CMS-10615 Disenrollee Lockout Survey

OMB Control Number: 0938-TBD

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-TBD.  The time required to complete this information collection is estimated to average 60 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 please contact Teresa DeCaro, [email protected].

Healthy Indiana Plan 2.0 Beneficiary Survey: Disenrollees & Lockouts

Introductions and Directions for Completing the Survey
The Centers for Medicare & Medicaid Services is conducting this survey to ask about your recent experiences receiving health care and should take about 15 minutes to complete.

Your participation is voluntary, and there is no loss of benefits or penalty of any kind for deciding not to participate. You may skip any questions that you do not feel comfortable answering. Your participation in this research is private, and we will not share your name or any other identifying information with any outside organization. You may notice a number on the cover of the survey. This number is ONLY used to let us know if you returned the survey. Please contact Thoroughbred Research Group toll-free at 1-800-264-1576 with questions about this research.

About Your HIP 2.0 Enrollment

The State of Indiana currently runs an insurance program called the Healthy Indiana Plan (or HIP 2.0) for Hoosiers ages 19 to 64.

1. Are you currently enrolled in the “Healthy Indiana Plan 2.0” or “HIP 2.0”?

1. Yes  GO TO HIP BASIC ENROLLED, FORMERLY HIP PLUS ENROLLED, PAGE 11

2. No

3. Don’t know  GO TO END

2. Have you ever been enrolled in HIP 2.0?

Source: MPR Leaver survey

1. Yes

2. No  GO TO END

3. Don’t know  GO TO END

4. Refuse  GO TO END

3. Were you enrolled in HIP 2.0 within the last 12 months?

Source: MPR Leaver survey

1. Yes

2. No  GO TO END

Experiences After Leaving HIP 2.0

The following questions are about your understanding and experiences since you left HIP.

4. Do you have any health insurance coverage right now?

Source: MPR leaver and Lewin leaver and previous member survey

Universe: Disenrollee and those locked out

1. Yes

2. No  GO TO QUESTION 7

5. How long have you had your current health insurance coverage?
   Universe: Disenrollees and those locked out

1. Less than one month

2. Between 1 and 6 months

3. More than 6 months

6. After you were no longer enrolled in HIP 2.0, how long did it take you to get your current health insurance coverage?
   Universe: Disenrollees and those locked out

1. Less than one month

2. Between 1 and 6 months

3. More than 6 months

7. After you were no longer enrolled in HIP 2.0, was there any time you needed health care but did not get it because of cost?
   Source: Adapted from BRFSS

Universe: Disenrollees and those locked out

1. Yes

2. No  GO QUESTION 9

3. Not sure  GO QUESTION 9

8. After you were no longer enrolled in HIP 2.0, what types of health care were you unable to get because of cost?

Source: Adapted from BRFSS

Universe: Disenrollees and those locked out

	Yes	No
A visit to the doctor when you were sick
Preventive care (such as blood pressure check, flu shot, or cholesterol or cancer screenings)
A follow up visit to get tests or care recommended by your doctor
Dental care and vision (eye) care
Prescription drugs
Emergency room care

9. After you were no longer enrolled in HIP 2.0, was there any time when you needed health care but did not get it because you could not pay for transportation or could not get transportation?

Source: Adapted from BRFSS

Universe: Disenrollees and those locked out

1. Yes

2. No  GO QUESTION 11

3. Not sure  GO QUESTION 11

10. What types of health care were you unable to get because you could not pay for transportation or could not get transportation?

Source: Adapted from BRFSS

Universe: Disenrollees and those locked out

	Could not pay for transportation	Could not get transportation	No trouble with transportation
A visit to the doctor when you were sick
Preventive care (such as blood pressure check, flu shot, or cholesterol or cancer screenings)
A follow up visit to get tests or care recommended by your doctor
Dental care and vision (eye) care
Prescription drugs
Emergency room care

11. Why are you no longer enrolled in HIP 2.0?

Source: Adapted from Lewin leavers or previous member survey and MPR leaver survey

