Form CMS-10710.GenIC#5 CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 2

Medicare.gov Satisfaction Survey 2020 Instrument Page 1

Medicare.gov Sitewide Exit Survey
Q1 Browser question (automated – not asked)

Q2. Who are you using Medicare.gov for?
1 Myself
2 Someone else

Q3. [IF Q2 = 1] Do you have Medicare?
1 Yes
2 No

Q4. [If Q3=1] How do you currently get Medicare coverage?
1 I have Original Medicare (sometimes called 80/20 or Fee-for-Service Medicare)
2 I have a Medicare Advantage Plan (like an HMO or PPO)
3 I’m not sure

Q5. [If Q4=1 or Q4-=3] Do you have any of these? [Select all that apply.]
1 A Medicare prescription drug (Part D) plan
2 Medicare Supplement Insurance (Medigap) policy
3 Neither
4 I’m not sure

Q6. [If Q3 = 2] Will you get Medicare soon?
1 Yes
2 No
3 I’m not sure

Medicare.gov Satisfaction Survey 2020 Instrument Page 2
Q7. [If Q2=2] Were you looking at Medicare.gov today as a:
1 Friend, relative, or unpaid caregiver
2 Health care provider or health care staff
3 Assistor, navigator, agent or broker
4 SHIP counselor
5 Researcher
6 Other

Q8. [ALL] What was the main reason you came to Medicare.gov today?
If you came for more than one reason, select the main one.

1 Get general information about Medicare (like how it works, what’s covered, or cost
information)
2 Create or use my online Medicare account (like viewing claims)
3 Apply or sign up for Medicare (Part A and/or Part B)
4 Enroll in a Medicare Advantage Plan, Part D drug plan, or Medigap policy
5 Look for, review, or compare Medicare Advantage Plans, Part D drug plans, or Medigap
policies
6 Look for a doctor, hospital, or other health care provider/facility.
7 Pay my premium
8 Other (specify)

Q9. [If Q8 =1] Which best describes the type of information you were looking for today?
1 When can a person get Medicare? Or how do they apply?
2 How does Medicare work in general?
3 How much does Medicare cost (like premium, deductibles, and copayments)?
4 How does Medicare work with my insurance?
5 Is a test, item, or service covered?
6 Just looking
7 Other (specify)

Medicare.gov Satisfaction Survey 2020 Instrument Page 3

Q10. [If Q8=2] What did you do in {your or another person’s} online Medicare account?
1 Created {my or another person’s} online account
2 Reviewed {my or another person’s} claim
3 Updated {my or another person’s} information (like name, address, email)
4 Changed how {I or another person} get(s) {my or their MSNs} or Medicare & You handbook (by
email or by mail)
5 Reviewed my current coverage
6 Other (specify)

Q11 [If Q8= 4 or 5] What type of plan or plans were you interested in (if Q8=4 “enrolling in” and if
Q8=5 “looking for, reviewing, or comparing”}? [Select all that apply.]
1 Medicare Advantage Plan
2 Medicare prescription drug (Part D) plan
3 Medicare Supplement Insurance (Medigap) policy
4 I don’t know
5 Other (specify)

Q12 [IfQ8=6] What, specifically, were you looking for today? [Select all that apply.]
1 Doctor or other health care provider
2 Nursing home
3 Hospital
4 Home health services
5 Dialysis facility
6 Medical equipment supplier
7 Long-term care hospital
8 Inpatient rehabilitation facility
9 Hospice care
10 Other (specify)

Medicare.gov Satisfaction Survey 2020 Instrument Page 4

Q13 [If Q8=4 or 5]: How confident are you that you could (or did) enroll in the right plan for you?
1 Very confident
2 Somewhat confident
3 Neutral
4 Not very confident
5 Not at all confident

Q14 [If Q8 = 6]: How confident are you that the information on Medicare.gov will help you select the
right provider or facility for you?
1 Very confident
2 Somewhat confident
3 Neutral
4 Not very confident
5 Not at all confident

Q15. [ALL] Were you able to successfully {Q8 response or “do what you came to do” if Q8 response =
7} during your visit today?
1 Yes
2 No
3 I don’t know

Q16 [ALL] How easy was it to {Q8 Response or “do what you came to do” if Q8=7} on Medicare.gov
today?
1 Very difficult
2 Somewhat difficult
3 Neutral
4 Somewhat easy
5 Very easy
Q17 [If Q15=2 or 3] What will you do next?

Medicare.gov Satisfaction Survey 2020 Instrument Page 5
1 Keep looking at Medicare.gov
2 Come back to Medicare.gov later
3 Go to a different website
4 Contact 1-800-MEDICARE
5 Get in-person help
6 Check the Medicare & You handbook
7 Don’t know/not sure
8 Other (specify)

Q18a [ALL] How satisfied were you with your overall experience on Medicare.gov?
1 Very dissatisfied
2 Somewhat dissatisfied
3 Neither satisfied nor dissatisfied
4 Somewhat satisfied
5 Very satisfied

Q18b [ALL] How satisfied were you with the information on Medicare.gov?
1 Very dissatisfied
2 Somewhat dissatisfied
3 Neither satisfied nor dissatisfied
4 Somewhat satisfied
5 Very satisfied

Q18c [ALL] How satisfied were you with how well the Medicare.gov website worked today?
1 Very dissatisfied
2 Somewhat dissatisfied
3 Neither satisfied nor dissatisfied
4 Somewhat satisfied
5 Very satisfied

Medicare.gov Satisfaction Survey 2020 Instrument Page 6

Q19 [ALL] How likely are you to return to Medicare.gov if you need information about Medicare in the
future?
1 Very likely
2 Somewhat likely
3 Neutral
4 Not very likely
5 Not at all likely

Q20 [ALL] How can we improve Medicare.gov? [open-ended responses]

Q21 [ALL] Would you be interested in being contacted in the future to take part in
research activities related to Medicare.gov? If so, please include your email address below:
You have the right to get Medicare information in an accessible format, like large print,
Braille, or audio. You also have the right to file a complaint if you feel you’ve been
discriminated against.
Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE
(1-800-633-4227) for more information. TTY users can call 1-877-486-2048.
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