Form CMS-10632 Appendix B Consumer Survey: Informed Consent and Survey

EVALUATION OF FROM COVERAGE TO CARE IN
COMMUNITIES
Appendix B
Consumer Survey: Informed Consent and Survey
(CMS-10632; OMB 0938-1342)
NOTE: This interview protocol is annotated to show (1) the standard demographics and insurance
information that PIRE will purchase from the survey panel (i.e., thus this information will be obtained but
absent on the survey); (2) bolded section headers to denote survey topic areas; (3) project research
questions associated with each topic area (with parenthetical references to logic model question
numbers); (4) more detailed “domains” and “subdomains” within topic areas; (5) skip logic notes in
brackets to indicate how skip logic will minimize participant burden; and (6) an appendix with sample
visuals to include with question 39. These annotations will not be seen by research participants, except
for appendix materials. Changes from the previously approved surveys appear in green text.

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 CMS-10632; OMB 0938-1342 (Expiration
Date). The time required to complete this information collection is estimated to average 20
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 Disclaimer* 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.

OMB No.: CMS-10632; OMB 0938-1342
Expiration Date: (EXPIRATION DATE)

Evaluation of Health Insurance and Health Care Use
INFORMED CONSENT FOR CONSUMERS
Thank you for agreeing to participate in this survey. Pacific Institute for Research and Evaluation (or
PIRE) is conducting a study for the Centers for Medicare & Medicaid Services on From Coverage to
Care, or C2C. As you may know, C2C aims to help people with health care coverage understand their
benefits and connect to primary care. It is also designed to help community organizations and providers
support consumers as they connect to care.
Purpose of the Study
This is a research project being conducted by PIRE. This study is funded by the Centers for Medicare &
Medicaid Services (CMS) Office of Minority Health. This survey will ask you about health care, health
insurance, and if you have seen or received informative health insurance materials. Your responses are
important for understanding and improving health care utilization in the United States.
Procedures
This survey should take approximately 20 minutes to complete and can be completed at your
convenience. We will not collect personally identifiable information, and your answers will not be linked
back to you. Question types include multiple choice and fill-in-the-blank. You may skip any questions
you do not feel comfortable answering.
Potential Risks and Discomforts
There are no identifiable risks associated with this survey. All information will be kept confidential. Your
name will not be collected or linked to the data you provide at any time.
Potential Benefits
This research is not designed to help you personally, but the results may help improve health care
utilization in the United States. We hope that, in the future, other people might benefit from this study
through improved understanding of this phenomenon.
Confidentiality
We will not collect any identifiable information; thus, confidentiality will be maintained, except as
required by law. Should you choose not to participate in the study, information on your refusal to
participate will not be released to CMS. The data collected through this survey will be summarized in
aggregate form, grouped with data others provide for reporting and presentation.
All data collected will only exist in electronic form. Data collected will be securely stored on Ipsos data
servers. All communications between your web browser and the Ipsos servers will be encrypted to
maintain your confidentiality. Data provided to the PIRE Principal Investigator will not contain any
personally identifying information and will only occur through encrypted electronic communication (i.e.,

secure file transfer protocol). All analysis data files possessed by PIRE will be securely stored on the
investigators’ password-protected computers and network drives.
Incentives
You will receive your standard panel incentive for completing this survey.
Right to Withdraw and Questions
Your participation in this research is completely voluntary. You may choose not to take part at all. If you
decide to participate in this research, you may stop participating at any time.
If you have questions or concerns about this study, please contact the Principal Investigator of the study,
Bill Scarbrough at 502-238-7326 or by emailing [email protected].
Participant Rights
For questions about your rights as a research participant, you may call Elysia Oudemans-Tilley at 866PIRE-ORG (866-747-3674), option 1, or by emailing [email protected].
This research has been reviewed according to PIRE’s Institutional Review Board (IRB) procedures for
research involving human subjects.

