CMS-10726 Consent Forms

Attachment B - QHP Enrollee Survey Focus Group and Cognitive Testing Consent Forms

Consumer and QHP Issuer Consent Forms

Consumer Focus Group Consent Form

What is this project about and what will you ask me to do?

We are interested in finding out about your experiences selecting and using your health insurance plan and what might be improved. Each focus group will take about two hours.

Who is doing this project?

The project is funded by the Centers for Medicare & Medicaid Services, and is being conducted by Booz Allen Hamilton, a management consulting firm CMS has contracted with.

Do I have to participate in this project?

No. Your participation is completely voluntary. You have the right to stop participating and leave the focus group session at any time, and you do not have to answer any questions that you prefer not to answer. If you choose not to participate or to stop participating, there are no penalties. However, you must participate in the entire focus group session in order to receive the $100 gift card incentive.

What are the risks and benefits?

There are no anticipated or known risks in participating in this project. By participating you may help improve the quality of the health plans offered by insurance companies in the Marketplace; this would benefit people like you in the future. There is no immediate benefit to you for participating in the focus group. In addition, as an incentive for participation in the full focus group session, you will receive $100.

How will you protect my privacy?

By consenting to participate, you are giving us permission to audio-record the focus group to accurately capture information you share with us. The audio recordings will begin after participants introduce themselves, it will NOT capture your name. Recordings will be edited to remove all personally identifiable information (such as your name, if it’s mentioned), as necessary. The recordings will be destroyed within one year. We will keep your identity and the information you supply confidential and will share this information only with the small research team at Booz Allen Hamilton; your personal information will not be shared with an insurance company or CMS.

What if I want more information?

• If you want more information about this project or if you have questions, please contact [email protected].

Consent to Participate: I acknowledge that I have received and understand the above information and agree to participant in the focus group.

Print Name: __________________________________

Signature:____________________________________ Today’s Date:_______________

Consumer Focus Group Verbal Consent

Thank you for attending today’s session. Before we start the discussion, please review and sign the consent form provided. I will now go over this form and then ask each of you whether you agree to participate.

By providing verbal consent, you are indicating that you understand the information provided to you and agree to participate in the focus group session.

Verbal Consent: Please answer yes or no to each of the following questions.

Do you understand the described focus group and agree to be a participant as part of this project?	Yes No
Do you agree to have the focus group recorded?	Yes No
Do you understand that your name will not be associated with reports or documents related to this project?	Yes No
Do you understand that you can withdraw your consent at any time and stop participating in the focus group without any penalty prejudice to you?	Yes No

Name________________________________ Today’s date________________

QHP Issuer Representatives Focus Group Consent Form

What is this project about and what will you ask me to do?

We are interested in finding out how your organization uses the Qualified Health Plan Enrollee Survey findings to inform quality improvement activities and how the QHP Enrollee Survey could collect more useful information to your organization. We will use your input when identifying refinements to the Qualified Health Plan Enrollee Survey. This focus group will take about 2 hours.

Who is doing this project?

This project is being funded by the Centers for Medicare & Medicaid Services, and is being conducted by Booz Allen Hamilton, a management and technology consulting firm headquartered in McLean, VA.

Do I have to participate in this project?

No. It is your choice whether to participate or not. You have the right to stop participating at any time, and you do not have to answer any questions that you prefer not to answer.  If you choose not to participate or stop participating, there are no penalties. 

What are the risks and benefits?

There are no anticipated or known risks in participating in this project. By participating, you will receive the opportunity to provide input that will improve the Qualified Health Plan Enrollee Experience Survey to collect more actionable information for you and other issuer representatives to facilitate quality improvement. There are no direct benefits to you for participating in the focus groups.

How will you protect my privacy?

By consenting to participate, you are giving us permission to audio-record the focus group to ensure accuracy in capturing what you share with us. The audio recordings will begin after participants introduce themselves, it will NOT capture your name. The recordings will be destroyed no later than the end of the project (approximately one year). We will keep your identity and the information you supply confidential and will only share this information with the small research team at Booz Allen Hamilton; your personal information will not be shared with your employer or CMS.   

What if I want more information?

• If you want more information about this project or your rights as a participant, please contact the director of the research project at [email protected].

Consent to Participate: I acknowledge that I have received and understand the above information and agree to participant in the focus group.

Print Name: __________________________________

Signature:____________________________________ Today’s Date:_______________

QHP Issuer Representative Focus Group Verbal Consent

Thank you for attending today’s session. Before we start the discussion, I will go over the consent form you received via email. I will then ask each of you whether you agree to participate.

By providing verbal consent, you are indicating that you understand the information provided to you and agree to participate in the focus group session.

Verbal Consent: Please answer yes or no to each of the following questions.

Do you understand the described focus group and agree to be a participant as part of this project?	Yes No
Do you agree to have the focus group recorded?	Yes No
Do you understand that your name will not be associated with reports or documents related to this project?	Yes No
Do you understand that you can withdraw your consent at any time and stop participating in the focus group without any penalty to you?	Yes No

Name________________________________ Today’s date________________

Consumer Cognitive Testing Verbal Consent

What is this project about and what will you ask me to do?

We are interested in finding out how you understand and interpret questions included in a survey completed by consumers enrolled in Qualified Health Plans in the Health Insurance Marketplace. Each phone interview will take about 90 minutes.

Who is doing this project?

The project is funded by the Centers for Medicare & Medicaid Services, and is being conducted by Booz Allen Hamilton, a management consulting firm CMS has contracted with.

Do I have to participate in this project?

No. It is completely voluntary. You have the right to stop participating at any time, and you do not have to answer any questions that you prefer not to answer. If you choose not to participate or to stop participating, there are no penalties. The $100 incentive, provided as a thank you for participation, will be sent after the completion of the full interview session.

What are the risks and benefits?

There are no anticipated or known risks in participating in this project. By participating you may help improve the quality of the health plans offered by insurance companies in the Marketplace; this would benefit people like you in the future. There are no immediate benefits to you for participating in an interview. In addition, as an incentive for your participation in an interview, you will receive a $100 gift card for completing the entire interview session.

How will you protect my privacy?

By consenting to participate, you are giving us permission to audio-record the focus group to accurately capture information you share with us. The audio recordings will begin after participants introduce themselves, it will NOT capture your name. The recordings will be destroyed within one year. We will keep your identity and the information you supply confidential and will share this information only with authorized persons; your personal information will not be shared with an insurance company or CMS.

What if I want more information?

• If you want more information about this project or if you have questions, please contact [email protected].

By providing verbal consent, you are indicating that you understand the information provided to you and agree to participate in the interview.

Verbal Consent: Please answer yes or no to each of the following questions.

Do you understand the described interview and agree to be a participant as part of this project?	Yes No
Do you agree to have the interview recorded?	Yes No
Do you understand that your name will not be associated with reports or documents related to this project?	Yes No
Do you understand that you can withdraw your consent at any time and stop participating in the interview without any penalty to you?	Yes No

Name________________________________ Today’s date________________

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