CMS-10635 Beneficiary Survey: Enrollees (paper)

OMB Control Number: 0938-NEW

Expira on Date: TBD

Montana Health and Economic Livelihood Partnership Plan
Beneficiary Survey: Enrollees
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for improving this form, please write to: CMS, 7500 Security Boulevard, A n: PRA Reports Clearance Officer, Mail Stop C4-26-05, Bal more, Maryland
21244-1850.

IntroducƟon and DirecƟons for CompleƟng the Survey
The Centers for Medicare & Medicaid Services is conduc ng this survey to ask about your recent experiences
receiving health care and should take about 15 minutes to complete.
Your par cipa on is voluntary, and there is no loss of benefits or penalty of any kind for deciding not to
par cipate. You may skip any ques ons that you do not feel comfortable answering. Your par cipa on in this
research is private, and we will not share your name or any other iden fying informa on with any outside
organiza on. You may no ce a number on the cover of the survey. This number is ONLY used to let us know
if you returned the survey. Please contact the survey help desk toll-free at 1-855-443-2692 with ques ons
about this research.
• Use pen with blue or black ink.
• Mark all your answers with an ‘X’.
• If you make an error, cross it out with a single line and mark the correct answer.
• If you are told to skip a ques on, follow the arrow for instruc ons about what ques on to answer next.

Study ID

1

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About Your HELP Enrollment
The State of Montana currently runs an insurance program called the Montana Health and Economic
Livelihood Partnership (HELP) Plan for adults ages 19 to 64.
1.

Are you currently enrolled in the “Montana Health and Economic Livelihood Partnership Plan”
(also called “HELP”)?
Yes
No
Not sure/Don’t know

2.

GO TO END

How long have you been enrolled in HELP?
1 to 3 months
4 to 6 months
7 to 12 months
More than 12 months

3.

Since you enrolled in HELP, was there ever a Ɵme you lost your coverage or were disenrolled from HELP?
Yes
No
Not sure/Don’t know

4.

GO TO QUESTION 5

About how long were you disenrolled from HELP?
Less than 1 month
1 to 3 months
More than 3 months
Not sure/Don’t know

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Before You Enrolled in Your HELP Plan
For the next few ques ons, please think back to the 12 months before you enrolled in HELP.
5.

In the 12 months before you enrolled in HELP, did you have any health insurance?
Yes
No
Not sure/Don’t know

6.

GO TO QUESTION 9

How long did you have that health insurance?
All 12 months
6 to 11 months
Less than 6 months

7.

What type of health insurance did you have? Mark one or more.
Medicaid
Private (insurance from an employer or union or purchased directly from insurance company)
TRICARE or other military health care, including Veterans Health (VA enrollment)
Indian Health Service
Other
Not sure/Don’t know

8.

In the 12 months before you enrolled in HELP, did you get any prevenƟve care (such as a rouƟne check up,
blood pressure check, flu shot, family planning services, prenatal services, cholesterol or cancer screening)?
Yes
No
Not sure/Don’t know

3

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About Your HELP Plan
For the following ques ons please think about your current experience in your HELP plan.
9.

How well do you think you understand how your HELP plan works?
Very well
Somewhat
Not at all

10.

When you enrolled in HELP, did you look for any informaƟon in wriƩen materials or on the Internet about the
HELP plan?
Yes
No  GO TO QUESTION 12

11.

How helpful was the informaƟon about the HELP plan?
Very helpful
Somewhat helpful
Not at all helpful

12.

When you enrolled in HELP, did you get informaƟon or help from a customer service representaƟve?
Yes
No  GO TO QUESTION 14

13.

How helpful was the informaƟon you got?
Very helpful
Somewhat helpful
Not at all helpful

14.

From the Ɵme you submiƩed your applicaƟon unƟl your HELP coverage started, how much Ɵme did it take?
Less than a month
1 to 3 months
More than 3 months
Not sure/Don’t know
4

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Premiums and Copays
The following ques ons are about your understanding and experience with HELP premiums and copays.
15.

How much is your monthly HELP premium?
$0 to $9
$10 to $19
$20 to $29
$30 to $39
$40 to $49
$50 and above
Not sure/Don’t know

16.

