Form CMS-10437 - GenIC# CMS-10437 - GenIC# Medicare Beneficiary Consumer Survey

PRA Disclosure Statement

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 information collection is 0938-1247.  The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review 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.  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Allyssa Allen at 410-786-8436 or [email protected].

I am calling on behalf of Medicare from an independent research company called _____. We are conducting a survey with Medicare beneficiaries such as yourself to understand your experience with the program. Your opinion is very important in helping to improve how Medicare serves its beneficiaries. Your responses will be kept completely confidential and at no time, now or in the future, will we attempt to sell you anything or share your information with anyone.

This interview will only take about 15 minutes of your time. Let’s begin.

SCREENING QUESTIONS

SG1. Have you or any member of your household or immediate family ever worked for the Social Security Administration or the Centers for Medicare & Medicaid Services, formerly known as the Health Care Financing Administration?

1	Yes [Terminate]
2	No
-1	Don’t know [Terminate]
-2	Refused [Terminate]

ING1. Do you currently have health insurance through Medicare, including through a Medicare health plan (also called Medicare Advantage)?

1	Yes
2	No [Terminate]
-1	Don’t know [Terminate]
-2	Refused [Terminate]

DG2. In what year were you born? (Open end; age is computed)

1	Under 65 [If ING1=2 and DG2 = 1, Terminate]
2	65-66
3	67-80
4	81 + [Terminate]
-2	Refused [Terminate]

HSG1. Do you have any medical or health-related disabilities?

1	Yes
2	No [Terminate if DG2= 1]
-1	Don’t know
-2	Refused

ING2. What best describes the health insurance you have to cover your hospital expenses or doctor visits? Do you have:

1	Original Medicare, sometimes called Fee for Service or Medicare Parts A and B
2	A Medicare HMO or PPO plan, also known as Medicare Advantage (these plans are sold by private insurance companies)
-1	Don’t know [Terminate if also DK or Ref at ING1]
-2	Refused [Terminate if also DK or Ref at ING1]

ING9. With your Medicare plan, can you see any doctor you choose for no additional cost, or must you choose doctors from the plan’s list?

1	I can go to any doctor
2	I must choose a doctor from a list [Skip to ING7]
-1	Don’t know [Skip to ING7]
-2	Refused [Skip to ING7]

ING7. Do you also have other health insurance in addition to your Medicare?

1	Yes
2	No [Skip to BP1]
-1	Don’t know
-2	Refused

ING7a. [ASK IF ING7=1 or -1] What other health insurance do you have in addition to your Medicare? (Please select all other health insurance coverage that you have)

1	Medicare supplement, sometimes called Medigap and sold through private health insurance companies
2	Medicaid or State health insurance [LIST STATE MEDICAID NAME]
3	Coverage through you or your spouse’s current employer or union
4	Retiree coverage through you or your spouse’s former employer or union
5	VA or veterans’ health insurance
6	Tri-care or Military health insurance
7	A health plan through the Health Insurance Marketplace (Healthcare.gov)
8	I don’t have any of these
9	Other (Specify)
-1	Don’t know
-2	Refused

BP1. Does your primary doctor require you to coordinate all of your care through his or her office, including specialist visits and hospitalizations?

1	Yes
2	No
-1	Don’t know
-2	Refused

ING7b. Do you currently have insurance for prescription drugs?

1	Yes
2	No [Skip to ISG1a]
-1	Don’t know [Skip to ISG1a]
-2	Refused [Skip to ISG1a]

ING7c. [Ask if ING7b = 1] What kind of insurance do you have for prescription drugs?

1	A separate Medicare Part D drug plan
2	A drug plan that is included in my Medicare Advantage plan
3	A drug plan that is included in my Medigap or supplemental plan
4	Other (Specify)
-1	Don’t know
-2	Refused

BRAND CONTACT

ISG1a. How satisfied would you say you are with Medicare or your Medicare health plan?

1	Extremely satisfied
2	Somewhat satisfied
3	Somewhat dissatisfied
4	Extremely dissatisfied
-1	Don’t know
-2	Refused

INFORMATION RESOURCES

BG10a. Each fall, Medicare sends out a Handbook of information called Medicare & You. Do you recall receiving this Handbook?