Universe: Disenrolled and those locked out

1. I did not pay my monthly or annual contribution (e.g. forgot, was too late, did not have money)

2. I did not finish my paperwork to stay in HIP 2.0 another year

3. Other reason  GO TO QUESTION 13

12. Would you try to reenroll in HIP 2.0 if you became eligible for the program again?

Source: Adapted from Lewin Basic and Plus survey and MPR Enrollee survey
Universe: Disenrollees and those locked out

1. Yes  GO TO POWER ACCOUNTS SECTION, PAGE 5

2. No  GO TO POWER ACCOUNTS SECTION, PAGE 5

3. Unsure/ Don’t know  GO TO POWER ACCOUNTS SECTION, PAGE 5

13. What are the reasons why you left HIP 2.0?

Universe: Disenrollees

	Yes	No	Not sure
I had to pay a copay for the emergency room. Copays are payments you make at the time you visit your doctor’s office, go to the hospital, or get prescription drugs.
I could not afford it
I did not need it anymore
I could not get transportation to my health care visits
I did not understand how to use my POWER account. POWER accounts are special savings accounts called Personal Wellness and Responsibility Accounts.
Other

POWER accounts and monthly or annual contributions

The following questions are about your understanding and experiences while you were in HIP 2.0.

14. While you were in HIP 2.0, did you have a POWER account? POWER accounts are special savings accounts called Personal Wellness and Responsibility Accounts.

Universe: Disenrollees and those locked out

1. Yes

2. No

15. While you were in HIP 2.0, were you required to make a monthly or annual contribution to your POWER account?

Source: Adapted from Lewin leaver or previous member survey

Universe: Disenrollees and those locked out

1. Yes

2. No  GO TO QUESTION 20

16. While you were in HIP 2.0, how was that monthly or annual contribution paid?

Universe: HIP Plus Disenrollees and those locked out

1. I paid it

2. Someone paid the full amount for me

3. I paid part and someone else paid part

4. The contribution has not been paid

5. Not sure

17. While you were in HIP 2.0, would you say the amount you were required to contribute monthly or annually to your POWER account was:

Source: Adapted from HIP 1.0 2010 survey

Universe: HIP Plus Disenrollees and those locked out

1. More than I could afford

2. The right amount

3. Less than I could afford

4. Not sure

18. While you were in HIP 2.0, how worried were you about not having enough money to pay your monthly or annual contribution?

Source: Adapted from Lewin leaver or previous member survey and MPR leaver survey

Universe: HIP Plus Disenrollees and those locked out

1. Not at all worried

2. Somewhat worried

3. Very worried

19. After you were no longer enrolled in HIP 2.0, was any portion of your monthly or annual contributions returned to you or refunded?

Source: Adapted from MPR leaver member survey

Universe: HIP Plus Disenrollees and those locked out

1. Yes

2. No

3. Account had zero balance

4. Unsure/ Don’t know

20. While you were in HIP 2.0, what did you think would happen, if anything, if your monthly or annual contribution was not made on time? Please select the best answer.

Universe: Disenrollees and those locked out

1. Nothing would change

2. My HIP 2.0 coverage would end

3. I would get automatically moved to HIP Basic

4. Not sure/Don’t know

21. How easy or hard was it to understand how to use your POWER account?

Universe: Disenrollees and those locked out

1. Very easy

2. Somewhat easy

3. Neither easy nor hard

4. Somewhat hard

5. Very hard

22. While you were in HIP 2.0, did you know how much money was in your POWER account?

Source: Adapted from MPR HIP 1.0 enrollee survey

Universe: Disenrollees and those locked out

1. Yes, I knew exactly how much

2. Yes, I had a pretty good idea

3. No, I did not really know at all

23. For each of the following statements about POWER accounts, please tell us whether you agree, disagree, or are not sure.

Universe: Disenrollees and those locked out

	Agree	Disagree	Not sure
The State of Indiana contributed to my POWER account
My POWER account helped me get the health care services I needed
My POWER account helped me pay for my health care services
My POWER account made me feel comfortable about paying for my health care services

24. How easy or hard was it to understand what happens to any left over money in your POWER account at the end of year?

Universe: Disenrollees and those locked out

1. Very easy

2. Somewhat easy

3. Neither easy nor hard

4. Somewhat hard

5. Very hard

Preventive services are routine health care that includes getting a flu shot or annual checkups to prevent illness, disease, and other health–related problems. The following questions ask about your experience with preventive services and your POWER account while you were in HIP 2.0.

