Form CMS-10437.GenIC#3 OMB OE PRE CAMPAIGN SURVEY

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-XXXX (Expires XX/XX/XXXX).  The time required to complete this information collection is estimated to average [Insert Time (hours or 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.

CMS OPEN ENROLLMENT PRE CAMPAIGN CONSUMER RESEARCH

Objectives: For Open Enrollment, this assessment will address the following objectives:

• Measure beneficiaries’ awareness of open enrollment

• Measure beneficiaries’ perceptions of open enrollment

• Measure beneficiary awareness of the need to review their health and drug plans

• Measure beneficiary behavior regarding reviewing and comparing plans

• Measure beneficiary understanding of their ability to change plans, and their awareness of what to look for and consider when comparing and contrasting such plans

• Assess how the Open Enrollment campaign is making contact with beneficiaries, and the extent to which communications prompt action

• Compare results with previous years to identify long term trends

• Compare effectiveness of campaign in reaching beneficiaries via paid versus earned media

• Assess demographics of weighted sample

• Compare beneficiary responses on demographic variables

Good morning/afternoon/evening. This is _________. I am calling on behalf of Medicare from____, which is an independent research company. We are conducting a short survey today and your opinion is important to us. We are not selling anything and your responses are completely confidential. May I speak with someone who is between the ages of 65 and 80 years old? This person must reside at this address.

DG2

S1. First, can you please tell me the year you were born? [DO NOT READ LIST]

RECORD YEAR _______ [4 DIGITS] RESPONSE WILL BE AUTOMATICALLY CODED]

Under 65	1	THANK AND END
65-66	2
67-70	3
71-75	4
76-80	5
81+	7	THANK AND END
DK	-1
Refused	-2

DG1

S2. GENDER [DO NOT ASK]

Male	1	[CHECK QUOTAS]
Female	2	[CHECK QUOTAS]

SG2

SG6

S3. Do you or does anyone in your household currently work for a health maintenance organization, a health insurance company, the Social Security Administration or the Centers for Medicare & Medicaid Services, formerly known as the Health Care Financing Administration?

Yes	1	THANK AND END
No	2
DK	-1	THANK AND END
Refused	-2

S4. Do you currently have Medicare or Medicaid benefits?

ING1

Yes, covered by Medicare	1
Yes, covered by Medicaid	2
Yes, covered by both	3
No	4	THANK AND END
DK	-1
Refused	-2

SG11

S4A. Do you have any medical or health-related disabilities? By disability I mean having difficulty hearing or seeing or having a physical, mental, or emotional condition that causes difficulty when running errands, climbing stairs, dressing or bathing, or making decisions.

Yes	1	CODE AS DISABLED
No	2
DK	-1
Refused	-2

DG11

S5. What state do you live in? [IF RESPONDENT MENTIONS THAT THEY HAVE MULTIPLE HOMES/LIVE IN MULTIPLE STATES, SAY: “Please give me the state you live in at least six months out of the year or the state that you consider to be your primary residence.] [IF RESPONDENT REFUSES TO GIVE THEIR STATE, THANK AND END.]

RECORD STATE AND CLASSIFY INTO CENSUS DIVISION. _____

Source: 2012 American Community Survey 65 Years and Over

SG4

S6. Within the past year, have you ever provided help, assistance or advice to a spouse, family member, friend, or other person with Medicare? This includes help with their Medicare insurance.

Yes	1
No	2	SKIP TO Q1
DK	-1
Refused	-2

SG6

SG6

SG6

S7. What is your relationship to the person or persons you care for?

Paid caregiver/nurse/aide	1	Exclude from caregiver sample
Child	2	CLASSIFY AS CAREGIVER
Spouse	3
Sibling	4
Other family member	5
Other	6

[IF RESPONDENT REQUESTS ADDITIONAL INFORMATION ABOUT MEDICARE, PLEASE SAY, "You may call 1-800 MEDICARE for more information."] IF RESPONDENT ASKS WHAT THE SURVEY IS FOR, PLEASE SAY: “Medicare is conducting this survey because they want to improve how it serves beneficiaries like you. The information you provide will be used to improve the Medicare program.”

