Form CMS-10458 Individual Survey

Individual Marketplace Tracking Survey
Length and Reason for Being Uninsured
ING3. [IF ING2B=4] How long have you been without health insurance?
Less than 6 months
6 months to less than one year
One year to less than two years
Two years or longer
DK/REF (VOL)

1
2
3
4
-1

ING4. What is the main reason you do not currently have health insurance? [ASK OPEN END]
RECORD RESPONSE
DK/REF (VOL)

_________________________________________________________
-1

CMS Segmentation and Health Literacy
[ASK ALL] BG1A. Have you ever looked for information on health topics like staying healthy and
preventing disease, managing ongoing conditions like pain, arthritis, or diabetes; healthcare quality
information and support networks; or changes in health insurance benefits?
Yes
No
DK/REF (VOL)

1
2
-1

ATG1. Using a scale from 1 to 7, where 1 means you completely disagree and 7 means you completely
agree, how would you rate each of the following statements? [READ AND ROTATE STATEMENTS].
a.
b.
c.
d.
e.
f.
g.
h.
i.

Someone else takes care of health care issues so I don’t really need to
It is very important for me to be informed about health issues
I have other people I can always turn to if I need help
I’m concerned about not being able to pay for healthcare
I have a financial plan that includes funding for future healthcare costs
I am usually one of the first to try new technologies
Most health issues are too complex for me to understand
I have difficulty understanding a lot of the health information that I read
It is hard to find good answers to my health questions and concerns

Heath Insurance Perceptions/Attitudes/Experiences
Now, I’m going to ask you about some of your opinions and experiences.…
ISG1. How satisfied would you say you are with your current health insurance situation? [READ LIST]
Very satisfied
Somewhat satisfied
Somewhat dissatisfied

1
2
3
Individual Marketplace Tracking Survey 01-02-2013

1

Very dissatisfied
DK/REF (VOL)

4
-1

BG1B. In the past 90 days, have you done the following:
a.
b.
c.
d.
e.
f.
g.

Researched health insurance plans [ANCHOR TO TOP AND ROTATE THE REST]
[IF ING1=2] Considered buying a health insurance plan
[IF ING1=1] Considered changing health insurance plans
Attempted to purchase a new health insurance plan
Contacted an agent or broker to help you find health insurance
Shopped online for health insurance
Looked into or inquired about Medicaid or other government insurance
programs

YES
1
1
1
1
1
1
1

NO
2
2
2
2
2
2
2

REF
-1
-1
-1
-1
-1
-1
-1

ISG2. [IF F=1] You mentioned that you have shopped online for health insurance in the past 90 days.
What website or websites did you use to shop for health insurance? (ASK OPEN END)
RECORD RESPONSE
DK/REF (VOL)

_________________________________________________________
-1

Individual Marketplace Tracking Survey 01-02-2013

2

PG1. How difficult do you think the process of finding and choosing a new health insurance plan is (or
would be)?
Very easy
Somewhat easy
Somewhat difficult
Very difficult
Not sure (VOL)
REF (VOL)

1
2
3
4
5
-1

ISG2. Where do you get (or could get) information about health insurance, including what plan options
are available to you? [ASK OPEN END. SEE FOLLOW UP QUESTIONS BELOW]
RECORD RESPONSE
_________________________________________________________
DK/REF (VOL)
-1
ISG2A. [IF INTERNET SOURCE] You indicated that you have gotten or could get information about health
insurance from the internet. What website do you (or could you) use to get this information?
RECORD RESPONSE
DK/REF (VOL)

_________________________________________________________
-1

ISG2A2. [IF MAIL SOURCE] You indicated that you have gotten or could get information about health
insurance through mailings. Who has or could send you these mailings?
RECORD RESPONSE
DK/REF (VOL)

_________________________________________________________
-1

Health Insurance Marketplace Awareness
DG11. In what state do you reside? [IF RESPONDENT MENTIONS THAT THEY HAVE MULTIPLE
HOMES/LIVE IN MULTIPLE STATES, SAY: “Please give me the state you live in at least six months out of
the year or the state that you consider to be your primary residence.”]
RECORD STATE
____________
DK
-1
REF
-2
[TERMINATE IF DG11=-1 OR -2]
AWG1A. How much attention do you pay to news and information about health insurance? [READ LIST]
A lot of attention
Some attention
A little attention
Very little attention
DK/REF (VOL)

1
2
3
4
-1

AWG2A. When key parts of the health care law take effect in 2014, there will be a new way to buy
health insurance: the Health Insurance Marketplace (If the marketplace is being referred to by a Statespecific name add: in your state this is known as the [insert marketed exchange name]). Have you
recently seen, heard, or read anything about this new Health Insurance Marketplace?
Individual Marketplace Tracking Survey 01-02-2013

