Form CMS-10632 Appendix A - Partner Survey: Informed Consent and Survey

EVALUATION OF FROM COVERAGE TO CARE IN
COMMUNITIES
Appendix A
Partner Survey: Informed Consent and Survey
(CMS-10632; OMB 0938-1342)

NOTE: This interview protocol is annotated to show (1) bolded section headers to denote survey
topic areas; (2) project research questions associated with each topic area (with parenthetical
references to logic model question numbers); (3) more detailed “domains” and “subdomains”
within topic areas; and (4) skip logic notes in brackets to indicate how skip logic will minimize
participant burden These annotations will not be seen by research participants. Changes from the
previously approved surveys appear in green text.

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 CMS-10632; OMB 0938-1342
(Expiration Date). The time required to complete this information collection is estimated
to average 20 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 212441850. *CMS Disclaimer*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.

OMB No.: CMS-10632; OMB 0938-1342
Expiration Date: (EXPIRATION DATE)

INFORMED CONSENT FOR ORGANIZATIONS
Thank you for agreeing to participate in this survey. Pacific Institute for Research and Evaluation
(or PIRE) is conducting a study for the Centers for Medicare & Medicaid Services on From
Coverage to Care, or C2C. As you may know, From Coverage to Care aims to help people with
health care coverage understand their benefits and connect to primary care. It is also designed to
help community organizations and providers support people as they connect to care.
Purpose of the Survey
You have been selected as a representative of your organization to take this survey because our
information suggests your organization is involved with connecting people to health insurance
and health care services (sometimes referred to as Health care Navigation). The purpose of this
survey is to help CMS understand how materials connecting individuals to health care services
are being used and how they can be improved.
The goals of this survey are to learn about:
1. How your organization uses materials that help connect individuals to health
insurance navigation and health care services (including C2C materials)
2. Which materials or messages (including C2C materials) are most helpful, as well as
how they could be more helpful
3. Your perceptions of how consumers respond to these materials
Procedures
The survey should last approximately 15-20 minutes. We will not collect personally identifiable
information, and your answers will not be linked back to you. This survey contains questions
related to your experiences with C2C. Question types include multiple choice (single and multianswer options) and fill-in-the blank. You may skip any questions you do not feel comfortable
answering.
This survey does not require the assistance of outside resources. Please complete the survey to
the best of your ability or based on minimal information searching.
Potential risks and discomforts
There are no identifiable risks associated with this survey. All information will be kept
confidential. Your name will not be collected or linked to the data you provide at any time. The
researchers will provide an electronic copy of this written consent directly to all research
participants prior to conducting the survey.
Potential benefits
This research is not designed to help you directly, but the results may help improve C2C
materials, messages, and outreach practices to encourage improved community health. We hope
that, in the future, other people and organizations might benefit from this study.

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Confidentiality
We will not collect any personally identifiable information; thus, confidentiality will be
maintained, except as required by law. Should you choose not to participate in the study,
information on your refusal to participate will not be released to CMS or your organization. The
data collected through this survey will be summarized in aggregate form, grouped with data
others provide for reporting and presentation.
All data collected will only exist in electronic form. Data collected will be securely stored on
Qualtrics data servers. All communications between your web browser and the Qualtrics servers
will be encrypted to maintain your confidentiality. Data provided to the PIRE Principal
Investigator will only occur through encrypted electronic communication (i.e., secure socket
layer). All analysis data files possessed by PIRE will be securely stored on the investigators’
password protected computers and network drives. While the data collected are not anonymous,
information about who completed the survey will be destroyed at the end of data collection.
Incentives
You will receive a $35 gift card electronically upon completion of the survey for your time. At the
end of the survey, you will be provided with a link to access the gift card.
Right to withdraw and questions
Your participation in this research is completely voluntary. You may choose not to take part at
all. If you decide to participate in this research, you may stop participating at any time.
If you have questions or concerns about this study, please contact the Principal Investigator of the
study, Bill Scarborough at 502-238-7326 or by emailing bscarbrough@PIRE.org.
Participant Rights
For questions about your rights as a research participant, you may call Elysia Oudemans-Tilley at
866-PIRE-ORG (866-747-3674), option 1, or by emailing oudemans@pire.org. This research has
been reviewed according to PIRE’s Institutional Review Board (IRB) procedures for research
involving human subjects.

