2024 Content Management Cycle Cognitive Testing Report

MEDICARE CURRENT BENEFICIARY SURVEY (MCBS)

2024 Content Management Cycle
Cognitive Testing Report
Contract 75FCMC19D0092; Task Order 75FCMC21F0001

OCTOBER 12, 2022

PRESENTED TO:
William Long, Contracting Officer’s
Representative
Centers for Medicare & Medicaid
Services
7111 Security Boulevard
Baltimore, MD 21244

PRESENTED BY:
Felicia LeClere
Project Director
NORC at the University of Chicago
55 East Monroe Street
30th Floor
Chicago, IL 60603

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| 2024 Content Management Cycle Cognitive Testing Report

Table of Contents
Executive Summary .......................................................................................................................4
Introduction ....................................................................................................................................5
Item Source and Description ...................................................................................................5
Methods ...........................................................................................................................................6
Sampling, Recruitment, and Screener .....................................................................................6
Data Collection ........................................................................................................................7
Data Analysis Methods............................................................................................................7
Results and Recommendations .....................................................................................................8
Comparing Medicare Coverage Options .................................................................................8
Oral Health Items ..................................................................................................................11
Discussion......................................................................................................................................14
Appendix A: Cognitive Interview Screening Instrument (English) ........................................15
Appendix B: Cognitive Interview Screening Instrument (Spanish) .......................................17
Appendix C: Cognitive Interview Instrument (English) ..........................................................19
Appendix D: Cognitive Interview Instrument (Spanish) .........................................................24

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List of Exhibits
Exhibit 1.

2024 Content Cycle Requests and Requested Implementation Timeline ........................ 5

Exhibit 2.

Distribution of Sex, Ethnicity, Race, and Educational Attainment among Cognitive
Interview Respondents ..................................................................................................... 7

Exhibit 3.

Comparing Medicare Coverage Options, Item Q1-Q5 Question Text ............................ 8

Exhibit 4.

Comparing Medicare Coverage Options, Item Q3-Q4 Responses ................................ 10

Exhibit 5.

Oral Health Testing Items .............................................................................................. 12

Exhibit 6.

Proposed Revisions to Oral Health Testing Items ......................................................... 13

Exhibit 7.

Administration Schedule and Burden of Oral Health Items .......................................... 14

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Executive Summary
The Medicare Current Beneficiary Survey (MCBS) is a continuously fielded survey of a nationally
representative sample of the Medicare population conducted by the Centers for Medicare & Medicaid
Services (CMS) through a contract with NORC at the University of Chicago (NORC). The Medicare
population includes all Medicare eligible persons aged 65 and over, and persons under age 65 with
certain disabilities or with end-stage renal disease (ESRD). The MCBS uses a rotating panel design
and collects data from Medicare beneficiaries up to eleven times over a span of four years. Incoming
panels are sampled and recruited in the fall of each year to replace the panel that rotates out in the
winter. The survey covers topics including health care utilization and expenditures, sources of health
insurance coverage, and health status and functioning. Data are collected for sampled beneficiaries
living in noninstitutionalized (e.g., households) and institutionalized (e.g., nursing homes) settings.
Each year, CMS solicits content changes to the MCBS questionnaires from partners and
stakeholders. As a result of this call, in April 2022 CMS received requests for two new series of
items to be added to the MBCS Community questionnaire in 2024. These requests include two items
about comparing Medicare coverage options and five items related to oral health. Based on draft
wording of the new items (either directly from other surveys or from other resources), a small-scale
cognitive testing round was designed to assess comprehension and the overall flow of administration.
A total of eight cognitive tests were conducted by phone in Summer 2022; five of the eight tests were
conducted in English and three tests were conducted in Spanish.
Based on the results of this small-scale testing effort, the 5-Item Oral Health Impact Profile (OHIP-5)
is recommended for implementation on the MCBS. The testing found that a few of the questions
needed minor revisions to improve clarity but overall, the scale performed well and administration
was straightforward in both English and Spanish. Adding these new items beginning in Fall 2024
will close important data gaps related to oral health.
The remaining items about comparing Medicare coverage options are not recommended for
implementation at this time due to comprehension issues observed during testing.

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Introduction
The Medicare Current Beneficiary Survey (MCBS) is a continuously fielded survey of a nationally
representative sample of the Medicare population conducted by the Centers for Medicare & Medicaid
Services (CMS) through a contract with NORC at the University of Chicago (NORC). The Medicare
population includes all Medicare eligible persons aged 65 and over, and persons under age 65 with
certain disabilities or with end-stage renal disease (ESRD). The MCBS uses a rotating panel design
and collects data from Medicare beneficiaries up to eleven times over a span of four years. Incoming
panels are sampled and recruited in the fall of each year to replace the panel that rotates out in the
winter. The survey covers topics including health care utilization and expenditures, sources of health
insurance coverage, and health status and functioning. Data are collected for sampled beneficiaries
living in noninstitutionalized (e.g., households) and institutionalized (e.g., nursing homes) settings.
Each year, CMS solicits content changes to the MCBS questionnaires from partners and
stakeholders. As a result of this call, in April 2022 CMS received requests to consider two new series
of items to be added to the MBCS Community questionnaire in 2024. These requests include two
new items about comparing Medicare coverage options and five new items related to oral health
(Exhibit 1). Based on draft wording of the new and revised items (either directly from other surveys
or from other resources), a small-scale cognitive testing round was designed to assess comprehension
and overall flow of administration. A total of eight cognitive tests were conducted by phone in
Summer 2022; five of the eight tests were conducted in English and three tests were conducted in
Spanish.
Exhibit 1.

2024 Content Cycle Requests and Requested Implementation Timeline
Content Request

Item Source

Requested
Implementation Timeline

Comparing Medicare Coverage Options

Original Items

Winter 2024 Round 98

OHIP-5

Fall 2024 Round 100

Oral Health Items

Item Source and Description
All items in the 2024 content cycle required testing to assess comprehension and clarity among
Medicare beneficiaries.
 The “Comparing Medicare Coverage Options” items are original items designed to measure
the methods beneficiaries use to review and compare Medicare coverage options. These
items were requested and initially drafted by the CMS Office of Program Operations and
Local Engagement (OPOLE) Local and Engagement Administration.