3

Yes
1
No
2
DK/REF (VOL)
-1
[IF AWG2=1, CONTINUE. IF AWG2=2 OR-1, GO TO AWG2B]
AWG2A1. Can you briefly tell me what you saw, read, or heard? (OPEN END)
RECORD RESPONSE
_________________________________________________________
DK/REF (VOL)
-1
AWG4A. Would you say that what you saw, read, or heard about the Health Insurance Marketplace (If
the marketplace is being referred to by a State-specific name add: or the [insert marketed exchange
name]) was positive, negative, or neutral?
Positive
Neutral
Negative
DK/REF (VOL)

1
2
3
-1

AWG2B. [IF AWG2A=NO or DK/REF] In some places, the new Health Insurance Marketplace is also called
the Affordable Health Insurance Exchange. Have you recently seen, heard, or read anything about
called the Affordable Health Insurance Exchange?
Yes
1
No
2
DK/REF (VOL)
-1
[IF AWG2=1, CONTINUE. IF AWG2=2 OR-1, GO TO AWG1B]
AWG2B1. Can you briefly tell me what you saw, read, or heard? (OPEN END)
RECORD RESPONSE
_________________________________________________________
DK/REF (VOL)
-1
AWG4B. Would you say that what you saw, read, or heard about the Affordable Health Insurance
Exchange was positive, negative, or neutral?
Positive
Neutral
Negative
DK/REF (VOL)

1
2
3
-1

AWG5, AWG2B. More specifically, have you recently seen, read or heard about The Health Insurance
Marketplace also called Affordable Health Insurance Exchanges (If the marketplace is being referred to
by a State-specific name add: or the [insert marketed exchange name])… [READ AND ROTATE LIST.
AFTER EACH STATEMENT PAUSE. ACCEPT MULTIPLE RESPONSE.]
[FOR EACH YES, IMMEDIATELY FOLLOW UP WITH “And was that in an advertisement (like a commercial),
OR a news piece or article, OR both?”]
AWG5

AWG2B

Individual Marketplace Tracking Survey 01-02-2013

4

a.
b.
c.
d.
e.
f.
g.

On television
On the radio
In a newspaper
In a magazine
In the mail
On the Internet
Through word of mouth

Yes

No

1
1
1
1
1
1
1

2
2
2
2
2
2
2

(Do Not
News/
Read)
Adv
Both
Article
Other
Specify
1
2
3
_______
1
2
3
_______
1
2
3
_______
1
2
3
_______
DO NOT ASK FOR AWG2B
1
2
3
_______
DO NOT ASK AWG2B

DK
-1
-1
-1
-1
-1

AWG1B. How much attention do you pay to news and information about the healthcare law? [READ
LIST]
A lot of attention
Some attention
A little attention
Very little attention
DK/REF (VOL)

1
2
3
4
-1

Health Insurance Marketplace Knowledge and Intent
KG7. I am going to read you some short phrases describing specific features of this new Health Insurance
Marketplace(If the marketplace is being referred to by a State-specific name add: or the [insert
marketed exchange name]) . For each phrase, please tell me whether you feel it is true or false. If you
are unsure or haven’t heard enough to say, just let me know. [READ AND ROTATE STATEMENTS]
False

Unsure/
Haven’t heard

Refuse

True

a. At the Health Insurance Marketplace, you can find information about
many available health insurance plans in one place.
b. Health insurance plans available through the Marketplace are from
private health insurance companies.
c. The Health Insurance Marketplace allows you to make apples-toapples comparisons of costs and coverage between health insurance
plans.
d. At the health insurance marketplace, you can see what your premium,
deductibles, and out of pocket costs will be before you make a
decision to enroll.
e. You can find out if you are eligible for $0 or low cost health insurance
premiums through the Marketplace.
f. The rules for Medicaid have changed and more people will be eligible.
g. Some people will be eligible for a new tax credit that will help them
pay for their monthly health insurance premiums.
h. Under the new healthcare law, insurers will no longer be allowed to
charge more in premiums because an individual has a preexisting
condition.

1

2

3

-1

1

2

3

-1

1

2

3

-1

1

2

3

-1

1

2

3

-1

1

2

3

-1

1

2

3

-1

1

2

3

-1

Individual Marketplace Tracking Survey 01-02-2013

5

i.

All of the insurance plans in the Marketplace must meet minimum cost
1
and coverage standards.
j. You can get to the Health Insurance Marketplace by going to w-w-w
1
dot healthcare dot gov
k. Starting in 2014, most people in the US will be required to have health
1
insurance coverage or they will have to pay a tax.

2

3

-1

2

3

-1

2

3

-1

Individual Marketplace Tracking Survey 01-02-2013

6

GR8. Please tell me how much you agree or disagree with the following statements about the Health
Insurance Marketplace or the SHOP: [ROTATE QUESTIONS and READ LIST]
Som Ag

Som Disag

Comp Disag

Refuse

Comp Ag

a. I plan to use the Health Insurance Marketplace or SHOP.
b. I wish I had more information about the Health Insurance Marketplace
or SHOP.
c. I would be more likely to use the Health Insurance Marketplace or
SHOP if I had more information about it.
d. I know where to go to find out information about the Health Insurance
Marketplace or SHOP.