1	Yes
2	No [Skip to AWG7a]
-1	Don’t know [Skip to AWG7a]
-2	Refused [Skip to AWG7a]

ISG3a. [Ask if BG10a=1] The last time you received it, how much of the Handbook did you read?

1	None of it
2	A little of it
3	Some of it
4	Most or all of it
-1	Don’t know
-2	Refused

ISG3b. [Ask if ISG3a=1] What is the main reason that you did not read the Handbook this year? (Select one)

1	I can’t find the information I need in the Handbook
2	The information in the Handbook is confusing
3	The information in the Handbook doesn’t apply to me
4	I file it to read later if I have a question
5	My health plan sends me the information I need
6	It is not necessary to read the Handbook
7	I prefer to go to the Medicare website for information
8	Someone else takes care of this for me
9	Other (Specify)
-1	Don’t know
-2	Refused

ISG1b. [Ask if ISG3a ~=1] How satisfied are you with the information you found in the Medicare & You Handbook?

1	Extremely satisfied
2	Somewhat satisfied
3	Somewhat dissatisfied
4	Extremely dissatisfied
-1	Don’t know
-2	Refused

AWG7a. Were you aware that there is a 1-800 number you can call if you have questions about Medicare?

1	Yes
2	No [Skip to AWG7b]
-1	Don’t know [Skip to AWG7b]
-2	Refused [Skip to AWG7b]

BG10b. Have you ever called Medicare’s 1-800 number for any reason?

1	Yes
2	No [Skip to AWG7b]
-1	Don’t know [Skip to AWG7b]
-2	Refused [Skip to AWG7b]

ISG1c. [Ask if BG10b=1] How satisfied were you with your experience when you called Medicare’s 1-800 number?

1	Extremely satisfied
2	Somewhat satisfied
3	Somewhat dissatisfied
4	Extremely dissatisfied
-1	Don’t know
-2	Refused

AWG7b. Were you aware that there is a Medicare Beneficiary Ombudsman who can help you with Medicare-related complaints, grievances, and information requests?

1	Yes
2	No [Skip to AWG7c]
-1	Don’t know [Skip to AWG7c]
-2	Refused [Skip to AWG7c]

BG10c. Have you ever contacted the Medicare Beneficiary Ombudsman for any reason?

1	Yes
2	No [Skip to AWG7c]
-1	Don’t know [Skip to AWG7c]
-2	Refused [Skip to AWG7c]

ISG1d. [Ask if BG10c=1] How satisfied were you with your experience when you contacted the Medicare Beneficiary Ombudsman?

1	Extremely satisfied
2	Somewhat satisfied
3	Somewhat dissatisfied
4	Extremely dissatisfied
-1	Don’t know
-2	Refused

AWG7d. Were you aware that people with Medicare and their families can get free, local, personalized help and information to answer questions about Medicare through counselors that are sometimes called State Health Insurance Program or SHIP counselors?

1	Yes
2	No [Skip to AWG7]
-1	Don’t know [Skip to AWG7]
-2	Refused [Skip to AWG7c]

BG10d. [Ask if AWG7d=1] Have you ever contacted or received free, local, personalized help or information from a State Health Insurance Program or SHIP counselor for any reason?

1	Yes
2	No [Skip to AWG7e]
-1	Don’t know [Skip to AWG7e]
-2	Refused [Skip to AWG7e]

ISG1e. [Ask if BG10d=1] How satisfied were you with your experience when you contacted the State Health Insurance Assistance Program or SHIP counselor?

1	Extremely satisfied
2	Somewhat satisfied
3	Somewhat dissatisfied
4	Extremely dissatisfied
-1	Don’t know
-2	Refused

AWG7e. Were you aware that Medicare has regional offices where Medicare beneficiaries can get information about Medicare, as well as information about local seminars and health fairs?

1	Yes
2	No [Skip to AWG7f]
-1	Don’t know [Skip to AWG7f]
-2	Refused [Skip to AWG7f]

BG10e. Have you ever contacted a Medicare regional office for any reason?

1	Yes
2	No [Skip to AWG7f]
-1	Don’t know [Skip to AWG7f]
-2	Refused [Skip to AWG7f]

ISG1f. [Ask if BG10e=1] How satisfied were you with your experience when you contacted the Medicare regional office?

