
If you are disabled.
Don’t know .
Did you contact the Social Security Administration to enroll in Medicare?
Yes.
No.
Don’t know.
If contacted SSA. When did you contact the Social Security Administration to enroll in Medicare?
How did you know to contact the Social Security Administration?
Friends.
Family.
AARP.
Received information in the mail.
Heard about it on TV.
Other.
Did you receive information in the mail from the Social Security Administration about enrolling in Medicare?
Yes.
No.
Don’t know.
Before enrolling in Medicare did you do any of the following activities?
Talked with a professional advisor or financial planner.
Talked to your employer.
Talked to your friends and family.
Talked to a health insurance plan.
Talked to an insurance broker/agent.
Talked with someone about meeting your future health care costs.
Have you received a red, white, and blue Medicare card showing whether you have Part A, Part B or both?
Yes.
No.
Don’t know.
Have you received the Medicare and You booklet in the mail?
Yes.
No.
Don’t know.
Have you received a letter from Medicare telling you about mymedicare.gov?
Yes.
No.
Don’t know.
Have you received a “Welcome to Medicare” booklet from Medicare in the mail?
Yes.
No.
Don’t know.
Did you receive an Initial Enrollment Questionnaire from Medicare that asks whether you have other insurance that pays before Medicare?
Yes.
No.
Don’t know.
Satisfaction:
How satisfied were you with the enrollment information you received from Medicare?
Very Satisfied.
Satisfied.
Unsatisfied.
Very Unsatisfied.
In thinking about Medicare enrollment, did you feel you had enough information to make Medicare enrollment decisions?
Yes.
No.
Don’t know.
In thinking about Medicare enrollment, did you feel that you received enough information about the services and procedures that Medicare covers?
Yes.
No.
Don’t know.
Health Insurance Coverage:
In addition to Medicare Part A and B, some people also have other health insurance, do you have any of the follow?
Medicare Advantage.
Employer or Union coverage.
Medigap Plan.
Tri-care.
Don’t know.
If have employer coverage, What type of health insurance is your employer coverage?
HMO.
PPO.
Fee for service.
Consumer driven high deductible plan.
When enrolling in Medicare Part A and Part B, you could have also signed-up for Medicare Prescription drug coverage, also known as Medicare Part D. Did you sign up for one of the Medicare prescription drug plans?
Yes.
No.
Don’t know.
Refused.
When deciding to enroll in a Part D plan or a Medicare Advantage Plan did you compare multiple plans?
Yes
No
Don’t know
Refused
Where you aware that if you didn’t enroll in a Part D plan when you are first eligible there could be a 1% per month penalty?
Yes.
No.
Don’t know.
Did the penalty affect your decision to enroll in a Part D plan?
A lot.
A little.
Not at all.
Don’t know.
Do you have other coverage that pays for your prescription drugs?
Yes.
No.
Here is a list of the kinds of insurance and health plans that some people have that help pay for their prescription drugs. Please tell me which you have
Medigap or Medicare supplemental insurance.
An HMO.
A PPO.
Employer, Union or retiree health insurance.
Veterans benefits.
Military retiree benefits, also called tri-care.
Other.
Don’t know.
Refused.
When you or your spouse was/is working did/do you have choices of different health insurance plans?
Yes.
No.
Never had employer insurance.
Don’t know.
Refused.
Information about Medicare:
In thinking about when you first enrolled in Medicare, including what plan options were available to you, where would you say you got information about Medicare that you relied on the most? [Do not read list. Accept multiples. If respondent says “In the mail,” clarify from where.]
In the mail – from Medicare: A Letter.
In the mail – from Medicare: A Pamphlet.
In the mail – from Medicare: The Handbook.
In the mail – from elsewhere.
Medicare and You Handbook.
1-800-Medicare.
Social Security Administration.
AARP.
Physician or nurse.
Pharmacist.
Insurance or drug plan.
Friends/Family.
TV, radio, newspaper, magazine.
