2 Attachment B – In-depth Screening Questionnaire

Attachment B – In-depth Screening Questionnaire

Form Approved OMB No.

Exp. Date

Exp. Date

Exp. Date

In-Depth Screener for Employer-Sponsored Plan Study Participants

INTRODUCTION:

Thank you for your interest in our project and for responding to our notice. My name is (YOUR NAME) and I work at Econometrica, a research company located in Bethesda, MD. We are conducting a survey sponsored by the Agency for Healthcare Research and Quality, a unit of the U.S. Department of Health & Human Services.

The purpose of this project is better understand whether individuals can provide key pieces of health insurance benefits and coverage information and understand the level of effort necessary to provide this information.

We need to interview a group of people who live in the area. We are offering a thank you of $50 to the people who participate in these (focus groups/interviews). The (focus group/interview) is designed to take about 60 minutes on average and we would ask that you spend some time gathering health insurance benefits and coverage information prior to the interview.

May I ask you a few questions to find out if you are eligible to participate in this research?

1. PLEASE CODE LIKELY GENDER OF RESPONDENT (WITHOUT ASKING):

MALE 1

FEMALE 2

Public reporting burden for this collection of information is estimated to average XX minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

First, have you taken part in any research project, interview, or focus group during the past three months?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

If answer to Q2 is “YES”, thank and end.

2. In what state do you live?

_______________________

If answer to Q3 is outside of DC, Maryland, and Virginia, thank and end.

The focus groups will be taking place at Econometrica’s headquarters, on Wisconsin Avenue in Bethesda, Maryland. Are you within driving or commuting distance of our location?

PROVIDE MORE INFO ON LOCATION IF NEEDED:

YES 1

No, not within driving / commuting distance of Econometrica

If answer to Q4 is “NO”, thank and end.

3. Are you currently covered by any kind of health plan or health coverage that includes hospital and physician benefits?

IF NEEDED SAY: This includes insurance plans that cover beneficiaries for health care services received from hospitals and physicians. Do not include plans that cover only selected services such as prescription-, dental-, or vision-only plans.

YES 1

NO 2

DON’T KNOW 8

If answer to Q5 not “YES”, thank and end.

4. We’ve heard from participants that using records during the interview is helpful for them.

Are you willing to share information about your health insurance plan with an interviewer, for example, your insurance card, summary of benefits and coverage (SBC) documentation, or health policy booklets? Any information you provide would be held confidentially and would not be shared with anyone outside of this research team.

YES 1

NO 2

DON’T KNOW 8

If answer to Q6 not “YES”, thank and end.

5. Earlier you mentioned that you are currently covered by a health plan or health coverage that includes hospital and physician benefits. How do you get that coverage – would you say through a job, the government or state, is it privately purchased, or do you get it some other way?

IF NECESSARY, GIVE EXAMPLES FROM BELOW FOR EACH GENERAL RESPONSE CATEGORY.

IF RESPONDENT MENTIONS MORE THAN ONE HEALTH PLAN – PROBE FOR PLAN THAT PROVIDES HOSPITAL AND PHYSICIAN BENEFITS.

IF RESPONDENT HAS BOTH MEDICARE AND A PRIVATE PLAN – ANSWER QUESTIONS FOR PRIVATE PLAN, BUT MAKE A NOTE THAT RESPONDENT ALSO HAS MEDICARE.

A Job (Examples): -- A job of the person who is covered -- A spouse’s, parent’s, or other relative’s job -- A previous job -- A job with the government -- Coverage through a union -- COBRA Government or State (Examples): -- Medical Assistance -- Medicaid -- Any state-provided coverage, e.g., Maryland Children’s Health Program or DC Healthy Families or Family Access to Medical Insurance Security -- Medicare --Military health coverage, e.g., any form of TRICARE, CHAMPVA, Veterans Administration (VA)

Privately Purchased (Examples): -- Through Maryland Health Connection {OR STATE MARKETPLACE} -- Directly from an insurance agent -- Directly from an insurance company or HMO -- Any other privately-purchased healthcare coverage Some Other Way: Any other kinds of healthcare coverage that do not fit into the above categories.

JOB 1 Q9

GOVERNMENT OR STATE 2 Q8

PRIVATELY PURCHASED 3 Q20

SOME OTHER WAY 4 Q20

DON’T KNOW 8

REFUSED 9

If don’t know or refused, thank and end.

