Health Insurance (HX) Section
HX01 ====
{STR-DT}
{END-DT}
Now I’d like to talk with you about health insurance, an
important topic for most persons. We want to know about all
the health coverage that anyone in the family may have had to
help pay the costs of medical care at any time {since (START
DATE)/between (START DATE) and (END DATE)}.
{ASK RESPONDENT TO GET INSURANCE CARDS/IDENTIFYING INFORMATION
IF NOT ALREADY AVAILABLE.}
PRESS ENTER TO CONTINUE.
----------------------------------------------------
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
| |
| DISPLAY ‘ASK....AVAILABLE.’ IF ROUND 1. |
| OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| IF ROUND 1, GO TO BOX_03 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH BOX_01 |
----------------------------------------------------
BOX_01 ======
----------------------------------------------------
| ASK THE OLD EMPLOYMENT AND PRIVATE RELATED |
| INSURANCE (OE) SECTION. |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF OE SECTION, CONTINUE WITH BOX_02 |
----------------------------------------------------
BOX_02 ======
----------------------------------------------------
| ASK THE OLD PUBLIC RELATED INSURANCE (PR) SECTION.|
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF PR SECTION, CONTINUE WITH BOX_03 |
----------------------------------------------------
BOX_03 ======
----------------------------------------------------
| IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS MEET THE|
| FOLLOWING CONDITIONS: |
- ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS |
| PROVIDING HEALTH INSURANCE |
| AND |
| - ESTABLISHMENT IS AN EMPLOYER |
| AND |
| - PERSON IS OR WAS A JOBHOLDER AT ESTABLISHMENT |
| AND |
| - ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’|
| OR IS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM- |
| SIZE-GREATER-THAN-1, |
| CONTINUE WITH LOOP_01 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_05 |
----------------------------------------------------
LOOP_01 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-PAIRS-|
| ROSTER, ASK HX02-END_LP01 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION |
| ABOUT PRIVATE HEALTH INSURANCE OBTAINED THROUGH |
| AN EMPLOYER. THIS LOOP CYCLES ON ESTABLISHMENT- |
| PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS |
| PROVIDING HEALTH INSURANCE |
| AND |
| - ESTABLISHMENT IS AN EMPLOYER |
| AND |
| - PERSON IS OR WAS A JOBHOLDER AT ESTABLISHMENT |
| AND |
| - ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’|
| OR IS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM- |
| SIZE-GREATER-THAN-1. |
----------------------------------------------------
HX02 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
{END-DT}
You mentioned that (PERSON) (were/was) covered by health
insurance from (ESTABLISHMENT) at some point after (START DATE).
CODE ‘1’ UNLESS RESPONDENT VOLUNTEERS REPORTED IN ERROR.
HAS/HAD HEALTH INSURANCE THROUGH
(ESTABLISHMENT) AT SOME POINT AFTER
(START DATE) ........................... 1
DOES NOT HAVE HEALTH INSURANCE THROUGH
(ESTABLISHMENT) ........................ 2
[Code One]
----------------------------------------------------
| IF CODED ‘2’ (DOES NOT HAVE HEALTH INSURANCE |
| THROUGH (ESTABLISHMENT)), FLAG THIS |
| ESTABLISHMENT-PERSON-PAIR AS ‘NOT SEPARATE |
| SOURCE OF INSURANCE’ AND GO TO END_LP01 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH BOX_04 |
----------------------------------------------------
BOX_04 ======
----------------------------------------------------
| ASK THE PRIVATE HEALTH INSURANCE DETAIL (HP) |
| SECTION FOR THIS ESTABLISHMENT-PERSON-PAIR. |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF HP SECTION, CONTINUE WITH |
| END_LP01 |
----------------------------------------------------
END_LP01 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |
| THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |
| END LOOP_01 AND CONTINUE WITH BOX_05 |
----------------------------------------------------
BOX_05 ======
----------------------------------------------------
| IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS MEET |