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 The 5-Item Oral Health Impact Profile (OHIP-5) scale was requested for inclusion by the
Chief Dental Officer at CMS. These items assess oral function, orofacial pain, orofacial
appearance, and the psychosocial impact of having any problems with your teeth, mouth,
dentures, or jaw. Earlier iterations of the OHIP scale measured these same oral health
domains via a longer scale comprised of 49 items, 1 and later, 14 items. 2 In an attempt to
capture analytically similar information with the minimum number of items, a five-item
version of the scale was created. 3 The five-item version of the scale was validated in the adult
general population in both English and Spanish and was found to have sufficient reliability
and validity. 4,5 The five-item version of the scale has been found to be highly correlated with
longer versions and is recommended for usage in both research and clinical settings as it
provides interchangeable information and has minimal burden. 6

Methods
The purpose of this cognitive testing study was to understand the processes people use to answer
questions about several health-related topics and to identify potential problems in the questions and
response categories. A qualitative analysis of the interviews was conducted.

Sampling, Recruitment, and Screener
As is typical of cognitive interviewing, convenience sampling was used to identify eligible cases.
Cognitive interviewing staff recruited from retired 2018 panel respondents who consented to future
contact at their Winter 2022 Round 92 Community questionnaire. They were selected based on a
variety of demographic characteristics such as language, race/ethnicity, age, and education level.
Respondents were screened prior to interview administration to confirm their Medicare eligibility
and their demographic information (see screening instruments in Appendices A and B).
A total of eight interviews were completed from August to September 2022; five of the eight tests
were conducted in English and three tests were conducted in Spanish. Respondents were provided a

Slade, G. D., & Spencer, A. J. (1994). Development and evaluation of the Oral Health Impact Profile. Community dental
health, 11(1), 3–11.
2 Slade G. D. (1997). Derivation and validation of a short-form oral health impact profile. Community dentistry and oral
epidemiology, 25(4), 284–290. https://doi.org/10.1111/j.1600-0528.1997.tb00941.x
3 John, M. T., Miglioretti, D. L., LeResche, L., Koepsell, T. D., Hujoel, P., & Micheelis, W. (2006). German short forms of the
oral health impact profile. Community dentistry and oral epidemiology, 34(4), 277-288.
4 Naik, A., John, M. T., Kohli, N., Self, K., & Flynn, P. (2016). Validation of the English-language version of 5-item Oral Health
Impact Profile. Journal of prosthodontic research, 60(2), 85–91. https://doi.org/10.1016/j.jpor.2015.12.003
5 Simancas-Pallares, M., John, M. T., Enstad, C., & Lenton, P. (2020). The Spanish Language 5-Item Oral Health Impact
Profile. International dental journal, 70(2), 127–135. https://doi.org/10.1111/idj.12534
1

6

John, M. T., Omara, M., Su, N., List, T., Sekulic, S., Häggman-Henrikson, B., Visscher, C. M., Bekes, K., Reissmann, D. R.,
Baba, K., Schierz, O., Theis-Mahon, N., Fueki, K., Stamm, T., Bondemark, L., Oghli, I., van Wijk, A., & Larsson, P.
(2022). Recommendations for use and scoring of Oral Health Impact Profile Versions. Journal of Evidence-Based Dental
Practice, 22(1). https://doi.org/10.1016/j.jebdp.2021.101619

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$40 incentive for participating. They ranged in age from 64 to 91 (mean age = 79.9). Exhibit 2 shows
distributions by sex, ethnicity, race, and educational attainment as reported during screening.
Exhibit 2. Distribution of Sex, Ethnicity, Race, and Educational Attainment among Cognitive
Interview Respondents
Characteristic
Sex
Female
Male

Count
4
4

Ethnicity
Hispanic
Non-Hispanic
Race
Black or African American
White
Education
Nursery school to eighth grade
High school diploma
Some college, but no degree

3
5
2
6
2
1
1

Bachelor's degree

3

Master’s, professional or doctorate degree

1

Data Collection
Interviewers administered the questionnaire as a paper-and-pencil interview (PAPI) remotely via
telephone. Once potential respondents were screened and determined to be eligible, interviewers
reviewed and obtained informed consent and administered the test questionnaire in full. Interviews
were audio recorded with respondents’ permission, so analysts could reference the recording during
analysis as needed. After each series of items was administered, interviewers debriefed respondents,
probing for information about how they interpreted the questions and arrived at their answers. The
cognitive testing questionnaire is shown in Appendices C and D.

Data Analysis Methods
This cognitive testing effort used retrospective probing techniques in which respondents were asked
additional questions about the items being tested. During and after each interview, observers wrote
notes summarizing the themes and responses they heard. Analysts then reviewed the notes; listened
to the interview recordings for additional clarity when needed; and identified themes in the
responses. This analysis provided insights into any confusion respondents may have had in
responding to the draft items and identified items where respondents did not answer as intended. It
also identified possible opportunities for improvement of some measures.

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Results and Recommendations
The discussion below is structured around each set of items: (1) comparing Medicare coverage
options, and (2) oral health items. For each set of items, this section first describes the testing results
and, when appropriate, includes recommendations to improve or revise the questions. For each group
of test questions, the report includes descriptive statistics and a discussion of item performance.