C2C Consumer Survey
Standard Demographics
Note: Standard demographics will be provided by the Ipsos Knowledge Panel and do not appear on the
survey.
Gender
Age
Marital status
• Married
• Widowed
• Divorced
• Separated
• Never married
• Living with partner
Children
• Age
• Gender
• Number
Education
• No formal education
• 1st, 2nd, 3rd, or 4th grade
• 5th or 6th grade
• 7th or 8th grade
• 9th grade
• 10th grade
• 11th grade
• 12th grade, no diploma
• High school graduate—high school diploma or the equivalent (GED)
• Some college, no degree
• Associate’s degree
• Bachelor’s degree
• Master’s degree
• Professional or doctorate degree
Race
• White
• Black or African American
• American Indian or Alaska Native
• Asian
• Native Hawaiian/Pacific Islander
• 2+ races

Hispanic origin
• Mexican, Mexican-American, Chicano
• Puerto Rican
• Cuban, Cuban American
• Other Spanish/Hispanic/Latino
Household income
• Less than $5,000
• $5,000 to $7,499
• $7,500 to $9,999
• $10,000 to $12,499
• $12,500 to $14,999
• $15,000 to $19,999
• $20,000 to $24,999
• $25,000 to $29,999
• $30,000 to $34,999
• $35,000 to $39,999
• $40,000 to $49,999
• $50,000 to $59,999
• $60,000 to $74,999
• $75,000 to $84,999
• $85,000 to $99,999
• $100,000 to $124,999
• $125,000 to $149,999
• $150,000 to $174,999
• $175,000 to $199,999
• $200,000 to $249,999
• $250,000 or more
Home ownership
• Owned or being bought by you or someone in your household
• Rented for cash
• Occupied without payment of cash rent
Domicile location
• ZIP code
• County
• Metro area
• Urban/suburban/rural
• DMA
• State
• Region
Household head (yes/no)
Empty-nester (yes/no)
Internet access
• By paying a cell phone company or internet service provider
• Without paying a cell phone company or internet service provider
• No access to the internet in my house, apartment, or mobile home

Personal/household Internet use locations
• Home
• Work
• School or library
• Another place
Personal/household Internet access mode at home
• Cellular data plan for a smartphone or other mobile device
• High-speed Internet service such as cable, DSL, or fiber-optic service
• Satellite Internet service
• Dial-up service
• Other service
Employment status
• Working—as a paid employee
• Working—self-employed
• Not working—on temporary layoff from a job
• Not working—looking for work
• Not working—retired
• Not working—disabled
• Not working—other
Employed full time or part time (yes/no, of employed)
Currently a student (yes/no, of students)
Currently a stay-at-home spouse or partner (yes/no)
Sexual orientation
• Gay or Lesbian
• Straight, that is, not gay
• Bisexual
• Something else
Gender identity
• Cisgender
• Transgender
• Other
U.S. citizenship
• Born a citizen
• Naturalized citizen
• Not a citizen

Personal Health
Note: Variables below are collected by the Ipsos KnowledgePanel annually and do not appear on the
survey.

Self-reported health status (options not presented in reference)
Height/weight/BMI
Personal medical conditions
• Acid reflux disease
• ADHD or ADD
• Asthma, chronic bronchitis, or COPD
• Cancer
• Concussion
• Chronic pain (such as low back pain, neck pain, or fibromyalgia)
• Diabetes or pre-diabetes
• Eye condition (other than poor vision)
• Gastrointestinal condition
• Heart attack, heart disease, or other heart condition
• Hepatitis C
• High blood pressure
• High cholesterol
• HIV/AIDS
• Inflammatory Bowel Disease (IBD) (such as Ulcerative colitis or Crohn’s disease)
• Kidney disease
• Menopause or perimenopause
• Migraines
• Multiple sclerosis
• Nonalcoholic fatty liver disease
• Osteoarthritis, joint pain, or inflammation
• Osteoporosis or osteopenia
• Psoriasis
• Pulmonary Arterial Hypertension (PAH)
• Rheumatoid arthritis
• Seasonal allergies
• Sexual dysfunction
• Sleep disorders such as sleep apnea or insomnia
• Stroke
• Traumatic brain injury
• Uterine fibroids
Personal mental health conditions
• Anxiety disorder
• Bipolar disorder
• Depression
• Mood disorders
• Schizoaffective disorder
• Schizophrenia
Diagnosed with Type 1 diabetes/Type 2 diabetes/Pre-diabetes or IGT
How diabetes is managed (options not presented in reference, of those with diabetes)
Type of cancer diagnosis (options not presented in reference, of those with diabetes)

