CMS-10488 Marketplace Survey for the Beta Test English

OMB No. 0938-1221: Approval Expires 02/28/2017

Health Insurance Marketplace Survey
Language: English
Reference Period: Since November 15, 2014
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
FT = Field Test
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.

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Survey Indicator
HP5-AM-Q# = CAHPS Health Plan 5.0, Adult Medicaid, Question #
HP5-AM-mQ# = CAHPS Health Plan 5.0, Adult Medicaid, modified Question #
HP4-AS-mQ# = CAHPS Health Plan 4.0, Adult Supplemental, modified Question #
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 #
H-mQ = Hospital CAHPS, Modified Question #
OMH-4302-Q# = HHS Office of Minority Health ACA Section 4302 Data Collection Standards,
Question #
ACS-P-Q# = American Community Survey (ACS) – Person Section - Question #
NHBS-Q# = 2010 National HIV Behavioral Surveillance System – Question #
M-ACO-Q# = 2014 Medicare Provider Satisfaction Survey – Items for ACOs Participating in Medicare
Initiatives – Question #
Questions that don’t have a survey indicator are new questions written for the Marketplace Survey.

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OVERVIEW MARKETPLACE SURVEY DOMAINS
I.

APPLICATION PROCESS

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II.

Have health insurance through the Marketplace in 2014
Gave or updated information about the people in your family who wanted health insurance
Easy to give or update information about the people in your family
Giving/updating information about the people in your family took longer than expected
Mode used to give/update information about the people in your family
Told should update Marketplace about changes to household income or family size
Easy to understand how to update Marketplace about changes to household income or family
size
PREMIUM TAX CREDIT ELIGIBILITY

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III.

Gave or updated information about household income
Easy to find out if could get help paying for health insurance
Giving/updating information about household income took longer than expected
Qualify for Medicaid
Marketplace help pay for health insurance
Told could appeal decision about how much have to pay for health insurance
INFORMATION SEEKING ON THE WEBSITE

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IV.

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 information was hard to understand
Information as helpful as you thought it should be
INFORMATION SEEKING OVER THE PHONE

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V.

Called the Marketplace Call Center
Got information or help you needed
Why did not get information or help needed
Easy to understand the information
What information was hard to understand
Call Center as helpful as you thought they should be
Spoke to a person
Call Center staff treat you with courtesy and respect
INFORMATION SEEKING IN-PERSON

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



Met in person with anyone from an organization that helps people get health insurance through
Marketplace
Got information or help you needed
Why did not get information or help needed
Easy to understand the information
What information was hard to understand
Persons you met with as helpful as you thought they should be

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
VI.

Persons you met with treat you with courtesy and respect
HEALTH PLAN ENROLLMENT

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
VII.

Who is covered by 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
Enrolled in same health plan in 2014
Easy to choose a health plan
SPECIALIZED SERVICES

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
VIII.

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


Easy to find out which health plans offer physical, occupational, or speech therapy you needed
Easy to find out which health plans offer home health care services you needed
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

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Rating of information–Web
Rating of information–Phone
Rating of information–In-Person
Rating of Health Insurance Marketplace
Recommend Marketplace to friends and family

RESPONDENT CHARACTERISTICS

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Rating of overall health
Rating of overall mental or emotional health
Got care for 2 or more health problems or conditions that each lasted for at least a year
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
Difficulty doing errands alone because of a physical, mental, or emotional condition
Age
Sex
Education status
Employment status
Ethnicity
Race

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Preferred Language
Proficiency of English language skills
Covered by health insurance at any time in 2014
Confidence in understanding health insurance terms
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.

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Introduction
We are asking you to complete this survey because you contacted {INSERT MARKETPLACE NAME}
to learn about your health insurance options since November 15, 2014. You might have used the
website, sent an application by mail, called the toll free Call Center, or met with someone in person.
This survey asks about your experiences with {INSERT MARKETPLACE NAME}, also known as
Obamacare or {INSERT MARKETPLACE URL}, which was created by the Affordable Care Act.
Survey Instructions
Answer each question by marking the box next to 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
2

Yes
No  If No, go to #1

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this
information collection is 0938-1221. 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.