1	Extremely satisfied
2	Somewhat satisfied
3	Somewhat dissatisfied
4	Extremely dissatisfied
-1	Don’t know
-2	Refused

ISG2. If you had questions about your Medicare coverage, how would you find answers? (Choose all that apply)

1	The Medicare & You Handbook
2	Medicare’s 1-800 number
3	Free, local, personalized help from a SHIP counselor
4	The Medicare.gov website
5	My doctor or health care provider
7	The Internet
8	My employer or former employer
9	My local health department
10	The Social Security Administration
11	A senior center or department on aging
12	The local library
13	Friends or family members
14	Other (Specify)
-1	Don’t know
-2	Refused

ISG6. How much do you agree or disagree with the following statements:

A good way to reach me with notices and updates from Medicare is through…

	Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree	DK	REF
U.S. Mail	1	2	3	4	-1	-2
Email	1	2	3	4	-1	-2
Telephone call	1	2	3	4	-1	-2
Cell phone text messages	1	2	3	4	-1	-2
MyMedicare.gov	1	2	3	4	-1	-2

BRAND PERCEPTIONS

PG9. Please indicate how much you agree or disagree with the following statements about Medicare.

	Completely agree	Somewhat agree	Somewhat disagree	Completely disagree	Don’t know
Medicare is your health care partner	1	2	3	4	-1
Your life is better than it would be if you were not on Medicare	1	2	3	4	-1
Medicare is an organization you can trust	1	2	3	4	-1
Medicare provides resources to help you understand your health insurance choices	1	2	3	4	-1
Medicare is only there to help pay your medical bills	1	2	3	4	-1
Medicare provides resources to help you understand your choices when it comes to hospitals	1	2	3	4	-1
Information sent to you directly from Medicare does a good job of explaining your medical benefits	1	2	3	4	-1
Information sent to you directly from Medicare uses language that you can understand	1	2	3	4	-1

PG9. Please indicate how much you agree or disagree with the following statements about Medicare and your doctors.

	Completely agree	Somewhat agree	Somewhat disagree	Completely disagree	Don’t know
Medicare should collect information from doctors to measure the quality of care they provide	1	2	3	4	-1
Medicare should collect information from doctors to measure how well they communicate with their patients about their care	1	2	3	4	-1
Medicare should collect information from doctors to measure how healthy their patients are	1	2	3	4	-1
In addition to paying doctors for providing visits and services, Medicare should pay doctors extra for keeping their patients healthy	1	2	3	4	-1
It is important for you to know the value of gifts and incentives that your doctor receives from industry groups, such as drug companies	1	2	3	4	-1

KG6. Is the following statement true or false: In the next few years, all Medicare beneficiaries will be receiving new Medicare cards with new Medicare ID numbers?

1	True
2	False
-1	Don’t know
-2	Refused

PG6. Based on your experience, what is your overall opinion of the following organizations?

	Not at all favorable	Not too favorable	Somewhat favorable	Very favorable	Don’t know
Social Security	4	3	2	1	-1
United States Postal Service	4	3	2	1	-1
Medicare	4	3	2	1	-1
AARP (American Association of Retired Persons)	4	3	2	1	-1
Blue Cross Blue Shield	4	3	2	1	-1
The Centers for Medicare and Medicaid Services, also known as CMS	4	3	2	1	-1

YOUR HEALTH/PREVENTIVE CARE

BG3. In the past year, about how many times did you see a doctor – either for a check-up or for some type of treatment or exam?

1	None
2	1-2 visits
3	3-5 visits
4	6 or more visits
-1	Don’t know
-2	Refused

KG7. To the best of your knowledge, which of the following types of services does Medicare pay for (so they are at no cost to you)?

	Yes	No	DK
Preventive services, including screenings for different diseases	1	2	-1
A physical exam when you first join Medicare	1	2	-1
Counseling to quit smoking	1	2	-1
Shots for things like the flu or pneumonia	1	2	-1
Diabetes self-management training	1	2	-1

BG3. Have you had any of the following types of tests within the past five years?

