CMS-10615 HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper)

ID Number: CMS-10615

OMB Control Number: 0938-1300

Healthy Indiana Plan 2.0 Beneficiary Survey:
New Enrollees Survey
SURVEY INSTRUCTIONS
•	
•	

Answer each question by filling in the circle to the left of your answer, like this:   Yes
You are sometimes told to skip over some questions in this survey. When this happens you will see an
arrow with a note that tells you what question to answer next, like this:



Yes  GO TO QUESTION 1



No

The Centers for Medicare & Medicaid Services is conducting this survey to ask about your recent experiences receiving
health care and should take about 15 minutes to complete. Your participation is voluntary, and there is no loss of
benefits or penalty of any kind for deciding not to participate. You may skip any questions that you do not feel comfortable
answering. Your participation in this research is private, and we will not share your name or any other identifying
information with any outside organization. You may notice a number on the cover of the survey. This number is ONLY used
to let us know if you returned the survey. Please contact Thoroughbred Research Group toll-free at 844-859-7862 with
questions about this research.
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 0938-1300. The time required to complete
this information collection is estimated to average 15 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.

About Your HIP 2.0 Enrollment
The State of Indiana currently runs an insurance program called the Healthy Indiana Plan (also called
HIP 2.0) for Hoosiers ages 19 to 64.
1.	 Are you currently enrolled in the “Healthy Indiana Plan 2.0” (also called “HIP 2.0”)?

	 Yes
	 No  GO TO END
	 Not sure/Don’t know  GO TO END
2.	 Did you enroll in HIP 2.0 in 2016?

	 Yes
	 No  GO TO END
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3.	 With which HIP 2.0 health plan are you enrolled?

	 Anthem
	 MDwise
	 MHS – Managed Health Services
	 Not sure/Don’t know
Healthy Indiana Plan (HIP) 2.0
4.	 HIP 2.0 offers different benefits packages. Are you aware that HIP 2.0 offers:
Please mark one answer in each row.

Yes

No

Not sure

a.	 HIP Plus







b.	 HIP Basic







5.	 When you enrolled in HIP 2.0, did you look for any information in written materials or on the
Internet about your benefits package?

	Yes
	No  GO TO QUESTION 7
6.	 How helpful was the information about your benefits package?

	 Very helpful
	 Somewhat helpful
	 Not at all helpful
7.	 When you enrolled in HIP 2.0, did you get information or help from a customer service representative?

	Yes
	No  GO TO QUESTION 9
8.	 How helpful was the information you got?

	Very helpful
	Somewhat helpful
	Not at all helpful

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9.	 From the time you submitted your application, how much time did it take for your HIP 2.0
coverage to start?

	Less than a month
	1 to 3 months
	More than 3 months
	Not sure/Don’t know
10.	 What do you think will happen, if anything, if your contribution(s) is not made on time?

	I am not required to make contributions  GO TO QUESTION 12
	Nothing will change  GO TO QUESTION 12
	My HIP 2.0 coverage will end
	They would automatically get moved to HIP Basic  GO TO QUESTION 12
	Not sure/Don’t know  GO TO QUESTION 12
11.	 How long do you think you would need to wait to re-enroll in HIP 2.0?

	No wait time
	3 months
	6 months
	12 months
	Not sure/Don’t know

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For the next few questions, please think about your HIP 2.0 enrollment experience.
12.	 Please tell us whether you agree, disagree, or are not sure about the following statement: You
can do something to get coverage while your application is still being processed.

	 Agree
	 Disagree
	 Not sure/Don’t know
13.	 Which of the following things could you do to get your HIP 2.0 coverage as soon as possible?
Please mark one answer in each row.

Yes

No

Not sure

a.	 Pay my contribution(s) when I get my invoice







b.	 Pay $10 or make a “fast track” payment



















e.	 Return my completed application quickly







f.	 Ask for help to complete my application quickly







c.	 My health plan, health care provider, or a non-profit organization
pays $10 or makes a “fast track” payment for me
d.	 Apply for temporary coverage with the help of someone at a
health care provider's office or hospital

14.	 When you enrolled in HIP 2.0, did you do any of the following things to get your HIP 2.0
coverage as soon as possible?
Please mark one answer in each row.

