Form CMS-10549 Test Questionnaire

Section name

Item name

Intro

BOX INT1

INTRO_1

Question Text
IF PROXY FLAG=1, GO TO PROXYINT,
ELSE, GO TO INTRO_1
NO CONTACT
Hello, may I please speak to [SP]? My name is [TI_NAME] and I'm calling
from NORC at the University of Chicago on behalf of the Medicare
Current Beneficiary Survey. How are you today?

Code Frame

Question Routing

I am calling because you are a [recent/current] participant in the
Medicare Current Beneficiary Survey. We are contacting MCBS
respondents to participate in a new short telephone survey called MCBS
Pulse. This special opinion survey about your experiences with Medicare
and the health care system. We sent you a letter in the mail about this
survey. Do you recall receiving the letter?
[IF YES, RECEIVED THE LETTER:] Great! As the letter mentioned, the
survey will take about 20 minutes of your time and will be completed
over the phone. Would you be available to do the interview now or can
we schedule a time for me to call back and do it at your convenience?
[IF NO, DID NOT RECEIVE THE LETTER:] The letter explained the
importance of this survey to help Medicare understand how it can
improve healthcare experiences for Medicare enrollees like you. The
(01) CONTINUE WITHOUT
survey will take about 20 minutes of your time and will be completed
RECORDING
over the phone.
(02) CONTINUE WITH RECORDING
(03) CONFIRM BUSINESS
Would you be available to do the interview now or can we schedule a
(04) OUT OF SCOPE
time for me to call back and do it at your convenience?
(06) ANSWERING MACHINE
(01) INTRO_2
(07 ) R WILL CALL 800
This call may be recorded or monitored.
(02) INTRO_2
LINE/VERIFY WEBSITE
(03) - (21) END
(09) SUPERVISOR REVIEW
INBOUND CALL
(15) TEST SAMPLE
Thank you for calling, this is [TI_NAME] for NORC at the University of
(17) DROPPED CELL CALL
Chicago with the MCBS Pulse Survey, how may I help you?
(20) GOVERNMENT CELL CALL
(21) DON’T WANT TO USE
This call may be recorded or monitored
MINUTES TO DO SURVEY
PARTIAL COMPLETE / CALLBACK
Hello, my name is [TI_NAME] and I'm calling from NORC at the
University of Chicago on behalf of the Medicare Current Beneficiary
Survey. I am calling because you are a [recent/current] participant in
the Medicare Current Beneficiary Survey. We are contacting MCBS
respondents to participate in a new short telephone survey called MCBS
Pulse. We previously spoke about sharing your your experiences with
Medicare and the health care system. Are you available now to
continue?
This call may be recorded or monitored.

Question Source Link

Requestor

n/a

N/A - Operational

n/a

N/A - Operational

Section name

Item name

Question Text

Hello, my name is [TI NAME] from NORC [at the University of Chicago]
and I am calling on behalf of the Medicare Current Beneficiary Survey
regarding a study about ways Medicare can improve the services it
provides to Medicare enrollees. I’d like to speak with [PROXY NAME].
Are they available?

PROXYINT

[IF AVAILABLE:] Recently, [SP] was sent a letter explaining that someone
would contact them for an interview. [SP] indicated that they would not
be able to participate but gave me your name as the person most
knowledgeable about their healthcare. Because [SP] is irreplaceable in
this study, if they are unable to complete the interview, we still want to
allow them to have a role in improving Medicare. You can participate on
behalf of [SP] and allow for [SP]’s health care experiences to help guide
Medicare policies now and in the future. Would you be available to do
the interview now or can we schedule a time for me to call back and do
it at your convenience?

Question Source Link

Requestor

(01) CONTINUE WITHOUT
RECORDING
(02) CONTINUE WITH RECORDING
(03) CONFIRM BUSINESS
(04) OUT OF SCOPE
(06) ANSWERING MACHINE
(01) INTRO_2
(07 ) R WILL CALL 800
(02) INTRO_2
LINE/VERIFY WEBSITE
(03) - (21) END
(09) SUPERVISOR REVIEW
(15) TEST SAMPLE
(17) DROPPED CELL CALL
(20) GOVERNMENT CELL CALL
(21) DON’T WANT TO USE
MINUTES TO DO SURVEY

n/a

N/A - Operational

(01) CONTINUE INTERVIEW NOW
(02) SCHEDULE INTERVIEW USING
CASE MANAGEMENT SYSTEM
(03) PROXY NEEDED
(04) DO NOT CONTINUE
INTERVIEW

n/a

N/A - Operational

Code Frame

Question Routing

This call may be recorded or monitored.