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[SCREENER]
Are you a person in your organization who is knowledgeable about resources that aim to help
people with new health care coverage understand their benefits and connect to primary care?
•
•

Yes [START AT ITEM 1]
No [CONTINUE]

Would you please provide the name, email, and phone number of the person within your
organization who is knowledgeable about these matters? ____

Module 1: Organizational Module
Re se arch que sti ons addre sse d:
•

Among organizations working with C2C targeted populations, why are they using or
not using C2C materials? (i.e., distinction between organizations reached and not
reached)
1.

What best describes your organization? (Please choose most appropriate)
a. Health care provider —primary or preventive care
b. Health care provider — urgent care, emergency care, or hospital
c. Health care provider — mental or behavioral health care
d. Health care insurer
e. Social service agency
f. Public health organization (local, state, or federal)
g. Consumer/patient advocacy organization
h. Other community organization such as school or faith-based organization
i. Navigator/assister/certified application counseling organization
j. Other (please specify) ____________________

2.

What best describes your organization’s funding or tax status? (Please choose
most appropriate)
a. Private, not-for-profit (501c status) organization
b. Private, for-profit organization/company
c. State governmental organization
d. County governmental organization
e. Local/city governmental organization
f. Other (please specify: ___________________)

3.

How many paid employees does your organization have in total? (Please choose
most appropriate)
a. Small (less than 25 employees)
b. Medium (26-99 employees)
c. Large (100-249 employees)
d. Very large (250+ employees)

4.

How many unpaid volunteers does your organization have in total? (Please
choose most appropriate)
a. Small (less than 25 volunteers)
b. Medium (26-99 volunteers)

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c. Large (100-249 volunteers)
d. Very large (250+ volunteers)

Module 2: Organizational History with C2C and CMS
Re se arch que sti ons addre sse d:
•

Among organizations working with C2C targeted populations, why are they using or
not using C2C materials? (i.e., distinction between distribution channels for
organizations reached and not reached)

[ASK IF FROM SAMPLING FRAME OF THOSE NOT REQUESTING C2C MATERIALS]
5. Have you ever heard of the From Coverage to Care program through CMS, which
aims to help people with health care coverage understand their benefits and connect
to primary care?
a. Yes
b. No
6. Does your organization rely on an outside source for information and materials (such
as pamphlets, posters, or websites) to help people with health care coverage
understand their benefits and connect to primary care?
a. Yes
b. No [SKIP TO MODULE 6]
7. Where do you go for information and materials to help people understand their health
care coverage and connect to primary care? (OPEN-ENDED RESPONSE)
8. How did you first learn about [RESPONSE 7 NAME]? From.. (Please check all that
apply)
a. [RESPONSE 7 NAME] website
b. [RESPONSE 7 NAME] correspondence such as newsletter or
distribution list
c. Webinar where [RESPONSE 7 NAME] was discussed
d. [RESPONSE 7 NAME] office/distribution
e. Another organization in my community
f. A professional organization/society
g. A person in my community
h. The media
i. Online search
j. Don’t know
k. Other (please specify: _________________)
9. When did you first learn about [RESPONSE 7 NAME]? (Choose most appropriate
estimate)
a. In the last six months
b. Between six and twelve months ago
c. More than a year ago
e. Don’t know