Frequency of VIGOROUS exercise and frequency of LIGHT OR MODERATE exercise (options not
presented in reference)

Health Coverage and Attitudes
Note: Variables below are collected by the Ipsos Knowledge Panel annually and do not appear on the
survey.
Type of health insurance
• Through own or someone else’s employer or union
• Medicare
• Medicaid or a state medical assistance plan
• Health insurance you bought through an insurance exchange
• Veteran’s Affairs, Department of Defense, or other military program
• Health insurance from some other source
Ever covered by health insurance purchased through a state or federal exchange (yes/no)
Year in which first purchased health insurance through an exchange (yes/no, of those purchasing
exchange plan)
Sources of health information in past 12 months
• Doctor
• Pharmacist
• Nurse, nurse practitioner, or physician’s assistant
• Relative, friend, or co-worker
• Someone you know who has a particular medical condition
• Disease-related association or society
• Patient support group or foundation
• Educational forum at a local clinic, hospital, community center, or other location
• Pharmaceutical company
• Health insurance company
• Newspapers or magazines
• Television
• The internet
• Social media
• Health care app
Attitudes about vaccination (options not presented in reference)

[Begin survey]

Introduction
Welcome! Thank you for agreeing to complete this survey. It will ask you about health care, health
insurance, and if you have seen or received informative health insurance materials. Your responses are
important for understanding and improving health care use in the United States.
This survey should take about 20 minutes to complete. It should be completed in one session. All
responses will remain confidential, as we will not collect any personally identifiable information.
Thank you in advance for your time.

Survey Description
This survey contains multiple choice and fill-in-the-blank questions. Once you begin the survey, please
try to complete it in one sitting, as you will not be able to save or return to the survey. This survey does
not require the assistance of outside resources. Please complete the survey to the best of your ability, or
based on minimal information searching. If you have any questions about this survey or require
assistance, please contact the Panel Member Support Center at the toll free number (Ipsos help line
number).
[SCREENER]
KnowledgePanel records indicate that you have health insurance through [POPULATE WITH Medicare /
Medicaid or a state medical assistance plan / Health insurance you bought through an insurance
exchange]. Is this still your insurance provider?
• Yes [CONTINUE]
• No [ASK INSURANCE TYPE QUESTION AND CONTINUE ONLY IF ONE OF THREE
SELECTED INSURERS]
• Don’t know [END SURVEY]

Section 1: Usual Source of Care
Research questions answered:
•

Among those exposed to C2C, was there a greater change in the percentage with an identified
primary care provider? (INT8)

We would like to start with some questions about where you receive your health care services and who
provides your health care.
1. Is there a place that you usually go to when you are sick or need advice about your health?
• Yes
• No
[IF YES SHOW QUESTIONS 2 AND 3]

2. What kind of place [is it/do you go to most often] -- a clinic, a doctor’s office, an emergency
room, or some other place?
• Clinic (e.g. urgent care)
• Doctor’s office (e.g. primary care physician)
• Emergency room
• Some other place: ___________
3. When you attend ________(fill in from question 2), do you usually see the same care provider?
• Yes
• No

Section 2: Health Insurance and Health Literacy
Research questions answered:
•
•

Did consumers report HHIE materials improved their health insurance literacy (HIL) and
health literacy (HL)? (ST3)
Did the consumers understand and feel confident about key HIL and HL concepts? (ST4)