INFORMATION SOURCES

Our questions are about Medicare, the federal government’s health insurance program for seniors and some non-seniors with disabilities.

1. 

   ISG2

   Where would you say you get information about Medicare including the plans that are available to you? [DO NOT READ LIST. ACCEPT MULTIPLES. IF RESPONDENT SAYS “IN THE MAIL,” CLARIFY FROM WHERE – responses 1-4]

In the mail – from Medicare: A LETTER	1
In the mail – from Medicare: A PAMPHLET	2
In the mail – from Medicare: THE HANDBOOK	3
In the mail – from somewhere else (nonspecific)	4
Medicare and You handbook	5
1-800-MEDICARE	6
www.medicare.gov/(Medicare web site)	7
Physician or nurse	8
Pharmacist	9
Insurance or drug plan	10
Friends/family	11
Television, radio, newspaper, magazine	12
Senior Center	13
Health Fair	14
Internet (specify _____________)	15
Library	16
OTHER (Specify_____________)	17
DK	-1
Refused	-2

KG3

2. To the best of your knowledge, can you get answers to questions about Medicare… [READ EACH STATEMENT, WAIT FOR YES/NO. ALSO SAY “you can answer yes, no, or don’t know.” ROTATE STATEMENTS] [IF RESPONSE TO Q02, IS YES, IMMEDIATELY ASK Q03, OTHERWISE SKIP TO NEXT STATEMENT.]

	Yes	No	DK
Over the phone through 1-800-Medicare	1	2	-1
Over the Internet at www.medicare.gov	1	2	-1
Through the Medicare and You handbook	1	2	-1
Through AARP	1	2	-1
From local counselors	1	2	-1
At senior centers	1	2	-1
Through state or county offices on Aging	1	2	-1
Through state insurance departments	1	2	-1

[NET CODE e-h IN BANNERS]

3. 

   BG7

   And have you ever used [USE LIST BELOW FOR EACH "YES" FROM Q02]?

	Yes	No	DK
a. The 1-800 Medicare phone number	1	2	-1
b. www.medicare.gov website	1	2	-1
c. The Medicare and You handbook	1	2	-1
d. AARP	1	2	-1
e. Local counselors	1	2	-1
f. Senior centers	1	2	-1
g. State or county offices on Aging	1	2	-1
BG7 h. State insurance departments	1	2	-1

4. [FOR EACH YES TO Q3, IMMEDIATELY FOLLOW UP WITH “And was that in the past three months?]

Yes	1
No	2
DK	-1

DMG4A

5. In the past three months, have you talked about or discussed your Medicare Plan with anyone?

Yes	1
No	2
DK	-1
Refused	-2

6. [DELETE]

DECISION MAKER

DMG1

7. When it comes to your Medicare coverage and services, do you usually… [READ LIST.] [IF RESPONDENT STATES 'ON MY OWN', CLARIFY 'IS THAT ON YOUR OWN, WITHOUT TALKING TO ANYONE ELSE', OR 'ON YOUR OWN, BUT TALK WITH OTHERS ABOUT IT']

…make those decisions on your own, without talking to anyone else	1	SKIP TO Q9A
…make those decisions on your own, but talk with others about it	2
…make those decisions with someone else’s help	3
…rely on someone else to make those decisions for you	4

[IF CODE 3 OR 4 ON Q8, FOR Q9, Q11, Q24, Q25, and Q26 , INSERT “or the person who helps you”]

DMG2

8. Who do you [or the person who helps you] talk with about these decisions? [IF Q8=4, ASK “Who makes these decisions for you?] [DO NOT READ LIST. ACCEPT MULTIPLES.]