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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 {INSERT MARKETPLACE NAME} since November 15, 2014. You might
have used the website, sent an application by mail, called the toll free Call Center, or met with someone
in person.
1. Did you have health insurance through {INSERT MARKETPLACE NAME} at any time in 2014?
(AP/FT,T)
1
2

Yes
No

2. Since November 15th, did you give or update information about yourself or the people in your
family who wanted health insurance through {INSERT MARKETPLACE NAME}? (AP/T,CI2)
1
2

Yes
No  If No, go to #6

3. Was it easy to give or update information about yourself or the people in your family who wanted
health insurance? (AP/T,CI2)
1
2
3

Yes, definitely
Yes, somewhat
No

4. Did giving or updating information about yourself or the people in your family take longer than you
expected? (AP/L,S,T,CI2)
1
2
3

Yes, definitely
Yes, somewhat
No

5. How did you give or update information about yourself or the people in your family? Mark one or
more. (AP/T,CI1,CI2)
1
2
3
4

On {INSERT MARKETPLACE NAME}’s website
By mail
On the phone
In person

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6. Household income can be your income or the income from people in your family. Since November
15th, did you give or update information about your household income to see if you or the people in
your family could get help paying for health insurance through {INSERT MARKETPLACE
NAME}? (TC/T)
1
2

Yes
No  If No, go to #12

7. When you gave or updated your household income information, was it easy to find out if you or the
people in your family could get help paying for health insurance? (TC/T)
1
2
3

Yes, definitely
Yes, somewhat
No

8. Did giving or updating your household income information take longer than you expected?
(TC/L,S,T)
1
2
3

Yes, definitely
Yes, somewhat
No

9. Since November 15th, did you or the people in your family qualify for {INSERT MEDICAID
NAME}, the program in your state that provides health plan coverage for some low-income
persons, families and children, pregnant women, and persons with disabilities? (TC/T)
1
2
3

Yes  If Yes, go to #11
No
Don’t know

10. Since November 15th, did {INSERT MARKETPLACE NAME} help you or the people in your
family pay for your health insurance? (TC/T)
1
2
3

Yes
No
Don’t know

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11. 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 November 15th, 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
2

Yes
No

12. Since November 15th, were you told by {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
2

Yes
No  If No, go to #14

13. Was it easy to understand how to update {INSERT MARKETPLACE NAME} about changes to
your household income or the number of people in your family? (AP/CI1)
1
2
3

Yes, definitely
Yes, somewhat
No

Looking for Information on the Marketplace Website
The following questions ask about your experiences when you visited {INSERT MARKETPLACE
NAME}’s website since November 15, 2014.
14. Since November 15th, did you visit {INSERT MARKETPLACE NAME}’s website {INSERT
MARKETPLACE URL}? (IS/T)
1
2

Yes
No  If No, go to #22

15. Since November 15th, how often did you have to wait to get what you needed because of problems
on {INSERT MARKETPLACE NAME}’s website? (IS/OMB60)
1
2
3
4

Never
Sometimes
Usually
Always

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16. Since November 15th, how often did you get the information you needed from {INSERT
MARKETPLACE NAME}’s website? (IS/F,T/HP4-AS-mPW2)
1
2
3
4

Never
Sometimes
Usually
Always If Always, go to #18

17. Were any of the following a reason why you did not get the information you needed from
{INSERT MARKETPLACE NAME}’s website? Mark one or more. (IS/F,T/HP4-AS-mCS1)
Did not get the information
because
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)

You could not find the information you needed
The information was hard to understand
The website was confusing
It was hard to find out how to get help
The website was too complicated
The information the website gave you was inconsistent or wrong
The information was not in the language you prefer
You could not find the same health plan you had in 2014
The website was not working correctly
The website did not work well with the special equipment
or software you use because of a disability
k) Some other reason
Please specify: _________________________________________