[As the letter mentioned/The letter explained that] we want to learn
about your experience with Medicare. Whether you have Medicare
yourself or you are helping someone you care for who has Medicare,
your answers will help us understand how well Medicare works. When
you share your thoughts with us, it helps us do a better job serving
Medicare members and their families.

INTRO_2

Your privacy is important to us. Taking this survey is your choice. Your
answers will be kept private to the extent permitted by law, as
prescribed by the Privacy Act of 1974. The information you provide is
combined with information provided by many others and only used to
describe Medicare beneficiaries as a group. No information that could
identify you individually is ever publicly released. Your Medicare
benefits will not be affected in any way by your survey responses or
participation. This survey takes about 20 minutes to finish. Some
people may finish faster. Your answers will help make Medicare better.
Do you agree to participate in this interview now or can we schedule a
time for me to call back and do it at your convenience?
[IF R INDICATES THEY WANT SOMEONE PRESENT OR NEED HELP
ANSWERING QUESTIONS:] If you’d like, you can have a friend or family
member present on the call during the interview to help you answer
some questions. Or you can select someone to provide us with your
information on your behalf if you don’t think you will be able to
complete the interview.

(01) CELLSAFE
(02) END & SCHEDULE
(03) END & COLLECT
NAME/CONTACT INFORMATION
FOR ASSISTANT/PROXY
(04) END & RECORD DISP

Section name

Item name

Question Text

Code Frame

Question Routing

Question Source Link

Requestor

SHOW IF CELL PHONE
If you are not in a place where you can safely talk on the phone and
answer my questions, I could call you back at a later time.

(01) CONTINUE
(02) R UNABLE TO CONTINUE
(03) NOT A CELL PHONE

(01) SPPROXY
(02) SAFECB
(03) SPPROXY

n/a

N/A - Operational

SHOW IF CELL PHONE
For your safety, we will call you back at another time.

(01) NOT SAFE - SET GENERAL
CALL BACK
(02) R REQUESTS SPECIFIC CALL
BACK TIME
(03) CALL BACK AT ANOTHER
NUMBER REQUESTED
(04) WRONG TIME ZONE
(05) Go Back to CELLSAFE

(01)-(04) END
(05) CELLSAFE

n/a

N/A - Operational

SPPROXY

WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE PERSON OR
WITH A PROXY?

(01) SAMPLE PERSON
(02) PROXY

(01) HEALTHINS
(02) CAREGIVR

n/a

N/A - Operational

CAREGIVR

Are you currently taking care of (SP) or helping (SP) make healthcare
decisions?

(01) Yes
(02) No
(95) Don't know
(97) Refuse

(01) HEALTHINS
(02) END
(95) END
(97) END

n/a

N/A - Operational

HEALTHINS

As you (may) know, Medicare beneficiaries can enroll in either Original
(01) YES, INFORMATION HAS
Medicare or a Medicare Advantage plan, such as an HMO (Health
CHANGED
Maintenance Organization) and PPO (Preferred Provider Organization).
(02) NO, INFORMATION HAS NOT
CHANGED
According to our records, [you are/(SP) is] currently enrolled in
(95) Don't know
[Medicare/a Medicare Advantage Plan that might be called (CMS
(97) Refuse
MEDICARE MANAGED CARE PLAN NAME)]. Has this information
changed?

(01) WHYWRNG
(02) USUAL
(95) USUAL
(97) USUAL

MCBS

N/A - Operational

CELLSAFE

SAFECB

Section name

Item name

Question Text

How has this information changed?
WHYWRNG

USUAL

Trust in physician

SELECT ONLY ONE. IF MORE THAN ONE RESPONSE IS APPLICABLE,
SELECT THE RESPONSE THAT IS CLOSEST TO THE TOP OF THE LIST.

