Baseline Survey Materials

APPENDIX D

UNDERSTANDING OF BENEFITS FORMS

Accelerated Benefits Demonstration (AB Basic)

Understanding of Benefits

I am taking part in a study called the Accelerated Benefits Demonstration. MDRC and Mathematica Policy Research are conducting this study for the Social Security Administration.

As part of that study, I will receive a special health benefit. This health benefit will be paid by the Social Security Administration (SSA). POMCO, a company that manages health benefits for many companies, is providing this health benefit for SSA. I spoke with a representative from POMCO who explained the health benefit to me.

As a member of the group that will receive the health benefit, I understand:

What the health benefit covers:

• The health benefit pays for health care costs up to $100,000.

• The health benefit covers most of my medical expenses. I am responsible for the rest.

• I do not have to use the health benefit.

• The health benefit does not affect my Social Security benefits. It will not affect any other benefits that I receive

How long the health benefit will be available:

• The health benefit is available to me until I am eligible for Medicare coverage. I will receive Medicare coverage if I continue receiving Social Security disability benefits.

• Sometimes studies end early. If this happens, I will no longer receive the special health benefit. While unlikely, it might mean that I would be asked to pay for a treatment after it has begun. If it looks like the money for this benefit is going to run out, POMCO will let me know at least three months in advance. I can call POMCO at any time if I am concerned about this. POMCO’s telephone number is [TOLL FREE NUMBER].

• I can decide that I don’t want to take part in the study at any time. If I decide that I no longer want to take part, I will no longer receive the special health benefit.

My signature on the next page means that I understand the health benefits that I will receive through the Accelerated Benefits Demonstration Project. I have a copy of this form.

SIGNATURE PAGE

MPRID:		PARTICIPANT
Please check () one of the following boxes and sign the form:
 YES, The special health benefits being provided through the Accelerated Benefits (AB) Demonstration have been explained to me. I understand the AB benefits.
Sign your name here: Print your name here:

Please place this form in the enclosed pre-paid envelope and mail it to:

Accelerated Benefits Demonstration Project

Mathematica Policy Research, Inc.

P.O. Box ****

Princeton, NJ 08543

ATTN: [NAME]

Accelerated Benefits Demonstration (AB Plus)

Understanding of Benefits

I am taking part in a study called the Accelerated Benefits Demonstration. MDRC and Mathematica Policy Research are research companies that are conducting this study for the Social Security Administration.

As part of that study, I will receive a special health benefit. This health benefit will be paid by the Social Security Administration (SSA). POMCO, a company that manages health benefits for many companies, is providing this health benefit for SSA. I spoke with a representative from POMCO who explained the health benefit to me.

As a member of the group that will receive the health benefit, I understand:

What the health benefit covers:

• The health benefit pays for health care costs up to $100,000.

• The health benefit covers most of my medical expenses. I am responsible for the rest.

• I will talk with a counselor from an organization called Care Guide. My counselor will help me get the best health services and will give me advice about how to meet my health care needs and increase my level of activity if I choose to do so.

• I do not have to use the health benefit or accept the advice of my Care Guide counselor.

• The health benefit does not affect my Social Security benefits. It will not affect any other benefits that I receive.

How long the health benefit will be available:

• The health benefit is available to me until I am eligible for Medicare coverage. I will receive Medicare coverage if I continue receiving Social Security disability benefits.

• Sometimes studies end early. If this happens, I will no longer receive the special health benefit. While unlikely, it might mean that I would be asked to pay for a treatment after it has begun. If it looks like the money for this benefit is going to run out, POMCO will let me know at least three months in advance. I can call POMCO at any time if I am concerned about this. POMCO’s telephone number is [TOLL FREE NUMBER].

• I can decide that I don’t want to take part in the study at any time. If I decide that I no longer want to take part, I will no longer receive the special health benefit.

My signature on the next page means that I understand the health benefits that I will receive through the Accelerated Benefits Demonstration Project. I have a copy of this form.

SIGNATURE PAGE

MPRID:		PARTICIPANT
Please check () one of the following boxes and sign the form:
 YES, The special health benefits being provided through the Accelerated Benefits (AB) Demonstration have been explained to me. I understand the AB benefits.
Sign your name here: Print your name here:

Please place this form in the enclosed pre-paid envelope and mail it to:

Accelerated Benefits Demonstration Project

Mathematica Policy Research, Inc.

P.O. Box ****

Princeton, NJ 08543

ATTN: [NAME]