Comparing Medicare Coverage Options
The cognitive testing questionnaire contained a series of five items related to comparing Medicare
coverage options (Exhibit 3). Items Q1 and Q2 are existing MCBS items that ask about the ease and
frequency with which beneficiaries compare their Medicare coverage options. These items were
included in the test questionnaire to orient respondents and provide context to the topic of interest for
testing. Item Q3, requested by the OPOLE Local and Engagement Administration, asks how
beneficiaries review and compare their Medicare coverage options. Item Q4 was included in the
cognitive testing questionnaire as a close-ended probe to assess familiarity with the response options
tested in item Q3. Finally, item Q5, requested by the OPOLE Local and Engagement Administration,
asks about awareness of using a medicare.gov account to manage Medicare benefits.
Exhibit 3.
Variable
Name

Comparing Medicare Coverage Options, Item Q1-Q5 Question Text*
Question Text

Code List

Q1

How easy or difficult would you say it is for you
to review and compare your Medicare coverage
options? Would you say it is …

(01) Very easy
(02) Somewhat easy
(03) Somewhat difficult
(04) Very difficult
(05) DOES NOT MAKE DECISIONS ON
HEALTH INSURANCE
(-8) DON'T KNOW
(-9) REFUSED

Q2

How often do you review or compare your
Medicare coverage options? Would that be at
least once every year, once every few years,
rarely, or never?

(01) AT LEAST ONCE EVERY YEAR
(02) ONCE EVERY FEW YEARS
(03) RARELY
(04) NEVER  Skip to Q4
(05) ONLY ONCE WHEN FIRST
SIGNED UP FOR DRUG PLAN
(06) ONLY ONCE WHEN FIRST
SIGNED UP FOR MEDICARE
(07) JUST SIGNED UP FOR MEDICARE
(-8) DON'T KNOW
(-9) REFUSED

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Variable
Name
Q3

Q4

Question Text

How do you review or compare your
Medicare coverage options? Select all that
apply:
IF NEEDED: Medicare SHIP (State Health
Insurance Assistance Program) is a free, oneon-one counseling service to help answer your
questions about Medicare coverage and plan
options.
Before today, were you aware of the following
ways to review or compare your Medicare
coverage options? Please indicate yes or no to
each one:
•
•
•
•

Q5

Code List
(01) 1-800-MEDICARE
(02) medicare.gov
(03) “Medicare and You” Handbook
(04) State Health Insurance Assistance
Program (SHIP)
(05) Family member
(06) Other (Specify)
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

1-800-MEDICARE
medicare.gov
“Medicare and You” Handbook
State Health Insurance Assistance
Program (SHIP)

[IF NEEDED: Medicare SHIP (State Health
Insurance Assistance Program) is a free, one-onone counseling service to help answer your
questions about Medicare coverage and plan
options.]
Before today, were you aware that you can
create an account at medicare.gov to manage
your Medicare benefits?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

*Items requested by the OPOLE Local and Engagement Administration for inclusion in the 2024 MCBS
Community questionnaire are bolded.

All eight respondents answered items Q1 and Q2. At item Q1, 87.5% of respondents (n=7) found it
“very easy” or “somewhat easy” to compare their Medicare coverage options and 12.5% (n=1) found
it “somewhat difficult”. The majority of respondents (62.5%, n=5) reported reviewing or comparing
their coverage “at least once every year” at item Q2. Of the remaining respondents, one respondent
reported “rarely” comparing coverage options, one reported “never” comparing options, and one
answered, “Don’t Know.”
espondents who responded to items Q3 and Q4 reported using a variety of sources to review or
compare their coverage options (item Q3) and reported varying levels of awareness of these sources
(item Q4). Exhibit 4 shows the breakdown of responses reported at these items. As shown below, one
respondent reported using the State Health Insurance Assistance Program (SHIP) at item Q3.
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However, after receiving a definition of SHIP at item Q4 they realized they had not used SHIP to
review/compare their coverage options.
Exhibit 4.

Comparing Medicare Coverage Options, Item Q3-Q4 Responses

Methods for
reviewing/comparing coverage

Q3: How do you review or
compare your Medicare
coverage options?
(Total n=7)*

Q4: Before today, were you
aware of the following ways
to review or compare your
Medicare coverage options?
(Total n=8)

1-800-MEDICARE

0% (n=0)

37.5% (n=3)

medicare.gov

0% (n=0)

12.5% (n=1)

“Medicare and You” Handbook

14% (n=1)

50% (n=4)

State Health Insurance
Assistance Program (SHIP)

14% (n=1)**

50% (n=4)

Family member

29% (n=2)

n/a

Other (Specify)

43% (n=3)
Respondents reported the
following “other” methods:
Mailing, Medicare insurance
agent, and mail & television.

n/a

*One of the respondents elected to refuse answering the question due to lack of comprehension and frustration with
the series overall.
**This response was later discovered to be erroneous, the respondent realized that they did not use this program.

At item Q5, only one of the eight respondents was aware of the ability to create an account at
medicare.gov to manage their Medicare benefits.
Analysis and Recommendations
Several respondents were able to complete this section with relative ease. Of these individuals, one
respondent reported reviewing their coverage options annually and seemed very involved in their
health care decision making. Another respondent rarely reviewed their coverage options, but when
they did, it was with the help of a Medicare insurance agent. Other respondents received assistance
from family members.
The majority of respondents in the English-language interviews (and half of the respondents overall),
however, reported comprehension issue with this series. For those who reported challenges, this
series proved to be confusing for two main reasons.
1. First, some respondents had difficulty engaging with the question topic. One respondent had
difficulty understanding the series as they did not understand the concept of reviewing
Medicare coverage options. This led to them being unable to answer item Q3 (i.e., refusing to
respond), not necessarily because they did not use any of the methods but because they did
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not understand the concepts in the question. The frustration expressed by the respondent at
being asked questions they did not understand nearly led to a loss of cooperation for the rest
of the interview.
Another respondent struggled with the series because their spouse makes the healthcare
decisions in their household. Situations such as this, where a family member assists with
choosing coverage, are challenging at item Q3. A respondent may choose “family member”
from the list of available response options or may choose the program resources their family
member uses to compare coverage options, depending on how involved they are in the
decision-making process and how they interpret the question. This could lead to
inconsistencies in interpretation and variable responses and, therefore, may not provide
useful data for the requesting agency.
2. Second, respondents were unfamiliar with the technical terms used in items Q3, Q4, and Q5.
At Q3, one respondent mistook the State Health Insurance Assistance Program (SHIP) for
something else, but this was not revealed until the respondent was administered item Q4 and
received a definition of the program. Further, half or fewer respondents reported awareness
of each program resource at item Q4 (Exhibit 4), suggesting that a lack of selection of a
program resource at item Q3 is likely due to a combination of being unfamiliar with the
resource and/or not using the resource. Two respondents also struggled with item Q5
(knowledge of medicare.gov account creation) as they were unfamiliar with the website
entirely.
Two of the three Spanish interview respondents also struggled to understand the concepts of
the items Q3 and Q4. The field interviewer conducting this questionnaire added extra context
to the answer choices such as “the webpage medicare.gov” rather than simply
“medicare.gov” to attempt to alleviate confusion. When probed, one respondent stated that
they were “thinking about how much information [they] don’t know.” This implies that the
respondent understood that the questions were about Medicare, but they did not know enough
about the assistance tools for comparing coverage to answer these questions comfortably.
Given the comprehension issues encountered by at least half of respondents, NORC does not
recommend implementing this series of items. To make such questions viable in a population-based
survey would require a more extensive review of the literature and in-depth analysis to improve item
flow and comprehension.

