Form CMS-10615 Debriefing Script - Alternate Policy Survey Questions

OMB Control Number: 0938-1300
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 0938-1300. 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].

DEBRIEFING SCRIPT – ALTERNATE POLICY OPTIONS QUESTIONS

1

OMB Control Number: 0938-1300

Healthy Indiana Plan (HIP) 2.0
Alternate Policy Options Survey Testing Debriefing Script
Survey Background
Part of the federal evaluation of the Healthy Indiana Plan (HIP) 2.0 Demonstration will be based on
information collected using three beneficiary survey instruments. The three target populations for the
instruments include: (1) current HIP 2.0 beneficiaries; (2) newly enrolled HIP 2.0 beneficiaries; and (3)
HIP 2.0 disenrollees and beneficiaries who have been “locked out.” All instruments contain survey
questions from existing beneficiary questionnaires, survey questions adapted from existing beneficiary
questionnaires, and newly developed survey questions. The newly developed survey questions are
especially important for testing, and focus on specific policies of interest to CMS. The beneficiary
feedback captured by these instruments will help inform CMS decision making on health care policies.
A separate set of survey questions may be included in the HIP 2.0 beneficiary survey instruments that
focus on studying different ways to meet people’s health care needs. The intention of the additional
survey section is to provide valuable data on beneficiary preferences regarding health plan choices and
payment options.
This survey testing script serves as a guide for the interviewer debriefing focusing on the HIP 2.0
Beneficiary Survey Section: Health Coverage Cost and Payment Options.

Survey Section: Health Coverage Cost and Payment Options
General Interviewer Probes
[Interviewer Instructions: The following questions are general probes that interviewers may
use during the debriefing.]
•
•
•
•
•
•
•

Could you please tell me more about that?
Was that easy or hard to answer?
How did you decide on that answer?
How confident are you in your answer?
Were any of the answer choices not clear, or confusing?
I noticed that you hesitated – please tell me what you were thinking.
Were there any questions that were asked that did not seem to belong in this questionnaire?

INTERVIEWER: How easy or difficult was it to for you to understand and answer this section?
INTERVIEWER: What time period were you thinking about when you answered this section?
INTERVIEWER: Was it easy or hard to change your thinking from your current or previous HIP
experience, to a more general role as a health care consumer?
Question #: 2
INTERVIEWER: How easy or hard was it to answer this question?

DEBRIEFING SCRIPT – ALTERNATE POLICY OPTIONS QUESTIONS

2

OMB Control Number: 0938-1300
INTERVIEWER: How easy or hard was it to compare and choose between Health Plan A and Health
Plan B?
INTERVIEWER: How easy or hard was it to think about the different parts of Health Plan A and Health
Plan B?
PROBE: Did you think of the things listed in (1) and (2) as two different parts or as the same
thing?
Question #: 3
INTERVIEWER: How easy or hard was it to answer?
INTERVIEWER: Was it easy or hard to choose only one health plan?
Question #: 6
INTERVIEWER: What did the word “choice” mean to you?

DEBRIEFING SCRIPT – ALTERNATE POLICY OPTIONS QUESTIONS

3