Form CMS-10458 SHOP Survey

SHOP Tracking Survey
Insurance Status, Purchasing Behaviors, Perceptions
ING3A. [IF INBO1=1 or 2] For how long have you offered health insurance to your employees?
Less than 6 months
6 months to less than one year
One year to less than two years
Two years or longer
DK/REF

1
2
3
4
-1

INBO3. [IF INBO1=1 or 2] On average, what percent of each employee’s health insurance premium do
you pay? [ASK OPEN END]
RECORD RESPONSES
DK/REF (VOL)

_________________
-1

INBO1A. [IF INBO1=1 or 2] Do you currently offer health insurance plans to employees’ dependents or
family members, regardless of whether you pay a portion of that coverage?
Yes
No
DK/REF

1
2
-1

BG11A. [IF INBO1=1 or 2] When selecting health insurance to offer your employees, do you use a
broker?
Yes
No
DK/REF

1
2
-1

ING3B. [IF INBO1=3]For how long have you not offered health insurance to your employees?
Less than 6 months
6 months to less than one year
One year to less than two years
More than two years
Have never offered health insurance
DK/REF

1
2
3
4
5
-1

BG11B. [IF ING3B=1-4] When selecting health insurance for you employees in the past, did you use a
broker?
Yes
No
DK/REF

1
2
-1
SHOP Tracking Survey 11/26/2012

1

INBO2. [ASK ALL] What was or were the main decision factors for whether to provide health insurance
for the employees in your company? [ASK OPEN ENDED]
RECORD RESPONSES
DK/REF (VOL)

_________________
-1

BG1B. In the past 90 days, have you done the following for your business:

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

Researched health insurance plans [ANCHOR TO TOP AND ROTATE THE REST]
[IF INBO1=3] Considered buying a health insurance plan or plans
[IF INBO1=1 or 2] Considered changing health insurance plans
Attempted to purchase a new health insurance plan or plans
Contacted an agent or broker to help you find health insurance
Shopped online for health insurance

YES
1
1
1
1
1
1

NO
2
2
2
2
2
2

REF
-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

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

1
2
3
4
5
-1

ISG2. What sources or places do you (or could you) use to get information about health insurance,
including what plan options are available for your business? [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

_________________________________________________________
SHOP Tracking Survey 11/26/2012

2

DK/REF (VOL)

-1

Health Insurance Marketplace/SHOP Awareness
AWG1A. How much attention do you pay to news and information about health insurance?
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 for to small
businesses to buy health insurance called The Health Insurance Market Place or the Small Business
Health Options Program. Have you recently seen, heard, or read anything about the Health Insurance
Marketplace or Small Business Health Insurance Options Program – also called the “SHOP”?
Yes
1
No
2
DK/REF (VOL)
-1
[IF AWG2=1, CONTINUE. IF AWG2=2 OR-1, GO TO Q____]
AWG2AA. 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 or
the SHOP 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 or SHOP 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 Q____]
AWG2AB. 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
Exchanges was positive, negative, or neutral?
SHOP Tracking Survey 11/26/2012

3

Positive
Neutral
Negative
DK/REF (VOL)

1
2
3
-1

AWG5, AWG2B. More specifically, have you recently seen, read or heard about the new Health
Insurance Marketplace or Small Business Health Insurance Options Program (SHOP), also called
Affordable Health Insurance Exchanges… [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

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

AWG2B
(Do Not
Read)
Adv
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
News/
Both
Article

DK
-1
-1
-1
-1
-1

AWG1B. How much attention do you pay to news and information about the healthcare law?
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 the Health Insurance
Marketplace or the SHOP. 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. When employers use the SHOP to get health insurance for their
businesses, they will choose a level of coverage instead of a single
health plan for all employees.
b. Employers will be able to define the contribution they make toward
health insurance for their employees in the SHOP.
c. Employers will get one bill and make one payment each month for

1

2

3

-1

1

2

3

-1

1

2

3

-1

SHOP Tracking Survey 11/26/2012

4

d.
e.