Senior Center.
Internet (specify).
Library.
Other.
Don’t know.
Did you know you can help with questions about Medicare?
Over the phone through 1-800 Medicare.
Over the internet at www.medicare.gov.
Through the Medicare and You Handbook.
Through the AARP.
From local counselors.
Through state or county offices on Aging.
Through state insurance department.
None of the above.
Don’t know.
Refused.
Have you ever used any of the sources of help just mentioned?
Yes.
No.
Don’t know.
How would you prefer to receive information about Medicare?
Talk with someone in person.
Talk with someone on the telephone.
Receive information in the mail.
Use the internet or on the computer.
Watch and informational TV show.
Listen to an audiotape.
Attend a seminar or informational class/discussion.
Other.
When it came to making Medicare enrollment decisions about coverage and services did you…
Make those decisions on your own, without talking to anyone else.
Make those decisions on your own but talked to other about it.
Make those decisions with someone else’s help.
Rely on someone else to make those decisions.
Who did you talk with about these decisions or who makes these decisions for you?
Spouse.
Child.
Other family member.
A friend.
Receive help at a senior center.
Receive help from my state’s health insurance department.
Other.
Medicare Knowledge:
For each of the following statements, please tell me if it is accurate, inaccurate or you don’t know.
I feel knowledgeable about how Medicare works and what is covered
Medicare will cover most of my health care costs during my retirement years.
The Medicare program will change from year to year.
Medicare will cover my long term care needs, like a nursing home.
Medicare will cover my dental care.
Medicare will cover eye exams and eye glasses.
Medicare typically pays 80% of doctor’s visits.
Medicare will pay for a physical exam every year.
I do not need any supplemental health insurance.
Medicare has information that allows you to compare quality information on health insurance plans.
Medicare has information that allows you to compare quality information of nursing homes and hospitals.
Medicare will pay for a physical exam during the first 12 months that I have coverage.
Medicare will cover annual flu shots for everyone.
Medicare will cover annual mammograms (for women).
Medicare will cover annual prostate screening (for men).
Medicare Part D is coverage for prescription drugs.
Medicare Part D is run by private plans approved by Medicare.
There is a financial penalty if I don’t sign up for Part D when I’m first eligible for Medicare.
Medicare Part D is only for people with low incomes.
Medicare has an annual open enrollment period where I can switch prescription drug plans.
The drugs covered by Medicare Part D plans can switch from year to year.
I can find Part D plan comparison information in my Medicare and You Handbook.
I can find Part D plan comparison information on www.medicare.gov.
People with limited incomes can apply for extra help paying for their prescription drugs.
Knowledge about Medicare Advantage & Medigap.
Medicare Advantage plans are like PPO’s and HMO’s.
Medicare Advantage plans provide your Medicare health coverage and usually Medicare Drug coverage.
Only low income people can be in a Medicare Advantage Plan.
Medigap is supplemental insurance that covers costs that Medicare doesn’t cover.
Medigap policies are sold by private insurance companies.
I can find comparison information about Medicare Advantage plans on medicare.gov.
Medicare has a booklet where I can learn about Medigap information.
LIS Knowledge & Action:
Have you ever received a letter from Medicare or the Social Security Administration
advising you to apply for extra financial help with Medicare prescription drug plan costs?
Yes.
No.
Refuse.
Don’t know.
Did you know that people with limited income may qualify for financial assistance to help cover the cost of prescription drugs?
Yes.
No.
Refuse.
Don’t know.
Have you ever received a letter or call from your prescription drug plan advising you to apply for extra financial help with Medicare prescription drug costs?
Yes.
No.
Refuse.
Don’t know.
Did you apply to for Extra Help to pay for Medicare prescription drug costs?
Yes.
No.
Refuse.
Don’t know.
Have you ever been given or mailed an application for extra help to pay for prescription
drug coverage? [Read list. If needed, explain that this is an application sent to Social Security.]
Yes, applied and was approved.