25. Was the cost of preventive services deducted from your POWER account?

Source: Adapted from MPR survey

Universe: Disenrollees and those locked out

1. Yes

2. No

3. Not sure/ Don’t know

26. If you got all or some of your recommended preventive services, would some of the remaining money in your POWER account get rolled over to next year?

Universe: Disenrollees and those locked out

1. Yes

2. No  GO TO ACCESS SECTION, PAGE 9

3. Not sure/Don’t know  GO TO ACCESS SECTION, PAGE 9

27. Did having a POWER account make it more likely that you would try to get all or some of your recommended preventive services?

Universe: Disenrollees and those locked out

1. Yes  GO TO ACCESS SECTION, PAGE 9

2. No  GO TO ACCESS SECTION, PAGE 9

3. Not sure/ Don’t know  GO TO ACCESS SECTION, PAGE 9

Access

For the following questions please think about your health care experience in the last 6 months.

28. In the last 6 months, did you go to a doctor, nurse, or any other health professional?

Source: Adapted from BRFSS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Yes

2. No  GO TO THE SATISFACTION SECTION, PAGE 10

3. Not sure/Don’t know  GO TO THE SATISFACTION SECTION, PAGE 10

29. Were you asked to pay a copay at your most recent visit? Copays are payments you make at the time you visit your doctor’s office, go to the hospital, or get prescription drugs.

Source: Adapted from MPR enrollee survey

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Yes

4. No  GO TO QUESTION 31

5. Not sure/Don’t know  GO TO QUESTION 31

30. How was that copay paid?

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. I paid it

2. Someone paid it for me

3. The co-payment was not paid

4. Not sure/Don’t know

31. In the last 6 months, were any of your health care visits for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

Source: Adapted from BRFSS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Yes

2. No

3. Not sure

Satisfaction with Healthy Indiana Plan

32. Thinking about your overall experience with HIP 2.0, would you say you are:

Source: Lewin Basic and Plus survey and MPR Enrollee survey
Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Very Satisfied  GO TO DEMOGRAPHICS SECTION, PAGE 15

2. Somewhat Satisfied  GO TO DEMOGRAPHICS SECTION, PAGE 15

3. Neither Satisfied nor Dissatisfied  GO TO DEMOGRAPHICS SECTION, PAGE 15

4. Somewhat Dissatisfied

5. Very Dissatisfied

6. Not sure/ Don’t know  GO TO DEMOGRAPHICS SECTION, PAGE 15

33. Why are you dissatisfied with HIP 2.0? Mark one or more

Source: Adapted Lewin Basic and Plus survey and MPR Enrollee survey
Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Long wait for coverage to begin

2. Can’t see my doctor with HIP 2.0

3. Dissatisfied with choice of doctors in HIP 2.0

4. Does not cover services that I need

5. Hard understand how POWER account works

6. Have to pay too much for POWER account

7. Have to pay too much for copays

8. Shifted from HIP Plus to HIP Basic

9. Dissatisfied with administrative issue(s) or process

10. Other reason not listed above: (specify)______________________

 GO TO DEMOGRAPHICS SECTION, PAGE 15

HIP Basic enrolled, formerly HIP Plus enrolled

34. Are you currently in HIP Basic?

Universe: HIP Basic enrolled, formerly HIP Plus enrolled (locked out below 100%FPL)

1. Yes

2. No  GO TO END

35. Thinking about your current HIP Basic coverage, how does it compare to HIP Plus? Is better, worse, or about the same?