f.
g.
h.
i.
j.
k.

employee health insurance through the SHOP.
Starting in 2014, employers who buy health insurance through the
SHOP can get an expanded Small Business Health Care Tax Credit.
Under the new healthcare law, insurers will no longer be allowed to
charge more in premiums because an individual has a preexisting
health condition.
All of the insurance plans in the SHOP must meet minimum cost and
coverage standards.
Employees will have more choice about their health insurance plans if
employers choose to use the SHOP.
Using the SHOP will make it easier for employers to set up a simple
Internal Revenue Service (IRS) Section 125 plan.
Employers will be able to use their own brokers to purchase health
insurance through the SHOP.
You can get to the SHOP by going to w-w-w dot healthcare dot gov
Small businesses with fewer than 50 employees are not required by
the healthcare law to offer employee health insurance.

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

GR8. Please tell me how much you agree or disagree with the following statements: [ROTATE]
Som Ag

Som Disag

Comp Disag

Refuse

Comp Ag

a. I plan to use the SHOP.
b. I wish I had more information about SHOP.
c. I would be more likely to use the SHOP if I had more information
about it.
d. I know where to go to find out information about the SHOP.
e. I plan to ask my insurance broker about the SHOP

1
1

2
2

3
3

4
4

-1
-1

1

2

3

4

-1

1
1

2
2

3
3

4
4

-1
-1

ATG2. Do you think your business will be better or worse off due to the healthcare law, or do you think
it won’t make much difference?
Better off
No difference
Worse off
DK/REF (VOL)

1
2
3
-1

BG8. Starting in 2014, you’ll have more choice and control over your health insurance spending through
the Small Business Health Options Program (SHOP), a new program designed to simplify the process of
buying health insurance for your small business. The SHOP lets you make apples-to-apples comparisons
with clear, straightforward information that’s easy to understand. You choose the level of coverage
you’ll offer, and define how much you’ll contribute towards your employees’ coverage. You’ll have the
option to offer your employees a choice of coverage from multiple insurers — just like larger companies
do — but get one bill and make a single payment. Tax benefits available through the SHOP can help
make health insurance more affordable through tax savings, for you AND your employees. 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?
SHOP Tracking Survey 11/26/2012

5

Very likely
Somewhat likely
Somewhat unlikely
Very unlikely
DK/REF (VOL)

1
2
3
4
-1/-2

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

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

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

1
2
-1

Business Characteristics
SBO3. In what industry is your business? [USE DROP DOWN MENU FOR RESPONSES]
RECORD RESPONSES

_________________
SHOP Tracking Survey 11/26/2012

6

DK/REF (VOL)

-1

SBOX. How long has your business been in operation, including prior to your involvement with the
business, if applicable? [ASK OPEN ENDED]
RECORD RESPONSES
DK/REF (VOL)

_________________
-1

DG11. In what state is the primary or main office of your business? [USE DROP DOWN FOR RESPONSES]
RECORD RESPONSES
DK/REF (VOL)

_________________
-1

DG10. What is your business’ total annual income (gross receipts)?

Personal Demographics and Characteristics
ING1. Do you currently have health insurance coverage for yourself?
Yes
No
DK/REF

1 [GO TO ING2A]
2 [GO TO DG1]
-1

ING2A. [IF ING1=1] How do you currently get health insurance to cover your hospital expenses or
doctor’s visits? Do you get it through…
Your business
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)

1
2
3
4
5
6
7
8
9
-1

DG1. What is your gender?
Male
Female

1
2

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

1
2
-1

DG4. What is your race or ethnic background? (CHOOSE ALL THAT APPLY)
SHOP Tracking Survey 11/26/2012

7

White
1
Black/African American
2
Asian
3
American Indian
4
Native Hawaiian or other
5
Pacific Islander
DK/REF (VOL)
-1
*Note – response option “other” has been removed
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

*Note – question DG6 has been removed.
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.
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

SHOP Tracking Survey 11/26/2012

8