How is that monthly premium paid, if at all?
I pay it  GO TO QUESTION 18
Someone pays the full amount for me
I pay part and someone else pays part
The premium has not been paid

GO TO QUESTION 18

Not sure/Don’t know

17.

Which of the following groups help pay for your monthly premium? Mark one or more.
Family or friends
Community or non-profit organiza on (such as church, mul -cultural organiza on)
Health services organiza ons
Health care provider
Employer
Other

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18.

Would you say the amount of your monthly premium is:
More than I can afford
An amount that I can afford
Less than I can afford
Not sure/Don’t know

19.

In the last 6 months, how worried were you about not having enough money to pay your monthly premium?
Not at all worried
A li le worried
Somewhat worried
Very worried
Extremely worried

20.

What do you think will happen, if anything, if your monthly premium is not paid within 90 days?
Nothing will happen  GO TO QUESTION 22
My HELP coverage could end
Not sure/Don’t know  GO TO QUESTION 22

21.

For each of the following statements, please tell us whether you think it is part of your HELP plan.
Please mark one answer in each row.
Part of
Not part
your HELP of your
plan
HELP plan

Not sure

a. Payment of any unpaid premiums within 90 days will allow me to keep
my HELP coverage
b. Payment of any unpaid premiums aŌer 90 days will allow me to re-enroll
in HELP within 12 months of my HELP plan start date
c. Any unpaid premium balance may be collected from my future state
income tax refunds

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22.

In the last 6 months, have you paid any copays? Copays are payments owed by you to your health care
provider for health care services that you receive. You are responsible for paying the provider aŌer the claim
has been processed.
Yes
No
Not sure/Don’t know

23.

GO TO QUESTION 26

In the last 6 months, would you say the amount you were required to pay for copays was:
More than I could afford
An amount that I could afford
Less than I could afford
Not sure/Don’t know

24.

The last Ɵme you received a bill for a copay, how was that copay paid, if at all?
I paid it
Someone paid it for me
The copay has not been paid
Not sure/Don’t know

25.

How easy or hard was it to understand how HELP copays work?
Very easy
Somewhat easy
Neither easy nor hard
Somewhat hard
Very hard

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26.

For each of the following statements about HELP premiums, premium credits, and copays, please tell us
whether you think it is part of your HELP plan. Please mark one answer in each row.
Part of
Not part
your HELP of your
plan
HELP plan

Not sure

a. Monthly premiums depend on my income
b. Copays depend on which health care service(s) I use
c. Premium credits go toward copays owed
d. Copays must be paid out of my own pocket once my premium credit is
used up
e. Copays will not be collected at the me of my health care service(s)
f.

Unpaid premiums may be collected against my future state income tax
refunds

8

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Access to Care
For the following ques ons please think about your health care experiences in the last 6 months.

27.

In the last 6 months, did you go to a doctor, nurse, or any other health professional or get prescripƟon drugs?
Yes
No
Not sure/Don’t know

28.

GO TO QUESTION 29

In the last 6 months, were any of your health care visits for a rouƟne checkup? A rouƟne checkup is a general
physical exam, not an exam for a specific injury, illness, or condiƟon.
Yes
No
Not sure/Don’t know

29.

In the last 6 months, was there any Ɵme you needed health care but did not get it because of cost?
Yes
No  GO TO QUESTION 31

30.

In the last 6 months, what types of health care were you unable to get because of cost? Please mark one
answer in each row.
Yes

No

N/A

a. A visit to the doctor when I was sick
b. Preven ve care (such as blood pressure check, flu shot, family planning
services, prenatal services, cholesterol or cancer screenings)
c. A follow up visit to get tests or care recommended by my doctor
d. Dental care
e. Vision (eye) care
f.

Prescrip on drugs

g. Emergency room care

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The next set of ques ons is about emergency room (ER) care and treatment.
Some people use emergency rooms for both emergency and non-emergency care. An emergency is defined as
any condi on that could endanger your life or cause permanent disability if not treated immediately.
31.

As part of your HELP plan, is there an $8 copay for going to the emergency room for a non-emergency
condiƟon?
Yes
No
Not sure/Don’t know

32.

In the last 6 months, was there a Ɵme you thought about going to the emergency room when you needed
care?
Yes
No  GO TO QUESTION 35

33.