Domain: Health Insurance Literacy
Subdomain: Confidence choosing
These next questions deal with health, health care, and health insurance information.
4. How confident would you feel that you…
• Know where to go for help if you have trouble affording health insurance outside of an employer?
• Know how to estimate what you would have to pay for your health care needs in the next year,
not including emergencies?
• Know if a service is covered by insurance?
• Know what questions to ask so that you can choose the best health plan for you?
• Know where to find the information you need to choose a health plan if you were not offered
insurance through an employer?
• Understand health insurance terms?
• Would choose the health plan that is best for you?
o Not at all confident
o Slightly confident
o Moderately confident
o Very confident
Subdomain: Comparing plans
5. When comparing health plans how likely are you to…
• Find out if the plans cover unexpected costs such as hospital stays?
• Understand what you would have to pay for emergency department visits?
• Understand what you would have to pay for specialist visits?
• Understand what you would have to pay for prescriptions drugs?
• Find out if you have to meet a deductible for health care services?
• Look to see which doctors and hospitals are covered in each plan?
o Not at all likely
o Somewhat likely

o
o

Moderately likely
Very likely

Subdomain: Using insurance
6. How confident are you that…
• You know how to figure out your share of the costs for care, after the health plan pays their
share?
• You know what to do if your health plan refuses to pay for a service you think should be
covered?
• You know what questions to ask your health plan if you have a coverage problem?
• You know most of the things you need to know about using health insurance?
• You know how to find out what is and is not covered before you receive a health care service?
o Not at all confident
o Slightly confident
o Moderately confident
o Very confident
Subdomain: Being proactive
7. When using your health insurance plan, how likely are you to…
• Look to member services to tell you what medical services your health plan covers?
• Look into what your health plan will and will not cover before you get health care services?
• Review the statements you get from your health plan showing what you owe and what they paid
for a service?
• Find out if a doctor is in-network before you see him/ her?
o Not at all likely
o Somewhat likely
o Moderately likely
o Very likely

8. Please assume the following information is on your health insurance card. Please refer to this card to
answer the following questions…
INSURANCE COMPANY NAME
Plan type: PPO

Member Name: Jane Doe
Member Number: 123-45-678

Effective Date: 12/21/2019
Group Number: 98765-432
Prescription Group #: 13579
Prescription Copay:
$15.00 Generic
$20.00 Name brand

PCP Copay: $15.00
Specialist Copay: $25.00
Emergency Room Copay: $75.00

Member Service: 800-123-4567

a. Your doctor’s office asks you for your health insurance member number. Please enter it here:
______
b. The pharmacy fills a generic prescription for you. How much money total will you need to
pay out of your own pocket for this prescription? ______
c. You have forgotten to mail in your monthly insurance premium and you are not sure what to
do. What number should you call? ______
d. Your doctor’s office asks you if you have a PPO (preferred provider organization) or an
HMO (health maintenance organization). Which do you have? ______
e. You have visited your primary care physician, because of a cold that will not go away. How
much will you have to pay out of pocket for the visit? ______
f. This is your first insurance plan you have enrolled in. You visited the ER on 12/19/2019. Will
this insurance plan cover the services you received? yes/no
g. Will you have to pay more out of pocket for an ER visit or a PCP visit? PCP/ER
h. Your pharmacist asks you if you want the brand name prescription or you would like the
generic alternative. How much more money will you need to pay out of your pocket for the
brand name? ______

Domain: Health Literacy
Subdomain: Functional Health Literacy
9. This information is on the back of a container of a pint of ice cream.

•
•

If you eat the entire container, how many calories will you eat? [Answer: 1,000 is the only correct
answer]
If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you
have? [Answer: Any of the following is correct: 1 cup (or any amount up to 1 cup), half the
container.]

•

•

Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g
of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream,
how many grams of saturated fat would you be consuming each day? [Answer: 33 is the only
correct answer]
If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you
be eating if you eat one serving? [Answer: 10% is the only correct answer]

Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings.
•
•

Is it safe for you to eat this ice cream? [yes/no; Answer: No]
(Ask only if the patient responds “no” to question 5): Why not? [Answer: Because it has peanut
oil.]

