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OMB Control Number: 0938-1300
Healthy Indiana Plan 2.0 Beneficiary Survey:
Enrollees
SURVEY INSTRUCTIONS
•
•
Answer each question by filling in the circle to the left of your answer, like this: Yes
You are sometimes told to skip over some questions in this survey. When this happens you will see an
arrow with a note that tells you what question to answer next, like this:
Yes GO TO QUESTION 1
No
The Centers for Medicare & Medicaid Services is conducting this survey to ask about your recent experiences receiving
health care and should take about 15 minutes to complete. Your participation is voluntary, and there is no loss of
benefits or penalty of any kind for deciding not to participate. You may skip any questions that you do not feel comfortable
answering. Your participation in this research is private, and we will not share your name or any other identifying
information with any outside organization. You may notice a number on the cover of the survey. This number is ONLY used
to let us know if you returned the survey. Please contact Thoroughbred Research Group toll-free at 844-859-7862 with
questions about this research.
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 0938-1300. The time required to complete
this information collection is estimated to average 15 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.
About Your HIP 2.0 Enrollment
The State of Indiana currently runs an insurance program called the Healthy Indiana Plan (also called
HIP 2.0) for Hoosiers ages 19 to 64.
1. Are you currently enrolled in the “Healthy Indiana Plan 2.0” (also called “HIP 2.0”)?
Yes
No GO TO END
Not sure/Don’t know GO TO END
2. With which HIP 2.0 health plan are you enrolled?
Anthem
MDwise
MHS – Managed Health Services
Not sure/Don’t know
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Healthy Indiana Plan (HIP) 2.0
3. HIP 2.0 offers different benefits packages. Are you aware that HIP 2.0 offers:
Please mark one answer in each row.
Yes
No
Not sure
a. HIP Plus
b. HIP Basic
4. For the next question, please think about your HIP 2.0 benefits package. For each of the following
items, please mark whether they are part of your HIP 2.0 benefits package. Copays are payments
you make at the time you visit your doctor’s office, go to the hospital or get prescription drugs.
Please mark one answer in each row.
My HIP 2.0 benefits package includes…
Yes
No
Not sure
a. Vision and dental care
b. A way I can get prescriptions in the mail
c. Copays for doctor care
d. Copays for prescription drugs
e. Copays for hospital stays
f. Contribution(s)
5. Thinking about HIP Plus and HIP Basic, how well do you think you understand the differences
between the two benefits packages?
Very well
Somewhat
Not at all well
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Transportation
The next set of questions is about your transportation going to and from health care visits.
Please think about your health care visits in the last 6 months. Do not include visits to the emergency
room (ER).
6. Does your HIP 2.0 benefits package provide transportation or cover the costs of transportation
to and from health care visits (not including an ambulance)?
Yes
No GO TO QUESTION 8
Not sure/Don't know GO TO QUESTION 8
7. In the last 6 months, have you used transportation paid for by your HIP 2.0 benefits package to
get to or from a health care visit?
Yes
No
8. In the last 6 months, did you have transportation to get to and from the doctor’s office to get any
health care services you needed?
Yes
No
I did not have a health care visit in the last 6 months
9. In the last 6 months, how much have you worried about your ability to pay for the cost of
transportation or your ability to get transportation to a health care visit?
Not at all
A little
Somewhat
A great deal
10. In the last 6 months, was there any time when you needed health care but did not get it because
you could not pay for transportation or could not get transportation?
Yes
No GO TO QUESTION 12
Not sure/Don't know GO TO QUESTION 12
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11. What types of health care were you unable to get because you could not pay for transportation
or could not get transportation?
Could not pay for
transportation
Could not get
transportation
No trouble with
transportation for
this type of care
N/A
d. Dental care
e. Vision (eye) care
f. Prescription drugs
g. Emergency room care for a nonemergency condition
Please mark one answer in each row.
a. A visit to the doctor when you were sick
b. Preventive care (such as blood
pressure check, flu shot, family
planning services, prenatal services,
cholesterol or cancer screenings.)
c. A follow up visit to get tests or care
recommended by your doctor
12. In the last 6 months, was there any time you needed health care but did not get it because of
costs other than transportation?