Is there a particular doctor or other health professional, or a clinic
[you/(SP)] usually [go/goes] to when [you are/(SP) is] sick or for advice
about [your/(SP)'s] health?

Code Frame

Question Routing

Question Source Link

Requestor

(01) ENROLLED IN DIFFERENT
MEDICARE ADVANTAGE PLAN
(02) DOESN'T THINK PLAN IS A
MEDICARE ADVANTAGE PLAN
(03) NO LONGER IN ANY
MEDICARE ADVANTAGE PLAN
(04) SP NEVER COVERED BY OR
ENROLLED IN ANY MEDICARE
ADVANTAGE PLAN
(05) SP NO LONGER ENROLLED IN
MA PLAN OR ORIGINAL
MEDICARE
(95) Don't know
(97) Refuse

(01)-(04) USUAL
(05) END
(95) USUAL
(97) USUAL

MCBS

N/A - Operational

(01) Yes
(02) No
(95) Don't know
(97) Refuse

(01) PHYSINT
(02) MEDINT
(95) MEDINT
(97) MEDINT

MCBS

N/A - Operational

PHYSINT

The next questions are about how much you trust [your/(SP)'s] doctor
or health professional. For each statement, please tell us how much you (01) CONTINUE
agree or disagree.

PHY_TR1

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

PHY_TR1

(01) Strongly agree
Sometimes [your/(SP)'s] doctor or health professional cares more about (02) Agree
what is easy for them than about [your/(SP)'s] medical needs.
(03) Neutral
(04) Disagree
Would you say you strongly agree, agree, are neutral, disagree, or
(05) Strongly disagree
strongly disagree?
(95) Don't know
(97) Refuse

PHY_TR2

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

PHY_TR3

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

[Your/(SP)'s] doctor or health professional is thorough and careful.
PHY_TR2

[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

Section name

Item name

Question Text

Office of the Administrator

(01) Strongly agree
[Your/(SP)'s] doctor or health professional is honest and tells you about (02) Agree
all the different treatment options for [your/(SP)'s] condition.
(03) Neutral
(04) Disagree
[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
(05) Strongly disagree
neutral, disagree, or strongly disagree?]
(95) Don't know
(97) Refuse

PHY_TR5

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

MEDINT

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) CONTINUE

MED_TR1

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

MED_TR2

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

MED_TR3

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

Overall, you trust [your/(SP)'s] doctor or health professional.

MEDINT

[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

The next questions are about how much you trust doctors and
healthcare workers in general. For each statement, please tell us how
much you agree or disagree.

Sometimes doctors and health professionals care more about what is
easy for them than about their patients' medical needs.
MED_TR1
Would you say you strongly agree, agree, are neutral, disagree, or
strongly disagree?

Doctors and health professionals are thorough and careful.
MED_TR2

Requestor

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

Trust in medical
profession

Question Source Link

PHY_TR4

PHY_TR3

PHY_TR5

Question Routing

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

You trust [your/(SP)'s] doctor or health professional to choose the best
medical treatments for [you/(SP)].

PHY_TR4

Code Frame

[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

Section name

Item name

Question Text

You trust doctors and health professionals to choose the best medical
treatments.
MED_TR3
[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

A doctor or health professional would never mislead you about
anything.
MED_TR4
[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

Overall, you trust doctors and health professionals.
MED_TR5

Trust in CMS

[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

Code Frame

Question Routing

Question Source Link

Requestor

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

MED_TR4

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

MED_TR5

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

TRUSTINT

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) CONTINUE

CMS_TR1

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

TRUSTINT

The next questions are about how much you trust
[Medicare/[your/(SP)'s] Medicare Advantage insurance company].