1
1
1
1
1
1
1
1
1

1
1

______________________________________________________
18. Since November 15th, how often was it easy to understand the information on {INSERT
MARKETPLACE NAME}’s website? (IS/L,S,T/HP4-AS-mPW3)
1
2
3
4

Never
Sometimes
Usually
Always  If Always, go to #20

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19. What information on {INSERT MARKETPLACE NAME}’s website was hard to understand?
Mark one or more. (IS/L,S,T/HP4-AS-mPW4)
Hard to understand
1
How to get help paying for your health insurance
1
Important deadlines
1
Benefits and coverage for doctor or specialist visits
1
Benefits and coverage for prescription drugs
1
Benefits and coverage for prenatal care or childbirth
1
How much you would have to pay for each health plan
How much you would have to pay out-of-pocket for
1
health care services in each health plan
1
h) Which doctors are in each health plan
i) What you would have to pay if you used a doctor outside
1
of the health plan
1
j) How to figure out your family size or household income
k) Which doctors in each health plan have offices that are
1
accessible for people with disabilities
1
l) How to find a health plan that meets your family’s needs
1
m) Something else
Please specify: _________________________________________

a)
b)
c)
d)
e)
f)
g)

______________________________________________________
20. Since November 15th, how often was the information on {INSERT MARKETPLACE NAME}’s
website as helpful as you thought it should be? (IS/F,T/CG2-AC-m24)
1
2
3
4

Never
Sometimes
Usually
Always

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21. We want to know your rating of {INSERT MARKETPLACE NAME}’s website, {INSERT
MARKETPLACE URL}, that you visited since November 15, 2014. 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 {INSERT MARKETPLACE NAME}’s 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 {INSERT MARKETPLACE
NAME}’s customer service Call Center since November 15, 2014.
22. Since November 15th, did you call {INSERT MARKETPLACE NAME}’s customer service Call
Center? (IS/T)
1
2

Yes
No  If No, go to #31

23. Since November 15th, how often did you get the information or help you needed when you called
{INSERT MARKETPLACE NAME}’s customer service Call Center? (IS/F,T/HP5-AM-m22)
1
2
3
4

Never
Sometimes
Usually
Always  If Always, go to #25

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24. Were any of the following a reason why you did not get the information or help you needed when
you called {INSERT MARKETPLACE NAME}’s customer service Call Center? Mark one or
more. (IS/F,T/HP4-AS-mCS1)
Did not get the information
or help needed because
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)

They were unable to answer your questions
Was on hold too long
You had to call several times before you could speak with someone
You waited too long for someone to call you back
No one called you back
The information they gave you was inconsistent or wrong
They did not have the information you needed
The information they gave you was hard to understand
You could not talk to someone in the language you prefer
They were unable to find the same health plan you had in 2014
The Call Center had problems with the website when you called
There was no video relay service available for persons who are deaf
Some other reason
Please specify: _________________________________________

1
1
1
1
1
1
1
1
1
1
1
1
1

______________________________________________________
25. Since November 15th, how often was it easy to understand the information you got when you called
{INSERT MARKETPLACE NAME}’s customer service Call Center? (IS/L,S,T/HP4-AS-mPW3)
1
2
3
4

Never
Sometimes
Usually
Always  If Always, go to #27

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26. What information was hard to understand when you called {INSERT MARKETPLACE NAME}’s
customer service Call Center? Mark one or more. (IS/L,S,T/HP4-AS-mPW4)
Hard to understand
1
How to get help paying for your health insurance
1
Important deadlines
1
Benefits and coverage for doctor or specialist visits
1
Benefits and coverage for prescription drugs
1
Benefits and coverage for prenatal care or childbirth
1
How much you would have to pay for each health plan
How much you would have to pay out-of-pocket for
1
health care services in each health plan
1
h) Which doctors are in each health plan
i) What you would have to pay if you used a doctor outside
1
of the health plan
1
j) How to figure out your family size or household income
k) Which doctors in each health plan have offices that are
1
accessible for people with disabilities
1
l) How to find a health plan that meets your family’s needs
1
m) Something else
Please specify: _________________________________________

a)
b)
c)
d)
e)
f)
g)

