Form CMS-10488 English - Marketplace Survey

Health Insurance Marketplace Survey

Language: English

Reference Period: Since October 1, 2013

Each item has been labeled to indicate the domain, construct source, and CAHPS or other survey indicator for this review process; the lists below provide the abbreviations used. For example, if a question is labeled: (IS/F,T/HP5-AM-m1), it means this question is from the Information Seeking domain, the construct came from the Focus Groups and Technical Expert Panel, and the question wording is a modified version of the CAHPS Health Plan 5.0 Adult Medicaid Question #1. The headings in this survey are meant for respondent navigation, not domain headings.

Marketplace Domain Name

AP=Application Process

TC=Premium Tax Credit Eligibility

IS=Information Seeking

CuC=Cultural Competence

EP=Health Plan Enrollment Process

GR=Global Ratings

CM=Case Mix Adjusters

RC=Respondent Characteristics

SP=Specialized Services

All the questions have a domain label.

Construct Source

L=Lit Review

F=Focus Groups

S=Stakeholder Interviews

T=Technical Expert Panel

C=Centers for Medicare & Medicaid Services

CI1=Cognitive Interview Round 1

CI2=Cognitive Interview Round 2

OMB60 = OMB 60 Day Comment Period

OMB30 = OMB 30 Day Comment Period

Questions that don’t have a construct source were included because they came from the CAHPS Health Plan 5.0 survey. For example, we included global ratings and case mix adjuster questions because they are a CAHPS convention.

Survey Indicator

HP5-AM-Q# = CAHPS Health Plan 5.0, Adult Medicaid, Question #

https://cahps.ahrq.gov/surveys-guidance/docs/2152a_engadultmed_50.pdf

HP5-AM-mQ# = CAHPS Health Plan 5.0, Adult Medicaid, modified Question #

https://cahps.ahrq.gov/surveys-guidance/docs/2152a_engadultmed_50.pdf

HP4-AS-mQ# = CAHPS Health Plan 4.0, Adult Supplemental, modified Question #

https://cahps.ahrq.gov/surveys-guidance/docs/1157a_engadultsupp_40.pdf

HP5-AS-mQ# = CAHPS Health Plan 5.0, Adult Supplemental, modified Question #

These are new CAHPS questions that are not in public documentation yet.

CG2-AS-mQ# = CAHPS Clinician & Group 2.0, Adult Supplemental, modified Question #

https://cahps.ahrq.gov/surveys-guidance/docs/2312_about_cultural_comp.pdf

H-mQ = Hospital CAHPS, Modified Question #

http://www.hcahpsonline.org/files/HCAHPS%20V8.0%20Appendix%20A%20-%20HCAHPS%20Mail%20Survey%20Materials%20(English)%20March%202013.pdf

OMH-4302-Q# = HHS Office of Minority Health ACA Section 4302 Data Collection Standards, Question

http://minorityhealth.hhs.gov/templates/content.aspx?ID=9227&lvl=2&lvlID=208

ACS-P-Q# = American Community Survey (ACS) – Person Section - Question #

http://www.census.gov/acs/www/Downloads/questionnaires/2013/Quest13.pdf

NHBS-Q# = 2010 National HIV Behavioral Surveillance System – Question #

http://wwwn.cdc.gov/qbank/report/Ridolfo_NCHS_2011_NHBSS%20HIV.pdf

M-ACO-Q# = 2014 Medicare Provider Satisfaction Survey – Items for ACOs Participating in Medicare Initiatives – Question #

http://acocahps.cms.gov/Files/SurveyInstruments/MailSurveyEnglish.pdf

Questions that don’t have a survey indicator are new questions written for the Marketplace Survey.