Oral Health Items
The cognitive testing questionnaire contained a series of five items related to oral health (shown in
Exhibit 5). These new items were sourced from the OHIP-5, as requested by the Chief Dental Officer
at CMS, and ask about oral pain (Q1), oral function (Q2 and Q5), orofacial appearance (Q3), and the

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psychosocial impact of oral health problems (Q4). 7 The original series contained a reference period
of one month. Prior to cognitive testing, all items in this series were modified to accommodate an
annual reference period, typically used for health status and functioning questions in the MCBS.
Additionally, items Q3 and Q4 were modified to include interviewer help text that provide
definitions of terms that may be confusing for respondents.
Exhibit 5.
Variable
Name
Q1

Oral Health Testing Items
Question Text
Since [LAST HF MONTH YEAR], have you had
painful aching in your mouth? Would you say:

Q2

Since [LAST HF MONTH YEAR], have you had
difficulty chewing any foods because of problems with
your teeth, mouth, dentures, or jaw? Would you say:

Q3

Since [LAST HF MONTH YEAR], have you felt
uncomfortable about the appearance of your teeth,
mouth, dentures, or jaws? Would you say:
[IF NEEDED: “Uncomfortable” can include a wide
spectrum of emotions (embarrassment, anxiety, anger,
sadness, etc.).]

Q4

Since [LAST HF MONTH YEAR], have you had
difficulty doing your usual activities because of
problems with your teeth, mouth, dentures, or jaws?
Would you say:

[IF NEEDED: “Activities” may include going to a
job, doing housework such as light cleaning,
shopping, or running errands, preparing meals, etc.]

7

Code List
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

John, M. T., Miglioretti, D. L., LeResche, L., Koepsell, T. D., Hujoel, P., & Micheelis, W. (2006). German short forms of the
oral health impact profile. Community dentistry and oral epidemiology, 34(4), 277-288.

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Variable
Name
Q5

Question Text
Since [LAST HF MONTH YEAR], have you felt that
there has been less flavor in your food because of
problems with your teeth, mouth, dentures, or jaws?
Would you say:

Code List
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

Of the eight participants, two respondents reported oral pain, four respondents reported having
difficulty chewing, three respondents reported feeling uncomfortable with their oral appearance, two
respondents reported having difficulty doing their usual activities, and one respondent reported
feeling there had been less flavor in their food because of problems with their teeth, mouth, dentures,
or jaw. When probed on item Q2, one respondent indicated they “[did] not have any problems”
which was coded as “never” by the field interviewer.
Analysis and Recommendations
The items on oral health performed well as tested. They were easily understood, and every
participant was able to report on them.
One minor modification to the question text for items Q2-Q5 was identified to avoid field interviewer
confusion while coding responses. Items Q2-Q5 are written in a way that assumes the respondent has
problems with their teeth, mouth, dentures, or jaws. If the respondent reports they have no problems
or the question is not applicable to them, these responses can be confusing to code for inexperienced
field interviewers. NORC recommends updating the question text to include “if any” after
“problems” is read to avoid such confusion (shown in Exhibit 6).
Exhibit 6. Proposed Revisions to Oral Health Testing Items
Variable
Name
Q2
Q4

Q5

Question Text
Since [LAST HF MONTH YEAR], have you had difficulty chewing any foods because
of problems, if any, with your teeth, mouth, dentures, or jaw? Would you say:
Since [LAST HF MONTH YEAR], have you had difficulty doing your usual activities
because of problems, if any, with your teeth, mouth, dentures, or jaws? Would you say:

[IF NEEDED: “Activities” may include going to a job, doing housework such as
light cleaning, shopping, or running errands, preparing meals, etc.]
Since [LAST HF MONTH YEAR], have you felt that there has been less flavor in your
food because of problems, if any, with your teeth, mouth, dentures, or jaws? Would you
say:

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Discussion
This section summarizes recommendations for implementation.
 Comparing Medicare Coverage Options: Not Recommended for Implementation Due to
Lack of Comprehension. Items about comparing Medicare Coverage Options were
challenging for respondents to answer given the item wording, concepts of interest, format,
and use of technical terms. Any potential modifications to make these items viable in the
MCBS would require a more extensive review of the literature and in-depth analysis.
 Oral Health Items: Recommended for Implementation. The new oral health items (OHIP5) were easily understood and pose a relatively small increase to respondent burden. Based
on the results of this small testing effort, and the policy priority of oral health content, it is
recommended that this new set of items be implemented on the MCBS with minor wording
clarifications. The new oral health items will be included in a full clearance revision to the
main MCBS (0938-0568) for implementation in Fall 2024.
Exhibit 7.