Yes
No GO TO QUESTION 14
13. In the last 6 months, what types of health care were you unable to get because of costs other
than transportation?
Please mark one answer in each row.
Yes
No
N/A
a. A visit to the doctor when you were sick
b. Preventive care (such as blood pressure check, flu shot, family
planning services, prenatal services, cholesterol or cancer
screenings.)
c. A follow up visit to get tests or care recommended by your doctor
d. Dental care
e. Vision (eye) care
f. Prescription drugs
g. Emergency room care
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Emergency Room
The next set of questions is about emergency room (ER) care and treatment.
Some people use emergency rooms for both emergency and non-emergency care. An emergency is defined
as any condition that could endanger your life or cause permanent disability if not treated immediately.
14. How easy or hard is it for you to know when your health condition is an emergency?
Very easy
Somewhat easy
Somewhat hard
Very hard
15. What does HIP 2.0 say you should do if you think you may need to go to the emergency room,
but are not sure? Mark one or more.
Go directly to the emergency room
Call the phone number or hotline provided by HIP 2.0
Call my doctor
Ask my family or friends
Please think about how HIP 2.0 would work for you if you went to the emergency room for care.
16. If you go to the emergency room when your condition is an emergency and you did not call the
24-hour nurse helpline, do you have to pay a copay?
Yes
No
Not sure/Don’t know
17. If you go to the emergency room when your condition is not an emergency and you did not call
the 24-hour nurse helpline, do you have to pay a copay?
Yes
No
Not sure/Don’t know
18. If you go to the emergency room more than once a year when your condition is not an
emergency and you did not call the 24-hour nurse helpline, your copay would be…
Higher than $8
$8
Lower than $8
Not sure/Don’t know
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19. In the last 6 months, was there a time you thought about going to the emergency room when you
needed care?
Yes
No GO TO QUESTION 26
20. In the last 6 months, when you needed care, did you go to the emergency room?
Yes
No GO TO QUESTION 25
21. The last time you went to the emergency room, were you asked to pay a copay for the care you
received in the emergency room?
Yes
No GO TO QUESTION 26
Not sure/Don’t know GO TO QUESTION 26
22. Were you told the reason for the copay was because your condition was not an emergency?
Yes
No
Not sure/Don’t know
23. Were you told about another available provider where you could get the care you needed
without the emergency room copay?
Yes
No
Not sure/Don’t know
24. The last time you went to the emergency room, how was that copay paid, if at all?
I paid GO TO QUESTION 26
Someone paid for it for me GO TO QUESTION 26
The copay has not been paid GO TO QUESTION 26
Not sure/Don’t know GO TO QUESTION 26
25. What was the main reason you did not go to the emergency room for care?
Did not have a way to get there or could not afford to get there
Went to my doctor’s office or clinic instead
Did not want to pay the copay
Waited to see if I would get better on my own
Some other reason
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POWER Accounts and Contributions
The following questions are about your understanding and experience with HIP contributions and
POWER accounts.
26. Do you have a POWER account? POWER accounts are health savings accounts called Personal
Wellness and Responsibility Accounts.
Yes
No GO TO QUESTION 28
Not sure/Don’t know GO TO QUESTION 28
27. Do you know how much is in your POWER account today?
Yes, I know exactly how much
Yes, I have a pretty good idea
No, I do not really know at all
28. Do you currently contribute?
I currently contribute
Someone else contributes for me
I do not contribute GO TO QUESTION 32
Not sure/Don’t know GO TO QUESTION 33
29. How is that contribution paid, if at all?
I pay it
Someone pays the full amount for me
I pay part and someone else pays part
The contribution has not been paid
Not sure/Don’t know
30. Would you say the amount you contribute is:
More than I can afford
An amount that I can afford
Less than I can afford
Not sure/Don’t know
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31. In the last 6 months, how worried were you about not having enough money to pay
your contribution(s)?