Source: Adapted from NHIS

Universe: HIP Basic enrolled, formerly HIP Plus enrolled (locked out below 100%FPL)

1. Better

2. Worse  GO TO QUESTION 37

3. About the same  GO TO QUESTION 38

36. Why do you think your current HIP Basic coverage is better? Mark one or more

Universe: HIP Basic enrolled, formerly HIP Plus (locked out below 100%FPL)

1. I like the benefits in HIP Basic better than HIP Plus  GO TO QUESTION 38

2. I think HIP Basic is cheaper than HIP Plus  GO TO QUESTION 38

3. Other reason  GO TO QUESTION 38

37. Why do you think your current HIP Basic coverage is worse? Mark one or more

Universe: HIP Basic enrolled, formerly HIP Plus (locked out below 100%FPL)

1. I liked the benefits in HIP Plus better than HIP Basic

2. I think HIP Plus is cheaper than HIP Basic

3. Other reason

38. Would you try to re-apply for HIP Plus if you became eligible for HIP Plus again?

Source: Adapted from Lewin Basic and Plus survey and MPR Enrollee survey
Universe: HIP Basic enrolled, formerly HIP Plus (locked out below 100%FPL)

1. Yes

2. No

3. Unsure/ Don’t know

39. While you were in HIP Plus, what did you think would happen, if anything, if your monthly or annual contribution was not made on time?

Universe: HIP Basic enrolled, formerly HIP Plus enrolled (locked out below 100%FPL)

1. Nothing would change

2. My HIP 2.0 coverage would end

3. I would get automatically moved to HIP Basic

4. Not sure/Don’t know

40. Since your HIP 2.0 coverage changed from HIP Plus to HIP Basic, was there any time you needed health care but did not get it because of cost?

Source: Adapted from BRFSS

Universe: HIP Basic enrolled, formerly HIP Plus enrolled (locked out below 100%FPL)

1. Yes

2. No  GO TO QUESTION 42

3. Not sure/Don’t know  GO TO QUESTION 42

41. Since your HIP 2.0 coverage changed from HIP Plus to HIP Basic, what types of health care were you unable to get because of cost?

Source: Adapted from BRFSS

Universe: HIP Basic enrolled, formerly HIP Plus enrolled (locked out below 100%FPL)

	Yes	No
A visit to the doctor when you were sick
Preventive care (such as blood pressure check, flu shot, or cholesterol or cancer screenings)
A follow up visit to get tests or care recommended by your doctor
Dental care and vision (eye) care
Prescription drugs
Emergency room care

42. Since your HIP 2.0 coverage changed from HIP Plus to HIP Basic, was there any time you needed health care but did not get it because you could not pay for transportation or could not get transportation?

Source: Adapted from BRFSS

Universe: HIP Basic enrolled, formerly HIP Plus enrolled (locked out below 100%FPL)

1. Yes

2. No  GO TO QUESTION 44

3. Not sure/Don’t know  GO TO QUESTION 44

43. What types of health care were you unable to get because you could not pay for transportation or could not get transportation?

Source: Adapted from BRFSS

Universe: HIP Basic enrolled, formerly HIP Plus enrolled (locked out below 100%FPL)

	Could not pay for transportation	Could not get transportation	No trouble with transportation
A visit to the doctor when you were sick
Preventive care (such as blood pressure check, flu shot, or cholesterol or cancer screenings)
A follow up visit to get tests or care recommended by your doctor
Dental care and vision (eye) care
Prescription drugs
Emergency room care

44. Thinking about your experience in HIP Basic, would you say you are:

Source: Lewin Basic and Plus survey and MPR Enrollee survey
Universe: HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Very Satisfied  GO TO QUESTION 46

2. Somewhat Satisfied  GO TO QUESTION 46

3. Neither Satisfied nor Dissatisfied  GO TO QUESTION 46

4. Somewhat Dissatisfied

5. Very Dissatisfied

6. Not sure/ Don’t know  GO TO QUESTION 46

45. Why are you dissatisfied with HIP Basic? Mark one or more

Source: Adapted Lewin Basic and Plus survey and MPR Enrollee survey
Universe: HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Long wait for coverage to begin

2. Can’t see my doctor with HIP 2.0

3. Dissatisfied with choice of doctors in HIP 2.0

4. Does not cover services that I need

5. Hard understand how POWER account works

6. Have to pay too much for POWER account

7. Have to pay too much for copays

8. Shifted from HIP Plus to HIP Basic

9. Dissatisfied with administrative issue(s) or process

10. Other reason not listed above: (specify)______________________

46. Thinking about your previous experience in HIP Plus, would you say you are:

Source: Lewin Basic and Plus survey and MPR Enrollee survey
Universe: HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Very Satisfied  GO TO DEMOGRAPHICS SECTION, PAGE 15

