Form CMS-10318 CHIP Survey

Survey to Inform the Children's Health Insurance Program (CHIP) National Outreach & Education Campaign

CMS-10318. CHIP Survey FINAL-508COMPL

Screening

OMB: 0938-1112

Document [pdf]

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CMS Children’s Health Insurance Program (CHIP/MEDICAID) Survey
Note: With branching/skip patterns, the questionnaire will average 30 minutes for every respondent. No
respondent will receive all questions in the survey due to skips.
Introduction
The purpose of this survey is to learn about parents’ experiences with health insurance for their
children. All of your answers will be private and confidential. Your decision whether or not to participate
will not affect your insurance coverage, health care, or eligibility for health care services. The purpose is
simply to hear about your experiences and opinions on this issue.
1. Are you the parent or guardian of a child under age 19 living in your household?
Yes.
No (TERMINATE).
2. How many children do you have living in your household under age 19?
___.
3. When it comes to making decisions about a health insurance plan for your child[ren], do
you usually make those decisions on your own, or does someone else help you?
I usually make decisions on my own.
Someone else helps.
I’m not sure.
4. IF SOMEONE ELSE: Who usually helps you make these decisions?
Spouse/partner.
Other family member.
Friend.
School nurse.
Social worker.
Doctor/nurse/pharmacist.
Other (specify). ___________.
I’m not sure.

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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

Insurance Status of Child (If only one child)
If only one child:
5. We’d like to ask a few questions about the health insurance status of your child. To make
it easier to ask questions, could you please type your child’s name or initials below? This is
only to make it easier to ask questions.
NAME.
6. Is NAME a:
Boy.
Girl.
7. How old is NAME?
____.
8. Are you NAME’s:
Mother.
Father.
Grandparent.
Legal Guardian.
Other (SPECIFY: ______).
9. Does NAME happen to have health insurance coverage right now?
Yes.
No.
10. IF INSURED: Does NAME have health insurance through:
A plan from your work or your spouse’s work.
Medicaid or STATE NAME.
STATE NAME OF CHIP .
COBRA.
A plan you bought directly from an insurance company, not through a job.
Military health care, such as TRICARE.
Other (Specify: _____).
Not sure.

11. ALL EXCEPT MEDICAID/CHIP: Since NAME was born, has [he/she] ever received health
insurance through Medicaid or STATE NAME or CHIP NAME? MULTIPLE RESPONSE.
Yes – Medicaid or STATE NAME.
Yes – CHIP NAME.
No – neither.

12. YES TO Q11: Why is NAME no longer enrolled in Medicaid or STATE NAME or CHIP NAME?
My financial situation changed and we no longer qualified.
We were dropped from the program but I’m not sure why.
We were no longer eligible (Why? _____).
We moved.
Work situations changed so NAME could get coverage through work.
Other (SPECIFY: ______).
13. IF NOT MEDICAID/CHIP AND NO TO Q11: Have you ever tried to enroll any of your
children in Medicaid or STATE NAME or CHIP NAME? (MULTIPLE RESPONSE.)
Yes – Medicaid or STATE NAME.
Yes – CHIP NAME.
No – neither.
14. IF INSURED: Was there ever a time in the past 12 months that NAME had to go without
health insurance, even if it was just for a short time?
Yes.
No.

Insurance Status of All Children (If more than one child)
If more than one child:
15. We’d like to ask a few questions about the insurance status of your children. To make it
easier to ask questions, could you please insert each of your children’s names or initials
below? This is only to make it easier to ask questions for each child.
NAMES.
16. How old is ____?
INSERT NAME 1
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

INSERT NAME 2
INSERT NAME 3
INSERT NAME 4
“
“
“
“

17. Are you NAME’s:
Mother.
Father.
Grandparent.
Legal Guardian.
Other (SPECIFY: ______).
18. Does each of your children happen to have health insurance coverage right now?

Child

Yes – has health
insurance coverage right
now

No – does not have
health insurance
coverage right now

INSERT NAME 1
INSERT NAME 2
INSERT NAME 3
INSERT NAME 4
“
“
“
“

19. IF INSURED: Does NAME 1 receive health insurance through: (REPEAT FOR ALL NAMES.)
A plan from your work or your spouse’s job.
Medicaid or STATE NAME.
STATE NAME OF CHIP.
COBRA.
A plan you bought directly from an insurance company, not through a job.
Military health care, such as TRICARE.
Other (Specify: _____).
Not sure.
20. ALL EXCEPT MEDICAID/CHIP: Have any of your children ever received health insurance
through Medicaid or STATE NAME or CHIP NAME? (MULTIPLE RESPONSE.)
Yes – Medicaid or STATE NAME.
Yes – CHIP NAME.
No – neither.

