CMS-10615 Enrollee Survey

OMB Control Number: 0938-TBD

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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 Teresa DeCaro, [email protected].

Healthy Indiana Plan 2.0 Beneficiary Survey: Enrollees

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” or “HIP 2.0”?

1. Yes

2. No  GO TO END

3. Not sure/ Don’t know  GO TO END

Healthy Indiana Plan (HIP) 2.0

2. HIP 2.0 offers different benefits packages. Are you aware that HIP 2.0 offers:

Universe: HIP Basic and HIP Plus

	Yes	No	Not sure
HIP Plus
HIP Basic

3. For the next question, please think about your HIP 2.0 benefits package. For each of the following items, please indicate whether they are part of your HIP 2.0 benefits package. Copays are payments you make at the time you visit your doctor’s office, go to the hospital or get prescription drugs.

Source: Set-up similar to HRMS, KFF for ACA components

Universe: HIP Basic and HIP Plus

My HIP 2.0 benefits package includes …..	Yes	No	Not sure
Vision and dental care
A way I can get prescriptions in the mail
Copays for doctor care
Copays for prescription drugs
Copays for hospital stays
A monthly or annual contribution

4. Thinking about HIP Plus and HIP Basic, how well do you think you understand the differences between the two benefits packages?

Universe: HIP Basic and HIP Plus

1. Very well

2. Somewhat

3. Not at all well

Transportation/NEMT

The next set of questions is about your transportation going to and from health care visits.

Please think about your health care visits in the last 6 months. Do not include visits to the emergency room or ER.

5. Sometimes Medicaid or a benefits package provides transportation or covers the costs of transportation to and from health care visits. This could include mileage or taxi reimbursement or having a number to call your health plan to arrange transportation for you.

Does Medicaid or your HIP 2.0 benefits package provide transportation or cover any of the costs of your transportation?

Source: Adapted from Iowa Wellness Plan Survey

Universe: HIP Basic and HIP Plus

1. Yes

2. No

3. Unsure/ Don’t know

6. In the last 6 months, have you used transportation paid for by Medicaid or your HIP 2.0 benefits package to get to or from a health care visit?
   Source: Adapted from Iowa Wellness Plan Survey

Universe: HIP Basic and HIP Plus

1. Yes

2. No

7. In the last 6 months, how much have you worried about your ability to pay for the cost of transportation or your ability to get transportation to a health care visit?
   Source: Adapted Iowa Wellness Plan Survey

Universe: HIP Basic and HIP Plus

1. Not at all

2. A little

3. Somewhat

4. A great deal

8. In the last 6 months, 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: HIP Basic and HIP Plus

1. Yes

2. No  GO TO EMERGENCY ROOM SECTION, PAGE 5

3. Not sure/ Don’t know  GO TO EMERGENCY ROOM SECTION, PAGE 5

9. 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 and HIP Plus

	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

Emergency Room

The next set of questions is about emergency room (ER) care and treatment.

Some people use emergency rooms for both emergency and non-emergency care. An emergency is defined as any condition that could endanger your life or cause permanent disability if not treated immediately.

10. How easy or hard is it for you to know when your health condition is an emergency?

Source: Adapted from Iowa Wellness Plan survey

Universe: HIP Basic and HIP Plus

1. Very easy

2. Somewhat easy

3. Somewhat hard

4. Very hard

11. What does HIP 2.0 say you should do if you think you need to go to the emergency room? Mark one or more

Universe: HIP Basic and HIP Plus

1. Go directly to the emergency room

2. Call the phone number or hotline provided by HIP 2.0

3. Call my doctor

4. Ask my family or friends

Please think about how HIP 2.0 would work for you if you went to the emergency room for care. Copays are payments you make at the time when you visit your doctor’s office, go to the hospital or get prescription drugs.

12. If you go to the emergency room when your condition is an emergency, do you have to pay a copay?

Universe: HIP Basic and HIP Plus

1. Yes

2. No

3. Not sure/ Don’t know

13. If you go to the emergency room when your condition is not an emergency, do you have to pay a copay?

Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO QUESTION 15

3. Not sure/ Don’t know  GO TO QUESTION 15

14. If you go to the emergency room when your condition is not an emergency more than one time, your copay would be….

Universe: HIP Basic and HIP Plus

1. Higher

2. Lower

3. The same

4. Not sure/ Don’t know

15. In the last 6 months, was there a time you thought about going to the emergency room for care?

Source: Adapted from CAHPS Nationwide Medicaid

Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO POWER ACCOUNTS SECTION, PAGE 8

16. The last time you thought about going to the emergency room for care, did you go to the emergency room?

Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO QUESTION 20

17. The last time you went to the emergency room, was it for an emergency?

Universe: HIP Basic and HIP Plus

1. Yes  GO TO POWER ACCOUNTS SECTION, PAGE 8

2. No

18. Did you pay a copay?

Source: Adapted from HIP 1.0 survey 2013

Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO POWER ACCOUNTS SECTION, PAGE 8

3. Not sure  GO TO POWER ACCOUNTS SECTION, PAGE 8

19. How was that copay paid?

Universe: HIP Basic and HIP Plus

1. I paid it  GO TO POWER ACCOUNTS SECTION, PAGE 8

2. Someone paid for it for me  GO TO POWER ACCOUNTS SECTION, PAGE 8

3. The copay has not been paid  GO TO POWER ACCOUNTS SECTION, PAGE 8

4. Not sure  GO TO POWER ACCOUNTS SECTION, PAGE 8

20. What was the main reason you did not go to the emergency room for care?

Universe: HIP Basic and HIP Plus

1. Did not have a way to get there or could not afford to get there

2. Went to my doctor’s office or clinic instead

3. Did not want to pay the copay

4. Some other reason

POWER accounts and monthly or annual contributions

The following questions are about your understanding and experience with HIP POWER accounts.