CMS_TR1

(01) Strongly agree
[Medicare/[Your/(SP)'s] Medicare Advantage insurance company] cares
(02) Agree
more about saving money than about getting [you/(SP)] the treatment
(03) Neutral
[you/they] need.
(04) Disagree
(05) Strongly disagree
Would you say you strongly agree, agree, are neutral, disagree, or
(95) Don't know
strongly disagree?
(97) Refuse

CMS_TR2

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

CMS_TR3

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

CMS_TR2

You feel like you need to double check everything
[Medicare/[your/(SP)'s] Medicare Advantage insurance company]
company does.
[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

Section name

Item name

CMS_TR3

Question Text

Office of the Administrator

(01) Strongly agree
(02) Agree
(03) Neutral
(04) Disagree
(05) Strongly disagree
(95) Don't know
(97) Refuse

CMS_TR5

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

(01) Strongly agree
Overall, you trust [Medicare/[my/(SP)'s] Medicare Advantage insurance (02) Agree
company].
(03) Neutral
(04) Disagree
[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
(05) Strongly disagree
neutral, disagree, or strongly disagree?]
(95) Don't know
(97) Refuse

PREAUTHINT

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

Office of the Administrator

The next questions are about [your/(SP)'s] experiences with prior
authorization. Prior authorization means that your healthcare provider
requests approval from your insurer before you receive a treatment,
service, or prescription medicine.

(01) CONTINUE

PREAUTH

Original

Office of the Administrator, Center for
Medicaid & Medicaid Innovation,
Center for Medicare Parts C & D

(01) Yes
(02) No
(95) Don't know
(97) Refuse

(01) AUTHTYPE
(02) EOB
(95) EOB
(97) EOB

Original

Office of the Administrator, Center for
Medicaid & Medicaid Innovation,
Center for Medicare Parts C & D

In the past 12 months, did [your/(SP)'s] insurer require prior
authorization before [you/(SP)] could get a treatment, service, or
medicine that [your/(SP)'s] doctor recommended for [you/them]?
PREAUTH

Requestor

https://pmc.ncbi.nlm.nih.gov/articles/PM
C1262715/

[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
neutral, disagree, or strongly disagree?]

PREAUTHINT

Question Source Link

CMS_TR4

CMS_TR4

Experience with preauthorization

Question Routing

(01) Strongly agree
You believe [Medicare/[your/(SP)'s] Medicare Advantage insurance
(02) Agree
company] will pay for everything it is supposed to, even really expensive
(03) Neutral
treatments.
(04) Disagree
(05) Strongly disagree
[PROBE IF NECESSARY: Would you say you strongly agree, agree, are
(95) Don't know
neutral, disagree, or strongly disagree?]
(97) Refuse

If you have a question, you believe [Medicare/[my/(SP)'s] Medicare
Advantage insurance company] will give you a straight answer.

CMS_TR5

Code Frame

[IF NEEDED: Sometimes your insurance company needs you or your
doctor to share information about your medical care ahead of time to
make sure a treatment, service, or medicine will be covered. This is
referred to as "prior authorization"]

Section name

Item name

Question Text

Was this prior authorization for...
[Select all that apply]

AUTHTYPE

BOX PA1

AUTHTYPEO

A drug administered in a hospital, doctor’s office, or clinic?
A prescription drug from a pharmacy?
A visit to a health care provider?
A treatment, procedure, or surgery?
Imaging services?
Durable medical equipment?
Medical transport?
Dental services?
Or some other treatment or service?

Code Frame

Question Routing

(01) A drug administered in a
hospital, doctor’s office, or clinic
(02) A prescription drug from a
pharmacy
(03) A visit to a health care
provider
(04) A treatment, procedure, or
surgery
BOX PA1
(05) Imaging services
(06) Durable medical equipment
(07) Medical transport
(08) Dental services
(09) Other
(95) Don't know
(97) Refuse

Question Source Link

Requestor

Original

Office of the Administrator, Center for
Medicaid & Medicaid Innovation,
Center for Medicare Parts C & D

IF AUTHTYPE=9/ OTHER, GO TO AUTHTYPEO
ELSE GO TO BOX PA2.

What was this other treatment or service?

N/A - Operational

Write-in response

BOX PA2

IF AUTHTYPE=1/A DRUG ADMINISTERED IN A HOSPITAL, DOCTOR'S
OFFICE, OR CLINIC, GO TO XXXXSKIP,
ELSE GO TO BOX PA3.

XXXXSKIP

(01) Yes
In the past 12 months, did [you/(SP)] go without any drug administered (02) No
in a hospital, doctor's office, or clinic because of the prior authorization (03) Still waiting on approval
process?
(95) Don't know
(97) Refuse

XXXXDELY

In the past 12 months, did the prior authorization delay [you/(SP)]
getting any drug administered in a hospital, doctor's office, or clinic?