21. IF YES TO Q20: Why are your children no longer enrolled in Medicaid or STATE NAME or
CHIP NAME?
My financial situation changed and we no longer qualified.
We were dropped from the program but I’m not sure why.
We were no longer eligible. (Why? _____.)
My child is too old to qualify.
Work situations changed so they could get coverage through work.
Other (SPECIFY: ______).
22. IF NO TO Q20: Have you ever tried to enroll any of your children in Medicaid or STATE
NAME or CHIP NAME? (MULTIPLE RESPONSE.)
Yes – Medicaid or STATE NAME.
Yes – CHIP NAME.
No – neither.
23. FOR CHILDREN WHO HAVE HEALTH INSURANCE COVERAGE: Was there ever a time in the
past 12 months that any of your children had to go without health insurance, even if it
was just for a short time?

Child

Yes – had to go without
coverage at some time in
the past 12 months

No – has had insurance
coverage for all of the
past 12 months

INSERT NAME 1
INSERT NAME 2
INSERT NAME 3
INSERT NAME 4
“
“
“
“

RANDOMLY SELECT CHILD:
-

IF ANY UNINSURED IN Q14=18/23, RANDOMLY SELECT UNINSURED CHILD.
FOR ALL OTHERS, RANDOMLY SELECT CHILD.

For the rest of the survey, we’d like to ask about your experiences with [RANDOMLYSELECTED CHILD’S NAME’s] insurance situation.

Resume All
24. IF NAME UNINSURED NOW OR PAST 12 MONTHS. [IF PAST 12 MONTHS: You mentioned
NAME was uninsured at some point in the past 12 months.] Prior to losing coverage, what
type of insurance did NAME have?
A plan from your work or your spouse’s job.
Medicaid or STATE NAME.
STATE NAME OF CHIP.
COBRA.
A plan you bought directly from an insurance company, not through a job.
Military health care, such as TRICARE.
NAME has never had insurance coverage. (SKIP TO 26.)
Other (Specify: _____).
Not sure.
25. IF NAME UNINSURED NOW OR PAST 12 MONTHS: What was the main reason NAME’s
insurance coverage ended?
Lost a job that had health insurance for NAME.
Employer stopped offering health insurance.
Could no longer afford insurance through a job.
Was no longer eligible for Medicaid or STATE NAME or CHIP NAME. (Do you know why
NAME was no longer eligible? ______.)
Got dropped from Medicaid or STATE NAME or CHIP NAME. (Do you know why you were
dropped? ______.)
Could no longer afford Medicaid or STATE NAME or CHIP NAME.
Some other reason (SPECIFY: _______).
26. IF NAME UNINSURED: There are many reasons why children may not have health
insurance right now. What is the main reason NAME does not have health insurance
coverage right now?
I can’t afford insurance.
NAME was denied insurance because of pre-existing condition.
In a waiting period for coverage at work.
Some other reason (SPECIFY: ______).
27. IF NAME UNINSURED: How long has NAME been uninsured?
Less than 3 months.
3 months to less than 6 months.
6 months to less than 1 year.
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

1 to less than 2 years.
2 to less than 5 years.
5 or more years.
28. IF NAME RECEIVES MEDICAID/CHIP: How long has NAME been receiving health insurance
through MEDICAID/CHIP?
Less than six months.
6 months to 1 year.
1 to less than 2 years.
2 to less than 5 years.
5 or more years.

Satisfaction with Coverage
29. IF INSURED: In general, how satisfied or unsatisfied are you with NAME’s health insurance
coverage?
Very satisfied.
Somewhat satisfied.
Not too satisfied.
Not at all satisfied.
Not sure.
30. IF INSURED: How satisfied are you with… RANDOMIZE:
Very satisfied.
Somewhat satisfied.
Not too satisfied.
Not at all satisfied.
I’m not sure.
Does not apply to me.
a.
b.
c.
d.
e.
f.
g.

how quickly you can get an appointment to see a doctor for NAME?
how easy it is to see a specialist?
how easy it is to find a doctor for NAME who takes [his/her] insurance?
how easy it is to find a dentist for NAME who takes [his/her] insurance?
the quality of health care NAME receives?
how affordable NAME’s coverage is?
the range of services NAME’S insurance covers?