______________________________________________________
27. Since November 15th, how often was {INSERT MARKETPLACE NAME}’s customer service Call
Center as helpful as you thought it should be? (IS/F,T/CG2-AC-m24)
1
2
3
4

Never
Sometimes
Usually
Always

28. Since November 15th, did you speak to a person when you called {INSERT MARKETPLACE
NAME}’s customer service Call Center? (IS/CI1)
1
2

Yes
No  If No, go to #30

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29. Since November 15th, how often did {INSERT MARKETPLACE NAME}’s customer service Call
Center staff treat you with courtesy and respect when you called? (IS/L,F/HP5-AM-m23)
1
2
3
4

Never
Sometimes
Usually
Always

30. We want to know your rating of {INSERT MARKETPLACE NAME}’s customer service Call
Center that you called since November 15th, 2014. Using any number from 0 to 10, where 0 is the
worst customer service Call Center possible and 10 is the best customer service Call Center
possible, what number would you use to rate {INSERT MARKETPLACE NAME}’s customer
service Call Center? (GR/HP5-AM-m26)
0 Worst customer service Call Center possible
1
2
3
4
5
6
7
8
9
10 Best customer service Call Center 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 {INSERT MARKETPLACE NAME}, since
November 15, 2014.
31. Since November 15th, did you meet in person with anyone from an organization that helps people
get health insurance through {INSERT MARKETPLACE NAME}? (IS/T)
1
2

Yes
No  If No, go to #39

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32. Since November 15th, how often did you get the information or help you needed when you met in
person with someone about getting health insurance from {INSERT MARKETPLACE NAME}?
(IS/F,T/HP5-AM-m22)
1
2
3
4

Never
Sometimes
Usually
Always  If Always, go to #34

33. 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 {INSERT MARKETPLACE
NAME}? Mark one or more. (IS/F,T/HP4-AS-mCS1)
Did not get the information
or help needed because
a)
b)
c)
d)
e)
f)
g)
h)

There was not enough time
They did not have the information you needed
The information they gave you was hard to understand
The information they gave you was inconsistent or wrong
You could not talk or sign to someone in the language you prefer
They were unable to find the same health plan you had in 2014
The person you met with had problems with the website
Some other reason
Please specify: _________________________________________

1
1
1
1
1
1
1
1

______________________________________________________
34. Since November 15th, how often was it easy to understand the information you got when you met in
person with someone about getting health insurance from {INSERT MARKETPLACE NAME}?
(IS/L,S,T/HP4-AS-mPW3)
1
2
3
4

Never
Sometimes
Usually
Always  If Always, go to #36

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35. What information was hard to understand when you met in person with someone about getting
health insurance from {INSERT MARKETPLACE NAME}? Mark one or more. (IS/L,S,T/HP4AS-mPW4)
Hard to understand
1
How to get help paying for your health insurance
1
Important deadlines
1
Benefits and coverage for doctor or specialist visits
1
Benefits and coverage for prescription drugs
1
Benefits and coverage for prenatal care or childbirth
1
How much you would have to pay for each health plan
How much you would have to pay out-of-pocket for
1
health care services in each health plan
1
h) Which doctors are in each health plan
i) What you would have to pay if you used a doctor outside
1
of the health plan
1
j) How to figure out your family size or household income
k) Which doctors in each health plan have offices that are
1
accessible for people with disabilities
1
l) How to find a health plan that meets your family’s needs
1
m) Something else
Please specify: _________________________________________

a)
b)
c)
d)
e)
f)
g)

______________________________________________________
36. Since November 15th, how often were the persons you met with about getting health insurance from
{INSERT MARKETPLACE NAME} as helpful as you thought they should be? (IS/F,T/CG2-ACm24)
1
2
3
4

Never
Sometimes
Usually
Always

37. Since November 15th, how often did the persons you met with about getting health insurance from
{INSERT MARKETPLACE NAME} treat you with courtesy and respect? (IS/L,F/HP5-AM-m23)
1
2
3
4