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[ASK 10-11 OF THOSE REQUESTING C2C MATERIALS OR AWARE OF C2C]
10. How did your organization first learn about C2C? From.. (Please choose one)
a.
CMS website
b.
CMS correspondence such as newsletter or distribution list
c.
Webinar where C2C was discussed
d.
CMS regional office/distribution
e.
Another organization in my community
f.
A professional organization/society
g.
A person in my community
h.
The media
i.
Online search
j.
Don’t know
k.
Other (please specify: _________________)
11. When did your organization first learn about C2C? (Choose most appropriate
estimate)
a.
In the last six months
b.
Between six and twelve months ago
c.
One to two years ago
d.
Three to five years ago
e.
More than five years ago
f.
Don’t know
12. Thinking about your organization’s use of C2C, what were your roles? (Please
choose all that apply)
a.
I placed the C2C product orders for my organization.
b.
I trained staff in my organization to communicate about C2C topics and
materials with community members.
c.
I provided management support for the use of C2C in my organization.
d.
I used C2C materials with community members.
e.
Other (please specify:) ____________________
[ASK MODULE 3 IF FROM SAMPLING FRAME OF THOSE REQUESTING C2C
MATERIALS]

Module 3: C2C Ordering and Distribution Practices
Re se arch que sti ons addre sse d:
•
•
•

Did insurance navigators use HHIE resources (and which materials specifically were
used) to enhance services to consumers? (INT10)
Were regional networks formed and did partner organizations join networks as a result
of C2C efforts? (INT11)
Do organizations report reaching their targeted audience with C2C materials? (INT12)

Now we are interested to learn a little more about your organization’s experience with C2C
materials.
13. Why did your organization decide to use C2C materials? (Please choose all that
apply)
a. Addressed a knowledge gap in my community

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b. Addressed a knowledge gap in our organization/helped us to know how
to talk about these issues
c. Easy to use formats/easy to understand
d. Free resources
e. Other (Please specify: ____________________________)
14. Which C2C materials did your organization order? Please select all that apply
(Include categorized list of materials in drop box)
a. Roadmap to Better Care
b. A Roadmap to Behavioral Health and a Healthier You
c. Roadmap Poster Tabloid
d. Step 1: Put Your Health First
e. Step 2: Understand Your Health Coverage
f. Sample Insurance Card
g. Step 3: Know Where to Go
h. Differences Between Your Provider's Office and the Emergency
Department
i. Step 4: Pick a Provider
j. Step 5: Make an Appointment
k. Step 6: Be Prepared for Your Visit
l. Step 7: Decide if the Provider is Right for You
m. Step 8: Next Steps After Your Appointment
n. Sample Explanation of Benefits
o. 5 Ways to Make the Most of Your Health Coverage
p. Preventive Services Flyer
q. Coronavirus and Your Health Coverage: Get the Basics
r. Stay Safe: Getting the Care You Need, at Home
s. [ADDITION OF FUTURE MATERIALS]
t. Other (specify _______)
15. How did your organization determine what types of C2C materials to order? (Please
choose all that apply)
a. We selected materials that address the questions our community
members have.
b. We selected materials that come in a language other than English.
c. We selected materials that can be easily handed out to community
members.
d. We selected materials that address the needs of our staff.
e. Other (please specify: ________________________)

16. Does your organization plan to order more C2C materials in the future?
a. Yes [GO TO QUESTION 18]
b. No [GO TO NEXT QUESTION]
c. I do not know if my organization plans to order more C2C materials [GO
TO QUESTION 18]
17. Why will your organization stop ordering C2C materials? (Please choose all that
apply)
a. Our organization has enough C2C materials to last us for a long time.
b. The materials were not helpful to my community.

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c. We use other materials to address these topics. (If checked, what is the
name of those materials? _______)
d. We did not have the resources (such as staff, storage space, etc.) to use
C2C materials.
e. The materials were not available in a language we use. (If checked, what
language is needed? ____________________)
f. We no longer provide services relevant to C2C (for example, we do not
provide patient navigation services anymore).
g. Other (please specify: __________________________)
[IF OPTION b-g SELECTED ASK 18, OTHERWISE SKIP TO 19]
18. In the space below, briefly describe the most important factor causing your
organization to stop using C2C materials? (1-2 sentences, Fill in blank)

