Form CMS-10437.GenIC#20 -Qualitative Panel Survey (final)

CMS Online Qualitative Panel –Questions for Monthly Survey

1. [AWG2] In the past 30 days, have you seen, read, or heard anything about Medicare?

   1. Yes

   2. No

   3. Don’t know / Refused

1a. [AWG3] [If Q1 = Yes] Where did you see, hear, or read about Medicare? [Select all]

1. Television

2. Radio

3. Magazine

4. Newspaper

5. Internet

6. In the mail

7. Word of mouth

8. Other (specify)

9. DK/REF

1b. [AWG2B] [If Q1 = Yes and Q1a = a, b, c, d, or e] What type of information did you see, read, or hear?

1. A news story

2. An advertisement

3. Both news story and advertisement

4. DK/REF

1c. [AWG4] [If Q1b = a or c] Would you say that the news story you heard about Medicare in the past 30 days was:

1. Very positive

2. Somewhat positive

3. Neutral

4. Somewhat negative

5. Very negative

6. DK/REF

1d. [AWG2A] Briefly describe what you saw, read or heard about Medicare in the past 30 days.

Questions 2 and 3 will be alternated from month-to-month

2. [ISG1][SOI1] In the past 30 days, have you looked for any health- or healthcare coverage-related information (e.g., services, conditions, etc.)?

1. Yes

2. No

3. Don’t Know / Refused

Q2a. [ISG1] [If Q2 = Yes] Briefly describe the information or question you had about your health or healthcare coverage. [verbatim]

Q2b. [SOI2C] [If Q2 = Yes] Were you able to find the information or get the answer to your question?

1. Yes

2. No

3. Don’t Know / Refused

Q2c [ISG4A] [If Q2 = Yes] What resource(s) did you use to find the information or answer your question about your health or healthcare coverage? (Select all)

1. The internet (websites like Google, WebMD, etc.)

2. Contacted my doctor or healthcare provider

3. Contacted a friend or family member

4. Contacted an insurance agent or broker

5. Called my insurance company

6. My insurance company’s Benefits Plan Brochure/ Handbook

7. Other (specify)

Q2d. [SOI2C] [If Q2 = Yes] How easy or difficult was it to use this resource to find the information or answer your question about your health or healthcare coverage?

1. Very easy

2. Somewhat easy

3. Somewhat difficult

4. Very difficult

5. Don’t Know/ Refused

3. [ISG1][SOI1] In the past 30 days, have you looked for information or tried to find an answer for a question about Medicare?

1. Yes

2. No

3. Don’t Know / Refused

Q3a. [ISG1] [If Q3 = Yes] Briefly describe the information or question you had about Medicare. [verbatim]

Q3b. [SOI2C] [If Q3 = Yes] Were you able to find the information or get the answer to your question?

1. Yes

2. No

3. Don’t Know / Refused

Q3c [ISG4A] [If Q3 = Yes] What resource(s) did you use to find the information or answer your question about Medicare? (Select all)

1. Medicare & You Handbook

2. Medicare’s 1-800 number

3. A SHIP counselor

4. An insurance agent or broker

5. Local county office on aging

6. Medicare.gov

7. A friend or family member

8. Other (specify)

Q3d. [SOI2C] [If Q3c = More than one option & Q3b = Yes] Where did you ultimately find the information or answer to your question about Medicare?

1. Medicare & You Handbook

2. Medicare’s 1-800 number

3. A SHIP counselor

4. An insurance agent or broker

5. Local county office on aging

6. Medicare.gov

7. A friend or family member

8. Other (specify)

Q3e. [ISG4A] [If Q3b = No] What will you do next to find the answer to your question? [verbatim]

The next set of questions will ask about some of your experiences.

4. [SOI1] In the last month, please indicate whether you or someone in your household has done any of the following (Check all that apply):

	Yes	No	Don’t know	Prefer not to answer
Started seeing a new physician
Started going to a new hospital
Looked into or inquired about Physicians
Looked into or inquired about Hospitals
Looked into or inquired about Nursing Homes
Looked into or inquired about Home Health Agencies
Looked into or inquired about Inpatient Rehabilitation facilities
Looked into or inquired about Dialysis facilities
Looked into or inquired about Hospice Care
Looked into or inquired about Durable Medical Equipment
[For Coming-Of-Agers]: Looked into or inquired about Medicare coverage options (Original Medicare, Medicare Advantage, Medigap/ Medicare Supplement, Medicare Prescription Drug)

4a. [ISG1] [If ANY of Q4i-4xi= YES] How satisfied were you with that experience?

1. Very satisfied

2. Somewhat satisfied

3. Somewhat dissatisfied

4. Very dissatisfied

5. Don’t Know/ Refused

4b. [If Q4a = C or D] What problems or complications did you experience? [Verbatim]

5. [ISG4A] [If Q4i-4xi= YES] You indicated that you or someone in your household did <ANY OF THE FOLLOWING IN 4i- 4x>. How did you go about finding the <PROVIDER/ HOSPITAL/ FACILITY/ SUPPLIER/ MEDICARE COVERAGE OPTIONS>?

1. Through a referral from a family member or friend

2. Through a referral from my Primary Care Physician

3. Through a Google search

4. Through my insurance company’s website

5. Through Medicare.gov

6. Other, record reason here ________
   
   

Questions 6 - 8 will be alternated from month-to-month

6. [AWG1] How much attention do you pay to news about <TOPIC or INITIATIVE >?

1. A lot

2. Some

3. A little

4. None

5. Don’t Know/ Refused

7. [AWG2] <TIMEFRAME EX: EVER, PAST 30 DAYS> have you seen, heard, or read anything about <ITEM EX: TERM, WEBSITE, INITIATIVE>?

1. Yes

2. No

3. Don’t Know/ Refused

8. [AWG2A] Can you briefly tell me what you saw, read or heard? [Verbatim]

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1247 (Expires 12/31/2020).  This is a voluntary information collection. The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact

Clarese Astrin,

Office of Communications, Strategic Marketing Group, Division of Research, 410-786-5424, [email protected]