| THE FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS |
| PROVIDING HEALTH INSURANCE |
| AND |
| - ESTABLISHMENT IS AN EMPLOYER |
| AND |
| - PERSON IS A JOBHOLDER AT ESTABLISHMENT |
| AND |
| - ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’ |
| AND |
| - FIRM SIZE OF ESTABLISHMENT = 1, |
| CONTINUE WITH LOOP_02 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_07 |
----------------------------------------------------
LOOP_02 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-PAIRS-|
| ROSTER, ASK LOOP_03-END_LP02 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_02 COLLECTS INFORMATION |
| ABOUT THE SOURCES OF DIRECTLY PURCHASED HEALTH |
| INSURANCE ASSOCIATED WITH A SELF-EMPLOYED JOB |
| WHERE FIRM SIZE = 1. THIS LOOP CYCLES ON |
| ESTABLISHMENT-PERSON-PAIRS THAT MEET THE |
| FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS |
| PROVIDING HEALTH INSURANCE |
| AND |
| - ESTABLISHMENT IS AN EMPLOYER |
| AND |
| - PERSON IS A JOBHOLDER AT ESTABLISHMENT |
| AND |
| - ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’ |
| - FIRM SIZE OF ESTABLISHMENT = 1 |
----------------------------------------------------
LOOP_03 =======
----------------------------------------------------
| FOR EACH OF THE FOLLOWING: |
| |
| INSURANCE CATEGORY 1 |
| INSURANCE CATEGORY 2 |
| INSURANCE CATEGORY 3 |
| INSURANCE CATEGORY 4 |
| INSURANCE CATEGORY 5 |
| INSURANCE CATEGORY 6 |
| |
| ASK HX03 - END_LP03 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_03 COLLECTS INFORMATION |
| ABOUT THE WAYS PERSON PURCHASED HEALTH INSURANCE |
| (INSURANCE CATEGORIES AT HX03) ASSOCIATED WITH A |
| SELF-EMPLOYED JOB WITH FIRM-SIZE = 1. THE FIRST |
| CYCLE OF THIS LOOP COLLECTS THE MAIN WAY PERSON |
| PURCHASES INSURANCE. SUBSEQUENT CYCLES COLLECT |
| ADDITIONAL WAYS PERSON PURCHASES INSURANCE. |
| |
| THE RESPONSE AT HX04 DETERMINES WHETHER THE LOOP |
| CYCLES AGAIN. IF HX04 IS CODED ‘1’ (YES), THE |
| LOOP CYCLES TO COLLECT THE NEXT INSURANCE |
| CATEGORY. IF HX04 IS CODED ‘2’ (NO), ‘-7’ |
| (REFUSED), OR ‘-8’ (DON’T KNOW), THE LOOP ENDS. |
----------------------------------------------------
HX03 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
{END-DT}
SHOW CARD HX-1.
{You mentioned that (PERSON) {(are/is)/(were/was)} self-employed
and had health insurance through that business.} Which
category on this card comes closest to {the main/another} way
(PERSON) (purchase/purchases) this insurance?
FROM A PROFESSIONAL ASSOCIATION ........ 1 {BOX_06}
FROM A SMALL BUSINESS GROUP ............ 2 {BOX_06}
FROM A UNION ........................... 3 {BOX_06}
FROM A HEALTH INSURANCE PURCHASING
ALLIANCE ............................... 4 {BOX_06}
DIRECTLY FROM AN INSURANCE AGENT ....... 5 {BOX_06}
DIRECTLY FROM INSURANCE COMPANY ........ 6 {BOX_06}
DIRECTLY FROM AN HMO ................... 7 {BOX_06}
FROM A PREVIOUS EMPLOYER ............... 8 {BOX_06}
FROM A PREVIOUS EMPLOYER (COBRA) ....... 9 {BOX_06}
OTHER ................................. 91
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
| DISPLAY ‘You mentioned that (PERSON) {(are/is)/ |
| (were/was)} self-employed and had health insurance|
| through that business.’ IF FIRST CYCLE THROUGH |
| LOOP_03. OTHERWISE USE A NULL DISPLAY. |
| |
| DISPLAY ‘(are/is)’ IF ESTABLISHMENT IS FLAGGED AS |
| A CURRENT EMPLOYER. DISPLAY ‘(were/was)’ IF |
| ESTABLISHMENT IS NOT FLAGGED AS A CURRENT |
| EMPLOYER OR IF CURRENT ROUND IS ROUND 5. |
| |
| DISPLAY ‘the main’ IF FIRST CYCLE THROUGH LOOP_03.|
| OTHERWISE (I.E., NOT FIRST CYCLE), DISPLAY |
| ‘another’. |
----------------------------------------------------
HX03OV ======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
BOX_06 ======
----------------------------------------------------
| ASK PRIVATE HEALTH INSURANCE DETAIL (HP) SECTION |
| FOR THE RESPONSE CATEGORY SELECTED AT HX03. |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF HP SECTION, CONTINUE WITH HX04 |
----------------------------------------------------
HX04 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
{END-DT}
SHOW CARD HX-1.