Overview Marketplace survey domains

I. application process

• Gave information about the people in your family who wanted health insurance

• Reason why you did not give information about the people in your family

• Easy to give information about the people in your family

• Giving information about the people in your family took longer than expected

• Mode used to give information about the people in your family

• Told should update Marketplace about changes to income or family size

• Easy to understand how to update Marketplace about changes to income or family size

Ii. premium tax credit eligibility

• Gave information about household income

• Reason why you did not give information about household income

• Easy to find out if could get help paying for health insurance

• Giving information about household income took longer than expected

• Mode used to give information about household income

• Qualify for Medicaid

• Marketplace help paying for health insurance

• Told could appeal decision about how much have to pay for health insurance

• Told how to appeal

• Easy to understand how to appeal

Iii. information seeking on the website

• Visited the Marketplace website

• Had to wait to get what you needed because of problems on website

• Got information you needed

• Why did not get information needed

• Easy to understand the information

• What kind of information not easy to understand

• Information as helpful as you thought it should be

Iv. information seeking over the phone

• Called the Marketplace Help Line

• Got information or help you needed

• Why did not get information or help needed

• Easy to understand the information

• What kind of information not easy to understand

• As helpful as you thought they should be

• Used words or phrases you did not understand

• Spoke to a person

• Treat you with courtesy and respect

v. information seeking in-person

• Met in person with anyone from an organization that helps people get health insurance through Marketplace

• Unable to meet in person because building was not accessible for persons with disabilities

• Got information or help you needed

• Why did not get information or help needed

• Easy to understand the information

• What kind of information not easy to understand

• As helpful as you thought they should be

• Used words or phrases you did not understand

• Treat you with courtesy and respect

vI. Health Plan enrollment

• Who is covered in health plan

• Considered services covered and how much you have to pay

• Easy to understand services covered and how much you have to pay

• Try to find out which health plans had doctors or hospitals you wanted

• Easy to understand which health plans had doctors or hospitals you wanted

• Try to find out which health plans covered prescription medicines you needed

• Easy to understand which health plans covered prescription medicines you needed

• Chose a health plan through Marketplace

• Easy to choose a health plan

viI. Specialized services

• Easy to find out which health plans offer physical, occupational therapy you needed

• Easy to find out which health plans offer home health care services you needed

viiI. cultural competence

• Need interpreter

• How often got an interpreter

• Forms available in preferred language

• Forms available in preferred format, such as large print or braille

Global ratings

• Rating of information–Web

• Rating of information–Phone

• Rating of information–In-Person

• Rating of health insurance marketplace

• Recommend marketplace to friends and family

case mix adjusters

• Rating of overall health

• Age

• Sex

Respondent characteristics

• Rating of overall mental or emotional health

• Got health care 3 or more times for same condition

• Got health care 3 or more times for condition lasted for at least 3 months

• Take medicine prescribed by a doctor

• Take medicine for condition lasted for at least 3 months

• Are you deaf

• Are you blind

• Difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition

• Difficulty walking or climbing stairs

• Difficulty dressing or bathing because of a physical, mental, or emotional condition

• Education status

• Employment status

• Ethnicity

• Race

• Eligibility to get health services from Indian Health Service

• Received care at an Indian Health Service facility

• Preferred Language

• Rating of English language skills

• Covered by health insurance at any time in 2013

• Knowledge of health insurance terms

• Comfortable using the Internet

• Someone help you complete this survey

• How did someone help you complete this survey

Domain Overview Note: The Domain Overview is meant to provide a quick overview of what is measured in this survey. It is NOT meant to list hypothesized composite items. There are a mix of screener, assessment/composite, and single items listed under each domain. It also does NOT list out every item but rather is meant to cover unique constructs. For example, if there is a screener item and an assessment item that measure the same construct, then the assessment item is listed.

Introduction

We are asking you to complete this survey because you contacted the {INSERT MARKETPLACE NAME} to learn about your health insurance options since October 1, 2013. You might have used the website, sent an application by mail, called the toll free Help Line, or met with someone in person. This survey asks about your experiences with the {INSERT MARKETPLACE NAME}, also known as Obamacare or Healthcare.gov, which was created by the Affordable Care Act.

Survey Instructions

Answer each question by marking the box to the left of your answer.

You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

¹ Yes

² No  If No, go to #1

Giving Information to Learn About Your Health Insurance Options

The following questions ask about your experiences giving information to learn about your health insurance options through the {INSERT MARKETPLACE NAME} since October 1, 2013. You might have used the website, sent an application by mail, called the toll free Help Line, or met with someone in person.

