CMS-10816 Cognitive Interview Protocol

Instrument 1: Cognitive Interview Protocol - English

PARTICIPANT NUMERIC IDENTIFIER: ___________________________

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 ____-____.  The time required to complete this information collection is estimated to average 30 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. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE or William Long at 410-786-7927.

MATERIALS NEEDED FOR INTERVIEW

• INTERVIEWER PROTOCOL BOOKLET (THIS BOOKLET)

• CONSENT SCRIPT

• PENS AND PENCILS

STEP 1: INFORMED CONSENT

ANSWER ANY QUESTIONS THE BENEFICIARY MAY HAVE AND HAVE THE RESPONDENT VERBALLY CONSENT.

• NOTE VERBAL CONSENT COLLECTED

• IF THE RESPONDENT HAS CONSENTED TO RECORDING, START RECORDING.

STEP 2: INTERVIEW

Earlier this year you completed a Medicare Part C or D Enrollment Form for your [health plan or prescription drug plan]. The form asked you to provide information on the plan you wanted to join, like your name, birthdate, gender, phone number, and address and it also asked some optional questions on your ethnicity and race. I would like to talk to you today about the questions on that form.

Since you did not complete the optional questions on your ethnicity or race, we are interested in learning about any concerns you had about those questions when you completed the form.

1. My first question is do you remember seeing or completing the part of the enrollment form with the questions that asked you to report your ethnicity and race? Yes No

   1. If Yes, what did you think?

   2. If No, skip to Question #9

2. What concerns did you have when you were asked questions about your ethnicity or your race on a Medicare enrollment form?

Probes:

1. Confidentiality, privacy

2. How the government uses that information

3. No concerns, really

3. The enrollment form says, “Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.” Did the question raise any concerns about your Medicare coverage? What did you think about/do you think about when I read the instructions?

Now, I am going to ask you some questions about the available response options that were provided for you to report on your ethnicity and race. If you are not sure whether you remember what the response options were, I can read them to you. Would you like me to read the response options for those questions to you? Yes No

If Yes,

The first question was: Are you Hispanic, Latino/a, or Spanish origin? Select all that apply. And, the response options were

No, not of Hispanic, Latino/a, or Spanish origin

 Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic, Latino/a, or Spanish origin

 I choose not to answer.

4. What concerns, if any, did you have about the available response options for this question?

   1. Probe: Did you think there are enough options? Was your preferred response to these questions missing? Do you understand the differences between the different options?

The second question was: What’s your race? Select all that apply. And the response options were:

 American Indian or Alaska Native

Asian

 Asian Indian

Chinese

Filipino

Guamanian or Chamorro

Japanese

Korean

Vietnamese

 Other Asian

 Black or African American

Native Hawaiian and Pacific IslanderNative Hawaiian

Other Pacific Islander

Samoan

White

 I choose not to answer.

5. What concerns, if any, did you have about the available response options for this question?

   1. Probe: Did you think there are enough options? Was your preferred response to these questions missing? Do you understand the differences between the different options?

6. Have you ever seen these questions about race and ethnicity on other forms, Do you have the same concerns about providing your race or ethnicity?

7. How do you think CMS could change these types of questions so people with Medicare would be more likely to answer them?

Probes: Is it the wording? Is it the location on the form? Is it that you would prefer to be asked about your ethnicity and/or race in some other way, not on an enrollment form?

8. Do you think it is important for Medicare to have information on race and ethnicity?

   1. Why?

For participants who don’t recall seeing the Part C or D enrollment form, ask Q9-Q14.

You told me that you don’t think you saw the questions about your ethnicity or your race. I would like to read the questions to you now and then I have a few questions for you about each of the questions.

The first question was: Are you Hispanic, Latino/a, or Spanish origin? Select all that apply. And, the response options were:

No, not of Hispanic, Latino/a, or Spanish origin

 Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic, Latino/a, or Spanish origin

 I choose not to answer.

9. If you had seen the questions, do you think you would have answered them? The questions were [read questions]. Why?

The second question was: What’s your race? Select all that apply. And the response options were:

 American Indian or Alaska Native

Asian

 Asian Indian

Chinese

Filipino

Guamanian or Chamorro

Japanese

Korean

Vietnamese

 Other Asian

 Black or African American

Native Hawaiian and Pacific IslanderNative Hawaiian

Other Pacific Islander

Samoan

White

 I choose not to answer.

10. If you had seen the questions, do you think you would have answered them? The questions were [read questions]. Why?

11. What concerns, if any, did you have about the available response options for this question?

    1. Probe: Did you think there are enough options? Was your preferred response to these questions missing? Do you understand the differences between the different options?

12. Have you ever seen these questions about race and ethnicity on other forms, Do you have the same concerns about providing your race or ethnicity?

13. How do you think CMS could change these types of questions so people with Medicare would be more likely to answer them?

Probes: Is it the wording? Is it the location on the form? Is it that you would prefer to be asked about your ethnicity and/or race in some other way, not on an enrollment form?

14. Do you think it is important for Medicare to have information on race and ethnicity? Why?

Conclusion

For all participants

15. This year when enrolling in a Medicare plan, where did you get information on the health plan you were choosing?

Probes:

1. Medicare.gov or the internet

2. Insurance brokers

3. Family or friends

4. Called the health plan

5. State Health Insurance Assistance Program (SHIP Program)

6. Other organizations that help seniors

16. Did you ask anyone to help you complete the form and if so, can you describe how they helped you or what you did together?

Probes:

1. Completed it with a family member

2. Completed it with an insurance broker

3. Completed it with a SHIP volunteer

4. Other

17. Is there anything else about your experience completing the enrollment form that we have not discussed that you would like to share with me?

Thank you for your participation. As a token of our appreciation, we would like to send you a $40 gift card. We can provide your gift card to you electronically or we can mail it to you. Can you please provide the cell phone number, email address or mailing address you would like us to use?

Email address:

Mailing address:

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