Administration Schedule and Burden of Oral Health Items

Content Request
Oral Health Items

# of New
Items

Quex Section

Administration
Schedule

Anticipated
Burden

5

Health Status and
Functioning
Questionnaire (HFQ)

Annually, Fall
Round

1.9 minutes

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Appendix A: Cognitive Interview Screening Instrument (English)
PARTICIPANT NUMERIC IDENTIFIER: ___________________________
1. What is your sex? Are you male, female, or do you identify yourself another way?
 MALE
 FEMALE
 I IDENTIFY AS________
 I don’t know
 Refused
2. How old are you?
_______ years
3. Medicare is the federal health insurance program for people who are 65 or older, certain younger
people with disabilities, and people with End-Stage Renal Disease. Do you receive health insurance
through Medicare?
 YES
 NO  I am sorry, but only people who receive insurance through Medicare are eligible
for this study.
4. What is the highest degree or level of school you have completed?
 NO SCHOOLING COMPLETED
 NURSERY SCHOOL TO 8TH GRADE
 9TH-12TH GRADE, NO DIPLOMA
 HIGH SCHOOL GRADUATE (HIGH SCHOOL DIPLOMA OR THE EQUIVALENT)
 VOCATIONAL/TECHNICAL/BUSINESS/TRADE SCHOOL CERTIFICATE OR
DIPLOMA (BEYOND THE HIGH SCHOOL LEVEL)
 SOME COLLEGE, BUT NO DEGREE
 ASSOCIATE DEGREE
 BACHELOR'S DEGREE
 MASTER'S, PROFESSIONAL OR DOCTORATE DEGREE
5. Are you of Hispanic, Latino, or Spanish origin?
 YES
 NO
6. What is your race? [SELECT ONE OR MORE. READ RESPONSE OPTIONS IF NEEDED.]
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Something else:__________________

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IF CONDUCTING SCREENER DURING RECRUITMENT, CONTINUE TO NEXT QUESTION
TO SCHEDULE THE APPOINTMENT. OTHERWISE ADMINISTER QUESTIONNAIRE.

7. CONFIRM CONTACT INFORMATION AND SCHEDULE APPOINTMENT:
Ok, let’s schedule an appointment to do the interview.
[TAKE INFORMATION]

8. Can you confirm that [PHONE NUMBER] is the best number to contact you on [DATE] for
the interview?
[TAKE INFORMATION]

Thank you for volunteering to participate. We will speak with you on [REPEAT DATE AND TIME OF
APPOINTMENT].
With your permission, your interview session will be recorded to allow us to ensure we capture all of the
feedback you provide us. Only staff directly involved in the project will have access to the recording. If
you do not want to be recorded, we can do the interview without recording. Your answers will always be
kept private, and none of the information that you provide will be used for any purpose other than
research.

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Appendix B: Cognitive Interview Screening Instrument (Spanish)
PARTICIPANT NUMERIC IDENTIFIER: ___________________________
1. ¿Cuál es su sexo? ¿Es usted hombre, mujer o se identifica de otra manera?
 MALE
 FEMALE
 I IDENTIFY AS________
 I don’t know
 Refused
2. ¿Cuántos años tiene?
_______ años
3. Medicare es el programa federal de seguro de salud para personas de 65 años de edad o mayores,
ciertas personas más jóvenes con discapacidades y personas con enfermedad renal en etapa
terminal. Necesito confirmar, ¿usted recibe seguro de salud a través de Medicare?
 YES
 NOà Lo siento, pero sólo las personas que reciben seguro a través de Medicare son
elegibles para este estudio.
READ IF NECESSARY: ¿Tiene una tarjeta de Medicare? La Parte A de Medicare incluye la
cobertura de hospitalizaciones y la Parte B incluye la cobertura de los servicios del médico. La
Parte C, Planes Medicare Advantage, se ofrece a través de compañías de seguros privadas bajo
contrato con Medicare. Algunas personas optan por agregar la Parte D, que es la cobertura de
medicamentos recetados.
4. ¿Cuál es el grado o nivel más alto de la escuela que usted ha completado?
 NO SCHOOLING COMPLETED
 NURSERY SCHOOL TO 8TH GRADE
 9TH-12TH GRADE, NO DIPLOMA
 HIGH SCHOOL GRADUATE (HIGH SCHOOL DIPLOMA OR THE EQUIVALENT)
 VOCATIONAL/TECHNICAL/BUSINESS/TRADE SCHOOL CERTIFICATE OR
DIPLOMA (BEYOND THE HIGH SCHOOL LEVEL)
 SOME COLLEGE, BUT NO DEGREE
 ASSOCIATE DEGREE
 BACHELOR'S DEGREE
 MASTER'S, PROFESSIONAL OR DOCTORATE DEGREE
5. ¿Es de origen hispano, latino o español?
 YES
 NO

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6. ¿Cuál es su raza? [SELECT ALL THAT APPLY. READ RESPONSE OPTIONS IF NEEDED.]
 Indio/a americano/a o nativo/a de Alaska
 Asiático/a
 Negro/a o afroamericano/a
 Nativo/a Hawaiano/a u otra isla del Pacífico
 Blanco/a
 SOMETHING ELSE:__________________
IF CONDUCTING SCREENER DURING RECRUITMENT, CONTINUE TO NEXT QUESTION
TO SCHEDULE THE APPOINTMENT. OTHERWISE ADMINISTER QUESTIONNAIRE.
7. CONFIRM CONTACT INFORMATION AND SCHEDULE APPOINTMENT:
Ok, programemos una cita para hacer la entrevista.
[TAKE INFORMATION]
8. ¿Puede usted confirmar que [NÚMERO DE TELÉFONO] es el mejor número para contactarlo/a
en la [FECHA] para la entrevista?
[TAKE INFORMATION]
Gracias por ofrecerse como voluntario/a para participar. Hablaremos con usted el [REPETIR FECHA Y
HORA DE LA CITA].
Con su permiso, se grabará la sesión de su entrevista para permitirnos asegurarnos de capturar todos los
comentarios que usted nos proporcione. Sólo el personal directamente involucrado en el proyecto tendrá
acceso a la grabación. Si usted no quiere que le graben, podemos hacer la entrevista sin grabar. Sus
respuestas siempre se mantendrán en privado, y la información que usted proporcione no se utilizará para
ningún otro propósito que no sea la investigación.

