Supporting Statement A Health Policy Booklets Marketplaces_Exchanges

The mission of the Agency for Healthcare Research and Quality (AHRQ), as set out in its authorizing legislation, the Healthcare Research and Quality Act of 1999, is to enhance the quality, appropriateness, and effectiveness of health services, and access to such services, through the establishment of a broad base of scientific research and the promotion of improvements in clinical and health systems practices, including the prevention of diseases and other health conditions. AHRQ shall promote healthcare quality improvement by conducting and supporting:

Research that develops and presents scientific evidence regarding all aspects of healthcare.
The synthesis and dissemination of available scientific evidence for use by patients, consumers, practitioners, providers, purchasers, policymakers, and educators.
Initiatives to advance private and public efforts to improve healthcare quality.

In addition, AHRQ shall conduct and support research and evaluations and support demonstration projects, with respect to (a) the delivery of healthcare in inner-city areas and rural areas (including frontier areas); and (b) healthcare for priority populations, which shall include (1) low-income groups, (2) minority groups, (3) women, (4) children, (5) the elderly, and (6) individuals with special healthcare needs, including individuals with disabilities and individuals who need chronic care or end-of-life healthcare.

Furthermore, AHRQ shall conduct and support research to provide data to improve the quality of healthcare through the healthcare utilization and expenditure estimates (Section 912, (b)(2)(A)(ii)(II) and (iii)(II) and (c)(1)(2) and (3), http://www.ahrq.gov/hrqa99b.htm).

In support of this mission, AHRQ sponsors the Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the civilian non-institutionalized population of all ages in the United States that collects comprehensive data on healthcare coverage and expenditures from all payors (including private payors, Medicaid, the U.S. Department of Veterans Affairs (VA), and out-of-pocket) over a 2-year period. The MEPS Household Component collects data on health insurance use, cost, and coverage directly from individuals and supplements it with information from medical providers. Participants in the MEPS Household Component are drawn from a subsample of households that participated in the National Health Interview Survey (NHIS), conducted by the National Center for Health Statistics. The MEPS has been conducted annually since 1996, and its current clearance is Office of Management and Budget (OMB) #0935-0118, with an expiration date of November 30, 2021.

Following a preliminary contact interview, MEPS respondents complete five rounds of interviews over 2 years. One adult in the household aged 18 or over is responsible for answering about all others in the Respondent Unit (RU) who have a direct or indirect family relation, including children. After Round 1, coverage is established by asking whether the coverage reported in the earlier round(s) is still applicable or when it ended, and identifying any new coverage. The combined data provide information on health insurance coverage over the 2-year timeframe.

AHRQ is seeking to enhance data collection practices beginning with the 2020 fielding of the MEPS Household Component to collect more-detailed information about insurance coverage from respondents while decreasing the response burden, such as by linking limited information from a respondent (e.g., an insurance policy number) to publicly available sources that report policy details.

The purpose of this request is to conduct cognitive interviews to test the ability of respondents to accurately provide a set of requested documentation about their insurance coverage (e.g., their plan’s Summary of Benefits and Coverage (SBC)) during a MEPS Household Component interview. Further, the study aims to assess the ability to link information from the materials provided by the respondent to publicly available information about the details on their coverage. Lastly, the study will assess the level of increased burden that is placed on respondents when asking them to locate and produce the requested documentation to determine whether such a request will diminish their willingness to participate in MEPS. This study will target individuals who hold insurance plans through either a State Marketplace/Exchange, or the Federal Marketplace/Exchange. The findings will be used to design potential enhancements to the 2020 fielding of the MEPS Household Component.

This research has the following goal:

Assess the feasibility of implementing the collection of health policy coverage and benefits information for Marketplace plans during the MEPS Household Component interview.

Achieving this goal will be accomplished by researching Marketplace insurance plans with regard to health insurance coverage and benefits information. Specifically, we first conduct background research to identify the minimum amount of information that an individual respondent needs to provide during a MEPS interview to allow for the proper identification of their plan and current Summary of Benefits and Coverage (SBC) information. In this process, we will explore the public accessibility of various forms and formats of marketplace health insurance coverage and benefit information. Preliminary background research shows that Marketplaces do post plan details on their public-facing websites, so our research will take a deep-dive into marketplaces across states to examine the consistency of the publicly provided information. The background research is then followed by a series of 15 cognitive interviews with individuals who hold insurance plans purchased via a Marketplace (these individuals will represent a mix of Maryland, Virginia, and Washington DC residents). We will ask participants to produce as many relevant documents as possible and will assess the success rate at which they can do so, as well as the burden of this task. The interviews will provide information on participants’ experiences with collecting the requested documentation and their familiarity with their insurance coverage. The following steps are involved in the interview process:

