CMS-10615 New 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: New 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

2. Did you enroll in HIP 2.0 in 2016?

1. Yes

2. No  GO TO END

Healthy Indiana Plan (HIP) 2.0

3. 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

4. When you enrolled in HIP 2.0, did you look for any information in written materials or on the Internet about your benefits package?

Source: Adapted from CAHPS QHP survey
Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO QUESTION 6

5. How helpful was the information about your benefits package?
   Universe: HIP Basic and HIP Plus

1. Very helpful

2. Somewhat helpful

3. Not at all helpful

6. When you enrolled in HIP 2.0, did you get information or help from a customer service representative?

Source: Adapted from CAHPS QHP survey
Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO QUESTION 8

7. How helpful was the information you got?

Universe: HIP Basic and HIP Plus

1. Very helpful

2. Somewhat helpful

3. Not at all helpful

8. When you enrolled in HIP 2.0, did you receive any forms to fill out?

Source: Adapted from CAHPS QHP survey
Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO QUESTION 10

9. How easy or hard was it to fill out the forms?

Universe: HIP Basic and HIP Plus

1. Very easy

2. Somewhat easy

3. Neither easy nor hard

4. Somewhat hard

5. Very hard

10. How long did it take you to get HIP 2.0 coverage?

Universe: HIP Basic and HIP Plus

1. A few days

2. A few weeks

3. A few months

4. More than a few months

11. When you enrolled in HIP 2.0, did you have a choice between HIP Basic and HIP Plus?

Source: Adapted from CAHPS Supplemental Medicaid Enrollment questions
Universe: HIP Basic and HIP Plus

1. Yes

2. No  GO TO QUESTION 16

3. Unsure/Don’t know  GO TO QUESTION 16

12. How important were the following factors in helping you choose between HIP Basic and HIP Plus?

Universe: Those with a choice are at or below 100% FPL

	Very important	Somewhat important	Not at all important
Making a monthly or annual contribution
Paying a copay at each visit
Having dental and vision benefits
Fits within my budget
Getting coverage more quickly

13. When you enrolled in HIP 2.0, how easy or hard was it to understand the differences between HIP Basic and HIP Plus?
    Universe: Those with a choice are at or below 100% FPL

1. Very easy

2. Somewhat easy

3. Neither easy nor hard

4. Somewhat hard

5. Very hard

14. Did you get any help in deciding which benefits package would be best for you? Mark one or more

Universe: Those with a choice are at or below 100% FPL

1. I got help from family or friends

2. I got help from my doctor or health care provider

3. I got help from a HIP toll free number

4. I got help from an online HIP representative

5. I did not get any help

15. How easy or hard was it to decide which benefits package would be best for you?

Universe: Those with a choice are at or below 100% FPL

1. Very easy

2. Somewhat easy

3. Neither easy nor hard

4. Somewhat hard

5. Very hard

16. Please tell us whether you agree or disagree with the following statements:

Universe: HIP Basic and HIP Plus

	Agree	Disagree	Not sure
A $10 “fast track” payment would get me coverage quickly
Choosing to make a $10 “fast track” payment would not allow me to change health plans (e.g. Anthem, MDwise, MHS)
There was nothing I could have done to get coverage quickly

17. Did you do to get your HIP 2.0 coverage quickly? Mark one or more

Universe: HIP Basic and HIP Plus

1. Yes, I made my monthly or annual contribution

2. Yes, I made a $10 payment or “fast track” payment

3. Yes, My health plan, health care provider, or a non-profit organization made a $10 payment or “fast track” payment for me

4. No, I did not do anything to get my HIP 2.0 coverage more quickly

18. How satisfied were you with how long it took to get your HIP 2.0 coverage?
    Universe: HIP Basic and HIP Plus

1. Very satisfied

2. Satisfied

3. Neutral

4. Dissatisfied

5. Very dissatisfied

For the next few questions, please think about your current HIP 2.0 benefits package.

19. For each of the following items, please tell us 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 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 required monthly or annual contribution

20. How well do you think you understand your benefits package?

Universe: HIP Basic and HIP Plus

1. Very well

2. Somewhat

3. Not at all well

21. 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. I am not required to make contributions

2. Nothing will change

3. My HIP 2.0 coverage will end

4. I will get automatically moved to HIP Basic

5. Not sure/Don’t know

Satisfaction with HIP

22. 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 THE DEMOGRAPHICS SECTION, PAGE 8

2. Somewhat Satisfied  GO TO THE DEMOGRAPHICS SECTION, PAGE 8

3. Neither Satisfied nor Dissatisfied  GO TO THE DEMOGRAPHICS SECTION, PAGE 8

4. Somewhat Dissatisfied

5. Very Dissatisfied

6. Not sure/ Don’t know  GO TO THE DEMOGRAPHICS SECTION, PAGE 8

23. 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

24. 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

25. 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

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

1. Employed full- or part-time

2. Unemployed

27. 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

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

1. Male

2. Female

29. 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

30. 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

31. [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

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

1. Yes

2. No → GO TO END

33. 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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