CS-10-214C- COMPLIANCE CENTER EXAMINATION; CS-10-233- TO MEASURE SATISFACTION OF TAX PROFESSIONALS SB/SE ; CS-10-234- National Research Program; CS-10-235- HCTC Participant ; CS-236 ; CS-10-237

QUESTIONNAIRE FOR THE HCTC SUPPLEMENTAL

CUSTOMER SATISFACTION SURVEY CY2010 1545-1432

Intro:

Hello, I’m calling from XCompany, an independent national survey research firm. Our records show [Respondent Name] is enrolled in the IRS Health Coverage Tax Credit program, or has been enrolled during the past year, and that he/she participated in a survey on the program a few months ago.

May I please speak with [Respondent Name]?

We’d like to ask you a few follow-up questions related to the health coverage options available under the Health Coverage Tax Credit. We’d like to include your opinions and promise you that your identity will be held private by XCompany. The survey is voluntary and will take only a few minutes to complete. Do you have a few minutes to participate?

(if unavailable, schedule a call back)

Thank you for agreeing to participate.

There are four types of qualified health coverage under HCTC Program: (1) COBRA - continuing your insurance through your former employer; (2) State-qualified health plans - plans approved by a state’s Department of Insurance as meeting the Trade Act’s requirements; (3) Spousal coverage - where your spouse has employer-sponsored coverage, and the spouse pays more than 50% of the cost; and (4) Individual/non-group coverage - an individual insurance policy started more than 30 days before leaving your job.

1. At the time you first learned of the HCTC Program, were you aware of the health coverage options available to you?

(yes or no)

2. When you first enrolled in the HCTC Program, which of the following qualified health coverage options were available to you? (Answer for all applicable)

- COBRA thru your former employer

- your state’s state-qualified health plan

- health plan thru your spouse’s employer

- individual, non-group health plan

3. What was your opinion of the health coverage option/s available to you?

(open ended - useful for anecdotal evidence)

If participant gave multiple answers for Q2, continue with survey. If participant only had one option, end survey here.

4. Did you research the various coverage options available to you?

4a. (yes or no - if no, prompt “why not?”)

5. On a scale of 1-5, where 5 is “very satisfied,” 3 is “neither satisfied nor dissatisfied,” and 1 is “very dissatisfied,” how satisfied were you with the available health coverage options?

5a. (4/5 “why?” or 1/2 “why not?”)

6. Using the same scale of 1-5, how satisfied were you with the range of premiums and out of pocket costs, like deductibles and co-pays, available to you?

7. Using the same scale of 1-5, how satisfied were you with the range of benefits and provider networks available to you?

Closing: Those are all the questions I have. We are required by law to report to you the Management and Budget Control Number for this public information request. That number is 1545-1432.

.In addition, if you have any comments about the time estimate to complete the survey or ways to improve the survey, you may write to the IRS. Would you like that address?

(If yes, address is):

Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP

1111 Constitution Ave, NW

Washington, DC 20024

Again this is _______, with XCompany on behalf of the IRS. Thank you very much for your time.