31. Would you say the out-of-pocket costs you pay for NAME’s health insurance are:
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

Something I can easily afford to pay?
Something I can afford, but it’s not always easy to pay?
Something I can’t really afford to pay?

Values

32. IF UNINSURED NOW OR IN PAST 12 MONTHS: What one or two words would you use to
describe how it feels to not have health insurance coverage for NAME?

33. IF INSURED: What one or two words would you use to describe how it feels to have
health insurance coverage for NAME?
34. Do you agree or disagree with each of the following statements: RANDOMIZE.
Strongly agree.
Somewhat agree.
Somewhat disagree.
Strongly disagree.
I’m not sure.
a. There are times when I can’t afford health insurance for NAME.
b. UNINSURED: I’m worried that without health insurance NAME won’t get the health
care that he/she needs.
c. INSURED: I would be worried if my child did not have health insurance because my
child would not be able to get the health care that he/she needs.
d. INSURED: I would know where to turn for help if NAME became uninsured.

Tracking Awareness
35. Before today, had you heard of MEDICAID/CHIP NAME?
Yes.
No.
I’m not sure.
36. Have you recently seen, read, or heard any information about MEDICAID/CHIP NAME?
Yes.
No.
Not sure.
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

37. IF YES: Did you see, read, or hear any information about MEDICAID/CHIP NAME from:
(Check all that apply.)
A newspaper.
A magazine.
Something you got in the mail.
TV.
Radio.
A poster or billboard.
On the internet.
A friend or family member.
Someone else.
Other [SPECIFY].
Don’t remember.
38. In the past two months, have you seen any advertisements about MEDICAID/CHIP NAME:
(Check all that apply.)
On TV.
On the radio.
In a newspaper.
In a magazine.
On the Internet.
On a poster or billboard.
Other [SPECIFY].
Have not seen any ads about MEDICAID/CHIP NAME.

39. IF ANY IN Q38: As a result of seeing an ad about MEDICAID/CHIP NAME, did you:
Yes.
No.
a.
b.
c.
d.

Call a phone number in the ad?
Go to a website that was in the ad?
Talk to someone about the program?
Try to learn more about the program?

40. Has anyone ever talked to you or given you information about enrolling your child[ren] in

MEDICAID/CHIP NAME?
Yes.
No.
Not sure.
PRA Disclosure Statement
10
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

41. Where did you get this information? (Check all that apply.)
From someone at your child’s [children’s] school.
It was something sent home with your child.
From a friend or family member.
From a social worker or caseworker.
From someone at a hospital.
From a doctor or nurse.
From someone else. (Who or where was this person? ______.)
Don’t remember.
42. Have you ever heard of the website: www.insurekidsnow.gov?
Yes.
No.
Not sure.
43. IF YES: Have you ever been to the www.insurekidsnow.gov website?
Yes.
No.
Not sure.

PRA Disclosure Statement
11
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

Interest in CHIP/MEDICAID
We’d like to ask a few more questions about MEDICAID/CHIP NAME.
As you may know, MEDICAID/CHIP NAME is a government program that provides health insurance to
low and moderate income, uninsured children in STATE.

44. IF CURRENTLY UNINSURED: How interested would you be in enrolling NAME in
MEDICAID/CHIP NAME?
IF INSURED, NOT CHIP/MEDICAID: If NAME happened to become uninsured, how
interested would you be in enrolling NAME in MEDICAID/CHIP NAME?
1 TO 7 SCALE, NOT AT ALL INTERESTED, EXTREMELY INTERESTED.
45. From what you know of MEDICAID/CHIP NAME, is it:
A very good program.
A somewhat good program.
A somewhat bad program.
A very bad program.
I’m not sure.
46. IF UNINSURED: Do you think NAME would be eligible for health insurance through
MEDICAID/CHIP NAME?
IF INSURED AND NOT MEDICAID/CHIP: Do you think NAME would be eligible for health
insurance through MEDICAID/CHIP NAME if he/she happened to become uninsured?
Definitely eligible.
Probably eligible.
Probably not eligible.
Definitely not eligible.
47. IF NOT ELIGIBLE: Why do you think NAME is PROBABLY/DEFINITELY not eligible for
MEDICAID/CHIP NAME?
Barriers to Enrollment
48. As far as you know, can a child be eligible for MEDICAID/CHIP NAME if:
PRA Disclosure Statement
12
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

Yes.
No.
I’m not sure.
RANDOMIZE.
a.
b.
c.
d.

his or her parent has a full-time job?
his or her parent has a car?
the child has a pre-existing condition?
his or her parents are not US citizens or legal residents?