Aside from what you already told me about, is there another
category on this card which describes the way (PERSON)
(purchase/purchases) health insurance for (ESTABLISHMENT)?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF ITEMS ON SHOW CARD.
END_LP03 ========
----------------------------------------------------
| IF HX04 IS CODED ‘1’ (YES), CYCLE TO COLLECT THE |
| NEXT WAY OF PURCHASING INSURANCE. |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, END LOOP_03 AND CONTINUE WITH END_LP02 |
----------------------------------------------------
END_LP02 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |
| THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |
| END LOOP_02 AND CONTINUE WITH BOX_07 |
----------------------------------------------------
BOX_07 ======
----------------------------------------------------
| IF ROUND 1, GO TO HX06 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH BOX_08 |
----------------------------------------------------
BOX_08 ======
----------------------------------------------------
| IF: |
| |
| ANY NEW RU MEMBERS ADDED TO RU THIS ROUND, |
| OR |
| ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING |
| MEDICARE TURNED 65 SINCE START DATE (USE REAL |
| DATE OF BIRTH ONLY), |
| OR |
| ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING |
| MEDICARE WERE = OR > 65 (OR IN AGE CATEGORY 9) IN |
| PREVIOUS ROUND, |
| CONTINUE WITH HX05 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_12 |
----------------------------------------------------
HX05 ====
{STR-DT}
{END-DT}
My records indicate that (READ NAMES BELOW) {(are/is)}
{either} {65 years old or older} {or} {joined the household
since our last interview}.
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
(Has (READ NAME ABOVE)/Have any of these people) been covered
by Medicare {since (START DATE)/between (START DATE) and (END DATE)}?
YES .................................... 1
NO ..................................... 2 {LOOP_04}
REF ................................... -7 {LOOP_04}
DK .................................... -8 {LOOP_04}
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
| DISPLAY ‘(are/is)’ AND ‘65 years old’ IF ANY RU |
| MEMBERS NOT ALREADY FLAGGED AS RECEIVING |
| MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU |
| MEMBERS NOT ALREADY FLAGGED AS RECEIVING |
| MEDICARE WERE = OR > 65 PREVIOUS ROUND. |
| |
| DISPLAY ‘joined the household since our last |
| interview’ IF ANY NEW RU MEMBERS ADDED TO THE RU |
| THIS ROUND. |
| |
| DISPLAY ‘either’ AND ‘or’ IF ANY NEW RU MEMBERS |
| ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS |
| NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED |
| 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY |
| FLAGGED AS RECEIVING MEDICARE WERE = OR > 65 |
| PREVIOUS ROUND. |
| |
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS|
| ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE |
| FOLLOWING CONDITIONS: |
| - PERSON IS AN RU MEMBER WHO IS NOT ALREADY |
| FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65|
| SINCE START DATE |
| OR |
| - PERSON IS AN RU MEMBER WHO IS NOT ALREADY |
| FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT |
| HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR > |
| 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS |
| ROUND |
| OR |
| - PERSON IS A NEW RU MEMBER |
----------------------------------------------------
----------------------------------------------------
| IF HX05 IS CODED ‘1’ (YES) AND ONLY ONE RU MEMBER |
| ELIGIBLE FOR HX05, SELECT THAT PERSON |
| AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04 |
----------------------------------------------------
----------------------------------------------------
| IF HX05 IS CODED ‘1’ (YES) AND MORE THAN ONE RU |
| MEMBER ELIGIBLE FOR HX05, GO TO HX07 |
----------------------------------------------------
HX06 ====
{STR-DT}
There are several large public health insurance programs {with
similar names} that are easily confused.