	Yes	No	DK
Bone mass measurement	1	2	-1
Cardiovascular or cholesterol screening	1	2	-1
Colonoscopy or stool test	1	2	-1
Blood sugar testing	1	2	-1
Glaucoma test	1	2	-1
[ASK ONLY OF WOMEN] Pap test or Pap smear	1	2	-1
[ASK ONLY OF WOMEN] Mammogram or breast cancer screening	1	2	-1
[ASK ONLY OF MEN] Prostate cancer screening	1	2	-1

HSG3. Compared to other people who are the same age as you, do you consider your health to be:

1	Excellent
2	Good
3	Fair
4	Poor
-1	Don’t know
-2	Refused

HSG2. Do you currently have any chronic health conditions that require ongoing care? (for example arthritis, chronic pain, high blood pressure, heart disease, or similar conditions)

1	Yes
2	No
-1	Don’t know
-2	Refused

INTERNET, ERESOURCES, QUALITY

IUG4. How often do you access the Internet either on your own or with someone else’s help?

1	Daily or almost daily
2	Once or twice a week
3	Once or twice a month
4	A few times a year
5	Never [Skip to BG10i]
-1	Don’t know
-2	Refused

IUG21. Have you ever used the Internet for the following activities?

	Yes	No	DK
Used Twitter, Facebook, Linked-In or any other social networking websites?	1	2	-1
Listened to a podcast?	1	2	-1
Watched videos on the Internet or on YouTube?	1	2	-1
Looked up information on Wikipedia or other wiki pages?	1	2	-1
Read blogs	1	2	-1
Looked up information on a search engine, like Google or Yahoo	1	2	-1
Bought something from an online store	1	2	-1
Paid bills or done personal banking	1	2	-1
Accessed or managed your personal health information	1	2	-1

AWG7f. Were you aware that there is a website where you can get information about Medicare called Medicare.gov?

1	Yes
2	No [Skip to AWG7g]
-1	Don’t know [Skip to AWG7g]
-2	Refused [Skip to AWG7g]

BG10f. Have you ever visited Medicare.gov?

1	Yes
2	No [Skip to AWG7g]
-1	Don’t know [Skip to AWG7g]
-2	Refused [Skip to AWG7g]

ISG1g. [Ask if BG10f=1] How satisfied were you with your experience when you visited Medicare.gov?

1	Extremely satisfied
2	Somewhat satisfied
3	Somewhat dissatisfied
4	Extremely dissatisfied
-1	Don’t know
-2	Refused

AWG7g. Were you aware that Medicare has a free, secure online service called MyMedicare.gov where beneficiaries can access personalized information about their Medicare benefits and services?

1	Yes
2	No [Skip to ISG2]
-1	Don’t know [Skip to ISG2]
-2	Refused [Skip to ISG2]

BG10f. Do you have an account with MyMedicare.gov?

1	Yes
2	No [Skip to BG8a]
-1	Don’t know [Skip to BG8a]
-2	Refused [Skip to BG8a]

BG10g. Have you ever logged into your account and used MyMedicare.gov?

1	Yes
2	No [Skip to BG8a]
-1	Don’t know [Skip to BG8a]
-2	Refused [Skip to BG8a]

ISG1g. [Ask if BG10g=1] How satisfied were you with your experience with MyMedicare.gov?

1	Extremely satisfied
2	Somewhat satisfied
3	Somewhat dissatisfied
4	Extremely dissatisfied
-1	Don’t know
-2	Refused

BG8a. How likely would you be to sign up for an account or use MyMedicare.gov if you knew that you could go online to access your Medicare Summary Notices (MSNs) monthly, instead of waiting to receive them quarterly in the mail?

1	Very likely
2	Somewhat likely
3	Not very likely
4	Not at all likely
-1	Don’t know
-2	Refused

BG8c. If you knew that this was an option for you, how likely would you be to opt out of receiving a hard copy of the Medicare & You Handbook in the mail and opt in to receiving an email link to the Handbook online each time it is updated?

1	Very likely
2	Somewhat likely
3	Not very likely
4	Not at all likely
-1	Don’t know
-2	Refused

BG8b. How likely would you be to sign up for an account or use MyMedicare.gov if you knew that you could go online to download the most up-to-date version of the Medicare & You Handbook?