Subdomain: General Health Literacy
10. How confident are you filling out medical forms by yourself?
o Extremely confident
o Quite confident
o Somewhat confident
o A little confident
o Not at all confident

Subdomain: Provider Fosters Health Literacy
11. These next questions ask about the person or place from whom you receive most of your health care
services. This is often referred to as your provider. With this provider in mind, how often…
•
•
•
•
•

Does this provider give you all the information you want about your health?
Does this provider encourage you to talk about all your health problems or concerns?
Does this provider ask you to repeat back or describe how you are going to follow their
instructions?
Did this provider give you easy to understand instructions about how to take your medicines?
Are the results of your blood test, x-ray, or other test easy to understand?
o Never
o Almost never
o Sometimes
o Usually
o Almost always
o Always

Domain: Confidence in understanding health insurance terms
12. How confident are you that you know what the following terms mean?…
• Provider
• Network
• Deductible
• Co-insurance
• Co-payment

•
•
•
•

Premium
Out-of-pocket maximum
Prescription drug list (or formulary)
Explanation of benefits
o Not at all confident
o Slightly confident
o Moderately confident
o Very confident

Section 3: Preventive Health Care Utilization
Research questions answered:
•
•

Among those exposed to C2C, was there greater utilization of preventive care (including checkups, screenings, and vaccinations)? (INT9)
Return on Investment Items

These next questions ask about your use of health care services.
13. About how long has it been since you had a routine check-up by a doctor or other health
professional?
o Within past 12 months
o Within past 1-2 years
o Within past 3-4 years
o Within past 5-6 years
o More than 7 years
o Never
o Don’t know
14. About how long has it been since you had your blood pressure checked by a doctor, nurse, or
other health professional?
o Within past 12 months
o Within past 1-2 years
o Within past 3-4 years
o Within past 5-6 years
o More than 7 years
o Never
o Don’t know
15. About how long has it been since you had a flu vaccination (shot or nasal spray)?
o Within past 12 months
o Within past 1-2 years
o Within past 3-4 years
o Within past 5-6 years
o More than 7 years
o Never
o Don’t know
16. About how long has it been since you had bloodwork to try to prevent future health problems?
o Within past 12 months
o Within past 1-2 years

o
o
o
o
o

Within past 3-4 years
Within past 5-6 years
More than 7 years
Never
Don’t know

17. Do you have Hypertension, Diabetes, or Heart Disease?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO 22]
• Don’t Know [SKIP TO 22]
18. Has a doctor given you instructions on how to manage your condition?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO 20]
• Don’t Know [SKIP TO 20]
19. Have you generally followed your doctor’s instructions?
• Yes
• No
• Don’t Know
20. Have you received regular diagnostic tests (blood pressure, A1C, and/or cholesterol count) for your
chronic condition?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO 22]
• Don’t Know [SKIP TO 22]
21. Have your test results been within the acceptable range your doctor mentioned?
• Yes
• No
• Don’t Know
22. Have you taken a test to see if you have COVID-19 (also called the coronavirus or SARS-CoV-2)?
o Yes
o No
o Don’t know

Section 4: Care Utilization
Research questions answered:
•
•

Among those exposed to C2C, was there greater utilization of behavioral health services?
(INT9)
Among those exposed to C2C, was there a change in the use of emergency department (ED)
services? (INT9))?

Domain: Primary care use
23. During the past 12 months, how many times have you seen your doctor or other health care
professional about your own health (this could be for a well visit or when you were sick)?

o
o
o
o
o
o
o
o
o
o

None
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Don't know

Domain: ER use
24. During the past 12 months, how many times have you gone to a hospital emergency room about
your own health (this includes emergency room visits that resulted in a hospital admission)?
o None
o 1
o 2-3
o 4-5
o 6-7
o 8-9
o 10-12
o 13-15
o 16 or more
o Don't know
[IF PARTICIPANT REPORTS ER USE (ALL BUT FIRST OR LAST RESPONSE) SHOW
QUESTIONS 25 AND 26]
25. Did your last emergency room visit result in a hospital admission?
o Yes
o No
26. Tell me which of these apply to your last emergency room visit? Check all that apply.
o It was a life-threatening illness or injury
o You didn't have another place to go
o Your doctor’s office or clinic was not open
o It was a night or weekend
o Your health provider advised you to go
o The problem was too serious for the doctor’s office or clinic
o The emergency room is your closest provider
o You get most of your care at the emergency room
o You arrived by ambulance or other emergency vehicle
Domain: Urgent care use
27. During the past 12 months, how many times have you gone to an urgent care clinic about your
own health?
o None
o 1
o 2-3