Medicare is a health insurance program for persons 65 years or
over and for disabled persons. Other programs, such as
{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP NAME}, are
state programs which cover low income families and individuals
or children who do not have private health insurance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare
usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been
covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
| DISPLAY ‘with similar names’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED USES ‘MEDICAID’ OR A |
| NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL). |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS ONE OF THE FOLLOWING: |
| ALASKA KENTUCKY NORTH CAROLINA |
| ALABAMA LOUISIANA NORTH DAKOTA |
| ARKANSAS MICHIGAN RHODE ISLAND |
| COLORADO MISSISSIPPI TEXAS |
| FLORIDA MONTANA UTAH |
| GEORGIA NEBRASKA VERMONT |
| IDAHO NEVADA WASHINGTON |
| ILLINOIS NEW HAMPSHIRE WEST VIRGINIA |
| INDIANA NEW JERSEY WISCONSIN |
| IOWA NEW MEXICO |
| KANSAS NEW YORK |
| |
| DISPLAY ‘Medical Assistance’ FOR ‘STATE NAME FOR |
| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS ONE OF THE FOLLOWING: |
| CONNECTICUT MARYLAND SOUTH DAKOTA|
| DISTRICT OF COLUMBIA MINNESOTA VIRGINIA |
| HAWAII PENNSYLVANIA |
| |
| DISPLAY ‘Arizona Health Care Cost Containment |
| System’ FOR ‘STATE NAME FOR MEDICAID’ IF STATE IN |
| WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA. |
| |
| DISPLAY ‘Medi-Cal’ FOR ‘STATE NAME FOR MEDICAID’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| CALIFORNIA. |
| |
| DISPLAY ‘Delaware Medical Assistance Program |
| (DMAP)’ FOR ‘STATE NAME FOR MEDICAID’ IF STATE IN |
| WHICH INTERVIEW IS BEING CONDUCTED IS DELAWARE. |
| |
| DISPLAY ‘MaineCare’ FOR ‘STATE NAME FOR MEDICAID’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| MAINE. |
| |
| DISPLAY ‘MassHealth’ FOR ‘STATE NAME FOR MEDICAID’|
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| MASSACHUSETTS. |
| |
| DISPLAY ‘Medicaid/MC+’ FOR ‘STATE NAME FOR |
| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS MISSOURI. |
| |
| DISPLAY ‘Ohio Health Plan’ FOR ‘STATE NAME FOR |
| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS OHIO. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Oregon Health Plan’ FOR ‘STATE NAME FOR |
| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS OREGON. |
| |
| DISPLAY ‘SoonerCare’ FOR ‘STATE NAME FOR MEDICAID’|
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| OKLAHOMA. |
| |
| DISPLAY ‘Partners for Health’ FOR ‘STATE NAME FOR |
| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS SOUTH CAROLINA. |
| |
| DISPLAY ‘TennCare’ FOR ‘STATE NAME FOR MEDICAID’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| TENNESSEE. |
| |
| DISPLAY ‘Equality Care’ FOR ‘STATE NAME FOR |
| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS WYOMING. |
| |
| DISPLAY ‘or Denali KidCare’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| ALASKA. |
| |
| DISPLAY ‘or ALL Kids’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| ALABAMA. |
| |
| DISPLAY ‘or KidsCare’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| ARIZONA. |
| |
| DISPLAY ‘or ARKids First’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| ARKANSAS. |
| |
| DISPLAY ‘or California Healthy Families’ FOR |
| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS CALIFORNIA. |
| |
| DISPLAY ‘or Child Health Plan Plus (CHP+) FOR |
| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS COLORADO. |
| |
| DISPLAY ‘or Husky Plan B’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| CONNECTICUT. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or DC Healthy Families’ FOR ‘STATE |
| CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS WASHINGTON, DC. |
| |
| DISPLAY ‘or Delaware Healthy Children Program’ FOR|
| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS DELAWARE. |
| |
| DISPLAY ‘or Florida Healthy Kids or MediKids’ FOR |
| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS FLORIDA. |
| |
| DISPLAY ‘or PeachCare for Kids’ FOR ‘STATE CHIP |
| NAME’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS GEORGIA. |
| |
| DISPLAY ‘Children’s Health Insurance Program |
| (CHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS HAWAII. |
| |
| DISPLAY ‘or Hawk-i (Healthy and Well Kids in |
| Iowa)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS IOWA. |
| |
| DISPLAY ‘or Idaho Children’s Health Insurance |
| Program’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS IDAHO. |
| |