Yes, applied, but was denied.
Yes, applied and am waiting to hear the results.
Yes, I gave it to someone else to fill out, but I’m not sure what happened.
Yes, I’ve received an application, but I have not filled it out.
No, I have never been given or mailed an application.
Not sure.
Refuse.
You would accept financial assistance from the government to help pay for your prescription drugs.
True.
False.
Refuse...
Don’t know.
You would qualify as a person with limited income.
True.
False.
Refuse.
Don’t know.
And why do you think you might not qualify as a person with limited income?
My income is too high.
I don’t take enough prescription drugs.
I don’t pay much for prescription drugs.
I (or spouse) is still working.
I have other insurance.
I have been denied as a person with limited income in the past.
Other. (Specify________________________________________________.)
Refuse.
Don’t know.
Medicare Branding:
For each of the following statements, please tell me if it is accurate, inaccurate or you don’t know:
Medicare is complicated.
Medicare does not care about me.
Medicare benefits are flexible.
Medicare is stable.
Medicare gives me a sense of security.
I trust Medicare.
Medicare will be there in the future.
Caregiver:
Have you ever provided help, assistance or advice to a spouse, family member, friend or other person with Medicare?
Yes.
No.
Don’t know.
Which of the following types of assistance have you provided for a spouse, family member, friend or other person with Medicare?
Medicare and other insurance decisions.
Health care decisions.
Spoken with a healthcare provider on behalf of or along with someone else.
Financial and legal decisions.
Paying bills.
Transportation.
Household chores or grocery shopping.
Other.
What is the relationship to the person you care for?
How frequently do you or did you provide care to this person?
Internet Usage:
Do you usually access the Internet on your own or with someone else’s help, or not at all?
Usually on my own.
Usually with someone else’s help.
Do not access the internet.
Don’t know.
How often do you access the internet on your own?
Daily or almost daily.
Once or twice a week.
Once or twice a month.
Only a few times a year.
Don’t have internet access/don’t use internet.
Have you ever visited Medicare’s website. www.medicare.gov
Yes.
No.
Would you be interested in receiving the Medicare and You Handbook electronically?
Yes.
No.
Don’t know.
Have you ever used an electronic Personal Health Record?
Yes.
No.
Don’t Know.
Do any of your doctors use an Electronic Health Record?
Yes.
No.
Don’t know.
Health Behaviors:
For each of the following please tell me if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree:
I understand my personal health risks.
I actively try to prevent disease and illness.
I leave it to the doctor to make right decisions about my health.
I rely on the doctor to tell me everything I need to know to manage my health.
I work together with the doctor to manage my health.
When I read/hear something relevant to my health, I bring it up with my doctor.
Most health issues are too complicated for me to understand.
I have difficulty understanding health information that I read.
It is important to be informed about health issues.
I need to know about health issues so I an keep myself and my family healthy.
Do you regularly get physical exams?
Yes.
No.
Don’t know.
When was the last time you had a physical exam?
<6 months ago.
6-12 months ago.
<1 year.
<2 years.
<5 years.
Other.
Never.
How confident are you that you can identify when it is necessary for you to get medical care?
Very confident.
Confident.
Somewhat confident.
Not at all confident.
Do you _______, take a list of all your prescribed medicines to your doctor visits?
Always.
Usually.
Sometimes.
I don’t take any prescriptions.
Compared to other people who are the same age as you, do you consider you health to be:
Excellent.
Very good.
Good.
Fair.
Poor.
Refuse.
Don’t know.
Do you have any physical disabilities?
Yes.
No.
Do you have any health conditions that require you to see a doctor or take prescription drugs regularly?
Yes.
No.
Demographics:
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)______________________.
Refuse.
Don’t know.
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 | New Enrollee Survey |
| Subject | New Enrollee Collection Instrument |
| Author | CMS/OEA/CSG/DoR |
| Last Modified By | CMS |
| File Modified | 2009-05-27 |
| File Created | 2009-05-27 |