Form CMS-10437.GenIC#25 Medicare Savings Program and Extra Help Awareness Survey

Medicare Savings Program and Extra Help Awareness Survey

Medicare Savings Program and Extra Help Awareness Survey

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 0938-1247.  The time required to complete this information collection is estimated to average 10 minutes per survey, 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 Matthew Yuen at matthew.yuen@cms.hhs.gov.

Introduction

This survey is being done on behalf of the Centers for Medicare and Medicaid Services, the government agency that oversees Medicare. This survey will help Medicare understand your experiences with Medicare. Your opinions are very important in helping improve how Medicare serves the people in their programs. Your responses will be confidential and at no time will any identifying information about you be stored or shared with anyone.

This survey will only take about 10 minutes. Let’s begin.

Screening Questions

DG2. In what year were you born?

____________ (four digit year)

[End if: age <65; DG2=1959 or greater, don’t know, or refuse]

ING1. Do you currently have Medicare?

1. Yes

2. No

98. I don’t know

99. Refuse to answer

[End if 2, 98, or 99]

ING2a. (If yes) Do you have any of the following Medicare coverages? (Select all that apply)

1. Medicare Part A, or hospital insurance, which helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care.

2. Medicare Part B, or medical insurance, which helps cover services from doctors and other health care providers

3. A Medicare Advantage plan, which is a Medicare health plan, such as an HMO or PPO, that is offered by a private company

4. A Medicare prescription drug plan

98. I don’t know

99. Refuse to answer

[End if 98, 99, only 1 is selected, only 2 is selected]

DG6. What is your marital status?

1. Single (Go to DG10a)

2. Married (Go to DG10b)

3. Separated or Divorced (Go to DG10a)

4. Widowed (Go to DG10a)

98. I don’t know

99. Refuse to answer

[End if 98 or 99]

DG10a. (If single, divorced, widowed) What is your total household income?

1. Less than $13,590

2. Between $13,591 and $27,180

3. Between $27,181 and $40,770

4. More than $40,770

98. I don’t know

99. Refuse to answer

[End if 4, 98, or 99]

DG10b. (If married) What is your total household income?

1. Less than $18,310

2. Between $18,311 and $36,620

3. Between $36,621 and $54,930

4. More than $54,930

98. I don’t know

99. Refuse to answer

[End if 4, 98, or 99]

Medicare Savings Program and Extra Help Status

ING2b. Some people get help paying for Medicare costs. Do you get help from any of the following? (Select all that apply)

1. The Medicare Extra Help Program, which provides help with Part D drug cots

2. A Medicare Savings Program

3. The Qualified Medicare Beneficiary Program (also called QMB)

4. The Specified Low-Income Medicare Beneficiary Program (also called SLMB)

5. The Qualifying Individual Program (also called QI)

6. Medicaid

7. None of these

98. I don’t know

99. Refuse to answer

Awareness of Medicare Savings Program

AWG2a1. In the past few months, have you seen, heard or read anything about Medicare Savings Programs that can help people who have limited incomes to pay for their Medicare premiums or other Medicare costs?

1. Yes

2. No

98. I don’t know

99. Refuse to answer

[If 2, 3, 98, 99, skip to AWG2a2]

AWG2b1. Was what you saw about Medicare Savings Programs in an advertisement, a news story, or both?

1. Advertisement

2. News story

3. Both

98. I don’t know

99. Refuse to answer

[If 2, 98, 99, skip to KG7a]

AWG5a. Where did you see, hear, or read an advertisement about Medicare Savings Programs? (Select all that apply)

1. Television

2. Radio

3. Newspaper or magazine

4. Billboard

5. Internet

6. In the mail

7. Other (Specify)

98. I don’t know

99. Refuse to answer

KG7a. Do you think the following statements about Medicare Savings Programs are true or false?

1. To enroll in a Medicare Savings Program, you must apply through your state

2. There are savings programs that can help you pay for your out-of-pocket Medicare costs, like deductibles and copays

3. You may qualify for a Medicare Savings Program, even if you don’t qualify for Medicaid

4. There are Medicare Savings Programs that help pay for the monthly Medicare premium payment that usually comes out of people’s Social Security checks

5. Even though you have to enroll for a Medicare Savings Program through your state, your Medicare coverage remains the same

1. True

2. False

98. I don’t know

99. Refuse to answer

BG1a1. (If ING2b ~= 2, 3, 4, 5, or 6) In the past few months, have you looked for information Medicare Savings Programs?