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Appendix C: Cognitive Interview Instrument (English)
MATERIALS NEEDED FOR INTERVIEW





INTERVIEWER PROTOCOL BOOKLET (THIS BOOKLET)
INFORMED CONSENT
RECORDING DEVICE/VOICE RECORDING APP
PENS AND PENCILS; SOFTWARE FOR DIGITAL NOTETAKING

STEP 1: INFORMED CONSENT
INT1. The Medicare Current Beneficiary Survey (MCBS) asks Medicare beneficiaries about their health
status, sources of health care, satisfaction with care, and health care expenditures. In today’s interview I
will be asking you about how you review your Medicare options and your oral health.
Periodically during the interview, I will ask you some questions about how you decided to answer some
of the survey questions. Getting your feedback on the questions can help make the questions better.
[CONTINUE]
INT2. All survey information will be kept private to the extent permitted by law, as prescribed by the
Privacy Act of 1974. Medicare benefits will not be affected in any way by survey responses or
participation.
Do you agree to participate in this interview?
a. YES -> GO TO NEXT QUESTION
b. NO -> STOP INTERVIEW AND THANK THEM FOR THEIR TIME.
INT3. In order to have a complete record of your comments, with your permission, your interview session
will be audio taped. The recording will be stored electronically on NORC’s secure servers. We plan to use
the recording to ensure that we capture all of the feedback you provide us. Only staff directly involved in
this research project will have access to the recording. Any quotes used in presentations and publications
will not include any names or any information that could identify any participant.
Is it okay for me to proceed with the recording on?
a. YES -> TURN RECORDING ON
b. NO -> PROCEED WITHOUT RECORDING
STEP 2: COMPLETION OF THE QUESTIONNAIRE
The Medicare Current Beneficiary Survey (MCBS) asks Medicare beneficiaries about their health status,
sources of health care, satisfaction with care, and health care expenditures. In today’s interview I will be
asking you about how you review your Medicare options and your oral health.
After we have finished the survey, I would like to talk with you about some of the questions in the survey.
Getting your feedback on the questions can help make the questions better.

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[INTERVIEWER: EACH SERIES OF QUESTIONS IN THE PROTOCOL IS IMMEDIATELY
FOLLOWED BY A SET OF PROBES AND INTERVIEWER NOTES DESIGNED TO AID THE
DEBRIEFING PROCESS; WHILE SPECIFIC PROBES WILL VARY, THE EXAMPLES PROVIDED
IN THE PROTOCOL ARE MEANT TO BE A STARTING POINT FOR DIALOG WITH THE
RESPONDENT. INTERVIEWERS ARE INSTRUCTED TO ADMINISTER EACH SERIES AND
THEN ADMINISTER THE PROBES TO DEBRIEF WITH THE RESPONDENT. REMIND THE
RESPONDENT OF THE QUESTION AND HIS/HER RESPONSE IN ADVANCE OF USING
PROBES AS NEEDED.]

MEDICARE KNOWLEDGE ITEMS
[INTERVIEWER READ]: We’re interested in learning more about how people covered under
Medicare navigate their coverage options. We’re going to ask you a few questions about how
you review your Medicare coverage options.
Q1. (KNCOVOPT): How easy or difficult would you say it is for you to review and compare
your Medicare coverage options? Would you say it is …
(01) Very easy
(02) Somewhat easy
(03) Somewhat difficult
(04) Very difficult
(05) DOES NOT MAKE DECISIONS ON HEALTH INSURANCE
(-8) DON'T KNOW
(-9) REFUSED
Q2. (KNCOVREV): How often do you review or compare your Medicare coverage options?
Would that be at least once every year, once every few years, rarely, or never?
(01) AT LEAST ONCE EVERY YEAR
(02) ONCE EVERY FEW YEARS
(03) RARELY
(04) NEVER
(05) ONLY ONCE WHEN FIRST SIGNED UP FOR DRUG PLAN
(06) ONLY ONCE WHEN FIRST SIGNED UP FOR MEDICARE
(07) JUST SIGNED UP FOR MEDICARE
(-8) DON'T KNOW
(-9) REFUSED
If response is “Never” then skip to Q4 (KMEDACCT). Otherwise, continue to next
question.
Q3. (KNCOVMTH): How do you review or compare your Medicare coverage options? Select all
that apply:
(01) 1-800-MEDICARE
(02) medicare.gov
(03) “Medicare and You” Handbook
(04) State Health Insurance Assistance Program (SHIP)
(05) Family member
(06) Other _____________
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IF NEEDED: Medicare SHIP (State Health Insurance Assistance Program) is a free, one-on-one
counseling service to help answer your questions about Medicare coverage and plan options.
Q4. Before today, were you aware of the following ways to review or compare your Medicare coverage
options? Please indicate yes or no to each one:
Yes No

1-800-MEDICARE

☐

☐

medicare.gov

☐

☐

“Medicare and You” Handbook

☐

☐

State Health Insurance Assistance Program (SHIP)

☐

☐

[IF NEEDED: Medicare SHIP (State Health
Insurance Assistance Program) is a free, one-on-one
counseling service to help answer your questions
about Medicare coverage and plan options.]
SECTION TIME: -REQUIRED PROBES:
− Please tell me in your own words what you think these questions are asking.
− What did you think about when answering these questions?
− How did you decide on your answers?
ORAL HEALTH
[INTERVIEWER READ]: We are now going to ask you some questions about your oral health.
Q1. (ORALPAIN): Since August 2021, have you had painful aching in your mouth? Would you

say:
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

Q2. (CHEWPROB): Since August 2021, have you had difficulty chewing any foods because of

problems with your teeth, mouth, dentures, or jaw? Would you say:
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often

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(-8) DON'T KNOW
(-9) REFUSED