| DISPLAY ‘or KidCare’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| ILLINOIS. |
| |
| DISPLAY ‘Children’s Health Insurance Program |
| (CHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS INDIANA. |
| |
| DISPLAY ‘or HealthWave’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| KANSAS. |
| |
| DISPLAY ‘or Kentucky Children’s Health Insurance |
| Program’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS KENTUCKY. |
| |
| DISPLAY ‘or LaCHIP’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| LOUISIANA. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or Maryland Children’s Health Program’ |
| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |
| IS BEING CONDUCTED IS MARYLAND. |
| |
| DISPLAY ‘Family Assistance’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| MASSACHUSETTS. |
| |
| DISPLAY ‘MIChild’ FOR ‘STATE CHIP NAME’ IF STATE |
| IN WHICH INTERVIEW IS BEING CONDUCTED IS MICHIGAN.|
| |
| DISPLAY ‘Children’s Health Insurance Program’ FOR |
| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS MINNESOTA. |
| |
| DISPLAY ‘or MC+ for Kids’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| MISSOURI. |
| |
| DISPLAY ‘or Mississippi Health Benefits Program’ |
| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |
| IS BEING CONDUCTED IS MISSISSIPPI. |
| |
| DISPLAY ‘or Montana Children’s Health Insurance |
| Plan’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS MONTANA. |
| |
| DISPLAY ‘or Kids Connection’ FOR ‘STATE CHIP NAME’|
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| NEBRASKA. |
| |
| DISPLAY ‘or Nevada Check Up’ FOR ‘STATE CHIP NAME’|
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| NEVADA. |
| |
| DISPLAY ‘or Healthy Kids’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| NEW HAMPSHIRE. |
| |
| DISPLAY ‘or NJ FamilyCare’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| NEW JERSEY. |
| |
| DISPLAY ‘or State Children’s Health Insurance |
| Program (SCHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN|
| WHICH INTERVIEW IS BEING CONDUCTED IS NEW MEXICO. |
| |
| DISPLAY ‘or Child Health Plus (CHPlus)’ FOR |
| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS NEW YORK. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or NC Health Choice for Children’ FOR |
| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS NORTH CAROLINA. |
| |
| DISPLAY ‘or Healthy Steps Program’ FOR ‘STATE |
| CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING |
| CONDUCTED IS NORTH DAKOTA. |
| |
| DISPLAY ‘or Healthy Start’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| OHIO. |
| |
| DISPLAY ‘or Pennsylvania’s Children’s Health |
| Insurance Program’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| PENNSYLVANIA. |
| |
| DISPLAY ‘or RIte Care’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| RHODE ISLAND. |
| |
| DISPLAY ‘or Partners for Healthy Children’ FOR |
| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED IS SOUTH CAROLINA. |
| |
| DISPLAY ‘or Children’s Health Insurance Program |
| (CHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS SOUTH DAKOTA. |
| |
| DISPLAY ‘or Children’s Health Insurance Program |
| (CHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS TEXAS. |
| |
| DISPLAY ‘or Children’s Health Insurance Program |
| (CHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED IS UTAH. |
| |
| DISPLAY ‘or Dr. Dynasaur’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |
| IS VERMONT. |
| |
| DISPLAY ‘or Family Access to Medical Insurance |
| Security (FAMIS) Plan’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| VIRGINIA. |
| |
| DISPLAY ‘or Children’s Health Insurance Program’ |
| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |
| IS BEING CONDUCTED IS WASHINGTON. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or West Virginia Children’s Health |
| Insurance Program’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| WEST VIRGINIA. |
| |
| DISPLAY ‘or BadgerCare’ FOR ‘STATE CHIP NAME’ IF |
| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| WISCONSIN. |
| |
| DISPLAY ‘or KidCare CHIP’ FOR ‘STATE CHIP NAME’ |
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |
| WYOMING. |
| |
| OTHERWISE, DISPLAY ‘or State Children’s Health |
| Insurance Program (CHIP)’ FOR ‘STATE CHIP NAME.’ |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘1’ (YES) AND SINGLE-PERSON RU, SELECT |
| PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO |
| LOOP_04 |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘1’ (YES) AND MULTI-PERSON RU, CONTINUE |
| WITH HX07 |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T |