21. Do you have a POWER account? POWER accounts are special savings accounts called Personal Wellness and Responsibility Accounts.

Universe: HIP Basic and HIP Plus

1. Yes

2. No

22. Some people are required to make monthly or annual contributions to their POWER account. Do you currently contribute to your POWER account?

Universe: HIP Basic and HIP Plus

1. I currently contribute

2. I made an up front annual payment

3. Someone else contributes for me

4. I do not contribute  GO TO QUESTION 24

23. How is that monthly or annual contribution paid?

Universe: HIP Plus

1. I pay it

2. Someone pays the full amount for me

3. I pay part and someone else pays part

4. The contribution has not been paid

5. Not sure

24. Would you say the amount you are required to contribute monthly or annually to your POWER account is:

Source: Adapted from HIP 1.0 2010 survey

Universe: HIP Plus

1. More than I can afford

2. The right amount

3. Less than I can afford

4. Not sure

25. In the last 6 months, how worried were you about not having enough money to pay your monthly or annual contribution?

Source: Adapted from Lewin HIP Plus survey

Universe: HIP Plus

1. Not at all worried

2. Somewhat worried

3. Very worried

26. What do you think will happen, if anything, if your monthly or annual contribution is not made on time? Please select the best answer.

Universe: HIP Plus and Basic

1. Nothing will change

2. My HIP 2.0 coverage will end  GO TO QUESTION 28

3. I will get automatically moved to HIP Basic  GO TO QUESTION 28

4. Not sure/Don’t know  GO TO QUESTION 28

27. Why do you not contribute to a POWER account?

Universe: HIP Basic

	Yes	No	Not sure
I do not have to contribute
I could not afford to make the contributions
I do not understand how to contribute/too confusing to understand
I do not think contributing to a POWER account helps me
Other
Unsure/ Don’t know

28. How easy or hard is it to understand how to use your POWER account?

Universe: HIP Basic and HIP Plus

1. Very easy

2. Somewhat easy

3. Neither easy nor hard

4. Somewhat hard

5. Very hard

29. Do you know how much is in your POWER account today?

Source: Adapted from MPR HIP 1.0 enrollee survey

Universe: HIP Basic and HIP Plus

1. Yes, I know exactly how much

2. Yes, I have a pretty good idea

3. I don’t really know at all

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

Universe: HIP Basic and HIP Plus

	Agree	Disagree	Not sure
The State of Indiana contributes to my POWER account
My POWER account helps me pay for my health care services
My POWER account helps me get the health care services I need
My POWER account makes me feel comfortable about paying for my health care services

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

Universe: HIP Basic and HIP Plus

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.

32. Is the cost of preventive services deducted from your POWER account?

Source: Adapted from MPR survey

Universe: HIP Basic and HIP Plus

1. Yes

2. No

3. Not sure/ Don’t know

33. If you get all or some of your recommended preventive services, will some of the remaining money in your POWER account get rolled over into next year?

Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO ACCESS SECTION, PAGE 12

3. Not sure/ Don’t know  GO TO ACCESS SECTION, PAGE 12

34. Does having a POWER account make it more likely that you will try to get all of your recommended preventive services?

Universe: HIP Basic and HIP Plus

1. Yes

2. No

3. Not sure/ Don’t know

Access

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

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

Source: Adapted from BRFSS

Universe: HIP Basic and Plus

1. Yes

2. No  GO TO QUESTION 41

3. Not sure/Don’t know  GO TO QUESTION 41

36. 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: HIP Basic

1. Yes

4. No  GO TO QUESTION 38

5. Not sure/Don’t know GO TO QUESTION 38

37. How was that copay paid?

Universe: HIP Basic

1. I paid it

2. Someone paid it for me

3. The copay has not been paid

4. Not sure/Don’t know

38. 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: HIP Basic

1. Yes

2. No

3. Not sure

39. In the last 6 months, was there any time you needed health care but did not get it because of cost?

Source: Adapted from BRFSS

Universe: HIP Basic and Plus

1. Yes

2. No  GO TO SATISFACTION SECTION, PAGE 14

3. Not sure  GO TO SATISFACTION SECTION, PAGE 14

40. In the last 6 months, what types of health care were you unable to get because of cost?

Source: Adapted from BRFSS

Universe: HIP Basic and Plus

	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

Satisfaction with HIP

41. 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: HIP Basic and Plus

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

42. Why are you dissatisfied? Mark one or more

Universe: HIP Basic and Plus

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

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

Source: BRFSS

Universe: HIP Basic and HIP Plus

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

44. What is the highest grade or level of school that you have completed?

Source: Nationwide Medicaid CAHPS
Universe: HIP Basic and HIP Plus

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

45. What best describes your employment status?
    Universe: HIP Basic and HIP Plus

1. Employed full- or part-time

2. Unemployed

46. What is your age?
    Source: Nationwide Medicaid CAHPS
    Universe: HIP Basic and HIP Plus

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

47. Are you male or female?
    Source: Nationwide Medicaid CAHPS
    Universe: HIP Basic and HIP Plus

1. Male

2. Female

48. Are you of Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected.)
    Source: Nationwide Medicaid CAHPS
    Universe: HIP Basic and HIP Plus

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

49. What is your race? Mark one or more

Source: Nationwide Medicaid CAHPS

Universe: HIP Basic and HIP Plus

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

50. [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.

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

51. Did someone help you complete this survey?
    Source: Nationwide Medicaid CAHPS
    Universe: HIP Basic and HIP Plus

1. Yes

2. No → GO TO END

52. How did that person help you? Mark one or more
    Source: Nationwide Medicaid CAHPS
    Universe: HIP Basic and HIP Plus

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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