49. Do you agree or disagree: RANDOMIZE
Strongly agree.
Somewhat agree.
Somewhat disagree.
Strongly disagree.
a. My family’s income is too high to be eligible for MEDICAID/CHIP NAME.
b. IF NOT MEDICAID/CHIP: It would be easy to find a doctor who takes MEDICAID/CHIP
NAME insurance.
c. IF NOT MEDICAID/CHIP: It would be easy to find a dentist who takes MEDICAID/CHIP
NAME insurance.
d. IF NOT MEDICAID/CHIP: I could probably afford MEDICAID/CHIP NAME.
e. I know where parents can go to apply for MEDICAID/CHIP NAME.
f. I know where parents can find information about MEDICAID/CHIP NAME.
g. IF CHIP/MEDICAID: I don’t like getting help from a government program.
h. I don’t want to deal with enrollment workers.
i. Children with MEDICAID/CHIP NAME get the same quality of health care as children
with private insurance.
j. There is too much paperwork and red tape to apply for MEDICAID/CHIP NAME.
k. MEDICAID/CHIP: Now that health reform has passed, I may not need MEDICAID/CHIP
for NAME.
l. ALL OTHERS: Now that health reform has passed, I may not need MEDICAID/CHIP as
an option.
m. IF UNINSURED: By the time my child got enrolled in MEDICAID/CHIP NAME, I’d
probably have some other health insurance coverage for him/her.
50. Do you think enrolling your child in MEDICAID/CHIP NAME would be:
Very easy.
Somewhat easy.
Somewhat hard.
PRA Disclosure Statement
13
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

Very hard.
51. How long do you think it would take to get your child covered by MEDICAID/CHIP NAME?
One day.
One week.
One month.
1-3 months.
3-6 months.
Longer than 6 months.
I’m not sure.
52. IF MEDICAID/CHIP: How long did it take to get MEDICAID/CHIP NAME insurance for NAME
from the time you first looked into MEDICAID/CHIP NAME? This would include completing
the application, handing in all of the paperwork, getting questions answered and anything
else up until the day you found out NAME was covered by MEDICAID/CHIP NAME.
One day.
One week.
One month.
1-3 months.
3-6 months.
Longer than 6 months.
Don’t recall.

Motivations – Reasons to Enroll
53. On a scale of 1 to 7, please rate whether each of these is a reason to enroll your child in
CHIP NAME.
IF CHIP/MEDICAID: Think back to when you enrolled NAME in MEDICAID/CHIP NAME. On
a scale of 1 to 7, please rate whether each of these was a reason you enrolled NAME in
MEDICAID/CHIP NAME.
IF INSURED, NOT CHIP/MEDICAID: On a scale of 1 to 7, please rate whether each of these
would be a reason to enroll NAME in MEDICAID/CHIP NAME, if [he/she] happened to
become uninsured.
1
2
Not a reason
to enroll

7
Major reason to enroll

PRA Disclosure Statement
14
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

RANDOMIZE.
a.
b.
c.
d.
e.
f.
g.

It would give me peace of mind.
I found out it was something I could afford.
My child could get dental care.
My child could get vision care.
My child could get mental health services if needed.
My child could get prescription drugs if needed.
I found out that a family of four can make $44,000 and still be eligible.

PRA Disclosure Statement
15
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

Motivations – Methods of Enrollment
54. Here are some ways parents might be able to apply for MEDICAID/CHIP NAME.
UNINSURED: Would it make you more likely or less likely to apply for MEDICAID/CHIP
NAME if it meant…
IF CHIP/MEDICAID: If you had to apply again for MEDICAID/CHIP NAME, would it make
you more or less likely to apply if it meant…
IF INSURED, NOT CHIP/MEDICAID: If you were interested in applying for MEDICAID/CHIP
NAME, would you be more or less likely to apply if it meant….
1
2
3
Much less likely
to apply

4
No
diff

7
Much more likely
to apply

RANDOMIZE.
a.
b.
c.
d.
e.