| KNOW) AND ONE OR MORE RU MEMBER = > 65 YEARS OLD, |
| GO TO LOOP_04 |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T |
| KNOW) AND NO RU MEMBER = > 65 YEARS OLD, GO |
| TO BOX_12 |
----------------------------------------------------
----------------------------------------------------
| NOTE: HX06 IS ASKED ONLY IN ROUND 1. |
----------------------------------------------------
HX07 ====
{STR-DT}
{END-DT}
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
| ROSTER DEFINITION: |
| IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE |
| RU-MEMBERS-ROSTER. |
| IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE |
| RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING |
| CONDITIONS: |
| - PERSON IS A NEW RU MEMBER THIS ROUND |
| OR |
| - PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT |
| FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND |
| OR |
| - PERSON => 65 YEARS OLD (OR IN AGE CATEGORY 9) |
| LAST ROUND AND NOT FLAGGED AS COVERED BY |
| MEDICARE DURING ANY ROUND. |
----------------------------------------------------
LOOP_04 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK |
| BOX_09-END_LP04 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_04 DETERMINES IF REASON FOR|
| MEDICARE IS CONDITION/DISABILITY FOR PERSONS < 65 |
| WHO RECEIVE MEDICARE AND COLLECTS SOCIAL SECURITY |
| STATUS FOR PERSONS = > 65 WHO ARE NOT COVERED BY |
| MEDICARE. THIS LOOP CYCLES ON PERSONS WHO MEET |
| ANY OF THE FOLLOWING CONDITIONS: |
| - IF ROUND 1: ALL CURRENT RU MEMBERS |
| - IF NOT ROUND 1: ALL CURRENT RU MEMBERS WHO |
| MEET ONE OF THE FOLLOWING CONDITIONS: |
| - PERSON IS A NEW RU MEMBER THIS ROUND, |
| OR |
| - PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT |
| FLAGGED AS COVERED BY MEDICARE DURING ANY |
| ROUND |
| OR |
| - PERSON => 65 YEARS OLD (OR IN AGE CATEGORY 9) |
| LAST ROUND AND NOT FLAGGED AS COVERED BY |
| MEDICARE DURING ANY ROUND. |
----------------------------------------------------
BOX_09 ======
----------------------------------------------------
| IF ROUND 1, GO TO BOX_11 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH BOX_10 |
----------------------------------------------------
BOX_10 ======
----------------------------------------------------
| IF PERSON ADDED THIS ROUND, CONTINUE WITH BOX_11 |
----------------------------------------------------
----------------------------------------------------
| IF HX05 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR |
| ‘-8’ (DON’T KNOW) AND RU MEMBER TURNED 65 THIS |
| ROUND, GO TO HX09 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO END_LP04 |
----------------------------------------------------
----------------------------------------------------
| NOTE: HX09 IS NOT RE-ASKED OF PERSONS WHO WERE |
| OVER 65 DURING THE PREVIOUS ROUND AND DID NOT |
| RECEIVE MEDICARE AND WHO CONTINUE NOT RECEIVING |
| MEDICARE DURING THE CURRENT ROUND. |
----------------------------------------------------
BOX_11 ======
----------------------------------------------------
| IF PERSON IS SELECTED AT HX07 AND IS < 65 YEARS |
| OLD (OR IN AGE CATEGORIES 1-8), CONTINUE WITH HX08|
----------------------------------------------------
----------------------------------------------------
| IF PERSON IS SELECTED AT HX07 AND IS = > 65 YEARS |
| OLD (OR IN AGE CATEGORY 9), GO TO END_LP04 |
----------------------------------------------------
----------------------------------------------------
| IF PERSON IS NOT SELECTED AT HX07 AND IS < 65 |
| YEARS OLD (OR IN AGE CATEGORIES 1-8), GO TO |
| END_LP04 |
----------------------------------------------------
----------------------------------------------------
| IF PERSON IS NOT SELECTED AT HX07 AND IS = > 65 |
| YEARS OLD (OR IN AGE CATEGORY 9), GO TO HX09 |
----------------------------------------------------
----------------------------------------------------
| IF HX07 IS NOT ASKED (I.E., HX05 OR HX06 IS CODED |
| ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW)) |
| AND PERSON IS < 65 YEARS OLD (OR IN AGE CATEGORIES|
| 1-8), GO TO END_LP04 |
----------------------------------------------------
----------------------------------------------------
| IF HX07 IS NOT ASKED (I.E., HX05 OR HX06 IS CODED |
| ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW)) |
| AND PERSON IS = > 65 YEARS OLD (OR IN AGE CATEGORY|
| 9), GO TO HX09 |
----------------------------------------------------
HX08 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
(Do/Does) (PERSON) receive Medicare because of a medical
condition or a disability?