Thank you. We would now like to understand more about how your organization shares C2C
information with the community you serve and with other organizations.
19. How does your organization share C2C information and materials with patients and
other members of your community? (Please choose all that apply)
a. Hand out materials and talk about them during community health fairs
b. Hand out materials and talk about them during health insurance
enrollment sessions
c. Use materials in courses/training we offer
d. Place materials on table or wall displays in our organization or other
public spaces for community members to pick up
e. Distribute materials to other partner organizations who pass them out
f. Mail materials to community members
g. Hand out or mail materials in response to community member requests
h. Re-post C2C materials directly on our website
i. Social media (e.g., Facebook, Twitter)
j. Email or email listservs
k. Text messaging (i.e., SMS, MMS)
l. Other (please specify: _________________________)
20. Of the ways selected in the last question, in your experience, what forms of sharing
C2C materials were most helpful to community members? (Please choose top 3)
a. Hand out materials and talk about them during community events/health
fairs
b. Hand out materials and talk about them during enrollment sessions
c. Use materials in courses/training we offer
d. Place materials on table or wall displays in our organization or other
public spaces for community members to pick up
e. Distribute materials to other organizations who pass them out
f. Mail materials to community members
g. Hand out or mail materials in response to community member requests
h. Re-post C2C materials directly on our website
i. Social media (e.g., Facebook, Twitter)
j. Email or email listservs
k. Text messaging (i.e., SMS, MMS)

35

l.

Other (please specify: _________________________)

21. How has your organization shared C2C materials and messages with other
organizations in your community? (Please choose all that apply)
a. Told colleagues or other community organizations about C2C
b. Mailed C2C materials to other organizations
c. Distributed C2C materials to other organizations at community events
(for example, at a health fair)
d. Presented C2C information to organizations (for example, at a local
meeting)
e. Re-post C2C materials directly on our website
f. Social media (e.g., Facebook, Twitter)
g. Email or email listservs
h. Text messaging (i.e., SMS, MMS)
i. Other (Please specify: _______________)
j. We have not shared materials
[IF OPTION j NOT SELECTED CONTINUE, OTHERWISE SKIP TO 25]
22. In your experience, what form of sharing C2C materials with other organizations
was most helpful to them? (Please choose one)
a. Told colleagues or other community organizations about C2C
b. Mailed C2C materials to other organizations
c. Distributed C2C materials to other organizations at community events
(for example, at a health fair)
d. Presented C2C information to organizations (for example, at a local
meeting)
e. Re-post C2C materials directly on our website
f. Social media (e.g., Facebook, Twitter)
g. Email or email listservs
h. Text messaging (i.e., SMS, MMS)
k. Other (Please specify: _______________)
23. Has working with C2C made your organization form or strengthen any relationships
with other organizations in your community? (Please choose all that apply)
a. Yes, we formed relationships with organizations we haven’t worked with
before
b. Yes, we strengthened existing relationships
c. No, everything has remained the same
[IF a OR b SELECTED, ASK 24, OTHERWISE SKIP TO 25]
24.

Do you plan to continue these relationships in the future?
a. Yes
b. No
c. Not sure

25.

Was use of C2C materials a burden for your organization?
a. Yes, a large burden (please describe: ____________________)
b. Yes, a small burden
c. Not a burden

36

26.

Did your organization train any of its staff to give out C2C materials or talk
about its topics?
a. Yes, for all staff
b. Yes, for some staff
c. No

27.

What would be most useful to your organization to help you use and distribute
C2C materials and messages? (1-2 sentences, open response)

Module 4: Perceptions of Community Needs and Value of C2C
We are interested in getting some feedback on the most pressing needs in your community at this
point in time.

Re se arch que sti ons answere d:
•

What factors influenced which materials and messages organizations decided to use
and how to use them?
28.