Yes

No

Not sure

a.	 Paid my contribution(s) when I got my invoice







b.	 Paid $10 or made a “fast track” payment



















e.	 Returned my completed application quickly







f.	 Asked for help to complete my application quickly







c.	 My health plan, health care provider, or a non-profit organization
paid $10 or made a “fast track” payment for me
d.	 Applied for temporary coverage with the help of someone at a
health care provider's office or hospital

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15.	 When you enrolled in HIP 2.0, did you think it was easy or hard to do any of the following?
Please mark one answer in each row.

Very easy

Somewhat Neither easy
easy
nor hard

Somewhat
hard

Very
hard

a.	 Pay my contribution(s) when I get my invoice











b.	 Pay $10 or make a “fast track” payment































e.	 Return my completed application quickly











f.	 Ask for help to complete my application quickly











c.	 My health plan, health care provider, or
a non-profit organization pays $10 or
makes a “fast track” payment for me
d.	 Apply for temporary coverage with
the help of someone at a health care
provider's office or hospital

16.	 When you enrolled in HIP 2.0, how easy or hard was it to understand the differences between
HIP Basic and HIP Plus?

	Very easy
	Somewhat easy
	Neither easy nor hard
	Somewhat hard
	Very hard
17.	 Did you get any help in understanding the differences between HIP Basic and HIP Plus?
Mark one or more.

	I got help from family or friends
	I got help from my doctor or health care provider
	I got help from a HIP toll free number and/or a HIP representative in-person or online
	I got help from my health plan (i.e. Anthem, MDwise, MHS – Managed Health Services)
	I got help from another source
	I did not get any help

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For the next few questions, please think about your current HIP 2.0 benefits package.
18.	 How well do you think you understand your benefits package?

	Very well
	Somewhat
	Not at all well
19.	 For each of the following items, please tell us whether they are part of your HIP 2.0 benefits
package. Copays are payments you make at the time you visit your doctor’s office, go to the
hospital or get prescription drugs. Please mark one answer in each row.
My HIP benefits package includes…

Yes

No

Not sure

a.	 Vision and dental care







b.	 A way I can get prescriptions in the mail







d.	 Copays for doctor care







d.	 Copays for prescription drugs







e.	 Copays for hospital stays







f.	 Contribution(s)







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Satisfaction with HIP
20.	 Thinking about your overall experience with HIP 2.0, would you say you are:

	Very Satisfied
	Somewhat Satisfied
	Neither Satisfied nor Dissatisfied  GO TO QUESTION 22
	Somewhat Dissatisfied
	Very Dissatisfied
	Not sure/Don’t know  GO TO QUESTION 22
21.	 Please tell us how satisfied or dissatisfied you are with each HIP 2.0 item below.
Please mark one answer in each row.

Very
Satisifed

Somewhat
Satisfied

Neutral

Somewhat
Dissatisfied

Very
Dissatisfied

a.	 Length of time for coverage to begin











b.	 Ability to see my doctors with HIP 2.0











c.	 Choice of doctors in HIP 2.0











d.	 Coverage of health care services that I need











e.	 Understanding how POWER accounts work











f.	 Cost of contribution(s)











g.	 HIP 2.0 enrollment process











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Health Coverage Cost and Payment Options
We are studying ways to meet people’s health care needs, and would like your thoughts about what
you would like in your benefits package.
People pay for their health care services in different ways. Some people pay monthly contributions,
some people pay copays, and some people pay both. Copays are payments you make at the time you
visit your doctor’s office, go to the hospital, or get prescription drugs.
22.	 If you could choose how to pay for your health care services, what would you choose?