In the last 6 months, when you needed care did you go to the emergency room?
Yes  GO TO QUESTION 35
No

34.

What was the main reason you did not go to the emergency room for care?
Did not have a way to get there or could not afford to get there
Went to my doctor’s office or clinic instead
Did not want to pay a copay
Waited to see if I would get be er on my own
Some other reason

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SaƟsfacƟon with HELP
35.

Thinking about your overall experience with HELP, would you say you are:
Very Sa sfied
Somewhat Sa sfied
Neither Sa sfied nor Dissa sfied GO TO QUESTION 37
Somewhat Dissa sfied
Very Dissa sfied
Not sure/Don’t know  GO TO QUESTION 37

36.

Please tell us how saƟsfied or dissaƟsfied you are with each HELP item below.
Please mark one answer in each row.
Very
Sa sfied

Somewhat
Sa sfied

Neutral

Somewhat
Dissa sfied

Very
Dissa sfied

a. Enrollment process
b. Length of me for coverage to begin
c. Ability to see my doctor
d. Choice of doctors
e. Coverage of health care services that I need
f.

How copays work

g. Cost of premiums
h. Paying the same amount each month for
premiums

11

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Now think about your current HELP plan compared to the health insurance plan you had in the 12 months
before you enrolled in HELP.

If you did not have a health insurance plan
in the 12 months before you enrolled in HELP

37.

GO TO QUESTION 38

For each of the following items, how does your current HELP plan compare to your previous health insurance
plan? Please mark one answer in each row.
Be er

The same

Worse

Not sure

a. Ability to afford my plan
b. Coverage of health care services that I need
c. Ability to see my doctor
d. Ability to get health care services that I need

12

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About You
38.

Would you say that in general your health is:
Excellent
Very good
Good
Fair
Poor

39.

What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

40.

What best describes your employment status?
Employed full- me
Employed part- me
Self-employed
A homemaker
A full- me student
Unable to work for health reasons
Unemployed

41.

What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
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42.

Are you male or female?
Male
Female

43.

Are you of Hispanic, LaƟno/a, or Spanish origin? Mark one or more.
No, not of Hispanic, La no/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, La no/a, or Spanish origin

44.

What is your race? Mark one or more.
White
Black or African-American
American Indian or Alaska Na ve
Asian
Na ve Hawaiian or Other Pacific Islander

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45.

Please circle the number of people in your family (including yourself) that live in your household. Mark
only one answer that best describes your family’s total income over the last year before taxes and other
deducƟons. Your best esƟmate is fine.
Family size
(including
yourself)

46.

Family Income Per Year

One
person

At or below
$6,000

Above $6,000
and up to $12,000

Above $12,000
and less than $17,000

At or above
$17,000

Two
people

At or below
$8,000

Above $8,000
and up to $16,000

Above $16,000
and less than $22,000

At or above
$22,000

Three
people

At or below
$10,000

Above $10,000
and up to $20,000

Above $20,000
and less than $28,000

At or above
$28,000

Four
people

At or below
$12,000

Above $12,000
and up to $25,000

Above $25,000
and less than $34,000

At or above
$34,000

Five
people

At or below
$14,000

Above $14,000
and up to $29,000

Above $29,000
and less than $40,000

At or above
$40,000

Six
people

At or below
$16,000

Above $16,000
and up to $33,000

Above $33,000
and less than $45,000

At or above
$45,000

Seven
people

At or below
$19,000

Above $19,000
and up to $37,000

Above $37,000
and less than $51,000

At or above
$51,000

Eight
people

At or below
$21,000

Above $21,000
and up to $41,000

Above $41,000
and less than $57,000

At or above
$57,000

Nine
people

At or below
$23,000

Above $23,000
and up to $45,500

Above $45,500
and less than $63,000

At or above
$63,000

Ten or more
people

At or below
$25,000

Above $25,000
and up to $50,000

Above $50,000
and less than $69,000

At or above
$69,000

Did someone help you complete this survey?
Yes
No → THANK YOU. Please return the completed survey in the postage-paid envelope.

47.

How did that person help you? Mark one or more.
Read the ques ons to me
Wrote down the answers I gave
Answered the ques ons for me
Translated the ques ons into my language

THANK YOU
Please return the completed survey in the postage-paid envelope.
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