1. Since October 1^st, did you give information about the people in your family, including yourself, who wanted health insurance through the {INSERT MARKETPLACE NAME}? (AP/T,CI2)

¹ Yes  If Yes, go to #3

² No

2. Were any of the following a reason why you did not give information about the people in your family, including yourself, who wanted health insurance? Mark one or more. (AP/CI2/HP4-AS-mCS1)

Did not give your information because

Go to #6

}

1. You did not have all the information they asked for ¹

2. You changed your mind and did not want to give your information ¹

3. You never intended to give your information ¹

4. There was a problem with the website ¹

5. Some other reason ¹

Please specify: _________________________________________

______________________________________________________

3. Was it easy to give information about the people in your family, including yourself, who wanted health insurance? If you did not give this information, go to #6. (AP/T,CI2)

¹ Yes, definitely

² Yes, somewhat

³ No

4. Did giving information about the people in your family, including yourself, take longer than you expected? (AP/L,S,T, CI2)

¹ Yes, definitely

² Yes, somewhat

³ No

5. How did you give information about the people in your family, including yourself? (AP/T,CI1,CI2)

¹ On the {INSERT MARKETPLACE NAME} website

² By mail

³ On the phone

⁴ In person

6. Since October 1^st, did you give the {INSERT MARKETPLACE NAME} information about your household income to see if you could get help paying for your health insurance? (TC/T)

¹ Yes  If Yes, go to #8

² No

7. Were any of the following a reason why you did not give your household income information? Mark one or more. (TC/CI2/HP4-AS-mCS1)

}

Did not give your information because

Go to #16

1. You did not have all the information they asked for ¹

2. You changed your mind and did not want to give your information ¹

3. You never intended to give your information ¹

4. There was a problem with the website ¹

5. Some other reason ¹

Please specify: _________________________________________

______________________________________________________

8. When you gave your household income information, was it easy to find out if you could get help paying for your health insurance? If you did not give this information, go to #16. (TC/T)

¹ Yes, definitely

² Yes, somewhat

³ No

9. Did giving your household income information take longer than you expected? (TC/L,S,T)

¹ Yes, definitely

² Yes, somewhat

³ No

10. How did you give your household income information? (TC/T,CI1)

¹ On the {INSERT MARKETPLACE NAME} website

² By mail

³ On the phone

⁴ In person

11. Since October 1^st, did you qualify for {INSERT STATE NAME FOR MEDICAID}, also known as Medicaid? (TC/T)

¹ Yes  If Yes, go to #13

² No

³ Don’t know

12. Since October 1^st, did the {INSERT MARKETPLACE NAME} help you pay for your health insurance? (TC/T)

¹ Yes

² No

³ Don’t know

13. To appeal means to tell someone at {INSERT MARKETPLACE NAME} that you think the decision is wrong, and ask for a fair review of the decision. Since October 1^st, were you told by {INSERT MARKETPLACE NAME} that you could appeal if you disagreed with the decision about how much you would have to pay for your health insurance? (TC/L,T)

¹ Yes

² No  If No, go to #16

14. Since October 1^st, were you told by the {INSERT MARKETPLACE NAME} how to appeal the decision? (TC/CI1)

¹ Yes

² No  If No, go to #16

15. Was it easy to understand how to appeal the decision? (TC/L,T)

¹ Yes, definitely

² Yes, somewhat

³ No

16. Since October 1^st, were you told by the {INSERT MARKETPLACE NAME} that you should update them about changes to your household income or the number of people in your family? (AP/CI1)

¹ Yes

² No  If No, go to #18

17. Was it easy to understand how to update the {INSERT MARKETPLACE NAME} about changes to your household income or the number of people in your family? (AP/CI1)

¹ Yes, definitely

² Yes, somewhat

³ No

Looking for Information on the Marketplace Website

The following questions ask about your experiences when you visited the {INSERT MARKETPLACE NAME} website since October 1, 2013.