When it comes to health care in your community, what would you say are the
biggest barriers individuals face? [PLEASE RANK TOP 3 CHOICES]
a. Individuals do not know how to access health care services
b. Individuals do not know how to find a regular provider or source of care
c. Individuals do not understand the importance of health care
d. Individuals do not understand the importance of health insurance
e. Individuals do not understand how to use their insurance benefits
f. Individuals do not understand when it is appropriate to use emergency or
urgent care services
g. Individuals do not understand how to access health services online (e.g.,
patient portals)
h. Individuals do not have the resources (e.g., electronic devices, internet
access) to access health services online (e.g., patient portals)
i. Individuals do not understand the importance of preventive health
services (e.g., vaccinations, screenings)
j. Individuals do not understand how to stay safe when there are publichealth concerns (e.g., COVID-19, SARS)
k. Individuals do not understand how to access health care services when
there are public-health concerns (e.g., COVID-19, SARS)
l. Other (please specify:)______________

For the next four questions, consider if the following issues would be considered a priority for
your organization and if any messaging was used on the topic.

29. Access to
health services

A. Is this topic an
area of focus or a
top priority of
your
organization?
(Yes/No drop
down menu –

B. Did your organization use any messaging or
materials in its work on this topic? (Please choose
all that apply) [OPTIONS A & B HIDDEN IF NOT
C2C AWARE AND NOT ORDERED]
a. Used C2C materials on this topic

37

SKIP part B if
NO)

b. Adapted C2C materials to our community’s
needs
c. Used other materials on this topic (please
specify: ___________________)
d. Created our own materials/messages on this
topic

30. Find a regular
provider or source
of care

(Yes/No drop
down menu –
SKIP part B if
NO)

31.Understand
insurance benefits
and how to use
insurance

(Yes/No drop
down menu –
SKIP part B if
NO)

32. Access
appropriate
care/services

(Yes/No drop
down menu –
SKIP part B if
NO)

a. Used C2C materials on this topic
b. Adapted C2C materials to our community’s
needs
c. Used other materials on this topic (please
specify: ___________________)
d. Created our own materials/messages on this
topic
a. Used C2C materials on this topic
b. Adapted C2C materials to our community’s
needs
c. Used other materials on this topic (please
specify: ___________________)
d. Created our own materials/messages on this
topic
a. Used C2C materials on this topic
b. Adapted C2C materials to our community’s
needs
c. Used other materials on this topic (please
specify: ___________________)
d. Created our own materials/messages on this
topic

[ASK MODULE 5 IF FROM SAMPLING FRAME OF THOSE REQUESTING C2C
MATERIALS]

Module 5: Perceptions of Community Engagement with C2C
Re se arch que sti ons answere d:
•
•

Did insurance navigators learn from HHIE resources? (ST5)
Did CMS/organizational partners learn about consumer motivations and HHIE
resource impact? (ST6)

Now we want to ask you about whether you think the community better understands health
insurance and how to access care.
In the next question, please think about your community members’ reactions to C2C. Then,
please rate how much you agree or disagree with each statement.
33.

After using C2C materials …
a. Members of my community understand why prevention and primary care
is important for their health.

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b. Members of my community gained a better understanding of health
insurance and how to use it.
c. Members of my community can choose coverage that best meets their
needs and expectations.
d. Members of my community reduce the inappropriate use of emergency
or urgent care.
e. Members of my community engage in more regular and or/preventive
care.
f. Members of my community are more able to find a provider and make an
appointment.
g. The topics covered in C2C materials are helpful to members of my
community.
h. Members of my community are better prepared to deal with public health
concerns (e.g., COVID-19, SARS).
• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Don’t know/I don’t work with the community directly

Please indicate your level of agreement with the following statements:
34.

Members of my community …
a. Are aware of online portals (e.g., insurance, hospital, doctor office).
b. Know how to use online portals.
c. Have lots of questions about how to use online portals.
• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Don’t know/I don’t work with the community directly
d. [ASK IF Agree OR Strongly Agree TO 34d] Would you please list some
examples of questions that members of your community have about
online portals.

In the next question, please think about organizations with whom you shared C2C materials
within your community. Then, please rate how much you agree or disagree with each statement.
35.