Spouse	1
Child	2
Other family member	3
A friend	4
Receive help at a senior center	5
Receive help from my state’s health insurance dept.	6
Other (specify) ____________	7

9A. Have you ever looked for information on health topics like staying healthy and preventing disease, managing ongoing conditions like pain, arthritis, or diabetes; or changes in benefits?

SOI1

Yes	1
No	2
DK	-1
Refused	-2

ATG1

9X. Now tell me how much you agree or disagree with the following statements. Use a scale where 1 means you completely disagree and 7 means you completely agree. The first statement is…[READ AND ROTATE STATEMENTS]. See comments on POST survey item – also income categories.

Someone else takes care of health care issues so I don’t really need to	1
It is very important for me to be informed about health issues	2
I have other people I can always turn to if I need help	3
I’m concerned about not being able to pay for healthcare	4
I have a financial plan that includes funding for future healthcare costs	5
Most health issues are too complex for me to understand	6
I have difficulty understanding a lot of the health information that I read	7
It is hard to find good answers to my health questions and concerns	8

INSURANCE COVERAGE

DMG2

9. And thinking about the insurance you have for doctor and hospital coverage, would you say you are satisfied or unsatisfied with your insurance coverage? [PROMPT, SAY “And is that very (satisfied/unsatisfied) or somewhat (satisfied/unsatisfied)?]

Very unsatisfied	1
Somewhat unsatisfied	2
Somewhat satisfied	3
Very satisfied	4
DK	-1
Refused	-2

ING9

10A. Does your insurance plan allow you to go to any doctor you choose or do you have to pick from a list of doctors provided by the insurance company?

Can go to any doctor	1
Must pick doctor from a list	2
DK	-1
Refused	-2

ING7

10B. Some seniors have additional health insurance or supplemental insurance to cover some of the expenses that are not covered by Medicare. These include a supplement that you might get from your employer or union. Do you have any of the following? [READ LIST. ROTATE STATEMENTS] [ACCEPT MULTIPLES.]

Medigap or Medicare Supplemental insurance	1
Insurance through your employer or union	2
Military retiree benefits, also called tri-care	3
A Medicare HMO or PPO not from an employer or union, sometimes called a Medicare Advantage Plan	4
Other SPECIFY	5
None	6
DK	-1
Refused	-2

10. 

    ING6

    Now I’d like to ask you about insurance for prescription drugs. Do you have one of the Medicare prescription drug plans, also known as Medicare Part D?

Yes	1	SKIP TO Q14
No	2
DK	-1
Refused	-2

ING5

11. Do you have other insurance coverage that pays for your prescription drugs?

Yes	1
No	2	SKIP TO Q15
DK	-1
Refused	-2

ISG1

12. Thinking about your Medicare prescription drug plan in general, would you say you are satisfied or unsatisfied with your prescription coverage? [PROMPT, SAY “And is that very (satisfied/unsatisfied) or somewhat (satisfied/unsatisfied)?]

Very unsatisfied	1
Somewhat unsatisfied	2
Somewhat satisfied	3
Very satisfied	4
DK	-1
Refused	-2

OPEN ENROLLMENT AWARENESS AND PREVIOUS BEHAVIOR

KG7

13. Please tell me if the following statement is true or false. “Each year, Medicare has an open enrollment period when people on Medicare can decide to make changes to their insurance coverage and switch to a different plan.”

True	1
False	2
DK	-1
Refused	-2

PG5

16B. Which of the following are the correct start and end dates for Open Enrollment? Is it from…[READ LIST.]

October 1 to March 31	8
October 15 to December 7	2
November 15 to December 31	1
January 1 to February 28	4
Some other dates	5
None of these dates	6
[DO NOT READ] DK	-1
[DO NOT READ] Refused	-2

14. Have you recently seen, read, or heard any information about Medicare Open Enrollment?

AWG5

Yes	1
No	2	SKIP TO Q22
DK	-1
Refused	-2

AWG5

15. More specifically, have you recently seen, read or heard about Medicare Open Enrollment… [READ AND ROTATE LIST. AFTER EACH STATEMENT PAUSE. ACCEPT MULTIPLE RESPONSE.]