6. Is that coverage related to a job with the government or state?

IF NECESSARY, SAY: Include coverage through former employers and unions, and COBRA plans.

YES 1 Q9

NO 2 Q10

DON’T KNOW 8 Q10

REFUSED 9 Q10

7. Is that plan related to military service in any way?

IF NECESSARY, SAY: Examples of military plans include: VA Care, TRICARE, TRICARE for Life, CHAMPVA, or other military care.

YES 1

NO 2 Q13

DON’T KNOW 8 Q13

REFUSED 9 Q13

If answer to Q9 is “YES”, thank and end.

8. Do you get government or state coverage through {Medicaid/STATE NAME}, {Children’s Health Program/STATE NAME}, Medicare, a Military program- such as Tricare, Champva, or the VA, the Indian Health Service, or through some other government or state program providing hospital and physician benefits?

MEDICAID 1

SCHIP 2

MEDICARE 3 Q11

TRICARE/CHAMPVA/VA 4

INDIAN HEALTH SERVICE 5

OTHER GOVERNMENT PROGRAM
PROVIDING HOSPITAL AND
PHYSICIAN BENEFITS 6

All answers other than Medicare, thank and end – respondent only has public insurance

9. In addition to Medicare, are you covered by a supplemental insurance plan, like Medigap or supplemental insurance from a current or retired job? Please include only supplemental insurance that covers hospital and physician benefits.

YES 1 Q12

NO 2

DON’T KNOW 8

REFUSED 9

If No/DK/RF, thank and end – respondent only has public insurance

10. Is your supplemental plan privately purchased or through an employer?

PRIVATELY PURCHASED 1 Q20

THROUGH AN EMPLOYER 2 Q13

DON’T KNOW 8

REFUSED 9

If DK/RF, thank and end – cannot classify insurance

Additional Information Needed About Employers

11. I’d like to know a little more about the job that provides the coverage. Who’s job provides the coverage?

MY JOB 1 Q14

MY SPOUSE/PARTNER’S JOB 2 Q14

MY PARENT’S JOB 3

SOMEONE ELSE 4

DON’T KNOW 8

REFUSED 9

If not R or SPOUSE’S job, thank and end.

12. What is the name of {your/SPOUSE’S} employer?

_____________________________________________ Q15

13. Is the job that provides coverage, a current job, a retired job, or a former job?

CURRENT 1 Q17

RETIRED 2 Q17

FORMER 3 Q16

DON’T KNOW 8 Q17

REFUSED 9 Q17

14. Is that coverage through COBRA?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

15. {(Are/Were) you/(Is/Was) SPOUSE} an employee of private company, individual or organization, the Federal government, state government, local government, the Armed Forces, or foreign (non U.S.) government?

PRIVATE COMPANY/INDIVIDUAL/ORG 1 Q18

FEDERAL GOVT 2

STATE GOVT 3

LOCAL GOVT 4

ARMED FORCES 5

FOREIGN (NON U.S.) GOVT 6

DON’T KNOW 8

REFUSED 9

For all OPTIONS (other than Private), thank and end – respondent potentially qualifies for State or Local employee plan

16. About how many persons are employed there? Would you say less than 50, 51-100, 101-200, 201-500, or more than 500?

LESS THAN 50 1

51-100 2

101-200 3

201-500 4

MORE THAN 500 5

DON’T KNOW 8

REFUSED 9

17. Is the insurance coverage provided through the employer or through a labor union {you/SPOUSE} belongs to at that job?

THROUGH EMPLOYER 1

THROUGH UNION 2

THROUGH BOTH 3

DOES NOT BELOW TO UNION 4

DON’T KNOW 8

REFUSED 9

Go to Schedule Interview

Additional Information Needed To Classify as Marketplace Vs Individual Market

18. How did you purchase this insurance – through the Maryland Health Connection {OR FEDERAL/STATE MARKETPLACE NAME}, directly from a group or association (e.g., AARP), directly from an insurance agent, directly from an insurance company or HMO, or directly from a school (e.g., Student Health Coverage)?

IF AGENT, PROBE FOR WHETHER THROUGH INSURANCE COMPANY OR HMO

MARKETPLACE/EXCHANGE 1 Q23

GROUP OR ASSOCIATION 2 Q24

INSURANCE CO 3 Q22

HMO 4 Q22

SCHOOL 5 Q24

OTHER 6 Q21

DON’T KNOW 8

REFUSED 9

If DK or RF, thank and end.

