Form CMS-10635 Beneficiary Survey: Disenrollees (paper)

OMB Control Number: 0938-NEW

Expira on Date: TBD

Montana Health and Economic Livelihood Partnership Plan
Beneficiary Survey: Disenrollees
PRA Disclosure Statement
According to the Paperwork Reduc on Act of 1995, no persons are required to respond to a collec on of informa on unless it displays a valid OMB control number.
The valid OMB control number for this informa on collec on is 0938-NEW. The me required to complete this informa on collec on is es mated to average 15
minutes per response, including the me to review instruc ons, search exis ng data resources, gather the data needed, and complete and review the informa on collec on. If you have comments concerning the accuracy of the me es mate(s) or sugges ons 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.

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  GO TO END
No
Not sure/Don’t know  GO TO END

2.

Have you ever been enrolled in HELP?
Yes
No
Not sure/Don’t know

GO TO END

Study ID

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3.

Were you enrolled in HELP within the last 12 months?
Yes
No  GO TO END

4.

How long ago did your HELP enrollment end?
Less than 3 months
3 to 6 months
More than 6 months
Not sure/Don’t know

5.

Why did your HELP enrollment end? Please mark one answer in each row.
My HELP enrollment ended because…

Yes

No

Not Sure

a. I got an increase in my income and was no longer eligible for HELP
b. I had other health insurance available to me
c. I could not afford my monthly HELP premiums
d. I no longer wanted HELP coverage
e. I did not pay my premium within 90 days

6.

Would you try to re-enroll in HELP if you could?
Yes
No
Not sure/Don’t know

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Experiences AŌer Leaving HELP
The following ques ons are about your understanding and experiences since you leŌ HELP.
7.

AŌer you were no longer enrolled in HELP, was there any Ɵme you needed health care but did not get it
because of cost?
Yes
No
Not sure/Don’t know

8.

GO TO QUESTION 9

AŌer you were no longer enrolled in HELP, 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

9.

AŌer you were no longer enrolled in HELP, did you go to a doctor, nurse, or any other health professional or
get prescripƟon drugs?
Yes
No
Not sure/Don’t know

GO TO QUESTION 11

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10.

AŌer you were no longer enrolled in HELP, 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

11.

Do you have any health insurance coverage right now?
Yes
No
Not sure/Don’t know

12.

GO TO QUESTION 15

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

13.

How long have you had your current health insurance?
Less than one month
Between 1 and 6 months
More than 6 months

14.

AŌer you were no longer enrolled in HELP, how long did it take you to get your current health insurance?
Less than one month
Between 1 and 6 months
More than 6 months

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Premiums and Copays
The following ques ons are about your understanding and experiences with HELP monthly premiums and
copays while you were in HELP.
15.

While you were in HELP, how much was 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 was that monthly premium paid, if at all?
I paid it  GO TO QUESTION 18
Someone paid the full amount for me
I paid part and someone else paid part
The premium has not been paid
Not sure/Don’t know

17.

GO TO QUESTION 18

Which of the following groups helped 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.

While you were in HELP, would you say the amount of your monthly premium was:
More than I could afford
An amount that I could afford
Less than I could afford
Not sure/Don’t know

19.

While you were in HELP, 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.

While you were in HELP, what did you think would happen, if anything, if your monthly premium was not paid
within 90 days?
Nothing would change  GO TO QUESTION 22
My HELP coverage would end
Not sure/Don’t know  GO TO QUESTION 22

21.

For each of the following statements, please tell us whether you thought it was 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 would have allowed me
to keep my HELP coverage
b. Payment of any unpaid premiums aŌer 90 days would have allowed 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.

While you were in HELP, did you pay 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 25

While you were in HELP, 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.

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

25.

For each of the following statements about HELP premiums, premium credits, and copays, please tell us
whether you thought they were 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

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Access to Care
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.
For the following ques ons, please think about your experience while you were in HELP.

26.

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

27.

While you were in HELP, was there a Ɵme you thought about going to the emergency room when you needed
care?
Yes
No  GO TO QUESTION 30

28.

While you were in HELP, when you needed care, did you go to the emergency room?
Yes  GO TO QUESTION 30
No

29.

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
30.

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 32
Somewhat Dissa sfied
Very Dissa sfied
Not sure/Don’t know  GO TO QUESTION 32

31.

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

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About You
32.

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

33.

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

34.

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

35.

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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36.

Are you male or female?
Male
Female

37.

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

38.

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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39.

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)

40.

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.

41.

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

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THANK YOU
Please return the completed survey in the postage-paid envelope.
Social & ScienƟfic Systems, Inc.
4505 Emperor Blvd, Suite 400
Durham, NC 27703

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