(01) Yes
(02) No
(95) Don't know
(97) Refuse

MCBS

Office of the Administrator, Center for
Medicaid & Medicaid Innovation,
Center for Medicare Parts C & D

Original

N/A - Operational

XXXXDELY

Original

Office of the Administrator, Center for
Medicaid & Medicaid Innovation,
Center for Medicare Parts C & D

XXXXPAY

Original

Office of the Administrator, Center for
Medicaid & Medicaid Innovation,
Center for Medicare Parts C & D

BOX PA2

Section name

Item name

Question Source Link

Requestor

Original

Office of the Administrator, Center for
Medicaid & Medicaid Innovation,
Center for Medicare Parts C & D

If other [SERVICE TYPE] are
selected, go to XXXXSKIP.
Otherwise, go to EOB

Original

Office of the Administrator, Center for
Medicaid & Medicaid Innovation,
Center for Medicare Parts C & D

(01) Always
(02) Often
(03) Sometimes
(04) Rarely
Not including the time spent reviewing statements as part of
(05) Never
[your/(SP)'s] participation in the MCBS, how often do you look at
(95) Don’t know
[your/(SP)'s] health insurance statements? Would you say always, often,
(97) Refuse
sometimes, rarely, or never?

(01) EOBEASY
(02) EOBEASY
(03) EOBEASY
(04) EOBEASY
(05) APPEAL
(95) APPEAL
(97) APPEAL

Original

CMS Health IT Ecosystem Team

(01) Very easy
(02) Easy
(03) Neither easy nor difficult
(04) Difficult
Would you say it's very easy, easy, neither easy nor difficult, difficult, or (05) Very difficult
very difficult?
(95) Don’t know
(97) Refuse

(01) EOBSERV
(02) EOBSERV
(03) EOBSERV
(04) EOBSERV
(05) EOBSERV
(95) APPEAL
(97) APPEAL

https://files.kff.org/attachment/ToplineSurvey-of-Consumer-Experiences-withHealth-Insurance.pdf

CMS Health IT Ecosystem Team

Question Text

Code Frame

Question Routing

What was the outcome of [your/(SP)'s] prior authorization(s) for
[SERVICE TYPE] in a hospital, doctor's office, or clinic in the past 12
months? Did [your/(SP)'s] insurer...
(01) Insurance APPROVED all
prior authorizations for a drug
administered in a hospital,
...Deny at least one prior authorization for for [SERVICE TYPE]
doctor's office, or clinic
(02) Insurance DENIED at least
...or, [are you/is (SP)] still waiting to resolve at least one prior
one prior authorizations for a
authorization for [SERVICE TYPE]
drug administered in a hospital,
XXXXSUBST
doctor's office, or clinic
IF SP RECEIVED RECEIVED A [SERVICE TYPE] THAN WHAT WAS
(03) SP still waiting to resolve at
REQUESTED, SELECT "Insurance DENIED at least one prior authorization least one prior authorization for a
for a drug administered in a hospital, doctor's office, or clinic"
drug administered in a hospital,
doctor's office, or clinic
IF PRIOR AUTHORIZATION HAS NOT RESOLVED YET, SELECT "Wating to (95) Don't know
resolve at least one prior authorization for [SERVICE TYPE]"
(97) Refuse
...Approve all prior authorizations for [SERVICE TYPE]

XXXXPAY

IF SP WAS LATER REIMBURSED FOR A CLAIM, SELECT "Insurance
APPROVED all prior authorizations for [SERVICE TYPE]"

XXXXSUBST

In the past year, did the prior authorization process cause you to get a
different [SERVICE TYPE] from what your doctor originally
recommended?

(01) Yes
(02) No
(95) Don't know
(97) Refuse

The next questions have to do with [your/(SP)'s] health insurance
statements. These statements are sometimes called "Explanation of
Benefits" or "Medicare Summary Notices".
Beneficiary health
literacy

EOB

How easy or difficult is it for you to understand these health insurance
statements?
EOBEASY

Section name

Item name

EOBSERV

Electronic medical
records

PORTPROV

Question Text

In the past 12 months, did you notice any medical services listed on
[your/(SP)'s] insurance statements that [you/(SP)] did not receive?