AWG5

16. 

    AWG2B

    [FOR EACH YES, IMMEDIATELY FOLLOW UP WITH “And was that in an advertisement (like a commercial), OR a news piece or article, OR both?”]

19G. And was that in an advertisement (g only: ON THE INTERNET: “along the top or on the side of a web page”) OR a news piece or article, OR both?

	Q.18		Q.19
	Yes	No	Adv	News/ Article	Both	(Do Not Read) Other Specify	DK
On television	1	2	1	2	3	_______	-1
On the radio	1	2	1	2	3	_______	-1
In a newspaper	1	2	1	2	3	_______	-1
In a magazine	1	2	1	2	3	_______	-1
In the mail	1	2	DO NOT ASK FOR 19E “In the mail”
[DELETE]
On the Internet	1	2	1	2	3	_______	-1
Through word of mouth	1	2	DO NOT ASK

[IF CODE “1” OR “3” ON Q19 FOR ANY RESPONSE, CONTINUE. ELSE SKIP TO Q20B]

AWG6

17. Which of the following do you recall seeing or hearing in the ad?

TBD	1
	2
	3
	4
	5
	6
[DO NOT READ] DK	-1
[DO NOT READ] Refused	-2

AWG6

Q20B INTRO: Now I’m going to describe an ad to you that you may or may not have seen on TV. You may or may not have seen the ad because it is NOT running in all parts of the country. But in the past month, did you happen to see an ad that…

…shows [REVISE FOR NEW AD]. Have you ever seen this ad?

Yes	1
No	2	SKIP TO Q22
DK	-1
PE8 Refused	-2

Q20C And how personally relevant would you say this ad was for you? Was it [READ LIST]

Very relevant	5
Somewhat relevant	4
Neither relevant nor irrelevant	3
Not very relevant	2
Not relevant at all	1
[DO NOT READ] DK	-1
[DO NOT READ] Refused	-2

KNOWLEDGE, ATTITUDES, AND PERCEPTIONS OF OPEN ENROLLMENT

KG7

18. Here are some short phrases. For each phrase, please tell me if you think it is True or False. If you don’t know, just let me know. [READ AND ROTATE STATEMENTS a-h]

	True	False	Haven’t heard	DK	Refuse
The costs that I have to pay out of my pocket for Medicare plans can change from year to year.	1	2	3	-1	-2
Monthly premiums for Medicare plans can change from year to year.	1	2	3	-1	-2
The drugs covered by Medicare plans can change from year to year.	1	2	3	-1	-2
People with Medicare can switch insurance plans during the open enrollment period.	1	2	3	-1	-2
Plan comparison information is available in the Medicare and You handbook.	1	2	3	-1	-2
Plan comparison information is available on www.Medicare.gov	1	2	3	-1	-2
DELETED
People with limited income may qualify for financial assistance to help lower their prescription drug costs	1	2	3	-1	-2

19. Do you agree or disagree with the following statement: I have the information and resources I need to make an informed comparison among different Medicare plan choices. [PROMPT, SAY “And do you completely (agree/disagree) or somewhat (agree/disagree)?]

KG2

Completely disagree	1
Somewhat disagree	2
Somewhat agree	3
Completely agree	4
DK	-1
Refused	-2

REVIEW OF COVERAGE

KG7

20. During the last open enrollment period, did you (or the person who helps you) review your insurance coverage to see if there were going to be changes in the monthly premium, deductibles, co-payments, or other out of pocket expenses? [DO NOT READ LIST.]

Yes, I did	1
No, I did not	2
Not applicable – 2014 was 1st year I was enrolled in a Medicare plan	3
Yes, the person who helped me did	4	[ONLY SHOW IF CODE “2”, “3”, OR “4” ON Q.8]
No, the person who helped me did not	5
Don’t recall what I did	6
Don’t recall what the person who helped me did	7
DK	-1
KG7 Refused	-2

21. During the last open enrollment period, did you (or the person who helps you) review your insurance coverage to see if the kinds of treatment, drugs and services covered will meet your health care needs? [DO NOT READ LIST.]