o
o
o
o
o
o
o

4-5
6-7
8-9
10-12
13-15
16 or more
Don't know

[IF PARTICIPANT REPORTS URGENT CARE USE SHOW QUESTION 28]
28. Tell me which of these apply to your last urgent care visit? Check all that apply.
o You didn't have anywhere else to go
o Your doctor’s office or clinic was not open
o The doctor’s office did not have any available sick appointments
o It was a night or weekend
o Your health provider advised you to go
o The problem was too serious for the doctor’s office or clinic
o Only an urgent care clinic could help you
o The urgent care clinic is your closest provider
o You get most of your care at the urgent care clinic
o You arrived by ambulance or other emergency vehicle
Domain: Confidence in Deciding Which to Use
29. I feel confident that I know…
• When to go to my doctor or another health care professional instead of going to the emergency
room or an urgent care.
• When to go to an urgent care instead of going to my doctor or another health care professional or
the emergency room.
• When to go to the emergency room instead of going to my doctor or another health care
professional or an urgent care.
o Not at all confident
o Slightly confident
o Moderately confident
o Very confident
Domain: Behavioral health use
30. During the past 12 months, have you seen or talked to a behavioral or mental health
professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
o Yes
o No
31. During the past 12 months, have you needed or wanted to see a behavioral or mental health
professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker but
didn’t?
• Yes
• No

32. If you needed or wanted to see a behavioral or mental health professional such as a psychiatrist,
psychologist, psychiatric nurse, or clinical social worker, do you know how to get this care?
• Yes
• No

Section 5: Health Care Experience
Research questions answered:
•
•

Do those exposed to C2C materials report a more favorable health care experience than those
not exposed? (LT15)
Is there a difference between Latino/Hispanic, African American, and Caucasian
subpopulations in their reported health care experiences? (LT17)

These next questions ask you about your experiences receiving health care.
Domain: Patient-Centeredness of Experience
32. How often do providers:
• Give you the chance to ask all the health-related questions you have?
• Give the attention you need to your feelings and emotions?
• Involve you in decisions about your health care as much as you want?.
• Make sure you understand the things you need to do to take care of your health?
• Explain things in a way you can understand?
• Spend enough time with you.?
• Help you deal with feelings of uncertainty about your health or health care?
o Always
o Often
o Sometimes
o Never
Domain: Discrimination in Medical Settings
33. Please indicate how often each of the following happen when you are receiving medical services.
• You are treated with less courtesy than other people.
• You are treated with less respect than other people.
• You receive poorer service than others.
• A doctor or nurse acts as if he or she thinks you are not smart.
• A doctor or nurse acts as if he or she is afraid of you.
• A doctor or nurse acts as if he or she is better than you.
• You feel like a doctor or nurse is not listening to what you were saying.
o Never
o Rarely
o Sometimes
o Most of the time
o Always

Section 6: Consumer Exposure to C2C
Research questions answered:

•
•
•
•
•

Among the populations targeted by C2C efforts, how are they being exposed or why are they
not being exposed to C2C materials? (Process)
Were consumers satisfied with the C2C health and health care information education (HHIE)
received? (ST1)
Did the consumers report that the C2C HHIE materials met their needs? (ST2)
Did consumers report C2C HHIE materials improved their health insurance literacy (HIL)
and health literacy (HL)? (ST3)
Did C2C increase the likelihood of consumer enrollment in health insurance? (INT7)