1	Very likely
2	Somewhat likely
3	Not very likely
4	Not at all likely
-1	Don’t know
-2	Refused

BG8d. [Ask if MA or Medicare + Medicaid] When it comes to the following resources, would you prefer to receive them in the mail or online?

	In the Mail	Online	DK	REF
Annual doctor or provider directory	1	2	-1	-2
Annual health plan handbook	1	2	-1	-2
Claims statements	1	2	-1	-2

If you knew that this was an option for you, how likely would you be to opt out of receiving a hard copy of the Medicare & You Handbook in the mail and opt in to receiving an email link to the Handbook online each time it is updated?

1	Very likely
2	Somewhat likely
3	Not very likely
4	Not at all likely
-1	Don’t know
-2	Refused

AWG7h. Were you aware that Medicare has a Facebook page?

1	Yes
2	No [Skip to AWG2a]
-1	Don’t know [Skip to AWG2a]
-2	Refused [Skip to AWG2a]

BG10h. Have you ever visited Medicare’s Facebook page?

1	Yes
2	No
-1	Don’t know
-2	Refused

AWG2a. Have you seen or heard of any of the following web sites that show how well hospitals and health care facilities care for their patients?

	Yes	No	DK
Hospital Compare, on Medicare’s website	1	2	-1
Nursing Home Compare, on Medicare’s website	1	2	-1
HealthGrades.com	1	2	-1
The Leapfrog Group hospital ratings	1	2	-1

BG10i. Have you, or someone who helps you use the internet, ever looked up quality ratings for a hospital?

1	Yes
2	No [Skip to ISG2]
-1	Don’t know [Skip to ISG2]
-2	Refused [Skip to ISG2]

BG10j. In the past year, have you ever asked a doctor or other health professional about the quality of the different hospitals in your area?

1	Yes
2	No [Skip to ISG2]
-1	Don’t know [Skip to ISG2]
-2	Refused [Skip to ISG2]

PG8. Medicare is considering allowing Medicare beneficiaries to provide ratings of their doctors, health professionals, and health insurance and displaying those ratings on websites designed to help people choose or find doctors, health professionals, and health plans. How useful do you think this type of information would be?

1	Very useful
2	Somewhat useful
3	Not very useful
4	Not at all useful
-1	Don’t know
-2	Refused

SEGMENTATION

PG7. How confident are you that you can identify when it is necessary for you to get medical care?

1. Very confident

2. Somewhat confident

3. Not very confident

4. Not at all confident

-1 Don’t know

-2 REF

BG3. How frequently do you bring to your doctor visits a list of questions or concerns you want to cover?

1. Always

2. Usually

3. Sometimes

4. Never

5. Not applicable

6. DK

7 REF

DEMOGRAPHICS

DG12. What is the five-digit zip code of your primary residence (where you live at least six months out of each year)? (Open end) [to be asked earlier for quota/skips]

DG13. In what state is your primary residence (where you live at least six months out of each year)? (Pull down) [to be asked earlier for quota]

DG1. What is your gender? [to be asked earlier for quota/skips]

1	Male
2	Female
-2	Refused

DG5. What is the highest level of education that you have completed?

1	Less than high school
2	High school graduate
3	Some college
4	Vocational, technical school, associate’s degree
5	College graduate (Bachelor’s)
6	Postgraduate (Master’s, PhD, JD, MD)
-1	Don’t know
-2	Refused

DG3 Are you Hispanic or Latino?

1	Yes
2	No
-1	Don’t know
-2	Refused

DG4. What is your race?

1	White
2	Black or African American
3	Asian
4	American Indian or Alaska Native
5	Native Hawaiian or other Pacific Islander
6	Other (Specify)
-1	Don’t know
-2	Refused

DG6. What is your current marital status?

1	Married and living with spouse
2	Divorced
3	Separated
4	Widowed
5	Single, never married
-2	Refused

DG10. What is our household’s total annual income before taxes?

1	Less than $10,000
2	$10,000 to $15,999
3	$16,000 to $20,999
4	$21,000 to $24,999
5	$25,000 to $34,999
6	$35,000 to $49,999
7	$50,000 to $74,999
8	$75,000 or more
-1	Don’t know
-2	Refused