1

2

3

4

-1

1

2

3

4

-1

1

2

3

4

-1

1

2

3

4

-1

BG8. When key parts of the health care law take effect in 2014, there will be a new way to buy health
insurance: the Health Insurance Marketplace. The Marketplace is designed to help you find health
insurance that fits your budget, with less hassle. One application, one time, and you and your family can
explore qualified health insurance plan in your area. You may even be eligible for a free plan, or a new
kind of tax credit that lowers your monthly premium right away. Based on what you know at this time,
how likely do you think you will be to use the Health Insurance Marketplace to find information about
health insurance coverage when the time comes? [READ LIST]
Very likely
Somewhat likely
Somewhat unlikely
Very unlikely
DK (VOL)
REF (VOL)

1
2
3
4
-2
-1

Health Status and Chronic Conditions
HSG3. Thinking about your own health status these days, would you say it is: [READ LIST]
Excellent
Very Good
Good
Fair
Poor
DK/REF (VOL)

1
2
3
4
5
-1

HSG2. Do you have any chronic health conditions that require ongoing care, such as arthritis, chronic
pain, high blood pressure, diabetes, or heart disease?
Yes
No
DK/REF (VOL)

1
2
-1

Individual Marketplace Tracking Survey 01-02-2013

7

Internet Use
IUG4. How often do you access the internet on your own or with someone else’s help? [READ LIST]
Daily or almost daily
1
Once or twice a week
2
Once or twice a month
3
A few times a year
4
Don’t use Internet
5
DK/REF (VOL)
-1
[IF IUG4=5, SKIP TO DEMOGRAPHICS SECTION]
MTG3. Do you use the following devices to access the Internet?
(RANDOMIZE; RECORD ALL YES RESPONSES.)
Personal desktop or laptop computer
iPad or other tablet computer
A smart phone like iPhone, Blackberry, or Android
Other (Specify__________)

1
2
3
4

MTG2. [IF MTG3 3=YES] Do you use text messaging?
Yes
No
DK/REF (VOL)

1
2
-1

IUG15. Which, if any, of the following social networking websites do you use? Do you use…
(RANDOMIZE; RECORD ALL YES RESPONSES.)
Facebook
Twitter
Linkedin
Pinterest
Google Plus
Blogs
Other (Specify__________)

1
2
3
4
5
6
7

AWG2. Have you ever heard of the following websites?
(RANDOMIZE; RECORD ALL YES RESPONSES. IF YES, ASK BG5 IMMEDIATELY)
w w w dot HealthInsuranceNow dot gov
w w w dot Healthcare dot gov
w w w dot esurance dot com

1
2
3
4
BG5. [ASK IMMEDIATELY FOLLOWING EACH ‘YES’ IN AWG2] Have you ever visited this site?
Yes
No
DK/REF (VOL)

1
2
-1
Individual Marketplace Tracking Survey 01-02-2013

8

Demographics and Characteristics
We are almost finished. I just have some questions for classification purposes.
DG1. Gender
Male
Female

1
2

DG3. Are you Hispanic or Latino?
Yes
No
DK/REF (VOL)

1
2
-1

{FOR SPANISH LANGUAGE SURVEY} What is the primary language spoken in your household? (OPEN
END)
DG4. What is your race or ethnic background? Please identify all of the categories that apply to you.
(READ LIST, ACCEPT MULTIPLES)
White
Black/African American
Asian
American Indian
Native Hawaiian or other
Pacific Islander
DK/REF (VOL)

1
2
3
4
5
-1

DG5. What is the highest level of education you have completed?
Grade school or less
Some high school
Graduated high school/GED
Some college but did not graduate
Vocational/Tech school/Associates
degree
Graduated four year college
Post graduate degree (e.g., Ph.D. or
Masters degree)
DK/REF (VOL)

1
2
3
4
5
6
7
-1

DG6. What is your marital status?
Married
Never married/single
Separated
Divorced
Widowed

1
2
3
4
5
Individual Marketplace Tracking Survey 01-02-2013

9

DK/REF

-1

DG8.How many dependent children, under the age of 19 live in your household? (RECORD NUMBER)
DG7. Including yourself, how many immediate family members live in your home? (RECORD NUMBER)
SG11. Do you have major responsibility for providing care to someone with a disability or another adult,
like a parent, spouse, or friend?
Yes
No
DK/REF (VOL)

1
2
-1

DG9. What is your current employment status?
Employed full time
Employed part time
Retired
Unemployed and looking
Not in the labor force (Student,
homemaker, etc)
Other (Specify__________)
DK/REF

1
2
3
4
6
7
-1

DG10. What is your total annual household income? If you are living with parents, a roommate or other
relatives, please tell me the income for only yourself and your spouse if applicable. [READ LIST]
Less than $15,000
$15,000 to under $25,000
$25,000 to under $50,000
$50,000 to under $75,000
$75,000 to under $100,000

1
2
3
4
5

$100,000 to under $150,000
$150,000 to under $200,000
$200,000 or more
DK/REF

6
7
8
-1

Individual Marketplace Tracking Survey 01-02-2013

10