IUG18

[USE SAME CODE LIST FROM Q24]

22. Did you (or the person who helps you) compare your plan with other plans that are available? [DO NOT READ LIST.]

[USE SAME CODE LIST FROM Q24]

ISG4

[ASK Q26A ONLY IF "YES" CODE 1 OR 4 AT Q26. OTHERWISE SKIP TO Q27].

26A. When you compared plans, did you compare the… [READ EACH STATEMENT AND ASK, "YES OR NO". . ROTATE. ACCEPT MULTIPLE]

	Yes	No	Don't Know (DO NOT READ)
aa. Cost of plans	1	2	-1
bb. Drugs covered	1	2	-1
cc. Doctors covered	1	2	-1
dd. Treatments covered	1	2	-1
ee. Quality ratings	1	2	-1

23. For the following statements, please tell me if you believe the statement is true or false. [READ AND ROTATE ORDER. PROBE FOR BEST GUESS ONLY ONCE IF DK ANSWER GIVEN. THEN ACCEPT DK]

ATG1	True	False	Don’t understand subject	DK	Refused
People with Medicare will receive more than 50% off brand name drugs if they enter the donut hole.	1	2	3	-1	-2
Medicare beneficiaries are eligible to receive a free Annual Wellness Visit.	1	2	3	-1	-2
DELETE	1	2	3	-1	-2
Medicare provides 100% coverage for many preventive health tests, such as colonoscopy.	1	2	3	-1	-2
Out of pocket costs are the same in all Medicare prescription drug plans	1	2	3	-1	-2
All Medicare prescription drug plans cover the same list of prescription drugs	1	2	3	-1	-2

CURRENT HEALTH BEHAVIORS

BG3

24. How often do you take a list of all your prescription medicines to your doctor visits? [READ LIST]

Never	1
Sometimes	2
Usually	3
Always	4
Not applicable, not on prescription meds	5
DK	-1
Refused	-2

BG3

28X.How often do you bring a list of questions you want to cover to your doctor visits? [READ LIST]

Never	1
Sometimes	2
Usually	3
Always	4
DK	-1
Refused	-2

PG7

25. How confident are you that you can identify when it is necessary for you to get medical care? [READ LIST]

Not at all confident	1
Somewhat confident	2
Confident	3
Very confident	4
DK	-1
Refused	-2

[29A–E previously 34A–E]

DMG4

29A Before today, have you heard anything about the new Health Insurance Marketplace or Exchanges that will help people who are uninsured get coverage?

Yes	1
No	2	SKIP TO Q30
DK	-1
Refused	-2

KG3

29B. For the following statements, please tell me if you believe the statement is true or false. If you don’t know, just let me know. [READ AND ROTATE ORDER. PROBE FOR BEST GUESS ONLY ONCE IF DK ANSWER GIVEN. THEN ACCEPT DK]

	True	False	DK	Refused
People with Medicare cannot buy health insurance on the new Health Insurance Marketplace.	1	2	-1	-2
[DELETE]
Medicare beneficiaries can keep using their health insurance the same as always	1	2	-1	-2

KG3

29C To the best of your knowledge, will anything about your Medicare coverage be changed because of the Health Insurance Marketplace?

Yes	1
No	2	SKIP TO Q30
DK	-1
Refused	-2

29D And how do you think your Medicare coverage will be changed? Please be specific. [RECORD VERBATIM]

INTERNET USAGE

IUG4

26. How often do you use the internet on your own or with someone else’s help? [READ LIST IF NECESSARY.]

Daily or almost daily	1
Once or twice a week	2
Once or twice a month	3
Only a few times a year	4
Don’t have internet access/don’t use the internet	5	SKIP TO Q35
DK	-1
Refused	-2

IUG6

27. Consumers can subscribe to various high speed connections to the Internet, including DSL, cable, broadband, satellite or WiFi. Do you or does your household have a high-speed connection to the Internet?