1. Yes

2. No

98. I don’t know

99. Refuse to answer

[If 1, go to KG4b]

BG1a2. (If ING2b ~= 2, 3, 4, 5, or 6) In the past few months, have you applied for a Medicare Savings Program?

1. Yes

2. No

98. I don’t know

99. Refuse to answer

KG4b. (If ING2b ~= 2, 3, 4, 5, or 6) How likely do you think it is that you would be eligible to enroll in a Medicare Savings Program?

1. Very likely

2. Somewhat likely

3. Not very likely

4. Not at all likely

98. DK

99. REF

BG8a. (If ING2b ~= 2, 3, 4, 5, or 6) How likely do you think it is that you will apply for a Medicare Savings Program?

1. Very likely

2. Somewhat likely

3. Not very likely

4. Not at all likely

98. DK

99. REF

PG1a. (If ING2b ~= 2, 3, 4, 5, or 6) How easy or difficult do you think it would be to apply for a Medicare Savings Program?

1. Very easy

2. Somewhat easy

3. Somewhat difficult

4. Very difficult

98. DK

99. REF

Awareness of Extra Help

AWG2a2. In the past few months have you seen, heard or read anything about a Medicare Low Income Subsidy program called “Extra Help” that helps with Part D prescription drug costs?

1. Yes

2. No

98. I don’t know

99. Refuse to answer

[If 2, 3, 98, 99, skip to AWG6]

AWG2b1. Was what you saw about the Medicare Extra Help program in an advertisement, a news story, or both?

1. Advertisement

2. News story

3. Both

98. I don’t know

99. Refuse to answer

[If 2, 98, 99, skip to KG7b]

AWG5a. Where did you see, hear, or read an advertisement about the Medicare Extra Help program? (Select all that apply)

1. Television

2. Radio

3. Newspaper or magazine

4. Billboard

5. Internet

6. In the mail

7. Other (Specify)

98. I don’t know

99. Refuse to answer

KG7b. Do you think the following statements about Medicare’s Extra Help program are true or false?

1. To enroll in Medicare’s Extra Help program, you must apply through the Social Security Administration

2. People who enroll in Medicare Savings Programs will automatically get Extra Help

3. All people who get Extra Help will pay $0 for their Part D drug plan monthly premium

4. People who get Extra Help pay $4.15 or less for generic drugs

5. People who get Extra Help pay $10.35 or less for brand name drugs

1. True

2. False

98. I don’t know

99. Refuse to answer

BG1a1. (If ING2b ~= 2, 3, 4, 5, or 6) In the past few months, have you looked for information Medicare’s Extra Help program?

1. Yes

2. No

98. I don’t know

99. Refuse to answer

[If 1, go to KG4b]

BG1a2. (If ING2b ~=1) In the past few months, have you applied for Medicare’s Extra Help program?

1. Yes

2. No

98. I don’t know

99. Refuse to answer

KG4b2. (If ING2b ~=1) How likely do you think it is that you would be eligible to enroll in Medicare’s Extra Help program?

1. Very likely

2. Somewhat likely

3. Not very likely

4. Not at all likely

98. I don’t know

99. Refuse to answer

BG8a2. (If ING2b ~=1) How likely do you think it is that you will apply for Medicare’s Extra Help program?

1. Very likely

2. Somewhat likely

3. Not very likely

4. Not at all likely

98. I don’t know

99. Refuse to answer

PG1b. (If ING2b ~=1) How easy or difficult do you think it would be to apply for Medicare’s Extra Help program?

1. Very easy

2. Somewhat easy

3. Somewhat difficult

4. Very difficult

98. I don’t know

99. Refuse to answer

Demographics

DG12. What is your zip code?

____________ (five digit zip code)

DG3. Are you Hispanic or Latino?

1. Yes

2. No

98. I don’t know

99. Refuse to answer

DG4. What is your race? (Select all that apply)

1. White

2. African American or Black

3. Asian

4. American Indian or Alaska Native

5. Native Hawaiian or other Pacific Islander

6. Another race (specify)

98. I don’t know

99. Refuse to answer

DG5. What is the highest level of education you have completed?

1. Less than high school

2. High school graduate

3. Some college

4. College graduate

5. Post graduate

98. I don’t know

99. Refuse to answer

DG1. What is your gender?

1. Male

2. Female

3. Other (specify)

98. I don’t know

99. Refuse to answer

Those are all of the questions we have for you. Thank you for your time today.

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