(01) Yes
(02) No
(95) Don't know
(97) Refuse

Have [your/(SP)'s] healthcare providers ever offered [you/(SP)] a way to
(01) Yes
see [your/their] medical records online, like through a patient portal?
(02) No
(95) Don't know
[IF NEEDED: This includes any doctor, dentist, eye doctor, lab, hospital,
(97) Refuse
or other healthcare provider [you have/(SP) has] visited.]

Have [your/(SP)'s] insurers ever offered [you/(SP)] a way to see
[your/their] medical records online, like through a patient portal?
PORTINS

Code Frame

[IF NEEDED: This includes Medicare, Medicare Advantage plans,
Medigap plans, dental and vision insurance, or any other health
insurance [you have/(SP) has].]

(01) Yes
(02) No
(95) Don't know
(97) Refuse

Question Source Link

Requestor

Original

Center for Program Integrity

PORTINS

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

BOX EHR1

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

Question Routing

PORTPROV

N/A - Operational

BOX EHR1

If PORTPROV = 1 or PORTINS = 1 then GO TO PORTUSE, else GO TO PRIV

PORTUSE

(01) 0 times
(02) 1 to 2 times
(03) 3 to 5 times
In the past 12 months, how many times did you use [your/(SP)'s] online
(04) 6 to 9 times
medical records or patient portal?
(05) 10 or more times
(95) Don’t know
(97) Refuse

(01) PRIV
(02) PORTEASY
(03) PORTEASY
(04) PORTEASY
(05) PORTEASY
(95) PRIV
(97) PRIV

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

(01) Very easy
(02) Easy
(03) Neither easy nor difficult
(04) Difficult
Would you say it was very easy, easy, neither easy nor difficult, difficult, (05) Very difficult
or very difficult?
(95) Don’t know
(97) Refuse

PRIV

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

How easy or difficult was it to understand the health information in
[your/(SP)'s] online medical records or patient portal?
PORTEASY

Section name

Item name

PRIV

Use of wearable
technology

TECHINT

Question Text

Question Routing

Question Source Link

Requestor

https://files.kff.org/attachment/ToplineKFF-Health-Tracking-Poll-January-2019

CMS Health IT Ecosystem Team

When you think about [your/(SP)'s] electronic medical records and
(01) Very concerned
personal health information, how concerned are you that someone who
(02) Somewhat concerned
shouldn't have access might see [your/(SP)'s] private records and
(03) Not too concerned
information?
(04) Not at all concerned
(95) Don’t know
Would you say you're very concerned, somewhat concerned, not too
(97) Prefer not to answer
concerned, or not at all concerned?

TECHINT

The next questions are about technology and [your/(SP)'s] health.

TECHWEAR

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

SHAREPROV

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

(01) CONTINUE

TECHWEAR

In the past 12 months, [have you/has (SP)] used an electronic wearable
device to monitor or track your health or activity? For example, a Fitbit, (01) Yes
Apple Watch, or a pedometer?
(02) No
(95) Don't know
INCLUDE BOTH SMART AND NON-SMART WEARABLE DEVICES (SUCH AS (97) Refuse
A BASIC PEDOMETER).

SHAREPROV

Would you be willing to share health data from [your/SP's] wearable
device with… [your/their] health care provider?

(01) Yes
(02) No
(95) Don't know
(97) Refuse

SHAREINS

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

SHAREINS

Would you be willing to share health data from [your/SP's] wearable
device with… [your/their] insurance providers?

(01) Yes
(02) No
(95) Don't know
(97) Refuse

SHAREFAM

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

SHAREFAM

Would you be willing to share health data from [your/SP's] wearable
device with… [your/their] family, friends, or caregiver?

(01) Yes
(02) No
(95) Don't know
(97) Refuse

AIPROV

https://hints.cancer.gov/docs/Instruments
/HINTS6-AnnotatedEnglishInstrument.pdf

CMS Health IT Ecosystem Team

(01) Very comfortable
(02) Somewhat comfortable
(03) Somewhat uncomfortable
(04) Very uncomfortable
(95) Don’t know
(97) Refuse

TOOLSINT

https://www.pewresearch.org/wpcontent/uploads/sites/20/2023/02/PS_20
23.02.22_AI-health_TOPLINE.pdf

CMS Health IT Ecosystem Team

(01) CONTINUE

IDEA1

Original

CMS Health IT Ecosystem Team

The next question is about artificial intelligence, or AI, being used in
healthcare.