Never
Sometimes
Usually
Always

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38. We want to know your rating of the in-person assistance you got to help you use {INSERT
MARKETPLACE NAME}’s services since November 15, 2014. 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 {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 {INSERT
MARKETPLACE NAME} since November 15, 2014. This could include choosing a new health
plan or choosing the same health plan you had in 2014.
39. Since November 15th, were you looking for health insurance for yourself through {INSERT
MARKETPLACE NAME}? (EP/C)
1
2

Yes
No

40. Since November 15th, were you looking for health insurance for another family member, such as a
spouse or child, through {INSERT MARKETPLACE NAME}? (EP/C)
1
2

Yes
No

41. Since November 15th, did you consider the services covered by the health plans available to you
through {INSERT MARKETPLACE NAME} and how much you would have to pay? (EP/L,S,T)
1
2

Yes
No  If No, go to #43

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42. Since November 15th, 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
2
3
4

Never
Sometimes
Usually
Always

43. Since November 15th, did you try to find out which health plans available to you through {INSERT
MARKETPLACE NAME} had the doctors or hospitals you wanted? (EP/L,S,T)
1
2

Yes
No  If No, go to #45

44. Since November 15th, how often was it easy to understand which health plans had the doctors or
hospitals you wanted? (EP/L,S,T)
1
2
3
4

Never
Sometimes
Usually
Always

45. Since November 15th, did you try to find out which health plans available to you through {INSERT
MARKETPLACE NAME} covered the prescription medicines you needed? (EP/OMB30)
1
2

Yes
No  If No, go to #47

46. Since November 15th, how often was it easy to understand which health plans covered the
prescription medicines you needed? (EP/OMB30)
1
2
3
4

Never
Sometimes
Usually
Always

47. Special therapy includes physical, occupational, or speech therapy. Since November 15th, did you
need any special therapy? (SP/C/HP5-AS-CC11)
1
2

Yes
No  If No, go to #49

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48. Since November 15th, was it easy to find out which health plans available to you through {INSERT
MARKETPLACE NAME} offered the physical, occupational, or speech therapy services you
needed? (SP/C/HP5-AS-mCC12)
1
2
3

Yes, definitely
Yes, somewhat
No

49. Home health care or assistance means home nursing, help with bathing or dressing, and help with
basic household tasks. Since November 15th, did you need someone to come into your home to give
you home health care or assistance? (SP/C/HP5-AS-CC13)
1
2

Yes
No  If No, go to #51

50. Since November 15th, was it easy to find out which health plans available to you through {INSERT
MARKETPLACE NAME} offered home health care services you needed? (SP/C/HP5-ASmCC14)
1
2
3

Yes, definitely
Yes, somewhat
No

51. Since November 15th, did you choose a health plan through {INSERT MARKETPLACE NAME}?
(EP/T)
1
2

Yes
No  If No, go to #54

52. Were you enrolled in that health plan in 2014? (EP/FT,T)
1
2
3

Yes
No
Don’t Know

53. Since November 15th, was it easy to choose a health plan? (EP/L,S,T/HP5-AM-m25)
1
2
3

Yes, definitely
Yes, somewhat
No

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Language Services
The following questions ask about language services you may have received through {INSERT
MARKETPLACE NAME} since November 15th, 2014.
54. An interpreter is someone who helps you talk with others who do not speak your language. Since
November 15th, did you need an interpreter to help you speak with anyone about getting health
insurance from {INSERT MARKETPLACE NAME}? (CuC/S,T/HP5-AS-mNew_Q#)
1
2

Yes
No  If No, go to #56

55. Since November 15th, when you needed an interpreter to help you speak with anyone about getting
health insurance from {INSERT MARKETPLACE NAME}, how often did you get one?
(CuC/S,T/HP5-AS-mNew_Q#)
1
2
3
4