18. Since October 1^st, did you visit the {INSERT MARKETPLACE NAME} website {INSERT MARKETPLACE URL}? (IS/T)

¹ Yes

² No  If No, go to #26

19. Since October 1^st, how often did you have to wait to get what you needed because of problems on the {INSERT MARKETPLACE NAME} website? (IS/OMB60)

¹ Never

² Sometimes

³ Usually

⁴ Always

20. Since October 1^st, how often did you get the information you needed from the {INSERT MARKETPLACE NAME} website? (IS/F,T/HP4-AS-mPW2)

¹ Never

² Sometimes

³ Usually

⁴ Always If Always, go to #22

21. Were any of the following a reason why you did not get the information you needed from {INSERT MARKETPLACE NAME} website? Mark one or more. (IS/F,T/HP4-AS-mCS1)

Did not get the

information because

1. You could not find the information you needed ¹

2. The information was hard to understand ¹

3. The website was confusing ¹

4. It was hard to find out how to get help ¹

5. The website was too complicated ¹

6. The information the website gave you was wrong ¹

7. The information was not in the language you prefer ¹

8. The website did not work well with the special equipment
   or software you use because of a disability ¹

9. Some other reason ¹

Please specify:

22. Since October 1^st, how often was it easy to understand the information on the {INSERT MARKETPLACE NAME} website? (IS/L,S,T/HP4-AS-mPW3)

¹ Never

² Sometimes

³ Usually

⁴ Always  If Always, go to #24

23. What kind of information on the {INSERT MARKETPLACE NAME} website was not easy to understand? Mark one or more. (IS/L,S,T/HP4-AS-mPW4)

Not easy to understand

1. How to get help paying for your health insurance ¹

2. Important deadlines ¹

3. Benefits and coverage for doctor or specialist visits ¹

4. Benefits and coverage for prescription drugs ¹

5. Benefits and coverage for prenatal care or childbirth ¹

6. How much you would have to pay for each health plan ¹

7. How much you would have to pay out-of-pocket for

health care services in each health plan ¹

8. Which doctors are in each health plan ¹

9. What you would have to pay if you used a doctor outside

of the health plan ¹

10. How to figure out your family size or income ¹

11. Which doctors in each health plan have offices that are

accessible for people with disabilities ¹

12. How to find a health plan that meets your family’s needs ¹

13. Something else ¹

Please specify:

24. Since October 1^st, how often was the information on the {INSERT MARKETPLACE NAME} website as helpful as you thought it should be? (IS/F,T/CG2-AC-m24)

¹ Never

² Sometimes

³ Usually

⁴ Always

25. We want to know your rating of the {INSERT MARKETPLACE NAME} website, {INSERT MARKETPLACE URL}, that you visited since October 1, 2013. Using any number from 0 to 10, where 0 is the worst website possible and 10 is the best website possible, what number would you use to rate the {INSERT MARKETPLACE NAME} website? (GR/HP5-AM-m26)

0 Worst website possible

1

2

3

4

5

6

7

8

9

10 Best website possible

Getting Information over the Phone

The following questions ask about your experiences when you called the {INSERT MARKETPLACE NAME} customer service Help Line since October 1, 2013.

26. Since October 1^st, did you call the {INSERT MARKETPLACE NAME} customer service Help Line? (IS/T)

¹Yes

²No  If No, go to #36

27. Since October 1^st, how often did you get the information or help you needed when you called the {INSERT MARKETPLACE NAME} customer service Help Line? (IS/F,T/HP5-AM-m22)

¹ Never

² Sometimes

³ Usually

⁴ Always  If Always, go to #29

28. Were any of the following a reason why you did not get the information or help you needed when you called the {INSERT MARKETPLACE NAME} customer service Help Line? Mark one or more. (IS/F,T/HP4-AS-mCS1)

Did not get the information or help needed because

1. They were unable to answer your questions ¹

2. Was on hold too long ¹

3. You had to call several times before you could speak with someone ¹

4. You waited too long for someone to call you back ¹

5. No one called you back ¹

6. The information they gave you was wrong ¹

7. They did not have the information you needed ¹

8. The information they gave you was hard to understand ¹

9. You could not talk to someone in the language you prefer ¹

10. There was no video relay service available for persons who are deaf ¹

11. Some other reason ¹

Please specify:

29. Since October 1^st, how often was it easy to understand the information you got when you called the {INSERT MARKETPLACE NAME} customer service Help Line? (IS/L,S,T/HP4-AS-mPW3)

¹ Never

² Sometimes

³ Usually

⁴ Always  If Always, go to #31

30. What kind of information was not easy to understand when you called the {INSERT MARKETPLACE NAME} customer service Help Line? Mark one or more. (IS/L,S,T/HP4-AS- mPW4)

Not easy to understand

1. How to get help paying for your health insurance ¹

2. Important deadlines ¹

3. Benefits and coverage for doctor or specialist visits ¹

4. Benefits and coverage for prescription drugs ¹

5. Benefits and coverage for prenatal care or childbirth ¹

6. How much you would have to pay for each health plan ¹

7. How much you would have to pay out-of-pocket for

health care services in each health plan ¹

8. Which doctors are in each health plan ¹

9. What you would have to pay if you used a doctor outside

of the health plan ¹

10. How to figure out your family size or income ¹

11. Which doctors in each health plan have offices that are

accessible for people with disabilities ¹

12. How to find a health plan that meets your family’s needs ¹

13. Something else ¹

Please specify:

31. Since October 1^st, how often was the {INSERT MARKETPLACE NAME} customer service Help Line as helpful as you thought it should be? (IS/F,T/CG2-AC-m24)

¹ Never

² Sometimes

³ Usually

⁴ Always

32. Since October 1^st, how often did the {INSERT MARKETPLACE NAME} customer service Help Line use words or phrases you did not understand when you called? (IS/L,T/CG2-AS-mCU2)

¹ Never

² Sometimes

³ Usually

⁴ Always

33. Since October 1^st, did you speak to a person when you called the {INSERT MARKETPLACE NAME} customer service Help Line? (IS/CI1)

¹Yes

²No  If No, go to #35

34. Since October 1^st, how often did the {INSERT MARKETPLACE NAME} customer service Help Line staff treat you with courtesy and respect when you called? (IS/L,F/HP5-AM-m23)

¹ Never

² Sometimes

³ Usually

⁴ Always

35. We want to know your rating of the {INSERT MARKETPLACE NAME} customer service Help Line that you called since October 1, 2013. Using any number from 0 to 10, where 0 is the worst customer service Help Line possible and 10 is the best customer service Help Line possible, what number would you use to rate the {INSERT MARKETPLACE NAME} customer service Help Line? (GR/HP5-AM-m26)

0 Worst customer service Help Line possible

1

2

3

4

5

6

7

8

9

10 Best customer service Help Line possible

Getting Information In Person

The following questions ask about your experiences when you met in person with anyone from an organization that helps people get health insurance through the {INSERT MARKETPLACE NAME}, since October 1, 2013.

36. Since October 1^st, did you meet in person with anyone from an organization that helps people get health insurance through the {INSERT MARKETPLACE NAME}? (IS/T)

¹ Yes  If Yes, go to #38

² No

37. Since October 1^st, did you want in-person help but were unable to get it because the building was not accessible for persons with disabilities? (IS/OMB60)

¹ Yes If Yes, go to #46

² No  If No, go to #46

38. Since October 1^st, how often did you get the information or help you needed when you met in person with someone about getting health insurance from the {INSERT MARKETPLACE NAME}? (IS/F,T/HP5-AM-m22)

¹ Never

² Sometimes

³ Usually

⁴ Always  If Always, go to #40

39. Were any of the following a reason why you did not get the information or help you needed when you met in person with someone about getting health insurance from the {INSERT MARKETPLACE NAME}? Mark one or more. (IS/F,T/HP4-AS-mCS1)

Did not get the information or help because

1. There was not enough time ¹

2. They did not have the information you needed ¹

3. The information they gave you was hard to understand ¹

4. The information they gave you was wrong ¹

5. You could not talk or sign to someone in the language you prefer ¹

6. Some other reason ¹

Please specify:

40. Since October 1^st, how often was it easy to understand the information you got when you met in person with someone about getting health insurance from the {INSERT MARKETPLACE NAME}? (IS/L,S,T/HP4-AS-mPW3)

¹ Never

² Sometimes

³ Usually

⁴ Always  If Always, go to #42

41. What kind of information was not easy to understand when you met in person with someone about getting health insurance from the {INSERT MARKETPLACE NAME}? Mark one or more. (IS/L,S,T/HP4-AS-mPW4)

Not easy to understand

1. How to get help paying for your health insurance ¹

2. Important deadlines ¹

3. Benefits and coverage for doctor or specialist visits ¹

4. Benefits and coverage for prescription drugs ¹

5. Benefits and coverage for prenatal care or childbirth ¹

6. How much you would have to pay for each health plan ¹

7. How much you would have to pay out-of-pocket for

health care services in each health plan ¹

8. Which doctors are in each health plan ¹

9. What you would have to pay if you used a doctor outside

of the health plan ¹

10. How to figure out your family size or income ¹

11. Which doctors in each health plan have offices that are

accessible for people with disabilities ¹

12. How to find a health plan that meets your family’s needs ¹

13. Something else ¹

Please specify:

42. Since October 1^st, how often were the persons you met with about getting health insurance from the {INSERT MARKETPLACE NAME} as helpful as you thought they should be? (IS/F,T/CG2-AC-m24)

¹ Never

² Sometimes

³ Usually

⁴ Always

43. Since October 1^st, how often did the persons you met with about getting health insurance from the {INSERT MARKETPLACE NAME} use words or phrases you did not understand? (IS/L,T/CG2-AS-mCU2)

¹ Never

² Sometimes

³ Usually

⁴ Always

44. Since October 1^st, how often did the persons you met with about getting health insurance from the {INSERT MARKETPLACE NAME} treat you with courtesy and respect? (IS/L,F/HP5-AM-m23)

¹ Never

² Sometimes

³ Usually

⁴ Always

45. We want to know your rating of the in-person assistance you got to help you use the {INSERT MARKETPLACE NAME} since October 1, 2013. Using any number from 0 to 10, where 0 is the worst in-person assistance possible and 10 is the best in-person assistance possible, what number would you use to rate the assistance you got when you met in person with someone about getting health insurance from the {INSERT MARKETPLACE NAME}? (GR/HP5-AM-m26)

0 Worst in-person assistance possible

1

2

3

4

5

6

7

8

9

10 Best in-person assistance possible

Choosing a Health Plan

The following questions ask about your experience choosing a health plan through the {INSERT MARKETPLACE NAME} since October 1, 2013.

46. Since October 1^st, were you looking for health insurance for yourself through the {INSERT MARKETPLACE NAME}? (EP/C)

¹ Yes

² No

47. Since October 1^st, were you looking for health insurance for another family member, such as a spouse or child, through the {INSERT MARKETPLACE NAME}? (EP/C)

¹ Yes

² No

48. Since October 1^st, did you consider the services covered by the health plans available to you in the {INSERT MARKETPLACE NAME} and how much you would have to pay? (EP/L,S,T)

¹ Yes

² No  If No, go to #50

49. Since October 1^st, how often was it easy to understand the services covered by the health plans available to you and how much you would have to pay? (EP/L,S,T)

¹ Never

² Sometimes

³ Usually

⁴ Always

50. Since October 1^st, did you try to find out which health plans in the {INSERT MARKETPLACE NAME} had the doctors or hospitals you wanted? (EP/L,S,T)

¹ Yes

² No  If No, go to #52

51. Since October 1^st, how often was it easy to understand which health plans had the doctors or hospitals you wanted? (EP/L,S,T)

¹ Never

² Sometimes

³ Usually

⁴ Always

52. Since October 1^st, did you try to find out which health plans in the {INSERT MARKETPLACE NAME} covered the prescription medicines you needed? (EP/OMB30)

¹ Yes

² No  If No, go to #54

53. Since October 1^st, how often was it easy to understand which health plans covered the prescription medicines you needed? (EP/OMB30)