Yes	1
No	2
DK	-1
Refused	-2

IUG8

31A. What devices do you use to go on the Internet? If you don’t have the item, just let me know. [READ LIST. ACCEPT MULTIPLE. ROTATE]

A personal computer or laptop (like a PC or Mac)	1
A tablet (like an iPad, Galaxy, Kindle, or Nook)	2
A smart phone (like an iPhone or Android phone)	3
DK	-1
Refused	-2

DMG4

28. 

    IUG8

    Have you ever heard of any of the following websites? [IMMEDIATELY FOLLOW EACH “YES” WITH Q33 “Have you ever visited this site?”].

	Yes	No	No Internet
w w w dot Medicare dot gov	1	2	3
w w w dot Healthcare dot gov	1	2	3
w w w dot Stop Medicare Fraud dot gov	1	2	3

BG5

29. [ASK Q33 IMMEDIATE AFTER EACH ‘YES’ IN Q32.] Have you ever visited this site?

	Yes	No	No Internet
w w w dot Medicare dot gov	1	2	3
w w w dot Healthcare dot gov	1	2	3
w w w dot Stop Medicare Fraud dot gov	1	2	3

ADDITIONAL DEMOGRAPHICS

We are nearing the end of the survey. Just a few more questions.

HSG3

30. Compared to other people who are the same age as you, do you consider you health to be … [READ LIST. ROTATE START WITH POSITIVE AND NEGATIVE END OF SCALE].

Poor	1
Fair	2
Good	3
Very Good	4
Excellent	5
DK	-1
Refused	-2

HSG2

31. Do you have any chronic health conditions that require ongoing care, such as arthritis, diabetes, chronic pain, high blood pressure, or heart disease?

Yes	1
No	2
DK	-1
Refused	-2

BG2

32. How many prescription drugs, if any, do you regularly take? [0-50, USE 98=DON’T KNOW, 99=REFUSED]

DG6

RECORD NUMBER _______

33. What is your current marital status? [IF NECESSARY, READ LIST]

Married	1
Divorced	2
Separated	3
Widowed	4
Single, never married	5
DK	-1
Refused	-2

DG5

34. What is the highest level of education that you have completed? [DO NOT READ LIST. CLARIFY AS NEEDED.]

Grade school or less	1
Some high school	2
Graduated high school/GED	3
Vocational/Technical school	4
Some college/2 years or less	5
Some college/ more than 2 years	6
Graduated college	7
Post-graduate degree (e.g. PhD or masters degree)	8
DK	-1
Refused	-2

DG3

35. Are you Hispanic or Latino? [IF NECESSARY, CLARIFY “For instance, Mexican American, Cuban, or Puerto Rican”]

Yes	1
No	2
DK	-1
Refused	-2

DG4

36. What is your racial or ethnic background? [IF NECESSARY, READ LIST.] [ACCEPT MULTIPLES.]

White	1
Black	2
Asian	3
American Indian	4
Native Hawaiian or other Pacific Islander	5
Other (Specify__________)	6
DK	-1
Refused	-2

SG3

42A Do you speak a language other than English at home?

Yes	1
No	2
DK	-1
Refused	-2

37. What is the annual income of your household before taxes and deductions? Is it - (IF NECESSARY, READ LIST)? Segmentation algorithm uses a different categorization for scoring --

DG10

Under $15,000	1
$15,000 to under $25,000	2
$25,000 to under $50,000	3
$50,000 to under $75,000	4
$75,000 to under $100,000	5
$100,000 to under $150,000	6
$150,000 to under $200,000	7
$200,000 or more	8
DK	-1
Refused	-2

Thank you for your time. Your opinions are very valuable to Medicare and will help improve their services.

28