Going to a government office to fill out an application?
Filling out an application online?
Filling out an application by telephone?
Filling out an application and sending it in by mail?
Someone from your child’s school, like a school nurse or a coach, would help you fill
out the application?
f. Someone from a community group, like a community center, would help you fill out
the application?
g. You had to show an original birth certificate for your child?
h. You would not be asked any questions about your immigration status, only
questions about your child’s status?
i. IF LATINO: The application would be available in Spanish?
j. IF LATINO: Someone who speaks Spanish would help you complete the application?

RESUME ALL.
55. Some states are trying to make it easier to apply for MEDICAID/CHIP. For example, if a
parent already applied for Food Stamps, the Food Stamp application information such as
family income could be shared with MEDICAID/CHIP, instead of the parent having to hand
in the same information twice.
How comfortable are you with this idea?
Very comfortable.
PRA Disclosure Statement
16
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

Somewhat comfortable.
Not too comfortable.
Not at all comfortable.

PRA Disclosure Statement
17
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

56. If you applied for a government program like Food Stamps or MEDICAID/CHIP NAME,
would you want the program to tell you if you were eligible for other programs?
Yes.
No.
Doesn’t matter to me.
57. Another idea is for MEDICAID/CHIP NAME to use information from people’s income tax
returns to find out which families in the state might be eligible for children’s health
insurance coverage. MEDICAID/CHIP NAME would then send these families information in
the mail about the program.
Do you think this is a good idea?
Yes.
No.
58. IF NO: Would you think this is a good idea if parents gave permission on their tax forms to
share income information?
Yes.
No.

Messengers and Media

59. For you personally, where would you want to get information about MEDICAID/CHIP
NAME? (Check all that apply. RANDOMIZE.)
















Your workplace
Child’s school
Child’s child care
Child’s sports programs
Doctor’s office
Hospital
Clinic
Unemployment office
Community organizations (IF YES: Which ones?)
Job training center
Other government programs like WIC or Food Stamps
Internet (IF YES: Which websites?)
Friends or family
TV ad

PRA Disclosure Statement
18
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.









Radio ad
Newspaper ad
Local parenting magazine
Health fair
Library
Facebook or other online social network
Other (SPECIFY: ______).

60. How much would you trust each of the following people on whether or not you should
sign up for MEDICAID/CHIP NAME? RANDOMIZE.
Trust a lot.
Trust some.
Trust a little.
Would not trust.
Not sure.
a.
b.
c.
d.
e.
f.
g.
h.
i.

Your child’s teacher.
A nurse.
A doctor.
A child care provider.
Your child’s coach.
A social worker.
An enrollment worker.
Your employer.
Other parents who have used CHIP NAME.

61. IF CURRENTLY UNINSURED: How interested would you be in enrolling NAME in
MEDICAID/CHIP NAME?
IF INSURED, NOT CHIP/MEDICAID: If NAME ever happened to become uninsured, how
interested would you be in enrolling NAME in MEDICAID/CHIP NAME?
1 TO 7 SCALE, NOT AT ALL INTERESTED, EXTREMELY INTERESTED.

Medicaid/CHIP Enrollees ONLY: Program Experience
IF NAME HAS MEDICAID/CHIP: Here are a few questions about your experiences with MEDICAID/CHIP
NAME for NAME.
IF PREVIOUSLY HAD MEDICAID/CHIP: We’d like to ask a few questions about your previous experience
with a child covered by MEDICAID/CHIP NAME.
PRA Disclosure Statement
19
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

62. Do/Did you have to do something to renew NAME’s MEDICAID/CHIP health insurance
every so often?
Yes.
No.
I’m not sure.

PRA Disclosure Statement
20
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

63. IF YES: Do/Did you know when you have/had to do something to renew NAME’S health
insurance?
Yes.
No.
I’m not sure.
64. IF YES: [Do/did] you know what you [have/had] to do to renew NAME’S insurance?
Yes.
No.
I’m not sure.
65. In the past, did you do anything to renew NAME’S coverage through MEDICAID/CHIP
NAME?
Yes.
No.
I’m not sure.
66. IF YES: How easy or hard was it to renew NAME in MEDICAID/CHIP NAME?
Very easy.
Somewhat easy.
Somewhat hard.
Very hard.
Don’t recall.
67. Have you ever received anything in the mail or a telephone call or some other notification
telling you when and what to do to renew NAME in MEDICAID/CHIP NAME?
Yes, I did.
No, I didn’t.
I don’t remember.
68. Has NAME ever lost coverage through MEDICAID/CHIP NAME because you didn’t have the
information you needed to renew?
Yes.
No.
I’m not sure.

