Form CMS-10597 Healthcare.gov Site Wide Survey

HealthCare.gov Site Wide Survey

Revised November 3, 2015

Launch from sticky button on selected trigger pages. For methodology see document ‘Site Wide Survey Approach’

Invitation:

“HealthCare.gov is looking for your feedback. Thanks for taking a moment to tell us about your experience today on HealthCare.gov!” – Insert OMB clearance number and related information about here.

Overall Experience

1. (RADIO) Including today, how many times have you visited HealthCare.gov since [INSERT Relevant Date: e.g., November 1, 2015]?

a.	Today was the only time
b.	2 to 3 times
c.	4 to 5 times
d.	6 to 10 times
e.	More than 10 times

2. (RADIO) How much time did you spend on Healthcare.gov today?

a.	Less than 1 hour
b.	1 to 2 hours
c.	2 to 3 hours
d.	3 to 4 hours
e.	4 to 5 hours
f.	5 hours or more

3. (RADIO) Which of these best describes you?

a.	An individual or family interested in getting Marketplace health insurance for the first time (code as ‘new’) (Go to Q4)
b.	An individual or family interested in getting Marketplace health insurance again (code as ‘re-enrolling’) (Go to Q4)
c.	A small business employee (skip to Q23)
d.	A small business employer (skip to Q23)
e.	A CMS call center representative (skip to Q23)
f.	A CMS certified assister or navigator (Go to Q4)
g.	A CMS certified broker or agent (skip to Q23)
h.	An insurance company representative (skip to Q23)
i.	None of these (skip to Q23)

4. (RADIO) What did you do most recently today on HealthCare.gov?

a.	Looked at information about Marketplace health insurance [Go to Q5 ]
b.	[if Q3=a] Created an account [Go to Q7 ]
c.	Viewed plans and prices BEFORE filling out an application (“See Plans and Prices”) [Go to Q8]
d.	Started or continued an Application [Go to Q10]
e.	Shopped and compared plans AFTER filling out the Application [Go to Q15]
f.	Enrolled or renewed a plan[Go to Q18]
g.	I didn’t do any of these today[Go to Q23]

Looking for/reading information

5. (RADIO) (if Q4=a or Q4=b) Did you find the information you were looking for on HealthCare.gov?

a.	Yes (Go to Q23)
b.	No (Go to Q6)
c.	Not applicable

6. (TEXT AREA) What information were you looking for that you couldn’t find? (Open-end)

(Go to overall satisfaction – Q23)

Creating a HealthCare.gov Account

7. (RADIO) [if Q4=b] Overall, how easy or difficult was it to create your account?

a.	Very easy
b.	Somewhat easy
c.	Somewhat difficult
d.	Very difficult

(Go to overall satisfaction – Q23)

Viewing plans and costs

8. (RADIO) Before you apply/applied for insurance, how helpful was See Plans and Prices in showing plans that may be available to you and the estimated prices?

a.	Very helpful
b.	Somewhat helpful
c.	Not very helpful
d.	Not at all helpful
e.	Not applicable

9. How much do you agree or disagree that See Plans and Prices made it clear that the plan prices were an estimate and not the final prices?

a.	Strongly agree
b.	Somewhat agree
c.	Somewhat disagree
d.	Strongly disagree
e.	Not applicable

(Go to overall satisfaction – Q23)

Starting or completing the Application

10. (RADIO) (if Q4=d) Overall, how easy or difficult was it to fill out the Application?

a.	Very easy
b.	Somewhat easy
c.	Somewhat difficult
d.	Very difficult
e.	Not applicable

11. (RADIO) Did you submit your application for health insurance on Healthcare.gov by pressing the SUBMIT APPLICATION button?

a.	Yes (Go to Q12)
b.	No (Go to overall satisfaction – Q23)

12. (RADIO) After you submitted your application, did the website give you a detailed Eligibility Report (a PDF file to download) showing if you are eligible to get help paying for insurance?

a.	Yes (Go to Q13)
b.	No (Go to overall satisfaction – Q23)
c.	I don’t know (Go to overall satisfaction – Q23)

13. (CHECK BOXES) Did the Eligibility Report say that someone in your household qualifies for any of these? (Check all that apply, except e. is exclusive)

1. A health plan with reduced deductibles or copayments (called cost-sharing reduction plans)

2. A health plan with a premium tax credit to lower your monthly premium

3. A health plan, but no cost-sharing reduction and no tax credit

4. A state insurance program for people with low income, such as Medicaid or CHIP

5. I don’t know (accept only if a-d are not checked)

14. (RADIO) Overall, how easy or difficult was it to understand your Eligibility Report?

a.	Very easy
b.	Somewhat easy
c.	Somewhat difficult
d.	Very difficult
e.	I didn’t read the Eligibility Report

(Go to overall satisfaction – Q23)

Shopping and comparing health plans

15. (RADIO) (if Q4=e) Overall, how easy or difficult was it to shop for a health plan on HealthCare.gov?

a.	Very easy
b.	Somewhat easy
c.	Somewhat difficult
d.	Very difficult
e.	I didn’t shop for a health plan

16. (CHECKBOX) When reviewing plans, did you do any of these activities? (Check all that apply, except h. is exclusive)

a.	Read “3 Things to know” about how to select a plan
b.	View monthly premiums
c.	View out-of-pocket costs (like deductible, copayment, or coinsurance)
d.	View maximum out-of-pocket cost (the most you would pay in a year)
e.	View plan details (such as benefits, types of medical services included, etc.)
f.	Look for a directory of doctors or hospitals
g.	Compare two or more plans
h.	I didn’t do any of these things [accept only if a-g not checked]