¹ Never

² Sometimes

³ Usually

⁴ Always

54. Since October 1^st, did you have any health problems that needed special therapy, such as physical, occupational, or speech therapy? (SP/C/HP5-AS-CC11)

¹ Yes

² No  If No, go to #56

55. Since October 1^st, was it easy to find out which health plans in the {INSERT MARKETPLACE NAME} offered the physical, occupational, or speech therapy services you needed? (SP/C/ HP5-AS-mCC12)

¹ Yes, definitely

² Yes, somewhat

³ No

56. Home health care or assistance means home nursing, help with bathing or dressing, and help with basic household tasks. Since October 1^st, did you need someone to come into your home to give you home health care or assistance? (SP/C/ HP5-AS-CC13)

¹ Yes

² No  If No, go to #58

57. Since October 1^st, was it easy to find out which health plans in the {INSERT MARKETPLACE NAME} offered home health care services you needed? (SP/C/ HP5-AS-mCC14)

¹ Yes, definitely

² Yes, somewhat

³ No

58. Did you choose a health plan through the {INSERT MARKETPLACE NAME}? (EP/T)

¹ Yes

² No  If No, go to #60

59. Was it easy to choose a health plan? (EP/L,S,T/HP5-AM-m25)

¹ Yes, definitely

² Yes, somewhat

³ No

Language Services

The following questions ask about language services, such as using an interpreter when you needed one, through the {INSERT MARKETPLACE NAME} since October 1, 2013.

60. An interpreter is someone who helps you talk with others who do not speak your language. Since October 1^st, did you need an interpreter to help you speak with anyone about getting health insurance from the {INSERT MARKETPLACE NAME}? (CuC/S,T/ HP5-AS-mNew_Q#)

¹ Yes

² No  If No, go to #62

61. Since October 1^st, when you needed an interpreter to help you speak with anyone about getting health insurance from the {INSERT MARKETPLACE NAME}, how often did you get one? (CuC/S,T/ HP5-AS-mNew_Q#)

¹ Never

² Sometimes

³ Usually

⁴ Always

62. Since October 1^st, did you fill out any forms for the {INSERT MARKETPLACE NAME}? (CUC/CI2)

¹ Yes

² No  If No, go to #66

63. Since October 1^st, how often were the forms that you had to fill out through the {INSERT MARKETPLACE NAME} available in the language you prefer? (CuC/S,T/CG2-AS-mHL32)

¹ Never

² Sometimes

³ Usually

⁴ Always

64. Since October 1^st, did you need the forms in a different format, such as large print or braille? (CuC/OMB30/HP5-AM-m24)

¹ Yes

² No  If No, go to #66

65. Since October 1^st, how often were the forms that you had to fill out available in the format you needed, such as large print or braille? (CuC/OMB30/CG2-AS-mHL32)

¹ Never

² Sometimes

³ Usually

⁴ Always

Overall Rating of Your Health Insurance Marketplace

1. Using any number from 0 to 10, where 0 is the worst health insurance marketplace possible and 10 is the best health insurance marketplace possible, what number would you use to rate your {INSERT MARKETPLACE NAME} since October 1^st? (GR/HP5-AM-m26)

0 Worst health insurance marketplace possible

1

2

3

4

5

6

7

8

9

10 Best health insurance marketplace possible

67. Would you recommend the {INSERT MARKETPLACE NAME} to your friends and family? (GR/CI1/H-m22)

¹ Yes, definitely

² Yes, somewhat

³ No

About You

68. In general, how would you rate your overall health? (CM/HP5-AM-27)

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

69. In general, how would you rate your overall mental or emotional health? (RC/HP5-AM-28)

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

70. Since October 1^st, did you get health care 3 or more times for the same condition or problem? (RC/HP5-AM-29)

¹ Yes

² No  If No, go to #72

71. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause. (RC/HP5-AM-30)

¹ Yes

² No

72. Do you now need or take medicine prescribed by a doctor? Do not include birth control. (RC/HP5-AM-31)

¹ Yes

² No  If No, go to #74

73. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause. (RC/HP5-AM-32)

