Word Version of Questionnaire

WELCOME The National Center for Health Statistics (NCHS), part of the Centers for Disease Control and Prevention, is conducting a study and we need your help. We are testing survey questions about health insurance, and your responses will show us how to improve the wording of these questions.

This should take about 10 minutes or less to complete. Click the “Next” button below to begin.

CONS-SM Form approved

OMB No. 0920- 0222

Exp. Date 06/30/2015

Your confidentiality is protected consistent with SurveyMonkey policies. Your privacy is important to us. SurveyMonkey is a well-known company that collects data for online research, and uses the most advanced technology for internet security that is commercially available today. This survey is encrypted to reduce the risk of responses being viewed by unauthorized persons. The security of information transmitted through the internet cannot be guaranteed.

NCHS promises not to release or share any information that could identify you, and we will only use your answers for statistical research. We do not collect identifying information such as your name or address. Email addresses and IP addresses are used for survey management only.

Taking part in this research is voluntary. You may choose not to answer any question you don’t wish to answer, or exit the survey at any time with no impact on the benefits you may receive. There are no direct benefits if you choose to take part in this survey.

If you have any questions you may contact us at [email protected].

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of the collection of this information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

CONS-NHCIS Form approved

OMB No. 0920- 0222

Exp. Date 06/30/2015

Your confidentiality is protected consistent with SurveyMonkey policies. Your privacy is important to us. SurveyMonkey is a well-known company that collects data for online research, and uses the most advanced technology for internet security that is commercially available today. This survey is encrypted to reduce the risk of responses being viewed by unauthorized persons. The security of information transmitted through the internet cannot be guaranteed.

NCHS promises not to release or share any information that could identify you, and we will only use your answers for statistical research. Answers to these questions may be compared to your answers to previous questions.

Taking part in this research is voluntary. You may choose not to answer any question you don’t wish to answer, or exit the survey at any time with no impact on the benefits you may receive. There are no direct benefits if you choose to take part in this survey. The possible risks of taking part in this survey are minimal.

If you have any questions you may contact us at [email protected].

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of the collection of this information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

SCREENER Are you 18 years of age or older?

• Yes

• No [skip to DISQUAL]

The following questions are about general terms and concepts related to health insurance.

TEST1 Which word or term best describes the flat fee that an individual pays for each doctor’s visit or other health care service?

• Deductible

• Rider

• Premium

• Co-payment

• Not sure

• Prefer not to answer

TEST2 Which word or term below best describes the amount that an individual must pay each year before his or her health insurance begins paying for services?

• Deductible

• Rider

• Premium

• Co-payment

• Not sure

• Prefer not to answer

TEST3 Have you ever heard the term “health insurance premium”?

• Yes

• No [skip to TEST5]

• Not sure

• Prefer not to answer

TEST4 A health insurance premium is what a person has to pay…

• At each doctor's visit

• After insurance pays its part of the cost of health care services

• Each month or year to have health insurance

• To get the best coverage a health insurance company offers

• Not sure

• Prefer not to answer

TEST5 A health insurance subsidy is… (Please mark all that apply)

• A benefit for people below a certain income

• A benefit given by some employers

• A tax some people pay

• A charge people pay for doctor’s visits

• Not sure

• Prefer not to answer

TEST6 If a family's health insurance premium is "subsidized based on income," that means that the premium amount the family has to pay depends on… (Please mark all that apply)

• The type of medical services the family receives

• The family's income

• How healthy the family is

• What type of health insurance plan the family buys

• The size of the health insurance company

• Not sure

• Prefer not to answer

TEST7 Have you ever compared health insurance policies to decide which one to choose?

• Yes

• No

• Not sure

• Prefer not to answer

The next questions are about terms used to describe health insurance offered as part of the Affordable Care Act.

TEST8 Have you heard of the Health Insurance Marketplace and/or exchange(s)?

• Yes

• No [skip to TEST10]

• Not sure

• Prefer not to answer

TEST9 The Health Insurance Marketplace or exchange is…

• Where medical providers share ideas

• Where people and employers can buy health insurance policies

• Where people can appeal medical bill charges

• Where health insurance companies trade policies

• Not sure

• Prefer not to answer

TEST10 Have you heard of the website www.healthcare.gov?

• Yes

• No [skip to TEST13]

• Not sure [skip to TEST13]

• Prefer not to answer [skip to TEST13]

TEST11 Have you visited the website www.healthcare.gov?

• Yes

• No [skip to TEST13]

• Not sure [skip to TEST13]

• Prefer not to answer [skip to TEST13]

TEST12 When you visited www.healthcare.gov, were you looking for information about… (Please mark all that apply)

• Where to buy insurance from the federal government

• Where to buy insurance from my state

• Where to buy insurance directly from a health insurance company

• How to get Medicaid

• How to get Medicare

• How to apply for the Children’s Health Insurance Program (CHIP)

• General facts about new health insurance programs

• How much insurance will cost me in 2014

• What kind of health care coverage I can choose from

• Nothing specific, just looking

• Not sure

• Prefer not to answer

TEST13 When did you visit www.healthcare.gov? (Please mark all that apply)

• Between June 1 and September 30, 2013

• On or after October 1, 2013

• Not sure

• Prefer not to answer

TEST14 Have you looked into purchasing insurance coverage through the Health Insurance Marketplace or exchange?