Q3. (ORALAPER): Since August 2021, have you felt uncomfortable about the appearance of your

teeth, mouth, dentures, or jaws? Would you say:
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

IF NEEDED: “Uncomfortable” can include a wide spectrum of emotions (embarrassment,
anxiety, anger, sadness, etc.).
Q4. (JOBTEETH): Since August 2021, have you had difficulty doing your usual activities because

of problems with your teeth, mouth, dentures, or jaws? Would you say:
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

IF NEEDED: “Activities” may include going to a job, doing housework such as light cleaning,
shopping, or running errands, preparing meals, etc.]
Q5. (LESSFLAV): Since August 2021, have you felt that there has been less flavor in your food

because of problems with your teeth, mouth, dentures, or jaws? Would you say:
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

SECTION TIME: -REQUIRED PROBES:
− Please tell me in your own words what you think these questions are asking.
− What did you think about when answering these questions?
o If R reported a problem, can ask: What type of problem were you thinking
about?

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o Additional probe as needed: What did you think about when I asked if you were
uncomfortable about the appearance of your teeth, mouth, dentures, or jaws?
− How did you decide on your answers?
Be sure to collect the Respondent’s address for their incentive in the next section, Step 3: THANK
YOU AND INCENTIVE on the next page.
STEP 3: THANK YOU AND INCENTIVE
[INTERVIEWER] Thank you for participating in the interview today. To thank you for your time,

we’d like to send you a check for $40. Could you please provide me with an address to mail the
check to?
NAME: __________________________________
STREET: _________________________________________________________________
CITY: ___________________________________________________________________
STATE: __________________________ ZIP: _________________________________

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Appendix D: Cognitive Interview Instrument (Spanish)
MATERIALS NEEDED FOR INTERVIEW





INTERVIEWER PROTOCOL BOOKLET (THIS BOOKLET)
INFORMED CONSENT
RECORDING DEVICE/VOICE RECORDING APP
PENS AND PENCILS; SOFTWARE FOR DIGITAL NOTETAKING

STEP 1: INFORMED CONSENT
INT1. La Encuesta de Beneficiarios Actuales de Medicare (MCBS) pregunta a los beneficiarios
de Medicare sobre su estado de salud, fuentes de cuidado de salud, satisfacción con el cuidado y
gastos de cuidado de salud. En la entrevista de hoy, le preguntaré cómo usted revisa sus opciones
de Medicare y su salud bucal.
Periódicamente durante la entrevista, le haré a usted algunas preguntas sobre cómo decidió
responder algunas de las preguntas de la encuesta. Obtener sus comentarios sobre estas preguntas
puede ayudar a mejorarlas.
[CONTINUE]
INT2. Toda la información de la encuesta se mantendrá privada en la medida permitida por la
ley, según lo prescrito por la Ley de Privacidad de 1974. Los beneficios de Medicare no se verán
afectados de ninguna manera por las respuestas o la participación en la encuesta.
¿Está usted de acuerdo con participar en esta entrevista?
a. SÍ -> VAYA A LA SIGUIENTE PREGUNTA
b. NO -> PARE LA ENTREVISTA Y AGRADÉCELES SU TIEMPO.
INT3. Para tener un registro completo de sus comentarios, con su permiso su sesión de entrevista
será grabada en audio. La grabación se almacenará electrónicamente en los servidores seguros de
NORC. Planeamos usar la grabación para asegurarnos de capturar todos los comentarios que
usted nos brinde. Sólo el personal directamente involucrado en este proyecto de investigación
tendrá acceso a la grabación. Las citas utilizadas en presentaciones y publicaciones no incluirán
ningún nombre ni información con la que se pueda identificar a algún participante.
¿Está bien que yo continúe con la grabación activada?
a. SÍ -> ACTIVE LA GRABACIÓN
b. NO -> CONTINÚE SIN GRABAR
STEP 2: COMPLETION OF THE QUESTIONNAIRE
La Encuesta de Beneficiarios Actuales de Medicare (MCBS) pregunta a los beneficiarios de
Medicare sobre su estado de salud, fuentes de cuidado de salud, satisfacción con el cuidado y

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gastos de cuidado de salud. En la entrevista de hoy, le preguntaré cómo usted revisa sus opciones
de Medicare y su salud bucal.
Después de que hayamos terminado la encuesta, me gustaría hablar con usted sobre algunas de
las preguntas de la encuesta. Obtener sus comentarios sobre las preguntas puede ayudar a
mejorarlas.
[INTERVIEWER: EACH SERIES OF QUESTIONS IN THE PROTOCOL IS IMMEDIATELY
FOLLOWED BY A SET OF PROBES AND INTERVIEWER NOTES DESIGNED TO AID
THE DEBRIEFING PROCESS; WHILE SPECIFIC PROBES WILL VARY, THE EXAMPLES
PROVIDED IN THE PROTOCOL ARE MEANT TO BE A STARTING POINT FOR DIALOG
WITH THE RESPONDENT. INTERVIEWERS ARE INSTRUCTED TO ADMINISTER
EACH SERIES AND THEN ADMINISTER THE PROBES TO DEBRIEF WITH THE
RESPONDENT. REMIND THE RESPONDENT OF THE QUESTION AND HIS/HER
RESPONSE IN ADVANCE OF USING PROBES AS NEEDED.]
MEDICARE KNOWLEDGE ITEMS
[INTERVIEWER READ]: Estamos interesados en obtener más información sobre cómo las
personas cubiertas por Medicare navegan con sus opciones de cobertura. Le haremos algunas
preguntas a usted sobre cómo revisa sus opciones de cobertura de Medicare.
Q1. (KNCOVOPT): Qué tan fácil o difícil usted diría que es para revisar y comparar sus
opciónes de cobertura de Medicare? ¿Diría usted que es...
(01) Muy fácil
(02) Algo fácil
(03) Algo difícil
(04) Muy difícil
(05) DOES NOT MAKE DECISIONS ON HEALTH INSURANCE
(-8) NO SABE
(-9) REHUSA
Q2. (KNCOVREV): Con qué frequencia revisa o compara sus opciónes de cobertura de
Medicare? ¿Diría usted que seria al menos una vez al año, una vez cada pocos años, rara vez, o
nunca?
(01) AT LEAST ONCE EVERY YEAR
(02) ONCE EVERY FEW YEARS
(03) RARELY
(04) NEVER
(05) ONLY ONCE WHEN FIRST SIGNED UP FOR DRUG PLAN
(06) ONLY ONCE WHEN FIRST SIGNED UP FOR MEDICARE
(07) JUST SIGNED UP FOR MEDICARE
(-8) NO SABE
(-9) REHUSA
If response is “Never” then skip to Q4 (KMEDACCT). Otherwise, continue to next
question.