2. Somewhat Satisfied  GO TO DEMOGRAPHICS SECTION, PAGE 15

3. Neither Satisfied nor Dissatisfied  GO TO DEMOGRAPHICS SECTION, PAGE 15

4. Somewhat Dissatisfied

5. Very Dissatisfied

6. Not sure/ Don’t know  GO TO DEMOGRAPHICS SECTION, PAGE 15

47. Why are you dissatisfied with HIP Plus? Mark one or more

Source: Adapted Lewin Basic and Plus survey and MPR Enrollee survey
Universe: HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Long wait for coverage to begin

2. Can’t see my doctor with HIP 2.0

3. Dissatisfied with choice of doctors in HIP 2.0

4. Does not cover services that I need

5. Hard understand how POWER account works

6. Have to pay too much for POWER account

7. Have to pay too much for copays

8. Shifted from HIP Plus to HIP Basic

9. Dissatisfied with administrative issue(s) or process

10. Other reason not listed above: (specify)______________________

Demographics/About You

48. Would you say that in general your health is:

Source: BRFSS
Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

49. What is the highest grade or level of school that you have completed?
    Source: Nationwide Medicaid CAHPS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

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

50. What best describes your employment status?

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Employed full or part-time

2. Unemployed

51. What is your age?
    Source: Nationwide Medicaid CAHPS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. 18 to 24

2. 25 to 34

3. 35 to 44

4. 45 to 54

5. 55 to 64

6. 65 to 74

7. 75 or older

52. Are you male or female?
    Source: Nationwide Medicaid CAHPS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Male

2. Female

53. Are you of Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected.)
    Source: Nationwide Medicaid CAHPS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. No, not of Hispanic, Latino/a, or Spanish origin

2. Yes, Mexican, Mexican American, Chicano/a

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, another Hispanic, Latino, or Spanish origin

54. What is your race? Mark one or more

Source: Nationwide Medicaid CAHPS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

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

15. Some other race

55. [display response items based on table below]

Please mark the category that best describes your family’s total income over the last year before taxes and other deductions. Your best estimate is fine.

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

Family size answer	Response item 1 At or below 50% FPL	Response item 2 Above 50% and less than 100%	Response item 3 At or above 100% and less than 138%	Response item 4 Above 138% FPL
One person	At or below $6,000	Above $6,000 and less than $12,000	At or above $12,000 and less than $16,000	At or above $16,000
Two  people	At or below $8,000	Above $8,000 and less than $16,000	At or above $16,000 and less than $22,000	At or above $22,000
Three people	At or below $10,000	Above $10,000 and less than $20,000	At or above $20,000 and less than $28,000	At or above $28,000
Four people	At or below $12,000	Above $12,000 and less than $24,000	At or above $24,000 and less than $33,000	At or above $33,000
Five people	At or below $14,000	Above $14,000 and less than $28,000	At or above $28,000 and less than $39,000	At or above $39,000
Six people	At or below $16,000	Above $16,000 and less than $33,000	At or above $33,000 and less than $45,000	At or above $45,000
Seven people	At or below $18,000	Above $18,000 and less than $37,000	At or above $37,000 and less than $51,000	At or above $51,000
Eight people	At or below $20,000	Above $20,000 and less than $41,000	At or above $41,000 and less than $56,000	At or above $56,000
Nine people	At or below $23,000	Above $23,000 and less than $45,000	At or above $45,000 and less than $62,000	At or above $62,000
Ten or more people	At or below $25,000	Above $25,000 and less than $49,000	At or above $49,000 and less than $68,000	At or above $68,000

56. Did someone help you complete this survey?
    Source: Nationwide Medicaid CAHPS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

1. Yes

2. No → GO TO END

57. How did that person help you? Mark one or more
    Source: Nationwide Medicaid CAHPS

Universe: All HIP disenrollees, those locked out above 100% FPL, and HIP Basic enrolled formerly HIP Plus enrolled (locked out below 100% FPL)

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
   
   
   

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

THOROUGHBRED RESEARCH GROUP

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