¹ Yes

² No

74. Are you deaf or do you have serious difficulty hearing? (RC/OMB60/ACS-P-17a, OMH-4302-5)

¹ Yes

² No

75. Are you blind or do you have serious difficulty seeing, even when wearing glasses? (RC/OMB60/ACS-P-17b, OMH-4302-5)

¹ Yes

² No

76. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (RC/OMB60/ACS-P-18a, OMH-4302-5)

¹ Yes

² No

77. Do you have serious difficulty walking or climbing stairs? (RC/OMB60/ACS-P-18b, OMH-4302-5)

¹ Yes

² No

78. Because of a physical, mental, or emotional condition, do you have difficulty dressing or bathing? (RC/OMB60/ACS-P-18c, OMH-4302-5)

¹ Yes

² No

79. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (RC/OMB60/ACS-P-19, OMH-4302-5)

¹ Yes

² No

80. What is your age? (CM/HP5-AM-33)

¹ 18 to 24 years

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 or older

81. What is your sex? (CM/CI1/OMH-4302-3)

¹ Male

² Female

82. What is the highest grade or level of school that you have completed? (CM/HP5-AM-35)

¹ 8th grade or less

² Some high school, but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

83. What best describes your employment status? Mark only ONE. (RC/OMB60/NHBS-DM6)

¹ Employed full-time

² Employed part-time

³ A homemaker

⁴ A full-time student

⁵ Retired

⁶ Unable to work for health reasons

⁷ Unemployed

⁸ Other

84. Are you Hispanic, Latino/a, or Spanish origin? (RC/OMB60/M-ACO-77)

¹ Yes, Hispanic, Latino/a, or Spanish origin

² No, not of Hispanic, Latino/a, or Spanish origin  If No, go to #86

85. Which group best describes you? (RC/OMB60/M-ACO-78)

¹ Mexican, Mexican American, Chicano

² Puerto Rican

³ Cuban

⁴ Another Hispanic, Latino, or Spanish Origin

86. What is your race? Mark one or more. (RC/CI1/OMH-4302-2)

¹ White

² Black or African American

³ American Indian or Alaska Native

⁴ Asian Indian

⁵ Chinese

⁶ Filipino

⁷ Japanese

⁸ Korean

⁹ Vietnamese

¹⁰ Other Asian

¹¹ Native Hawaiian

¹² Guamanian or Chamorro

¹³ Samoan

¹⁴ Other Pacific Islander

87. Are you eligible to get health services from an Indian Health Service, tribal, or urban Indian health program? (RC/OMB30)

¹ Yes

² No  If No, go to #89

³ Don’t Know  If Don’t Know, go to #89

88. Did you ever get health services from an Indian Health Service, tribal, or urban Indian health program? (RC/OMB30)

¹ Yes

² No

89. What is your preferred language? (RC,CuC/T,C,OMB60/ CG2-AS-CU22)

¹ English  If English, go to #91

² Spanish

³ Chinese

⁴ Other

Please specify: _____________________________________________________________

90. How well do you speak English? (RC,CuC/T,C,OMB60/OMH-4302-4)

¹ Very well

² Well

³ Not well

⁴ Not at all

91. Did you have health insurance in the United States at any time between January 1^st and December 31^st, 2013? (RC/T,C)

¹ Yes

² No

92. How confident are you that you understand health insurance terms? (RC/OMB30)

¹ Not at all confident

² Slightly confident

³ Moderately confident

⁴ Very confident

93. Do you feel comfortable using the internet through a computer, tablet, or smart phone? (RC/C)

¹ Yes, definitely

² Yes, somewhat

³ No

94. Did someone help you complete this survey? (RC/HP5-AM-38)

¹ Yes

² No Thank you. Please return the completed survey in the postage-paid envelope.

95. How did that person help you? Mark one or more. (RC/HP5-AM-39)

¹ Read the questions to me

² Wrote down the answers I gave

³ Answered the questions for me

⁴ Translated the questions into my language

⁵ Helped in some other way

Please print: ______________________________________________________________
_________________________________________________________________________

Thank you.

Please return the completed survey in the postage-paid envelope.

English Health Insurance Marketplace Survey after OMB/NCHS review 2-5-2014 Page 4 of 45