Never
Sometimes
Usually
Always

56. Since November 15th, did you fill out any forms for {INSERT MARKETPLACE NAME}?
(CUC/CI2)
1
2

Yes
No  If No, go to #60

57. Since November 15th, how often were the forms that you had to fill out through {INSERT
MARKETPLACE NAME} available in the language you prefer? (CuC/S,T/CG2-AS-mHL32)
1
2
3
4

Never
Sometimes
Usually
Always

58. Since November 15th, did you need the forms in a different format, such as large print or braille?
(CuC/OMB30/HP5-AM-m24)
1
2

Yes
No  If No, go to #60

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59. Since November 15th, 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
2
3
4

Never
Sometimes
Usually
Always

Overall Rating of Your Health Insurance Marketplace
60. 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 {INSERT
MARKETPLACE NAME} since November 15th? (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
61. Would you recommend {INSERT MARKETPLACE NAME} to your friends and family?
(GR/CI1/H-m22)
1
2
3

Yes, definitely
Yes, somewhat
No

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About You
62. In general, how would you rate your overall health? (RC/HP5-AM-27)
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

63. In general, how would you rate your overall mental or emotional health? (RC/HP5-AM-28)
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

64. In the last 12 months, did you get care for 2 or more health problems or conditions that each lasted
for at least a year? (RC/FT)
1
2

Yes
No

65. Are you deaf or do you have serious difficulty hearing? (RC/OMB60/ACS-P-17a,OMH-4302-5)
1
2

Yes
No

66. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
(RC/OMB60/ACS-P-17b,OMH-4302-5)
1
2

Yes
No

67. 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
2

Yes
No

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68. Do you have serious difficulty walking or climbing stairs? (RC/OMB60/ACS-P-18b,OMH-43025)
1
2

Yes
No

69. Because of a physical, mental, or emotional condition, do you have difficulty dressing or bathing?
(RC/OMB60/ACS-P-18c,OMH-4302-5)
1
2

Yes
No

70. 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
2

Yes
No

71. What is your age? (RC/HP5-AM-33)
1
2
3
4
5
6
7

18 to 24 years
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

72. What is your sex? (RC/CI1/OMH-4302-3)
1
2

Male
Female

73. What is the highest grade or level of school that you have completed? (RC/HP5-AM-35)
1
2
3
4
5
6

8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

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74. What best describes your employment status? Mark only ONE. (RC/OMB60/NHBS-DM6)
1
2
3
4
5
6
7
8

Employed full-time
Employed part-time
A homemaker
A full-time student
Retired
Unable to work for health reasons
Unemployed
Other

75. Are you Hispanic, Latino/a, or Spanish origin? (RC/OMB60/M-ACO-77)
1
2

Yes, Hispanic, Latino/a, or Spanish origin
No, not of Hispanic, Latino/a, or Spanish origin  If No, go to #77

76. Which group best describes you? (RC/OMB60/M-ACO-78)
1
2
3
4

Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish Origin

77. What is your race? Mark one or more. (RC/CI1/OMH-4302-2)
1
2
3
4
5
6
7
8
9
10
11
12
13
14

White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

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78. What is your preferred language? (RC,CuC/T,C,OMB60/CG2-AS-CU22)
English  If English, go to #80
Spanish
3
Chinese
4
Other
Please specify: _____________________________________________________________
1
2

79. How well do you speak English? (RC,CuC/T,C,OMB60/OMH-4302-4)
1
2
3
4

Very well
Well
Not well
Not at all

80. Did you have health insurance in the United States at any time between January 1st and December
31st, 2014? (RC/T,C)
1
2

Yes
No

81. How confident are you that you understand health insurance terms? (RC/OMB30)
1
2
3
4

Not at all confident
Slightly confident
Moderately confident
Very confident

82. Did someone help you complete this survey? (RC/HP5-AM-38)
1
2

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

83. How did that person help you? Mark one or more. (RC/HP5-AM-39)
1
2
3
4
5

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way

Please print: ______________________________________________________________
_________________________________________________________________________
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Thank you.
Please return the completed survey in the postage-paid envelope.

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