YES .................................... 1 {END_LP04}
NO ..................................... 2 {END_LP04}
REF ................................... -7 {END_LP04}
DK .................................... -8 {END_LP04}
PRESS F1 FOR DEFINITION OF CONDITION/DISABILITY.
HX09 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
People with Social Security usually get Medicare. (Do/Does)
(PERSON) receive Social Security?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF SOCIAL SECURITY.
END_LP04 ========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER WHO |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_04 AND CONTINUE WITH BOX_12 |
----------------------------------------------------
BOX_12 ======
----------------------------------------------------
| IF MEDICAID/SCHIP PROVIDED TO ANY RU MEMBER |
| DURING THE PREVIOUS ROUND, GO TO BOX_14 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH BOX_12A |
----------------------------------------------------
BOX_12A =======
----------------------------------------------------
| IF GOVT-HOSPITAL/PHYSICIAN IS A SOURCE OF |
| INSURANCE FOR ANY RU MEMBER DURING THE CURRENT |
| ROUND, GO TO BOX_14 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX10 |
----------------------------------------------------
HX10 ====
{STR-DT}
{END-DT}
{Some people are covered by programs called {Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME}. These are state
programs for low income families and individuals or children
who do not have private health insurance. They sometimes
cover persons with very large medical bills or those in
nursing homes.}
{SHOW CARD HX-3.}
{People covered by {Medicaid/{STATE NAME FOR MEDICAID}} usually
have a (piece of paper/card) that looks something like this.}
{During the last interview, we recorded that no one in the
family was covered by {Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}.}
Has anyone in the family been covered by {Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME} at any time {since (START
DATE)/between (START DATE) and (END DATE)}?
YES .................................... 1
NO ..................................... 2 {BOX_14}
REF ................................... -7 {BOX_14}
DK .................................... -8 {BOX_14}
PRESS F1 FOR DEFINITION OF MEDICAID/SCHIP.
----------------------------------------------------
| DISPLAY FIRST PARAGRAPH (‘Some .... homes.’) ONLY |
| IF ROUND 1. OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO |
| SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO|
| MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES |
| EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING |
| CONDUCTED IN TENNESSEE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY THIRD PARAGRAPH (‘During... CHIP NAME}}.’)|
| ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL |
| DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|
| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |
| STATE NAME FOR PROGRAM) IF THE STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|
| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |
| STATE, SEE BOX ON HX06. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |
| SUBSTITUTING THE REAL NAME FOR PROGRAM. FOR THE |
| SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘1’ (YES) AND SINGLE-PERSON RU, SELECT |
| PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO |
| LOOP_05 |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘1’ (YES) AND MULTI-PERSON RU, CONTINUE |
| WITH HX11 |
----------------------------------------------------
HX11 ====
{STR-DT}
{END-DT}
Who is covered by {Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}?
PROBE: Who else is covered by {Medicaid/{STATE NAME FOR
MEDICAID}} or {STATE CHIP NAME}?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
-----------------------------------------------------
| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY |
| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |
| STATE NAME FOR PROGRAM) IF THE STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |
| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |
| STATE, SEE BOX ON HX06. |
-----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |
| SUBSTITUTING THE REAL NAME FOR PROGRAM. FOR THE |
| SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06. |
----------------------------------------------------
-----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS THE |
| RU-MEMBERS-ROSTER. |
-----------------------------------------------------
LOOP_05 =======
-----------------------------------------------------
| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER, ASK BOX_13 - END_LP05 |
-----------------------------------------------------
-----------------------------------------------------
| LOOP DEFINITION: LOOP_05 COLLECTS TIME PERIOD |
| COVERAGE DETAIL FOR RU MEMBERS COVERED BY MEDICAID/|
| SCHIP. THIS LOOP CYCLES ON ESTABLISHMENT-PERSON- |
| PAIRS THAT MEET THE FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS MEDICAID/SCHIP |
| AND |
| - PERSON IS FLAGGED AS COVERED BY MEDICAID/SCHIP |
| DURING THE CURRENT ROUND (I.E., SELECTED IN |
| HX11) |
-----------------------------------------------------
BOX_13 ======
-----------------------------------------------------
| ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION |
| FOR THIS PERSON. |
-----------------------------------------------------
-----------------------------------------------------
| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |
| END_LP05 |
-----------------------------------------------------
END_LP05 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON THE RU-ESTABLISHMENT- |
| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |
| STATED IN THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |
| END LOOP_05 AND CONTINUE WITH BOX_14 |
----------------------------------------------------
BOX_14 ======
----------------------------------------------------
| IF TRICARE/CHAMPVA PROVIDED TO ANY RU MEMBER |
| DURING THE PREVIOUS ROUND, GO TO BOX_16 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX12 |
----------------------------------------------------
HX12 ====
{STR-DT}
{END-DT}
{During the last interview, we recorded that no one in the
family was covered by TRICARE or CHAMPVA.}
At any time {since (START DATE)/between (START DATE) and
(END DATE)}, has anyone in the family been covered by TRICARE
or CHAMPVA?
