Form CMS-10836 Interview Screener: Typical and Engaged Beneficiaries

Medicare Plan Performance Warning Information
Interview Screener: Typical and Engaged Beneficiaries
Recruiting Goals Vary by Project: See chart.
Typical Beneficiaries (n=84)

Engaged Beneficiaries (n=48)

Audits and Existing
Letters for Denials and
Appeals: Review and
test information

n=28 total, 90-minute IDIs
(virtual)
· n=14 MA
· n=14 Part D
Mix of new enrollees (50%)
and existing beneficiaries
(50%)

n=16 total, 90-minute IDIs
(virtual)
· n=8 MA
· n=8 Part D
Mix of new enrollees (50%) and
existing beneficiaries (50%)

Enforcement and
Compliance Information:
How best to
present/explain

n=28 total, 90-minute IDIs
(virtual)
· n=14 MA
· n=14 Part D
Mix of new enrollees (50%)
and existing beneficiaries
(50%)

n=16 total, 90-minute IDIs
(virtual)
· n=8 MA
· n=8 Part D
Mix of new enrollees (50%) and
existing beneficiaries (50%)

Desired Content Related
to Poor Plan
Performance: Evaluate
and assess various
indicators of plan
performance

n=28 total, 90-minute IDIs
(virtual)
· n=14 MA
· n=14 Part D
Mix of new enrollees (50%)
and existing beneficiaries
(50%)

n=16 total, 90-minute IDIs
(virtual)
· n=8 MA
· n=8 Part D
Mix of new enrollees (50%) and
existing beneficiaries (50%)

Key requirements:
● Have a Medicare Advantage plan (50%) or Original Medicare with a Part D drug
plan (50%)
● New enrollees (50%) or existing beneficiary (50%)
● Involved in selecting plan coverage
● Access to a computer and willing to take part in online interview OR no computer or
internet access at home and is willing to travel to a research facility
● Aged 54-80 (under 65 only qualifies if disabled)
● Engaged only: Engages in motivated consumer behaviors (see Q13-16)
Additional Recruitment Mix:

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Mix of education levels (Q20)
Mix of race/ethnicity (Q21-22)
Good split of male/female but also including some non-binary or transgender (see
Q23)
Ideally, some who are dual-enrolled in Medicare and Medicaid (see Q9c)
Ideally, some who are disabled (see Q11)
Ideally, some familiar with Medicare Star Ratings (see Q19)
Ideally, some who are lower income (see Q24, answered ‘c’ or ‘d’)

The screener will be translated to recruit Spanish speaking audiences (adjusting Q3 to
terminate English)

Recruitment Script:
Good morning/afternoon/evening, my name is __________ and I’m calling from (name of
company). We’re conducting research in (insert market). I am not selling anything nor will
you be asked to sign up for or purchase anything. We are looking for individuals to
participate in a discussion about healthcare issues that may be relevant to you and your life.
The discussion will last 90 minutes and participants will be offered an incentive of [up to
$XX].
May I ask you a few questions to see if you qualify to participate in the study? If yes,
continue. If no, thank and end.
1. Have you or any member of your household or immediate family ever worked: [IF
YES TO ANY, THANK AND TERMINATE]
a. For a market research company
b. For an advertising agency or public relations firm
c. For the media (TV/radio/newspapers/magazines)
d. In the healthcare profession (as a doctor, nurse, other healthcare
professional, in a pharmacy, for a pharmaceutical company, etc.)
e. For a health insurance provider
f. For a managed care organization or any healthcare provider
g. For a medical practice
h. In the state legislature or as an elected official
i. For the Social Security Administration or Centers for Medicare and Medicaid
services, formerly known as the Health Care Financing Administration, or the
Department of Health and Human Services or one of its related agencies
such as the Centers for Disease Control, or the Food and Drug
Administration?
2. Are you retired from a Federal Government job?
a. Yes [TERMINATE]
b. No