Not at all worried GO TO QUESTION 35
A little worried GO TO QUESTION 35
Somewhat worried GO TO QUESTION 35
Very worried GO TO QUESTION 35
Extremely worried GO TO QUESTION 35
Not sure/Don't know GO TO QUESTION 35
32. Why do you not contribute?
Please mark one answer in each row.
Yes
No
Not sure
a. I do not have to contribute
b. I cannot afford to make the contributions
c. I do not understand how to contribute/too confusing to understand
d. I do not think contributing helps me
33. Copays are payments you make at the time you visit your doctor’s office, go to the hospital, or
get prescription drugs. Would you say the amount you are required to pay for copays is:
More than I can afford
An amount that I can afford
Less than I can afford
Not sure/Don’t know
34. In the last 6 months, how worried were you about not having enough money to pay your copays?
Not at all worried
A little worried
Somewhat worried
Very worried
Extremely worried
35. What do you think will happen, if anything, if a person’s contribution(s) is not made on time?
Nothing will change GO TO QUESTION 37
Their HIP 2.0 coverage will end
They would automatically get moved to HIP Basic GO TO QUESTION 37
Not sure/Don’t know GO TO QUESTION 37
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36. How long did you think a person would need to wait to re-enroll in HIP 2.0?
No wait time
3 months
6 months
12 months
Not sure/Don’t know
37. How easy or hard is it to understand how a POWER account works?
Very easy
Somewhat easy
Neither easy nor hard
Somewhat hard
Very hard
38. For each of the following statements about POWER accounts, please tell us whether you agree,
disagree, or are not sure.
Please mark one answer in each row.
Agree
Disagree
Not sure
a. The State of Indiana contributes to POWER accounts
b. HIP 2.0 monthly contribution(s) go to POWER accounts
c. POWER accounts help people pay for the health care services
they need
d. POWER accounts help people understand the cost of their health
care services
e. POWER accounts make people feel comfortable about paying for
their health care services
39. How easy or hard is it to understand what happens to any leftover money in a POWER account at
the end of year?
Very easy
Somewhat easy
Neither easy nor hard
Somewhat hard
Very hard
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Preventive services are routine health care services that include getting a flu shot, annual checkups,
blood pressure checks, family planning services, prenatal services, cholesterol screenings, or cancer
screenings to prevent illness, disease, and other health-related problems. The following questions ask
about preventive services and POWER accounts.
40. Is the cost of preventive services paid from the POWER account?
Yes
No
Not sure/Don’t know
41. If someone gets all or some of their recommended preventive services, will some of the
remaining money in a POWER account get rolled over into next year?
Yes
No
Not sure/Don’t know
42. Please tell us whether you agree, disagree or are not sure about the following statement:
POWER accounts make it more likely for someone to try and get all or some of their
recommended preventive services.
Agree
Disagree
Not sure/Don’t know
Access
For the following questions please think about your health care experience in the last 6 months.
43. In the last 6 months, did you go to a doctor, nurse, or any other health professional or get
prescription drugs?
Yes
No GO TO QUESTION 47
Not sure/Don’t know GO TO QUESTION 47
44. Were you asked to pay a copay at your most recent visit? Copays are payments you make at
the time you visit your doctor’s office, go to the hospital, or get prescription drugs.
Yes
No GO TO QUESTION 46
No, I was asked to pay the whole bill GO TO QUESTION 46
Not sure/Don’t know GO TO QUESTION 46
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45. How was that copay paid, if at all?
I paid it
Someone paid it for me
The copay has not been paid
Not sure/Don’t know
46. In the last 6 months, were any of your health care visits for a routine checkup? A routine
checkup is a general physical exam, not an exam for a specific injury, illness, or condition.
Yes
No
Not sure/Don’t know
Satisfaction with HIP
47. Thinking about your overall experience with HIP 2.0, would you say you are:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied GO TO QUESTION 49
Somewhat Dissatisfied
Very Dissatisfied
Not sure/Don’t know GO TO QUESTION 49
48. Please tell us how satisfied or dissatisfied you are with each HIP 2.0 item below.
Please mark one answer in each row.