After seeing or using C2C materials…
a. The topics covered in C2C materials were helpful to other organizations
in my community.
b. Organizations in my community felt more prepared to talk to people
about why prevention and primary care is important for their health.
c. Organizations in my community felt more prepared to talk to people
about health insurance and how to use it.
d. Organizations in my community felt more prepared to help people
choose coverage that best meets their needs and expectations.

39

e. Organizations in my community felt more prepared to help reduce the
inappropriate use of emergency or urgent care.
f. Organizations in my community felt more prepared to encourage the use
of more regular and or/preventive care.
g. Organizations in my community felt more prepared to help people find a
provider and make an appointment.
e. Organizations in my community felt more prepared to deal with public
health concerns (e.g., COVID-19, SARS).
• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Don’t know/I didn’t share materials with other organizations
In the next question, please think about health care navigators with whom you shared C2C
materials. Then, please rate how much you agree or disagree with each statement.
36.

After using C2C materials…
a. Navigators learned more about why prevention and primary care is
important for consumer health.
b. Navigators learned more about health insurance and how to use it.
c. Navigators learned more about helping people choose coverage that best
meets their needs and expectations.
d. Navigators learned more about inappropriate use of emergency or urgent
care.
e. Navigators learned more about encouraging the use of more regular and
or/preventive care.
f. Navigators learned more about helping people find a provider and make
an appointment.
• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Don’t know/I didn’t share materials with Navigators

Now we are interested in your organization’s feedback about C2C materials and messages.
Please tell us about your organization’s experience with the C2C materials with which it is
familiar.
37.

For each of the materials you ordered, please rate how helpful the material was to
your organization? [Populated with list selected from Question 13]
• Very helpful
• Helpful
• Neither helpful nor unhelpful
• Unhelpful
• Very unhelpful

40

38.

[For responses of very helpful or helpful, ask] Why was that material helpful to
your organization? (please choose all that apply)
a. It addressed one of the biggest health care-related problems or needs in
my community.
b. It was the easiest set of materials for our organization to communicate
with community members.
c. It was the easiest set of materials for community members to understand.
d. Health care navigators learned a lot from these materials.
e. Other (please specify: _____________________)

39.

[For responses of very unhelpful or unhelpful, ask] Why was that material
unhelpful to your organization? (please choose all that apply)
a. It did not address relevant needs in my community.
b. It was the most difficult set of materials for our organization to
communicate with community members.
c. It was the most difficult set of materials for community members to
understand.
d. Health care navigators did not learn much from these materials.
e. Other (please specify: _____________________)

40.

Has your organization used any of the C2C online resources? (check all that
apply)
a. Someone in our organization has visited the C2C website.
b. Someone in our organization has downloaded C2C materials.
c. Someone in our organization has watched the C2C videos available on
the website.
d. Our organization uses the C2C website or other online resources to
discuss C2C topics with community members/patients.
e. Other (please specify): _________________________
f. No one has used C2C online resources.

41.

What additional topics or issues do you think should be added to C2C? (1-2
sentences, open response)

42.

What additional C2C materials or products would be helpful for community
members (for example, materials for a special population or health concern)?

Module 6: Respondent Demographics
Please answer some brief questions about yourself.
43.

How long have you worked at the organization?
a. Less than one year
b. 1 year to less than 4 years
c. 4 years to less than 6 years
d. 6-10 years
e. More than 10 years

44.

What is your job title? (open response) : ____________

41

45.

Is there anything else you would like to tell us about your experience with C2C?
(open response)

[ASK IF FROM SAMPLING FRAME OF THOSE REQUESTING C2C MATERIALS]
Snowball Sampling Question
46.

We are trying to identify organizations that might benefit from C2C materials,
but who are not currently using C2C materials. Are there other organizations in
your area that provide services to health care consumers that are similar to the
services you provide? [IF YES] Would you indicate the name of the
organization, the name of the contact person, the phone number of the contact
person, and the email address of the contact person? We would like to contact
them for a similar survey. It is OK if you do not know all of this information.
Please list the information that you know. ______

THANK YOU FOR COMPLETING THIS SURVEY.

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