These next questions ask about your exposure to information about health care.
Domain: Unaided ad recall
34. During the past 12 months, how many times have you needed information or materials to help
you understand your health insurance coverage or insurance terms?
o Not at all [SKIP NEXT ITEM]
o Once
o 2 to 4 times
o 5 to 10 times
o More than 10 times
35. During the past 12 months, how many times have you sought out health insurance information
or materials to help you understand your health insurance coverage or insurance terms?
o Not at all
o Once
o 2 to 4 times
o 5 to 10 times
o More than 10 times
36. During the past 12 months, how many times have you seen or received health insurance
materials that help you understand your health insurance coverage or insurance terms?
o Not at all
o Once
o 2 to 4 times
o 5 to 10 times
o More than 10 times
[IF NOT ALL ASK 37, ELSE, SKIP TO 38]
37. How do you prefer to see or receive resources that help you understand your health insurance
coverage or insurance terms? Please rank the top three sources you use.
o From an assister or navigator while enrolling in health insurance
o At your provider’s office or other health care setting
o Event (i.e., a community event, health promotion fair, etc.)
o From an informational table or bulletin board (e.g., at a community organization or library)
o Online (e.g., by visiting a website)
o Social media (Facebook, Twitter, etc.)
o Print (Newspaper, magazine, poster, etc.)
o Mail
o Radio

o
o
o

Television
I do not know where to find resources on health insurance
Other: _________________

[SKIP TO 39]
38. How did you see or receive these resources that helped you understand your health insurance
coverage or insurance terms? Check all that apply.
o From an assister or navigator while enrolling in health insurance coverage
o At your provider’s office or other health care setting
o At an event (i.e., a community event, health promotion fair, etc.)
o From an informational table or bulletin board (e.g., at a community organization or library)
o Online (e.g., by visiting a website)
o Social media (Facebook, Twitter, etc.)
o Print (Newspaper, magazine, poster, etc.)
o Mail
o Radio
o Television
o Other: _________________
Domain: Aided ad recall
[Sample visuals to be shown included in survey Appendix]
39. During the past 12 months, how many times have you seen or heard about From Coverage to
Care or its materials?
o Not at all
o Once
o 2 to 4 times
o 5 to 10 times
o More than 10 times
o Don’t Know
[IF NOT AT ALL OR DON’T KNOW, SKIP TO ITEM 53]
40. Have you seen, heard about, or received any From Coverage to Care materials? For example,
have you seen a booklet called “A Roadmap to Better Care and a Healthier You?”, or
“Preventive Services Flyer,” or “5 Ways to Make the Most of Your Health Coverage”?
o Yes
o No
[IF YES SHOW QUESTIONS 41-46]
41. How did you see or hear about From Coverage to Care? Check all that apply.
o From an assister or navigator while enrolling in health insurance coverage
o At your provider’s office or other health care setting
o At an event (i.e., a community event, health promotion fair, etc.)
o From an informational table or bulletin board (e.g., at a community organization or library)
o Online (e.g., by visiting a website)
o Social media (Facebook, Twitter, etc.)

o
o
o
o
o

Print (Newspaper, magazine, poster, etc.)
Mail
Radio
Television
Other

Domain: Consumer Enrollment
42. Please indicate the extent to which you agree or disagree that From Coverage to Care (C2C)
materials encouraged you to obtain health insurance or continue your health insurance coverage.
• Strongly Disagree
• Disagree
• Agree
• Strongly Agree