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Q3. (KNCOVMTH): ¿Cómo revisa o compara usted sus opciones de cobertura de Medicare?
Seleccione todas las que correspondan:
(01) 1-800-MEDICARE
(02) medicare.gov
(03) “Medicare y Usted” Manual
(04) Programa estatal de asistencia sobre seguro médico (SHIP)
(05) Miembro de la familia
(06) Otro _____________
IF NEEDED: Medicare SHIP (Programa estatal de asistencia sobre seguro médico) es un
servicio de asesoramiento personalizado gratuito para ayudar a responder sus preguntas sobre la
cobertura de Medicare y las opciones de planes.
Q4. Antes de hoy, ¿conocía usted las siguientes formas de revisar o comparar sus opciones de
cobertura de Medicare? Por favor indique sí o no a cada una:
Si No
1-800-MEDICARE
☐ ☐
medicare.gov

☐

☐

“Medicare y Usted” Manual

☐

☐

Programa estatal de asistencia sobre seguro médico
(SHIP)

☐

☐

[IF NEEDED: El programa estatal de asistencia
sobre seguro médico (SHIP) es un servicio de
asesoramiento personalizado gratuito para ayudar a
responder sus preguntas sobre la cobertura de
Medicare y las opciones de planes.
Q5. (KMEDACCT): Antes de hoy, ¿sabía usted que puede crear una cuenta en medicare.gov
para administrar sus beneficios de Medicare?
(01) SI
(02) NO
(-8) NO SABE
(-9) REHUSA
SECTION TIME: -REQUIRED PROBES:
− Por favor, dígame con sus propias palabras qué cree usted que significan estas preguntas.
− ¿En qué pensó usted al responder estas preguntas?
− ¿Cómo decidió usted sus respuestas?
ORAL HEALTH

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[INTERVIEWER READ]: Ahora vamos a hacerle a usted algunas preguntas sobre su salud
bucal.
Q1. (ORALPAIN): Desde Agosto de 2021, ha tendio molestias dolorosas en su boca? Diría:
(01) Nunca
(02) Prácticamente nunca
(03) Ocasionalmente
(04) Con bastante frecuencia
(05) Muy a menudo
(-8) NO SABE
(-9) REHUSA
Q2. (CHEWPROB): Desde Agosto de 2021, ha tenido dificultades mordiendo algun alimento
por problemas con sus dientes, boca, dentaduras postizas o mandíbula? Diría:
(01) Nunca
(02) Prácticamente nunca
(03) Ocasionalmente
(04) Con bastante frecuencia
(05) Muy a menudo
(-8) NO SABE
(-9) REHUSA
Q3. (ORALAPER): Desde Agosto de 2021, ha sentido incómodo/a sobre la apariencia de sus
dientes, boca, dentaduras postizas o mandíbula? Diría:
(01) Nunca
(02) Prácticamente nunca
(03) Ocasionalmente
(04) Con bastante frecuencia
(05) Muy a menudo
(-8) NO SABE
(-9) REHUSA
IF NEEDED: ¨Incómodo/a” puede incluir un amplio espectro de emociones (vergüenza,
ansiedad, ira, tristeza, etc.).
Q4. (JOBTEETH): Desde Agosto de 2021, ha tenido dificultades haciendo sus actividades

habituales por problemas con sus dientes, boca, dentaduras postizas o mandíbula? Diría:
(01) Nunca
(02) Prácticamente nunca
(03) Ocasionalmente
(04) Con bastante frecuencia
(05) Muy a menudo
(-8) NO SABE
(-9) REHUSA

IF NEEDED: “Las “actividades” pueden incluir ir a un trabajo, hacer tareas domésticas como
limpieza ligera, ir de compras o hacer mandados, preparar comidas, etc.]
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Q5. (LESSFLAV): Desde Agosto de 2021, has sentido que hay menos sabor en sus alimentos
por problemas con sus dientes, dentaduras postizas o mandíbula? Diría:
(01) Nunca
(02) Prácticamente nunca
(03) Ocasionalmente
(04) Con bastante frecuencia
(05) Muy a menudo
(-8) NO SABE
(-9) REHUSA
SECTION TIME: -REQUIRED PROBES:
− Por favor, dígame en sus propias palabras qué cree usted que significan estas preguntas.
− ¿En qué pensó usted al responder estas preguntas?
o If R reported a problem, can ask: ¿En qué tipo de problema estaba usted
pensando?
o Additional probe as needed: ¿En qué pensó usted cuando le pregunté si se sentía
incómodo/a con la apariencia de sus dientes, boca, dentaduras postizas o
mandíbulas?
− ¿Cómo decidió usted sus respuestas?
Be sure to collect the Respondent’s address for their incentive in the next section, Step 3:
THANK YOU AND INCENTIVE on the next page.
STEP 3: THANK YOU AND INCENTIVE
[INTERVIEWER] Gracias por participar en la entrevista de hoy. Para agradecerle su tiempo, nos
gustaría enviarle un cheque por $40. ¿Por favor podría usted proporcionarme una dirección para
enviarle el cheque por correo?
NAME: __________________________________
STREET: _________________________________________________________________
CITY: ___________________________________________________________________
STATE: __________________________ ZIP: _________________________________

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