	I would choose to pay copays at my health care visits
	I would choose to make monthly contributions
	It does not matter to me
23.	 How important are each of the following factors when thinking about enrolling in a benefits package?
Very
important

Somewhat
important

Not at all
important

a.	 The cost of monthly contributions







b.	 The cost of copays or doctor visits







c.	 The cost of copays for non-emergency visits to
the emergency room







d.	 The cost of copays for prescription drugs



















Please mark one answer in each row.

e.	 The length of time with no coverage if I miss a
monthly contribution
f.	 If I lose coverage, being able to pay a missed
contribution to get my coverage back

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Demographics/About You
24.	 Would you say that in general your health is:

	Excellent
	Very good
	Good
	Fair
	Poor
25.	 What is the highest grade or level of school that you have completed?

	8th grade or less
	Some high school, but did not graduate
	High school graduate or GED
	Some college or 2-year degree
	4-year college graduate
	More than 4-year college degree
26.	 What best describes your employment status?

	

Employed full-time

	

Employed part-time

	

Self-employed

	

A homemaker

	

A full-time student

	

Unable to work for health reasons

	

Unemployed

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27.	 What is your age?

	 18 to 24

	 55 to 64

	 25 to 34

	 65 to 74

	 35 to 44

	 75 or older

	 45 to 54
28.	 Are you male or female?

	Male
	Female
29.	 Are you of Hispanic, Latino/a, or Spanish origin? One or more categories may be selected.

	No, not of Hispanic, Latino/a, or Spanish origin
	Yes, Mexican, Mexican American, Chicano/a
	Yes, Puerto Rican
	Yes, Cuban
	Yes, another Hispanic, Latino/a, or Spanish origin
30.	 What is your race? Mark one or more.

	 White

	 Vietnamese

	 Black or African-American

	 Other Asian

	 American Indian or Alaska Native

	 Native Hawaiian

	 Asian Indian

	 Guamanian or Chamorro

	 Chinese

	 Samoan

	 Filipino

	 Other Pacific Islander

	 Japanese

	 Some other race

	 Korean

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31.	 Please circle the number of people in your family (including yourself) that live in your household.
Mark only one answer that best describes your family’s total income over the last year before
taxes and other deductions. Your best estimate is fine.
Family size
(including yourself)
One person

Two people

Three people

Four people

Five people

Six people

Seven people

Eight people

Nine people

Ten or more
people

Family Income Per Year

	
At or below $6,000

	
At or above $12,000 and less than $16,000

	
Above $6,000 and less than $12,000

	
At or above $16,000

	
At or below $8,000

	
At or above $16,000 and less than $22,000

	
Above $8,000 and less than $16,000

	
At or above $22,000

	
At or below $10,000

	
At or above $20,000 and less than $28,000

	
Above $10,000 and less than $20,000

	
At or above $28,000

	
At or below $12,000

	
At or above $24,000 and less than $33,000

	
Above $12,000 and less than $24,000

	
At or above $33,000

	
At or below $14,000

	At or above $28,000 and less than $39,000

	
Above $14,000 and less than $28,000

	
At or above $39,000

	
At or below $16,000

	
At or above $33,000 and less than $45,000

	
Above $16,000 and less than $33,000

	
At or above $45,000

	
At or below $18,000

	At or above $37,000 and less than $51,000

	
Above $18,000 and less than $37,000

	
At or above $51,000

	
At or below $20,000

	
At or above $41,000 and less than $56,000

	
Above $20,000 and less than $41,000

	
At or above $56,000

	
At or below $23,000

	
At or above $45,000 and less than $62,000


	
Above $23,000 and less than $45,000

	
At or above $62,000

	
At or below $25,000

	
At or above $49,000 and less than $68,000

	
Above $25,000 and less than $49,000

	
At or above $68,000

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32.	 Did someone help you complete this survey?

	Yes
	No  THANK YOU. Please return the completed survey in the postage-paid envelope.
33.	 How did that person help you? Mark one or more.

	Read the questions to me
	Wrote down the answers I gave
	Answered the questions for me
	Translated the questions into my language

THANK YOU

Please return the completed survey in the postage-paid envelope.
Thoroughbred Research Group, Inc.
PO Box 80490
Conyers, GA 30013-9903

0269

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