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3. Is English your first or primary language?
a. Yes
b. No [ASK FOLLOW-UP]
i.
Are you comfortable taking part in an interview in English and
reviewing written materials in English?
1. Yes
2. No [TERMINATE OR SWITCH TO SPANISH SCREENER]
4. Have you ever attended a focus group discussion or a personal interview for
research purposes? By that we mean an informal, round-table discussion or a
personal in-depth interview, conducted by a professional moderator, in which you
were asked your opinions regarding a product, a service, or advertising?
a. No
[SKIP TO Q5]
b. Yes
[ASK 4b-4d BELOW]
4b. How many of these interviews or groups have you attended? [RECORD
NUMBER, MAX 3 EVER]
4c. What was/were the topics discussed? [RECORD, IF HEALTHCARE OR
HEALTH INSURANCE (INCLUDING MEDICARE, MEDICAID OR CHIP)
TERMINATE]
4d. How long ago was the last one of these groups you attended? [RECORD,
MUST BE 6 OR MORE MONTHS]
5. This session will be conducted online. Which of the following do you have access
to? Please select all that apply.
a. A smart phone with a built-in camera
b. A tablet with a built-in camera
c. A desktop or laptop computer, with no camera, but has a microphone
[HOLD; WE MAY BE ABLE TO ACCEPT A FEW OF THESE]
d. A desktop or laptop computer, with a built-in or attached web camera
e. Reliable internet connection
f. None of the above
[Must select ‘c’ or ‘d’ and ‘e’ to qualify for virtual interview. Otherwise,
recruit for in-facility interview; n=12.].
6. [FOR ONLINE INTERVIEWS] You will need to use your desktop or laptop computer
for this interview and review materials on a screen as part of an online call, like a
Zoom call. Will you be comfortable doing that for an interview like this?
a. Yes
b. No [THANK AND END]
7. What month and year were you born? [RECORD AGE]
a. Year
b. Month
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c. Calculate age: ________ [TERM IF 54 OR YOUNGER; TERM IF 80 OR
OLDER]
Note: Participants under age 65 are only eligible IF they qualify for
Medicare because of a disability.
8. I’d like you to think about who is most involved in researching and making decisions
about your health insurance. When researching health or drug plans and deciding
which plans to join, would you say that:
a. You are most responsible for researching and selecting your health
insurance plan [CONTINUE]
b. You and another person are jointly responsible for researching and
selecting your health insurance plan [CONTINUE]
c. Someone else is mostly responsible for researching and selecting your
health insurance plan [TERMINATE]
9. Thinking about your current health insurance coverage, please tell me whether each
type of health insurance applies to you. Do you have…?
a. Health coverage you get through an employer or union (current or former,
yours or your spouses) [TERMINATE]
b. Medicare coverage, including Medicare Part A and/or Part B; a Medicare
health plan, or Medicare Advantage plan (sometimes referred to as a Part C
plan) (such as a Medicare HMO or PPO that you purchased from an
insurance company) a supplemental policy; or a separate, stand-alone
Medicare prescription drug plan (sometimes referred to as a Part D plan)
[REQUIRED]
c. Medical Assistance or Medicaid from the state of [INSERT STATE] [IF
NEEDED: These benefits are sometimes available for people with limited
income and financial assets.] [DUAL ENROLLED – MEDICARE PLUS
MEDICAID]
d. Health insurance that you purchase independently yourself and pay a
monthly premium for [TERMINATE]
e. COBRA [TERMINATE]
f. TRICARE, TRICARE for Life, Veterans or VA benefits [TERMINATE]
g. Currently do not have health insurance [TERMINATE]
h. Something else [TERMINATE]
10. When did you first enroll in a Medicare plan? [ASK FOR MONTH AND YEAR]
a. NOTE IF TWO OR MORE YEARS FOR Q13
[AIM FOR MIX OF NEW ENROLLEES (50%, 23 MONTHS OR LESS) AND
EXISTING BENEFICIARIES (50%, 24 MONTHS OR MORE)]

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11. [ASK IF UNDER AGE 65] Are you eligible for Medicare because of a disability or
end stage renal disease (ESRD)?
a. Yes
b. No [TERMINATE]
c. Unsure [TERMINATE]
12. You said you have Medicare coverage. Do you have a Medicare Advantage plan,
which is like a Medicare HMO or PPO plan that you purchase from an insurance
company, it’s sometimes called Part C? Or, do you have Medicare Part A and/or
Part B, also called “Original Medicare,” which provides hospital and medical
coverage?
a. Medicare Advantage, also called Part C
b. Medicare Part A and/or Part B, also called Original Medicare [ONLY
QUALIFIES IF SELECTS A MEDICARE DRUG PLAN IN Q14c]
c. Not sure [TERMINATE]
ASK IF Q9 IS ‘A’ ADVANTAGE
13. Please go get your Medicare Advantage card for me. Can you tell me the exact
name of your Medicare Advantage plan and the ZIP code where you reside?
[RECORD EXACT; CHECK INFORMATION AGAINST
https://www.medicare.gov/plan-compare/#/questions?year=2021&lang=en ;
SEARCH FOR ADVANTAGE PLANS IN THIS ZIP CODE TO CONFIRM VALIDITY
OF PLAN]
ASK ALL
14. Do you have prescription drug coverage with your Medicare?
a. No [TERMINATE IF Q9 IS B, ORIGINAL MEDICARE]
b. Yes, as a part of my Medicare Advantage plan [SEE Q12 for plan name]
c. Yes, a separate, standalone Prescription Drug Plan (also called Medicare
Part D)
i.
Please go get your Part D drug plan insurance card for me. Can you
tell me the exact name of your plan and the ZIP code where you
reside? [RECORD EXACT; CHECK INFORMATION AGAINST
https://www.medicare.gov/plancompare/#/questions?year=2021&lang=en; SEARCH FOR DRUG
PLANS IN THIS ZIP CODE TO CONFIRM VALIDITY OF PLAN]
d. Yes, I have prescription coverage but not through my Medicare Advantage
Plan or Medicare Part D [SPECIFY AND HOLD]
15. [FOR EXISTING BENEFICIARIES ONLY] During the most recent Medicare Open
Enrollment period when you were able to make changes to your coverage—from