Domain: C2C targeted knowledge
43. Have you seen From Coverage to Care’s (C2C): “A Roadmap to Better Care and a Healthier You”?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO ITEM 47]
• Don’t Know [SKIP TO ITEM 47]
44. Please rate the following statements to indicate how your understanding of the following topics
have changed as a result of seeing From Coverage to Care’s (C2C): “A Roadmap to Better Care
and a Healthier You”?
• Why I should see a doctor on a regular basis, even if I don’t feel sick
• Health insurance terms
• How to find out about my plan benefits and what my insurance covers
• Where to go for care if I don’t feel well
• How to find a regular health care provider that fits my needs
• What to bring with me to my health care appointment
• What to ask my provider when I am there
• That I can change my provider if I don’t like the one I have
• Where I can go if I have questions
• Other: ___________________
• None
o My understanding is the same as it was before I saw C2C materials.
o I have a slightly better understanding.
o I have a better understanding.
o I have a much better understanding.
Domain: C2C satisfaction
45. Please indicate the extent to which you were satisfied with From Coverage to Care’s (C2C): “A
Roadmap to Better Care and a Healthier You” coverage of the following topics?
• Why I should see a doctor on a regular basis, even if I don’t feel sick
• Health insurance terminology
• How to find out about my plan benefits and what my insurance covers

•
•
•
•
•
•

Where to go for care if I don’t feel well
How to find a regular health care provider that fits my needs
What to bring with me to my health care appointment
What to ask my provider when I am there
That I can change my provider if I don’t like the one I have
Where I can go if I have questions
o Very Satisfied
o Satisfied
o Dissatisfied
o Very Dissatisfied

Domain: C2C met needs
46. Please indicate the extent to which you agree that From Coverage to Care’s (C2C): “A Roadmap
to Better Care and a Healthier You” met your needs for the following topics?
• Why I should see a doctor on a regular basis, even if I don’t feel sick
• Health insurance terminology
• How to find out about my plan benefits and what my insurance covers
• Where to go for care if I don’t feel well
• How to find a regular health care provider that fits my needs
• What to bring with me to my health care appointment
• What to ask my provider when I am there
• That I can change my provider if I don’t like the one I have
• Where I can go if I have questions
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree

Domain: C2C targeted knowledge for future products
47. Have you seen [INSERT C2C MATERIAL NAME]?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO ITEM 51]
• Don’t Know [SKIP TO ITEM 51]
48. Please rate the following statements to indicate how your understanding of the following topics
have changed as a result of seeing [INSERT C2C MATERIAL NAME]?
• [Insert Learning Objective 1]
• [Insert Learning Objective 2]
• [Insert Learning Objective 3]
• [Insert Learning Objective 4]
• [Insert Learning Objective 5]
• Other: ___________________
o My understanding is the same as it was before I saw C2C materials.
o I have a slightly better understanding.
o I have a better understanding.
o I have a much better understanding.

Domain: C2C satisfaction
49. Please indicate the extent to which you were satisfied with [INSERT C2C MATERIAL NAME]?
• [Insert Learning Objective 1]
• [Insert Learning Objective 2]
• [Insert Learning Objective 3]
• [Insert Learning Objective 4]
• [Insert Learning Objective 5]
o Very Satisfied
o Satisfied
o Dissatisfied
o Very Dissatisfied
Domain: C2C met needs
50. Please indicate the extent to which you agree that [INSERT C2C MATERIAL NAME]?
• [Insert Learning Objective 1]
• [Insert Learning Objective 2]
• [Insert Learning Objective 3]
• [Insert Learning Objective 4]
• [Insert Learning Objective 5]
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree

Domain: C2C-related conversation
51. Have you shared information about C2C with someone else?
o Yes
o No
[IF YES SHOW QUESTION 52]
52. Who have you shared information with about C2C? Check all that apply.
o Health care professional
o Family member
o Friend
o Co-worker
o Community organization
o Other
53. Is there additional information you would like to see, which would help you understand your
health insurance coverage or insurance terms?
o Yes [ASK NEXT ITEM]
o No [SKIP TO END OF SURVEY]
54. Please indicate what additional information would be helpful? ____________________________

Conclusion
You have completed the survey. Thank you for your time!

Appendix
Visual 1: Coverage to Care’s (C2C): “Roadmap to Better Care and a Healthier You” Cover Page

Visual 2: Coverage to Care’s (C2C): “Roadmap to Better Care and a Healthier You” Map

Visual 3: Coverage to Care’s (C2C): “Preventive Services Flyer”?

Visual 4: Coverage to Care’s (C2C): “5 Ways to Make the Most of Your Health Coverage”?