Recruitment: Potential interview participants will be recruited from the Washington, DC, Maryland, and Northern Virginia area using traditional and online recruitment methods (e.g., flyers, mailers, posters, newspaper notices, Craigslist postings, Facebook, and other social media outreach). Potential participants will undergo an initial screener hosted on Qualtrics.com (Attachment A) that will serve to identify participants who are eligible for more detailed screening. Those who meet baseline eligibility requirements will be contacted via telephone for an in-depth screening (Attachment B). Individuals who maintain eligibility following the secondary screening and remain interested in participating will be scheduled for an interview.

Interview Preparation: Selected individuals will be mailed a package of reference materials to prepare for their participation in the study. The package will include a letter describing the study (Attachment C), a copy of the consent form (Attachment D), directions to the Interview facility (Attachment E), a checklist to reference while gathering requested documentation (Attachment F), and an empty document storage folder to organize the requested documents when bringing them to their interview. The checklist includes specific guidance for identifying and locating each requested document. The participant will be contacted via telephone 10 to 14 days before the scheduled interview to prompt the participant to locate and collect the requested documents and to answer any questions. The participant will be contacted again 3 days before the scheduled interview for a check-in and reminder. The participant will receive a final reminder via phone and/or text message the day before the scheduled appointment.

Interviews: The participant will be greeted at the interview facility, and his or her health insurance policy documents will be cataloged before the interview session. The moderator will conduct the Marketplace insurance source-specific protocol (Attachment G) to collect information from participants regarding the identification, procurement, and understanding of their health policy documents and information. The health insurance coverage, benefits documents, and checklists provided by the respondents will be cataloged and analyzed along with the interview results so that we may best understand what participants can provide and the level of burden associated with providing the coverage information. Following participation, respondents will be mailed a check along with a letter thanking them for their time.

This study is being conducted by AHRQ through its contractor—Econometrica, Inc.—pursuant to AHRQ’s statutory authority to conduct and support research on healthcare and on systems for the delivery of such care, including activities with respect to the quality, effectiveness, efficiency, appropriateness, and value of healthcare services and to quality measurement and improvement (42 U.S.C. 299a(a)(1) and (2)).

The interviews will be conducted at Econometrica’s facility located in Bethesda, MD. Respondents will be selected according to specific sampling criteria that will include respondents with multiple attributes. The interviews, with respondents’ written consent, will be observed and audio recorded and will take, on average, approximately one hour to complete. The consent form is provided in Attachment D.

2. Purpose and Use of Information

The information collected will be used to test the feasibility of collecting detailed information about Marketplace insurance plans from documentation provided by MEPS Household Component respondents. The MEPS Household Component data collection methodology for the 2020 fielding of the survey may be modified based on this study’s findings to improve the depth of information collected and to decrease respondent burden.

To achieve this purpose, we will ask participants to describe their experience in collecting the requested documentation, assess the participants’ familiarity with their insurance coverage, assess the accuracy with which participants can provide the requested documentation, assess the accuracy in which the participants can accurately select their specific Marketplace plan from a list of plans available in their state, and assess the ability to use the information provided to gather detailed information on each participant’s insurance policy. The qualitative data collected during the interviews will be analyzed to inform the feasibility of the enhancements to the MEPS described in Section 1.

3. Use of Improved Information Technology

With the respondent’s permission, the interviews will be audio-recorded using a small digital recording device. In addition, with the respondent’s consent, the study will also capture the respondent’s non-PII insurance documentation.

4. Efforts to Identify Duplication

Data on health insurance coverage in the United States are collected by several major Federal Government-sponsored surveys, in addition to MEPS and NHIS. These include the Survey of Income and Program Participation (SIPP), the Current Population Survey Annual Social and Economic Supplement (referred to as CPS), and the American Community Survey (ACS), all sponsored by the U.S. Census Bureau. While these surveys aim to collect similar information, AHRQ is not aware of any efforts similar to the study presented in this request. The study in this request does not aim to collect information that may be duplicative across these other surveys; rather, we aim to assess the feasibility of new data collection approaches that are specific to MEPS to improve the accuracy and efficiency of data collection efforts.