• Yes

• No [skip to TEST15]

• Not sure [skip to TEST15]

• Prefer not to answer [skip to TEST15]

TEST15 Where did you hear about purchasing insurance coverage through the Health Insurance Marketplace or exchange? (Please mark all that apply)

• www.healthcare.gov or my state's website

• Newspapers, TV reports or commercials, billboards, magazines

• Social networking sites like Facebook or Twitter

• Mailed information

• Direct marketing calls

• Community worker going door to door

• Community events or meetings

• Family member(s)

• Friend(s)

• School or work

• Somewhere else

• Not sure

• Prefer not to answer

TEST16 Since October 1, 2013, have you tried to apply for any type of health insurance using an online or electronic form?

• Yes

• No [skip to TEST19]

• Not sure [skip to TEST19]

• Prefer not to answer [skip to TEST19]

TEST17 Was this online or electronic form an application for insurance coverage through the Health Insurance Marketplace or exchange set up as part of the Affordable Care Act?

• Yes

• No

• Not sure

• Prefer not to answer

TEST18 Did you get help from anyone to fill out the application for insurance coverage through the Health Insurance Marketplace or exchange?

• Yes

• No [skip to TEST19]

• Not sure [skip to TEST19]

• Prefer not to answer [skip to TEST19]

TEST19 Who helped you fill out the application for insurance coverage through the Health Insurance Marketplace or exchange? (Please mark all that apply)

• Family member

• Friend

• Assister, navigator, or certified application counselor provided through the Affordable Care Act

• Community worker or local assistance organization

• Teacher, counselor, or parole officer

• Someone at a place of worship

• Staff at a Women, Infants, and Children (WIC), Temporary Assistance for Needy Families (TANF), or Medicaid program office

• Not applicable - I did not fill out an application for the health insurance marketplace or state exchange

• Not sure

• Prefer not to answer

• Other (please specify) _________________________

TEST20 Have you heard of government services to help people fill out application for insurance coverage through the Health Insurance Marketplace or exchange as part of the Affordable Care Act?

• Yes

• No

• Not sure

• Prefer not to answer

Next you will see some statements about the Affordable Care Act. For each statement, please mark if it is true or false.

TEST21 The Affordable Care Act provides financial help to low- and moderate-income Americans who don't get insurance through their jobs to help them purchase coverage.

• True

• False

• Not sure

• Prefer not to answer

TEST22 The Affordable Care Act gives states the option of expanding their existing Medicaid program to cover more low-income, uninsured adults.

• True

• False

• Not sure

• Prefer not to answer

TEST23 The Affordable Care Act cuts benefits for people in the traditional Medicare program.

• True

• False

• Not sure

• Prefer not to answer

TEST24 The Affordable Care Act creates a new government-run insurance plan to be offered along with private plans?

• True

• False

• Not sure

• Prefer not to answer

TEST25 The Affordable Care Act enables Americans to get preventive services (such as mammograms or colonoscopies) free of charge.

• True

• False

• Not sure

• Prefer not to answer

TEST26 The Affordable Care Act provides tax subsidies and tax credits to reduce the amount Americans have to pay for their health insurance.

• True

• False

• Not sure

• Prefer not to answer

TEST27 The goal of the new Premium Assistance Tax Credit is to make health insurance purchased through the Health Insurance Marketplace or exchange more affordable. Which of the statements about this new tax credit are true? (Please mark all that apply)

• The tax credit is available immediately upon enrollment in an eligible insurance plan

• If a family's income goes up after applying for the tax credit, they may have to repay some or all of the credit amount

• Higher-income families get a larger tax credit than lower-income families

• The tax credit does not apply to families with employer-based health insurance

• If a family takes the tax credit when they enroll in an eligible insurance plan, the IRS sends the money directly to their health insurance company

• Not sure

• Prefer not to answer

You're almost finished with the survey! This last section asks you for some basic demographic information.

TEST28 What is your gender?

• Male

• Female

• Not sure

• Prefer not to answer

TEST29 Which age group do you fall into?

• 18 to 25

• 26 to 35

• 36 to 45

• 46 to 55

• 56 to 64

• 65 or over

• Not sure

• Prefer not to answer

TEST30 What is your marital status?

• Single, never married

• Married

• Not married, living with a partner

• Divorced or separated

• Widowed

• Not sure

• Prefer not to answer

TEST31 What is the highest level of education you completed?

• Some high school

• High school graduate or GED

• Some college

• Associate's degree - Occupational/vocational program

• Associate's degree - Academic program

• Bachelor’s degree

• Master’s degree

• Doctorate or other professional degree

• Not sure

• Prefer not to answer

TEST32 Are you currently employed?

• Yes

• No

• Not sure

• Prefer not to answer

TEST33 What type of health insurance coverage do you have? (Please mark all that apply)

• Private, through my employer or union

• Private, other

• Medicaid

• Medicare

• Military (TRICARE, VA)

• Children’s Health Insurance Program (CHIP)

• Some other type of health care coverage

• No coverage of any type

• Not sure

• Prefer not to answer

ENDSURMO Those are all the questions we have. Thank you for the time and effort you’ve spent answering our survey.

If you have any questions about this survey, you may email us at [email protected].

ENDNHCIS Those are all the questions we have. Thank you for the time and effort you’ve spent answering our survey.
If you have any questions about this survey, you may email us at [email protected].

If you have questions about your rights as a survey participant, you may call the chairperson of the NCHS Research Ethics Review Board at 1-800-223-8118 and say you are calling about protocol 0920-0222.

DISQUAL You must be 18 or older in order to participate. Thank you for your time.