PRA Disclosure Statement
21
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

Thinking back to the most recent time you enrolled in MEDICAID/CHIP,
69. How easy or hard was enrolling your child in MEDICAID/CHIP NAME?
Very easy
Somewhat easy
Somewhat hard
Very hard
Don’t recall
How satisfied were you with… RANDOMIZE.
Very satisfied.
Somewhat satisfied.
Somewhat dissatisfied.
Very dissatisfied.
Don’t recall.
70. the enrollment process overall?
71. the length of time it took to get NAME enrolled?
72. the friendliness of enrollment workers?
How easy was it to… RANDOMIZE.
Very easy.
Somewhat easy.
Somewhat hard.
Very hard.
Don’t recall.
73.
74.
75.
76.
77.

gather the required pay stubs and other paperwork you needed?
find out what you needed to do in order to enroll?
find out if NAME was eligible for MEDICAID/CHIP NAME?
find out who to call or ask if you had questions?
get answers to your questions?

78. Did you fill out the application for MEDICAID/CHIP NAME:
Online?
By telephone?
By mail?
In-person at a government office?
In-person somewhere else? (SPECIFY: ______.)
PRA Disclosure Statement
22
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

79. Did you hand in your paperwork, such as pay stubs, for MEDICAID/CHIP NAME:
By mail?
In-person at a government office?
In-person somewhere else? (SPECIFY: ______.)

Uninsured ONLY
Since NAME has been uninsured, have you … RANDOMIZE.
Yes.
No.
Not sure.
80.
81.
82.
83.
84.

had to put off medical care for NAME because of cost?
had to pay for medical care for NAME out of pocket?
had to put off filling a prescription for NAME?
had to put off getting an immunization for NAME?
had to put off a dentist visit for NAME?

85. Is NAME not getting medical care right now for an illness [he/she] has?
Yes.
No.
Not sure.
86. Is NAME not getting dental care right now for a dental problem [he/she] has?
Yes.
No.
Not sure.

Private Insurance ONLY
Thinking about the next year or two, how concerned are you about: RANDOMIZE.
Very concerned.
Somewhat concerned.
Not too concerned.
Not at all concerned.
PRA Disclosure Statement
23
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

87.
88.
89.
90.
91.

someone in your household losing a job ?
your insurance premiums increasing?
your co-pays increasing?
an employer dropping your or your children’s health insurance ?
an employer reducing your benefits?

PRA Disclosure Statement
24
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

92. How secure do you feel about the insurance coverage you have for your child?
Very secure.
Somewhat secure.
Not too secure.
Not at all secure.
93. Do you feel the costs you pay for insurance are:
Too high.
Too low.
About right.
In the past year, have you had to:
Yes.
No.
94. put off or delay medical or dental care for NAME because of cost?
95. put off or delay medical or dental care for yourself because of cost?

Resume All
96. When you read or hear the word “Medicaid”, what comes to mind? There is no right or
wrong answer. OPEN END.
Has NAME ever been told by a doctor or health care provider that he/she:
Yes.
No.
97. Has asthma?
98. Has diabetes?
99. Has allergies?
100. Is overweight or obese?
101. Has behavioral or mental health problems?
102. Has another health problem or illness? (SPECIFY: _____.)
103. Does NAME have a regular doctor who watches over [his/her] health care?
Yes.
No.
PRA Disclosure Statement
25
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

104. Do you happen to have health insurance right now?
Yes.
No.
105. IF YES: What is your main source of insurance coverage?
A plan through your or your spouse’s employer.
Medicare.
Medicaid/STATE NAME.
Tricare/VA.
A plan you purchased yourself through the private market.
Other (specify).
Not sure.
106. IF NO: How interested would you be in enrolling in MEDICAID/CHIP, if you found out
you as a parent were eligible for coverage?
1 TO 7 SCALE, NOT AT ALL INTERESTED, EXTREMELY INTERESTED.
In the past 12 months, have you or someone in your household received help from:
Yes.
No.
107.
108.
109.
110.
111.

Food stamps?
WIC?
Social services?
TANF?
School lunch program?

PRA Disclosure Statement
26
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-XXXX. The time required to complete this
information collection is estimated to average ( XX hours) or (XX 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.

File Type	application/pdf
File Title	CMS Children's Health Insurance Program (CHIP/MEDICAID) Survey
Subject	Survey to Inform the CHIP National Outreach & Education Campaign
Author	CMS, OEA
File Modified	2010-06-01
File Created	2010-06-01