Artificial Intelligence

Code Frame

AIPROV

How would you feel if [your/(SP)'s] health care provider relied on AI to
do things like diagnose disease and recommend treatments for
[your/(SP)'s] medical care?
Would you feel very comfortable, somewhat comfortable, somewhat
uncomfortable, or very uncomfortable?

The next few questions are about healthcare management tools.
Tools offered by
Medicare

TOOLSINT

How interested would you be in the following tools if Medicare offered
them?

Section name

MAHA

Item name

Question Text

Code Frame

Question Routing

Question Source Link

Requestor

IDEA1

(01) Extremely interested
A secure digital health record system that allows [you/(SP)] to access all
(02) Very interested
[your/their] medical information from doctors, hospitals, and insurance
(03) Somewhat interested
companies in one place.
(04) A little interested
(05) Not at all interested
Would you be extremely interested, very interested, somewhat
(95) Don't know
interested, a little interested, or not at all interested?
(97) Refuse

IDEA1B

Original

CMS Health IT Ecosystem Team,
Office of Communications

IDEA1B

(01) Extremely interested
A digital Medicare ID card on [your/(SP)'s] phone that works for check(02) Very interested
ins at the doctor's office, shows [your/(SP)'s] benefits, and lets [you/(SP)
(03) Somewhat interested
share [your/their] health information with doctors.
(04) A little interested
(05) Not at all interested
Would you be extremely interested, very interested, somewhat
(95) Don't know
interested, a little interested, or not at all interested?
(97) Refuse

MAHAINT

Original

CMS Health IT Ecosystem Team,
Office of Communications

MAHAINT

The next questions are about "Make America Healthy Again," or MAHA. (01) CONTINUE

MAHAHRD

n/a

N/A - Operational

MAHAHRD

Have you heard about the term Make America Healthy Again (MAHA) ?

How much do you know about Make America Healthy Again ?
MAHAKNOW
Would you say you know a great deal, quite a bit, a little, or nothing?

Do you have a favorable or an unfavorable opinion of Make America
Healthy Again ?
MAHAOPN
Would you say your opinion is very favorable, somewhat favorable,
neutral, somewhat unfavorable, or very unfavorable?

(01) Yes
(02) No
(95) Don't know
(97) Refuse

(01) MAHAKNOW
(02) END
(95) END
(97) END

https://ygo-assets-websites-editorialOffice of the Administrator (Dr. Oz),
emea.yougov.net/documents/Health_and Office of Program Operations & Local
_Nutrition_Policy_poll_results_1.pdf
Engagement (OPOLE)

(01) A great deal
(02) Quite a bit
(03) A little
(04) Nothing
(95) Don't know
(97) Refuse

(01) MAHAOPN
(02) MAHAOPN
(03) MAHAOPN
(04) END
(95) END
(97) END

Office of the Administrator (Dr. Oz),
https://ygo-assets-websites-editorialemea.yougov.net/documents/Health_an Office of Program Operations & Local
d_Nutrition_Policy_poll_results_1.pdf
Engagement (OPOLE)

(01) Very favorable
(02) Somewhat favorable
(03) Neutral
(04) Somewhat unfavorable
(05) Very unfavorable
(95) Don't know
(97) Refuse

END

Office of the Administrator (Dr. Oz),
https://ygo-assets-websites-editorialemea.yougov.net/documents/Health_an Office of Program Operations & Local
d_Nutrition_Policy_poll_results_1.pdf
Engagement (OPOLE)

Section name

Item name

END

Question Text

I would like to thank you for your time and cooperation during this
interview. You have made a very important contribution to the
Medicare program and all of its beneficiaries by sharing [your/(SP's)]
experiences and opinions.

Code Frame

(01) CONTINUE

Question Routing

END SURVEY

Question Source Link

Requestor

MCBS

N/A - Operational