17. (RADIO) (if Q16g is checked) Overall, how easy or difficult was it to compare plans?

a.	Very easy
b.	Somewhat easy
c.	Somewhat difficult
d.	Very difficult
e.	I didn’t compare plans

(Go to overall satisfaction – Q23)

Enrolling in a plan

18. (RADIO) (if Q 4 = f) How easy or difficult was it to enroll in the plan that you selected on HealthCare.gov?

a.	Very easy
b.	Somewhat easy
c.	Somewhat difficult
d.	Very difficult
e.	I did not enroll in a plan (Go to Q23)

18. (RADIO) How confident are you that you enrolled in a health plan that meets your health and financial needs?

a.	Very confident
b.	Somewhat confident
c.	Not very confident
d.	Not at all confident
e.	I did not enroll in a plan (Go to Q23)

18. (CHECKBOX) What was the most difficult part of the process of getting insurance on HealthCare.gov, if any? (Check all that apply, except h. is exclusive)

a.	Creating or accessing my account
b.	Completing or revising the application
c.	Finding out how much my plan would cost
d.	Understanding the tax credit or subsidy
e.	Choosing a plan
f.	Finding the information I needed
g.	Something else
h.	None of these (accept only if a-g not checked)

18. (CHECKBOX) Did you get help enrolling in a Health Insurance Marketplace plan from any of the following? (Choose all that apply, except d. is exclusive)

a.	An in-person assister
b.	A customer service representative at the Marketplace 1-800 number
c.	An insurance agent or broker
d.	I did not contact any of these (accept only if a-c not checked)

(MATRIX TABLE) How satisfied are you with the following?

	Very satisfied	Somewhat satisfied	Not very satisfied	Not at all satisfied	N/A
The overall enrollment or re-enrollment process?

(Go to overall satisfaction – Q23)

Overall satisfaction

(MATRIX TABLE) How satisfied are you with the following:

	Very satisfied	Somewhat satisfied	Not very satisfied	Not at all satisfied	N/A
The information provided about the Health Insurance Marketplace?
The way information was explained on HealthCare.gov?
How well the HealthCare.gov website worked today?
Your overall experience on Healthcare.gov?

23. (TEXT AREA) [If Q26=not very satisfied or not at all satisfied] Please tell us the reason that you were not satisfied. (Open-end text to be output along with corresponding categorical information from Q3, Q13, Q26, Q29, Q34, Q35, Q36.)
    
    
    
    
    

24. (RADIO) How likely are you to recommend HealthCare.gov to family or friends who need health insurance?

a.	Very likely
b.	Somewhat likely
c.	Not very likely
d.	Not at all likely
e.	Not applicable

About You

23. (RADIO) Which of the following was true regarding your insurance before today?

a.	I was uninsured for more than 2 years
b.	I was uninsured for between 1 and 2 years
c.	I was uninsured for between 6 months and 1 year
d.	I was uninsured for less than 6 months
e.	I enrolled in a Health Insurance Marketplace health plan for 2015 and I came to HealthCare.gov to change plans or re-enroll in my current plan
f.	I had other health insurance in 2015, but came to HealthCare.gov to get a new plan

30. (RADIO) (If Q29=e) Did you enroll in the same Health Insurance Marketplace plan as in 2015?

    1. Yes, I enrolled in the same plan

    2. No, I enrolled in a different plan

    3. I have not re-enrolled yet
       
       

31. (RADIO) (Q29=e) Which of the following is true about your 2015 plan, if any?

    1. My plan costs increased

    2. My plan costs decreased

    3. My plan costs stayed the same

    4. I don’t know
       
       

30. (RADIO) (Q29=e) Which of the following is true about your 2015 plan, if any?

    1. My plan moved to a higher metal level (example: silver to gold)

    2. My plan moved to a lower metal level (example: silver to bronze)

    3. My plan stayed at the same metal level

    4. I don’t know

30. (RADIO) (Q29=e) Which of the following is true about your 2015 plan, if any?

1. The coverage changed and is better for me now

2. The coverage changed and it is not as good for me now

3. The coverage did not change

4. My plan was discontinued

5. I don’t know

30. (TEXT) What year were you born?

30. (RADIO) How many people in your household are applying/have applied for coverage for 2016?

a.	None (not applying for coverage)
b.	One
c.	Two
d.	Three
e.	Four
f.	Five
g.	Six
h.	Seven
i.	Eight or more
j.	I have not decided

30. (RADIO) What is your household’s total annual income before taxes?

a.	$0-14,999
b.	$15,000-24,999
c.	$25,000-34,999
d.	$35,000-49,999
e.	$50,000-74,999
f.	$75,000-99,999
g.	$100,000-149,999
h.	$150,000 or more
i.	I prefer not to answer

WE INVITE YOU TO PARTICIPATE IN FUTURE RESEARCH.

If you would like to be notified of future research by email, provide your name and email address:

Q37. Name: _____________________

Q38. Email Address: ____________________

Thank you for taking the time to fill out this survey.

(Expiration Date MM/DD/YY)

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 4 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.  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Frank Funderburk at (410)786-1820 or frank.funderburk@cms.hhs.gov.

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