19. How do you get this insurance?

___________________________________________________________

Thank and end, but may qualify for call back after evaluation.

20. Is the coverage with {Q26 RESPONSE} through {STATE MARKETPLACE NAME}?

YES 1 Q23

NO 2 Q24

DON’T KNOW 8 Q24

REFUSED 9 Q24

21. CHECK THE MARKETPLACE PLAN THE RESPONDENT HAS:

	Maryland	Maryland Health Connection	State-based Marketplace
	District of Columbia	DC Health Link/ DC Health Benefit Exchange	State-based Marketplace
	Virginia	the Health Insurance Marketplace	Federally-facilitated Marketplace

Go to Q24

22. Please give me the name of the {GROUP/ASSOCIATION/INSURANCE CO/HMO/ SCHOOL} from which you purchased this insurance.

___________________________________________________________

Go to Q25

23. Who is the primary insured person or policyholder of this health coverage?

ME 1 Q26

MY SPOUSE/PARTNER 2 Q26

MY PARENT 3

SOMEONE ELSE 4

DON’T KNOW 8

REFUSED 9

If not R or SPOUSE as policyholder, thank and end.

24. What is the name of the insurance company or HMO from which you receive hospital and physician benefits?

___________________________________________________________

VOLUNTEERED: PLAN DOES NOT
PROVIDE HOSPITAL AND
PHYSICIAN BENEFITS 1

If plan does not provide hospital and physician benefits, thank and end.

25. Please look at your insurance card. If you see a plan name listed on the card, like BlueChoice HMO or KP Standard, can you tell me the plan name listed on the card ?

___________________________________________________________

DON’T KNOW 8

REFUSED 9

If necessary, probe with state/district specific plan names on sample cards.

Go to Schedule Interview

Schedule Interview

Thank you very much for your time. I’d like to ask just a few demographic questions prior to scheduling your interview.

26. What is the highest degree or level of school you have completed?

LESS THAN HS DIPLOMA OR GED, 1

HS DIPLOMA OR GED, 2

SOME COLLEGE/ASSOCIATES DEGREE 3

BACHELOR’S DEGREE 4

GRADUATE/PROFESSIONAL DEGREE 5

DON’T KNOW 8

REFUSED 9

27. How old are you?

________________

REFUSED 9

If answer to Q8 under 18 or refused, thank and end.

28. How many people live in your household, including yourself?

______ people

DON’T KNOW 8

REFUSED 9

29. Are you of Hispanic, (Latino/Latina), or Spanish origin?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

30. For this survey, Hispanic origins are not races. What is your race? (Circle all races reported)

WHITE 1

BLACK OR AFRICAN AMERICAN 2

AMERICAN INDIAN OR ALASKA NATIVE 3

ASIAN INDIAN 4

CHINESE 5

FILIPINO 6

JAPANESE 7

KOREAN 8

VIETNAMESE 9

OTHER ASIAN 10

NATIVE HAWAIIAN 11

GUAMANIAN OR CHAMORRO 12

SAMOAN 13

OTHER PACIFIC ISLANDER 14

SOME OTHER RACE (SPECIFY) ________ 15

DON’T KNOW 88

REFUSED 99

31. What was your total household income before taxes during the past 12 months? Was it…

less than $25,000, 1

$25,000 to $34,999, 2

$35,000 to $49,999, 3

$50,000 to $74,999, 4

$75,000 to $99,999, 5

$100,000 to $149,999, or 6

$150,000 or more? 7

DON’T KNOW 8

REFUSED 9

Because the interview contains questions regarding the details of your health policy, you will receive a kit by mail and a phone call instructing you to gather records for use during the interview. We will call you to schedule an interview. The interviews will be scheduled between XX and XX from 09:00 AM to 05:00 PM. You will also receive two additional reminder calls prior to the interview. Again, the interview itself usually takes approximately 60 minutes, and you will be given $## for your participation.

Which dates and times are most convenient for you?

[ENTER DATE AND CHECK APPROPRIATE TIME]

9:00-10:00
10:00 – 11:00
11:00 – 12:00
1:00 – 2:00
2:00 – 3:00
3:00 – 4:00
4:00 – 5:00

Let me confirm your phone number. [CONFIRM PHONE NUMBER]. Is it okay if I text you at this number to send you a reminder?

YES 1

NO 2

Please feel free to contact me if you have any questions about the study or if your schedule changes. My name is (YOUR NAME) and I can be contacted at (PHONE NUMBER).

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