Form 1 Attachment A – Initial Screening Questionnaire

Attachment A – Initial Screening Questionnaire.

Form Approved OMB No.

Exp. Date

Exp. Date

Exp. Date

Thank you for your interest in participating in the enhancement of the Medical Expenditure Panel Survey (MEPS). This is an important effort being undertaken by Econometrica, Inc., a Bethesda-based research and management firm on behalf of the Agency for Healthcare Research and Quality (AHRQ).

MEPS is a survey administered by AHRQ to gather information on the use of healthcare and health insurance by American families and individuals and the costs thereof. Econometrica is helping AHRQ determine how they can learn more about people’s insurance plans (e.g., copays, plan coverage) by adding a few questions and requesting interviewees to bring some extra documents with them. If selected, your participation will help us provide recommendations to AHRQ on how to enhance the survey.

 

Please complete the interest form to the best of your abilities. We will reach out to you notifying you if you have been selected to participate in the interviews or focus group. If you have any questions, please reach out to Hallie Whitman at MEPS@econometricainc.com. 

Initial Screener Question

1. Are you 18 or older?

1. Yes.

2. No.

If answer to Q1 is B, proceed to Final Page 2; if A, proceed to Q2.

2. Do you have a health insurance plan?

1. Yes.

2. No.

If answer to Q2 is B, proceed to Final Page 2; if A, proceed to Q3.

Contact Information

3. Please provide your name.

1. [Text box]

4. Please provide your email address.

1. Email Address: [Text box]

2. Confirm Email Address [Text box]

Text in A and B must match to proceed.

5. Please provide your phone number.

1. [Text box]

6. If you are selected to participate, we will reach out to you by phone with additional information. What is the best time to contact you during Monday - Friday?

1. 9:00 – 11:00 am

2. 11:00am – 1:00pm

3. 1:00 – 3:00pm

4. 3:00 – 5:00pm

5. After 5:00pm

6. Is there a specific time that is best for you? [text box]

Insurance Plan Details

7. How would you describe your insurance plan?

1. Private insurance (e.g., Blue Cross Blue Shield, Kaiser Permanente, Aetna) from your or someone else’s employer.

2. Private insurance that you or someone else purchase directly from an insurance company or HMO.

3. COBRA.

4. Medicare, only.

5. Medicare and a supplemental private insurance.

6. Medicare and Medicaid.

7. Medicaid, only.

8. Other, please explain [text box]

8. How did you obtain your health insurance?

1. Through your employer.

2. Through your partner or spouse’s employer.

3. Through your parent, guardian, or relative’s employer.

4. Through the federal marketplace (e.g., healthcare.gov).

5. Through the Virginia marketplace (e.g., healthmatchup.com/virginia-health-exchange-marketplace)

6. Through the Maryland marketplace (e.g., marylandhealthconnection.gov).

7. Through the District of Columbia marketplace (e.g., dchealthlink.com).

8. Purchased directly from an insurance company or insurance agent.

9. Other, please explain. [text box]

If answer to Q8 is A, B, or C, proceed to Q9. Else proceed to Q11.

9. How would you describe the employer that you receive health insurance through?

1. Private company, individual, or organization.

2. Federal government.

3. State government.

4. Local government.

5. Armed forces.

6. Foreign (non U.S. government).

7. Other, please explain. [text box]

If answer to Q9 is A, proceed to Q10. If answer to Q9 is B, E, or F, proceed to Final Page 2. If answer to Q9 is C, D, or G, proceed to Q11.

10. Approximately, how large is the employer that you receive health insurance through?

1. 1-19 employees

2. 20-49 employees

3. 50-199 employees

4. 200-499 employees

5. 500-999 employees

6. Over 1,000 employees

7. I do not know.

11. Select the carrier you receive your healthcare through:

1. Aetna.

2. Blue Cross Blue Shield.

3. Cigna.

4. Kaiser Permanente.

5. United Healthcare.

6. Other, please explain. [text box]

Proceed to Demographics and Contact Information.

Demographics

12. What is your age?

1. [Text box]

13. What is the highest degree or level of school you have completed?

1. Less than high school diploma or GED

2. High school diploma or GED

3. Some college or associates degree

4. Bachelor’s degree

5. Graduate or professional degree

6. Prefer not to answer.

14. Are you of Hispanic, (Latino/Latina), or Spanish origin?

1. Yes.

2. No.

3. Prefer not to answer.

15. For this survey, Hispanic origins are not races. What is your race?

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Mixed race (two or more races)

6. Other race.

7. Prefer not to answer.

16. What was your total household income before taxes during the past 12 months?

1. less than $25,000

2. $25,000 to $34,999

3. $35,000 to $49,999

4. $50,000 to $74,999

5. $75,000 to $99,999

6. $100,000 to $149,999

7. $150,000 or more

8. Prefer not to answer.

17. The interviews will be taking place at Econometrica’s headquarters, on Wisconsin Avenue in Bethesda, Maryland. Are you willing to drive or commute to our location? There is a stipend of $70 provided to compensate you for your time.

1. Yes.

2. No.

18. How did you hear about this opportunity?

1. [Text box]

End Survey. Proceed to Final Page 1.

Final Page 1

Thank you for your time and interest. We will reach out to you notifying you if you have been selected to participate in the interviews or a focus group. If you have any questions, please reach out to Hallie Whitman at MEPS@econometricainc.com. 

Final Page 2

Thank you for your interest. Unfortunately, you are not eligible to participate in this study.