Very
Satisifed
Somewhat
Satisfied
Neutral
Somewhat
Dissatisfied
Very
Dissatisfied
a. Length of time for coverage to begin
b. Ability to see my doctors with HIP 2.0
c. Choice of doctors in HIP 2.0
d. Coverage of health care services that I
need
e. Understanding how POWER accounts work
f. Cost of contribution(s)
g. HIP 2.0 enrollment process
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Health Coverage Cost and Payment Options
We are studying ways to meet people’s health care needs, and would like your thoughts about what
things you would like in your benefits package.
People pay for their health care services in different ways. Some people pay monthly contributions,
some people pay copays, and some people pay both. Copays are payments you make at the time you
visit your doctor’s office, go to the hospital, or get prescription drugs.
49. If you could choose how to pay for your health care services, what would you choose?
I would choose to pay copays at my health care visits
I would choose to make monthly contributions
It does not matter to me
50. How important are each of the following factors when thinking about enrolling in a benefits package?
Very
important
Somewhat
important
Not at all
important
a. The cost of monthly contributions
b. The cost of copays or doctor visits
c. The cost of copays for non-emergency visits to
the emergency room
d. The cost of copays for prescription drugs
Please mark one answer in each row.
e. The length of time with no coverage if I miss a
monthly contribution
f. If I lose coverage, being able to pay a missed
contribution to get my coverage back
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Demographics/About You
51. Would you say that in general your health is:
Excellent
Very good
Good
Fair
Poor
52. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
53. What best describes your employment status?
Employed full-time
Employed part-time
Self-employed
A homemaker
A full-time student
Unable to work for health reasons
Unemployed
54. What is your age?
18 to 24
55 to 64
25 to 34
65 to 74
35 to 44
75 or older
45 to 54
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55. Are you male or female?
Male
Female
56. Are you of Hispanic, Latino/a, or Spanish origin? One or more categories may be selected.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
57. What is your race? Mark one or more.
White
Vietnamese
Black or African-American
Other Asian
American Indian or Alaska Native
Native Hawaiian
Asian Indian
Guamanian or Chamorro
Chinese
Samoan
Filipino
Other Pacific Islander
Japanese
Some other race
Korean
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58. Please circle the number of people in your family (including yourself) that live in your household.
Mark only one answer that best describes your family’s total income over the last year before
taxes and other deductions. Your best estimate is fine.
Family size
(including yourself)
One person
Two people
Three people
Four people
Five people
Six people
Seven people
Eight people
Nine people
Ten or more
people
Family Income Per Year
At or below $6,000
At or above $12,000 and less than $16,000
Above $6,000 and less than $12,000
At or above $16,000
At or below $8,000
At or above $16,000 and less than $22,000
Above $8,000 and less than $16,000
At or above $22,000
At or below $10,000
At or above $20,000 and less than $28,000
Above $10,000 and less than $20,000
At or above $28,000
At or below $12,000
At or above $24,000 and less than $33,000
Above $12,000 and less than $24,000
At or above $33,000
At or below $14,000
At or above $28,000 and less than $39,000
Above $14,000 and less than $28,000
At or above $39,000
At or below $16,000
At or above $33,000 and less than $45,000
Above $16,000 and less than $33,000
At or above $45,000
At or below $18,000
At or above $37,000 and less than $51,000
Above $18,000 and less than $37,000
At or above $51,000
At or below $20,000
At or above $41,000 and less than $56,000
Above $20,000 and less than $41,000
At or above $56,000
At or below $23,000
At or above $45,000 and less than $62,000
Above $23,000 and less than $45,000
At or above $62,000
At or below $25,000
At or above $49,000 and less than $68,000
Above $25,000 and less than $49,000
At or above $68,000
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59. Did someone help you complete this survey?
Yes
No THANK YOU. Please return the completed survey in the postage-paid envelope.
60. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
THANK YOU
Please return the completed survey in the postage-paid envelope.
Thoroughbred Research Group, Inc.
PO Box 80490
Conyers, GA 30013-9903
0268
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| File Type | application/pdf |
| File Modified | 2016-07-20 |
| File Created | 2016-07-20 |