Form CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11

Guide for Testing Medicare Form 500 Premium Payment Materials

Items listed in this guide will be used during qualitative data collection. These data collection efforts may take place in person, via the telephone, or on the internet

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.  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.  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.

II. Current Health Coverage

ING2. Please tell me about the Medicare coverage you have to cover your hospital expenses or doctor’s visits.

ING2. Please tell me about the coverage you have for prescription drugs.

ING3. How long have you had Medicare coverage?

III. General Review of the Medicare Premium Bill and Mailer

The Centers for Medicare and Medicaid Services (CMS) provides beneficiaries like you with a monthly or quarterly document that presents important cost and payment information related to your current healthcare coverage. The Medicare Premium Bill (CMS-500) document is a bill (or notice) for people who pay Medicare directly for their healthcare coverage (which could include Medicare Parts A, B, or D).

AW2. Looking at this document, what are your first impressions?

G1. Tell me more about that.

AW1. Have you received a statement like this before?

ACT1. Now, I would like you to read through the entire document. As you go through, please mark any information that is not clear, or that you would like to know more about.

G2. What do you think about the organization or layout of the document?

ACT1A. [Going over what was marked] What made you mark this word or phrase?

KG6. [For each marked phrase] What do you think that means?

ACT1B. What do you think could make this easier to understand?

PE8. What stands out as being important on this document?

G1. Tell me more about that.

KG6. Based on what the document you’ve just reviewed, please tell me…

• How much do you owe in total?

• When do you have to pay by?

• What happens if you don’t pay by then?

• What would you do if you had questions?

PE10. Who do you think might receive this premium bill?

PE10A. What makes you think that?

PE6. What do you think CMS wants people to do when the receive this premium bill?

G1. Tell me more about that.

IV. Section-by-Section Review

Let’s take a moment and look at the Medicare Premium Bill in more detail. We will be looking at each of the sections individually.

Moderator will ask the following questions for Each Section unless they have already been covered during the earlier discussion.

KG6. What do you think this is trying to tell you?

K1D. What is important in this section?

PE1B. Is anything in this section confusing or unclear?

G4. Where would you look or where would you go for help understanding this information?

PE1A. What could make it easier for people to understand this information?

Moderator will ask the following questions for the following terms, unless they have already been covered during the earlier discussion.

• Coverage termination dates, Delinquent, Medicare Parts (A, B, and D), Part B IRMAA, Part D IRMAA, MyMedicare.gov, Online Bill Pay, Medicare Easy Pay

KG6. Are you familiar with this term? What does it meant here?

G4. (If participant does not know) Does the document tell you? How would you find out?

PE1A. What could make it easier for people to understand this information?

VI. Conclusion (5 minutes)

PE1A. Do you have any final recommendations for improving the Medicare Premium Bill document?

G5. Those are all the questions I have for you. Do any of you have any final thoughts you would like to add?

Thank and dismiss participants.