Form CMS-10458 Individual Screener

Individual Marketplace Tracking Survey
INTRO: Good morning/afternoon/evening. This is _________. I am calling from ________. We are
conducting a random, nationally representative survey of adults aged 18 to 64. Your
household/telephone number has been selected for the survey. Is there someone in your household I
may speak with?
We are conducting a survey about health insurance and the healthcare law, and are interested in your
opinions. We are not selling anything or asking for any kind of contributions or donations. Your
responses will be completely confidential.
[IF RESPONDENT WANTS MORE CLARIFICATION ABOUT THE SURVEY SPONSOR: The Centers for
Medicare & Medicaid Services is the government agency responsible for Medicare and Medicaid. It
regularly sponsors research to help evaluate the health care Americans receive. May I continue?]

Screener
To begin with, I am going to ask you some questions about yourself, your health insurance situation, and
your general health.
DG2. Just to confirm your age, could you please tell me, in what year were you born?
RECORD YEAR _________________
DK/REF (VOL)
-1
[TERMINATE IF YEAR IS <1948 OR >1994 OR IF DG2=-1]
DGM1. When it comes to healthcare and health insurance, do you usually make decisions on your own,
with someone else’s help, or do you rely on someone else to make those decisions for you?
[IF NECESSARY, READ LIST TO CLARIFY.]
I make those decisions on my own without talking to anyone else
I make those decisions on my own, but talk with others about it
I make those decisions with someone else’s help
I rely on someone else to make those decisions for me
DK/REF (VOL)
[IF DGM1=4, ASK TO SPEAK WITH DECISION-MAKER]
[TERMINATE IF DGM1=-1]

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-1

ING1. Do you currently have health insurance coverage?
Yes
No
DK/REF (VOL)
[IF ING1=1, GO TO ING2A]
[IF ING1=2, GO TO ING2B]
[TERMINATE IF ING1=-1]

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Individual Marketplace Screening Instrument 0102-2013

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ING2A. How do you currently get health insurance to cover your hospital expenses or doctor’s visits? Do
you get it through [READ LIST stop at first YES]
Your current or former employer
Your spouse or partner’s current or former employer
{ASK IF AGE<=26} Your parents’ health plan
A plan you purchase on your own, directly from a health insurance company
A COBRA health insurance plan
Medicare for people 65 or older, or with certain disabilities
[State Medicaid name], Medicaid, or State Assistance
TRICARE, VA, or Veteran’s Health Insurance
Other (Specify)__________________________________________
DK/REF (VOL)
[CONTINUE TO NEXT SECTION IF ING2A=4,5]
[TERMINATE IF ING2A=1, 2, 3, 6, 7, 8, 9, -1]

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-1

ING2B. Do you currently get help paying for your hospital expenses or doctor’s visits from any of the
following? [READ LIST]
Your current or former employer
Your spouse or partner’s current or former employer
Any local, state, or federal government assistance program
Do not get any help paying
DK/REF (VOL)
[CONTINUE IF ING2B=4]
[TERMINATE IF ING2B=1, 2, 3, -1]

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-1

Individual Marketplace Screening Instrument 0102-2013

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