5. Involvement of Small Entities

This data collection will not impact small entities.

6. Consequences if Information Collected Less Frequently

This effort is a one-time test.

7. Special Circumstances

The data collection efforts will be consistent with the guidelines at 5 CFR 1320.5(d)(2).

8. Federal Register Notice and Outside Consultations

8.a. Federal Register Notice

This information collection request is being submitted under AHRQ’s generic pretesting clearance “Questionnaire and Data Collection Testing, Evaluation, and Research for the AHRQ,” OMB Control Number 0935-0124, and therefore does not require publication in the Federal Register.

8.b. Outside Consultations

Following individuals outside of AHRQ have been consulted on the design of the cognitive interviewing protocol:

Kristen Corey, Econometrica, Inc.

Brennan Folsom, Econometrica, Inc.

Jill Simmerman, Econometrica, Inc.

Hallie Whitman, Econometrica, Inc.

Ryan Hubbard, Westat, Inc.

Angie Kistler, Westat, Inc.

9. Payments/Gifts to Respondents

Interview respondents are identified based on their relationship or experiences with key study characteristics. In order to successfully fulfill the required number of participants for this study, a sufficient number must be recruited in those subgroups (OMB cognitive testing guideline A.2.1). To successfully recruit 15 interview participants who represent a diverse perspective on Marketplace insurance within a limited timeframe, it is appropriate to offer a cash incentive for participation. Keeping in mind the recruitment effort required to effectively fill hard-to-reach small subgroups for this test and effectively recruit respondents for 90 minute interviews in the metropolitan Washington, DC, area, we propose a $70 cash incentive. This will be paid as a thank you for participating; out of respect for the respondents’ time (including time spent preparing for the interview by gathering the requested materials, as well as participation in the 1-hour interview event); and, most importantly, to cover any out-of-pocket expenses involved, such as childcare, travel costs involved in getting to the Econometrica facility, and other incidentals. The proposed incentive amount offsets potential increased recruitment costs to the project by limiting the probability of no-shows and last-minute cancellations.

10. Assurance of Confidentiality

Institutional Review Board approval for this study will be obtained before starting any recruitment. Respondents will be assured of the confidentiality of their replies under Section 934(c) of the Public Health Service Act, 42 USC 299c-3(c). All those taking part will be aged 18 years or older. They will be told the purposes for which the information is collected and that, in accordance with this statute, any identifiable information about them will not be used or disclosed for any other purpose. Participants will be asked for their written consent before participating in any interview, for audio-recording the interview, and for the digital recording of any documentation they provide. The interviewer will review the consent form with respondents and offer to answer any questions they may have about participation. All participants will be asked to sign the form before starting the interview.

Information that can directly identify respondents will be collected as part of the screening process so that they can be contacted to schedule the interviews. This information will be stored separately from any other information provided either from the online screening tools, during the in-depth screening interview, or during the interview, for which respondents are assigned an ID number only. All information collected will be stored on a Federal Information Security Management Act of 2002 (FISMA)-compliant server to ensure that the data remains secure.

11. Questions of a Sensitive Nature

We do not believe that there are questions of a particularly sensitive nature included in the study. Participants will not be asked about their individual health conditions or any health insurance claims.

12. Estimates of Annualized Burden Hours and Costs

Exhibit 1 shows the estimated annualized burden hours for respondents’ time to participate in this research. We anticipate that the initial screener questionnaire will be completed by a relatively high number of participants, while the more in-depth screener will be administered to fewer targeted participants. The screener questionnaire will be completed by approximately 200 persons and takes 3 minutes to complete.¹ We plan to complete the in-depth screening process with up to 30 individuals to identify 15 eligible participants for participation. Selected participants will invest 30 minutes in interview preparation and will participate in a 90 minute interview.

Exhibit 2 shows the estimated annualized cost burden associated with respondents’ time to participate in this research. The total cost burden is estimated to be $950.95. The estimates for the hourly wage of adult participants are based on the average hourly earnings of all employees on private nonfarm payrolls as of August 2018 (see https://www.bls.gov/news.release/empsit.t19.htm).

Exhibit 1: Estimated Annualized Burden Hours

Activity	Number of Respondents	Number of Responses per Respondent	Hours per Response*	Total Burden Hours
Screener Questionnaire (Attachment A: Initial Screening Questionnaire)	200	1	3/60	10
In-depth Screener Questionnaire (Attachment B: In-depth Screening Questionnaire)	30	1	5/60	2.5
Participation in the Interview (Attachment G: Interview Protocol)	15	1	1.5	22.5
Total	245	n/a	n/a	35

*Time is an average response per respondent.