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[DATE] to [DATE]—did you look into options you had for making any changes to
your [HEALTH/DRUG] plan?
a. Yes
b. No [‘TYPICAL’ BENEFICIARY]
16. [FOR ALL] How did you look into plan options during the most recent enrollment
period [EXISTING]/ when you first enrolled [NEW]? [READ OPTIONS AS NEEDED]
a. Directly through the insurance company. IF YES:
i.
In-person or online?
b. Through the Medicare.gov website
c. By calling 1-800-Medicare
d. Through an insurance broker or agent
e. Some other way: _________________________
f. Did not look into options [‘TYPICAL’ BENEFICIARY; SKIP TO Q19]
17. How do you get information about plan options available to you, such as coverage
and cost, before making any decisions? [SELECT ALL THAT APPLY, NEED AT
LEAST TWO BE ‘ENGAGED’; IF ONE OR NONE, SKIP TO Q19]
a. Talked with the insurance company
b. Called 1-800-MEDICARE
c. Talked with an agent/broker
d. Read information I got in the mail or at a sales event
e. Visited health or drug plan websites
f. Visited medicare.gov
g. Other _____________
h. I did not / Someone else did it for me [‘TYPICAL’ BENEFICIARY; SKIP TO
Q19]
18. Do you typically engage in any of the following behaviors? [SELECT ALL THAT
APPLY]
a. Bring my prescriptions or a list of my prescription medications with me to a
doctor’s appointment
b. Read reviews from places such as Consumer Reports before making a major
purchase
c. Spend time reading multiple reviews and looking at ratings on Amazon or
other online retailers before making a purchase
d. Write reviews for products I’ve purchased or activities I’ve engaged in
e. Look up the technical details of how ratings are calculated
f. Personally appealed a medical decision with my insurance company (e.g., to
request coverage for a denied service)
g. Regularly read full inserts that come with my prescription medications
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h. Asked my doctor or pharmacist for more details about a prescribed
medication to understand if it is the right medication for me or if the doctor
should prescribe something else
i. Returned an item I purchased
j. Click on links “for more information” when I am visiting a website
k. None of the above
[THREE OR MORE=ENGAGED BENEFICIARY, IF TWO OR FEWER = TYPICAL]
19. When you selected your Medicare health or drug plan, did you happen to notice how
the plan was rated? This is called the Medicare Star Ratings.
a. Yes [AS MANY AS POSSIBLE, IDEALLY OVER HALF OF ENGAGED
BENEFICIARIES]
b. No
c. Not sure
Thank you. We want to ensure we speak with a diverse group of individuals. Please answer
the following demographic questions.
20. What is the highest level of education you have completed? [RECRUIT A MIX]
a. Less than high school
b. High school diploma/GED
c. Some college (1-2 years, no degree)
d. Some college (more than 2 years, no degree)
e. Associate’s or two-year degree
f. 4-year college degree
g. Graduate degree/more than 4-year degree
21. Are you of Hispanic or Latino origin or descent? [RECRUIT A MIX]
a. Yes
b. No
c. Prefer not to answer
22. Which of the following best describes your race? Please select all that apply.
[RECRUIT A MIX]
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. Caucasian/White
f. Use a different term: ______________
g. Prefer not to answer
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23. What ways do you identify yourself? Please select all that apply. [RECRUIT A MIX]
a. Male
b. Female
[CAP: NO MORE THAN HALF]
c. Transgender
d. Non-binary or gender fluid
e. Prefer not to answer
[RECRUIT MINIMUM OF 7 PARTICIPANTS WHO SELECT C OR D]
24. People can describe their financial situation in different ways, regardless of income.
If you are comfortable sharing, let me know which of these 4 descriptions best fits
you. The descriptions are: [RECRUIT A MIX]
a. I’m living comfortably
b. I have enough to get by
c. Sometimes I struggle to make ends meet
d. I cannot make ends meet
e. Prefer not to answer
25. Can you briefly tell me about a book you’ve recently read or a TV show or movie
you’ve recently seen, and what you liked about it?
[Record response. Articulation screen, participant must be able to and be
comfortable with expressing their thoughts.]
INVITATION & INSTRUCTIONS
Thank you for answering all of my questions. As I mentioned earlier, we are conducting a
research study regarding healthcare and would like to hear your views. In order to hear
them first-hand, we are conducting online interviews.
The interview will last 90 minutes. No one will attempt to sell you anything and no one will
call on you as a result of your participation. As a token of our appreciation for your help in
our research effort, you will receive a [$XX] honorarium after the session. This is an
important research effort and we hope that you will be part of it. We can only invite a few
people to take part. May we schedule your attendance? [IF NO THANK AND END]
I will be emailing you more information about the interview. I will also contact you again by
phone to remind you about the session closer to the date.
[NONE OF THE BELOW INFORMATION SHOULD BE SHARED AT ANY TIME, IT IS
STRICTLY FOR THE RECRUITER’S NEEDS; ONLY FIRST NAMES AND LAST INITIALS
SHOULD BE INCLUDED IN THE GRID]
26. Your full name?

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27. Your email address
28. What is the best number to reach you?
a. Is this home or cell?
b. Do you prefer text messages?
Thanks again. Have a good morning/afternoon/evening.

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