Q01
Message
All templatesHealthcare & Clinical
Patient Impact of Medicare Telehealth Coverage Rollback
Measures how recent reductions in Medicare telehealth coverage are affecting beneficiaries' access to care, out-of-pocket costs, and health outcomes. Built for health systems, patient advocacy groups, and policy researchers tracking rollback effects, with an AI follow-up that reconstructs one specific care disruption in the patient's own words.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
Multiple ChoiceRequired
In the last 6 months, has your Medicare coverage for telehealth (video or phone) visits changed?
- Yes, coverage was reduced or ended for some visits
- Yes, but coverage has stayed about the same
- No change that I'm aware of
- Not sure
Q03
Multiple ChoiceRequired
Which types of telehealth visits have you used in the last 12 months?
- Primary care check-ins
- Mental or behavioral health counseling
- Specialist consultations
- Chronic disease management (e.g., diabetes, blood pressure)
- Prescription refills or medication management
- Physical or occupational therapy
- Other
Q04
Opinion ScaleRequired
How much has the recent change in telehealth coverage affected your ability to get the care you need?
Scale: 1 – 7
Min:Not affected at allMax:Severely affected
Q05
MatrixRequired
Since the coverage change, how much do you agree with each statement about your own experience?
5 rows × 5 columns
- I have delayed or skipped a needed appointment
- I have paid more out-of-pocket for care
- I have switched to in-person visits I would rather have done remotely
- I have had trouble reaching my regular doctor or provider
- My overall health has gotten worse
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q06
Multiple Choice
Think of the most recent time a telehealth visit you wanted was no longer covered. What did you do?
- Paid out of pocket for the telehealth visit
- Switched to an in-person visit
- Delayed getting care
- Skipped the visit entirely
- Found a different, lower-cost provider or option
- This hasn't happened to me
Q07
Rating ScaleRequired
How would you rate your current ability to access telehealth visits under Medicare?
Range: 1 – 5
Min:Very poorMax:Excellent
Q08
Best–Worst Trade-off (MaxDiff)Required
Which of these changes would help you the most versus the least in getting the care you need?
- Restoring coverage for mental health telehealth visits
- Restoring coverage for specialist telehealth consultations
- Lower copays or cost-sharing for telehealth visits
- Coverage for audio-only (phone-only) visits
- Being able to keep seeing the same doctor via telehealth
- Faster approval or reimbursement for telehealth claims
- Expanded telehealth options for chronic disease management
- Clearer information about what is currently covered
Pick best & worst per setBest:Would help mostWorst:Would help least
Q09
AI Interview
Reconstruct in detail what happened the most recent time this patient's Medicare telehealth coverage change affected their care: what the visit or need was, what they tried, what got in the way, and how it was ultimately resolved or not. If they say the change hasn't affected them yet, probe whether they're worried about future changes and what specifically concerns them, anchoring on any condition they manage regularly.
Q10
Message
Just a few last questions about you — these help us see whether the impact differs across patient groups. All are optional.
Q11
Multiple Choice
Which best describes your Medicare coverage?
- Original Medicare
- Medicare Advantage
- Medicare plus a Medigap supplemental plan
- Dual eligible (Medicare and Medicaid)
- Not sure
- Prefer not to say
Q12
Multiple Choice
What is your age range?
- Under 65 (disability or other qualifying reason)
- 65-74
- 75-84
- 85 or older
- Prefer not to say
Q13
Multiple Choice
Which best describes where you live?
- Urban
- Suburban
- Rural
- Prefer not to say
Q14
Message
Thank you for sharing your experience. Your responses will be combined with others to build a report on how telehealth coverage changes are affecting Medicare patients' access to and continuity of care.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Directly measures the patient impact of the Medicare telehealth coverage rollback — coverage changes, care disruptions, out-of-pocket costs, and health outcomes — rather than general satisfaction or intake data
- Includes an adaptive AI follow-up interview that reconstructs one specific recent care disruption in the patient's own words, capturing detail a fixed-choice form can't
- Combines opinion scale, matrix, rating, and MaxDiff questions to quantify perceived access change and prioritize which policy fixes (e.g., restoring specific visit types) would help patients most
- Segments results by Medicare coverage type, age, and location so health systems, advocacy groups, and policy researchers can see who is hit hardest by the rollback
Jotform
Outpatient Telehealth Consent Form TemplateThis is a consent/intake form for authorizing outpatient telehealth services, not a survey instrument for measuring policy impact. It's easy to customize as a static form but isn't built to capture patient experience, access changes, or cost impact data. Best suited to clinical onboarding workflows rather than research or advocacy data collection.
What it does well
- Purpose-built for telehealth consent/intake workflows
- Simple, quick to deploy as a standard form
- Familiar Jotform form-builder ecosystem for clinics
Where it falls short
- No mechanism to measure coverage changes, care disruption, or out-of-pocket cost impact
- Static form fields only — no adaptive follow-up questioning to surface patient stories
- Not designed for demographic segmentation or policy-impact reporting
SurveyMonkey
Patient Satisfaction Survey TemplateA generic post-visit patient satisfaction template aimed at gauging care experience, not telehealth coverage policy effects. It's a ready-to-field static questionnaire, which is a plus for quick deployment, but it doesn't address Medicare coverage changes, cost burden, or care access disruption specifically. Would require substantial rebuilding to fit this use case.
What it does well
- Ready-to-field, widely used survey platform with fast setup
- Established benchmarking and reporting tools for general patient satisfaction
- Broad distribution options across a large existing user base
Where it falls short
- Not focused on telehealth coverage rollback, access, or cost impact — would need heavy customization
- Fixed question set with no adaptive AI probing to reconstruct specific disruption events
- No published methodology or per-response quality scoring for open-ended answers
Frequently asked questions
What questions are in the “Patient Impact of Medicare Telehealth Coverage Rollback” template?
The template includes 14 ready-to-use questions, starting with: “Thanks for taking a few minutes to share your experience with Medicare's telehealth coverage changes. Your answers help…” · “In the last 6 months, has your Medicare coverage for telehealth (video or phone) visits changed?” · “Which types of telehealth visits have you used in the last 12 months?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 14 questions in about 7 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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