Exhibit 2: Estimated Annualized Cost Burden

Activity	Number of Respondents	Total Burden Hours	Average Hourly Wage Rate*	Total Cost Burden
Screener Questionnaire (Attachment A: Initial Screening Questionnaire)	200	10	$27.17	$271.70
In-depth Screener Questionnaire (Attachment B: In-depth Screening Questionnaire)	30	2.5	$27.17	$67.92
Participation in the Interview (Attachment G: Interview Protocol)	15	22.5	$27.17	$611.33
Total	250	27.5	n/a	$950.95

*Based upon the average hourly earnings of all employees on private nonfarm payrolls as of August, 2018, at https://www.bls.gov/news.release/empsit.t19.htm (U.S. Department of Labor, Bureau of Labor Statistics).

13. Estimates of Annualized Respondent Capital and Maintenance Costs

Capital and maintenance costs include the purchase of equipment, computers or computer software or services, or storage facilities for records as a result of complying with this data collection. The only cost to the participants of this study will be that associated with their time, as shown in Exhibits 1 and 2, and any travel or other incidental expenses incurred to attend the interview, which will vary for each respondent according to personal circumstances. As noted in Section 9, participants will be offered compensation to offset any transportation and incidental costs.

14. Estimates of Annualized Cost to the Government

Exhibit 3 shows the estimated total cost for this study, which will last 4 months. The total cost for this study is approximately $41,136.80.

Exhibit 3. Estimated Total and Annualized Cost

Cost Component	Total Cost	Annualized Cost
Project Development	$8,227.36	$24,682.08
Recruitment	$10,284.20	$30,852.60
Data Collection Activities	$16,464.72	$49,364.16
Analysis and Reporting	$6,170.52	$18,511.16
Total	$41,136.80	$123,410.40

Exhibit 4: Annual Cost to AHRQ for MEPS Household Component Oversight

Personnel	Staff Count	Hourly Rate	% of Time	Cost
Management Support: GS-15, Step 5 average	2	$152,760	5%	$15,276.00
Survey/Statistical Support: GS-14, Step 5 average	2	$129,869	15%	$38,960.70
Research Support: GS-12, Step 5 average	1	$92,421	5%	$4,621.05
Total				$58,857.75

https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/DCB.pdf

15. Change in Burden

This is a new activity.

16. Time Schedule, Publication, and Analysis Plans

As soon as OMB approval is received, study activities will begin. The estimated schedule to conduct the interviews is as follows:

January 14, 2019: Recruitment begins.
January 21–24, 2019: In-depth screening, selection, and scheduling.
January 28, 2019–February 6, 2019: Conduct interviews.
January 4–February 15, 2019: Perform analysis and develop report.
February 15–March 1, 2019: Finalize and deliver report on findings.
March 1–March 31, 2019: Incorporate findings into generalized recommendations.

The study team will examine questionnaire data gathered during screening and recruitment; the ability to capture insurance card information; the content of the insurance cards and the feasibility of determining plan details, where appropriate; feedback from the participant on locating, obtaining, and providing SBC and policy booklet information; the quality of the submitted content; and the ability to extract key plan details. In addition, the team will evaluate hardware designed to capture policy document images, including necessary skills and potential fielding issues. The team will also evaluate participant feedback and pretest examination of electronic policy document procurement and transmission.

The study will result in a final report that summarizes the findings and provides suggestions for best practices to obtain benefit information for Marketplace insurance plans. The report will synthesize the by-source findings to suggest a cohesive yet varied approach for the integration of policy booklet/SBC collection into the MEPS interview process that minimizes respondent burden while collecting detailed plan information for the most MEPS respondents.

17. Exemption for Display of Expiration Date

No exemption is being requested.

List of Attachments

Attachment A – Initial Screening Questionnaire.

Attachment B – In-depth Screening Questionnaire.

Attachment C - Informational Letter for Participants.

Attachment D – Participant Consent Form.

Attachment E – Directions to Econometrica Facility.

Attachment F – Checklist and Directions for Gathering Requested Documents.

Attachment G – Interview Protocol.

1 Because this is an online screening tool, the number of respondents could be higher. We will be monitoring responses as they are submitted and will close the questionnaire when the total is approximately 200 participants.

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Supporting Statement A Health Policy Booklets Marketplaces_Exchanges