YES .................................... 1
NO ..................................... 2 {BOX_16}
REF ................................... -7 {BOX_16}
DK .................................... -8 {BOX_16}
PRESS F1 FOR DEFINITION OF TRICARE/CHAMPVA.
----------------------------------------------------
| DISPLAY FIRST PARAGRAPH (‘During .... TRICARE or |
| CHAMPVA.’) IF NOT ROUND 1. OTHERWISE, USE A |
| NULL DISPLAY. |
| |
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
HX12A =====
{STR-DT}
Which plan is it? Is it...
INTERVIEWER:
CODE MORE THAN ONE PLAN ONLY IF DIFFERENT RU MEMBERS
HAVE DIFFERENT PLANS.
TRICARE Standard; ...................... 1
TRICARE Prime; ......................... 2
TRICARE Extra; ......................... 3
TRICARE for Life; or ................... 4
CHAMPVA? ............................... 5
[Code All That Apply]
----------------------------------------------------
| IF HX12 IS CODED ‘1’ (YES) AND SINGLE-PERSON RU, |
| SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND |
| GO TO LOOP_06 |
----------------------------------------------------
----------------------------------------------------
| IF HX12 IS CODED ‘1’ (YES) AND MULTI-PERSON RU, |
| CONTINUE WITH HX13 |
----------------------------------------------------
HX13 ====
{STR-DT}
{END-DT}
Who is covered by TRICARE or CHAMPVA
PROBE: Who else is covered by TRICARE or CHAMPVA?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS THE |
| RU-MEMBERS-ROSTER. |
----------------------------------------------------
LOOP_06 =======
----------------------------------------------------
| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER, ASK BOX_15-END_LP06 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_06 COLLECTS TIME PERIOD |
| COVERAGE DETAIL FOR RU MEMBERS COVERED BY TRICARE |
| OR CHAMPVA THIS LOOP CYCLES ON ESTABLISHMENT- |
| PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS TRICARE/CHAMPVA |
| AND |
| - PERSON IS FLAGGED AS COVERED BY TRICARE/CHAMPVA|
| DURING THE CURRENT ROUND (I.E., SELECTED AT |
| HX13) |
----------------------------------------------------
BOX_15 ======
----------------------------------------------------
| ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION |
| FOR THIS PERSON. |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |
| END_LP06 |
----------------------------------------------------
END_LP06 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED |
| IN THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |
| END LOOP_06 AND CONTINUE WITH BOX_16 |
----------------------------------------------------
BOX_16 ======
----------------------------------------------------
| IF MEDICAID/SCHIP IS A SOURCE OF INSURANCE FOR |
| ANY RU MEMBER DURING CURRENT ROUND, GO TO BOX_19 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH BOX_17 |
----------------------------------------------------
BOX_17 ======
----------------------------------------------------
| IF GOVT-HOSPITAL/PHYSICIAN PROVIDED TO ANY RU |
| MEMBER DURING THE PREVIOUS ROUND, GO TO BOX_19 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX14 |
----------------------------------------------------
HX14 ====
{STR-DT}
{END-DT}
{During the last interview, we recorded that no one in the
family was covered by any other state sponsored program which
provided hospital and physician benefits.}
At any time {since (START DATE)/between (START DATE) and
(END DATE)}, has anyone in the family had any type of health
insurance obtained through any state or local government agency
which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 {BOX_19}
REF ................................... -7 {BOX_19}
DK .................................... -8 {BOX_19}
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
| DISPLAY FIRST PARAGRAPH (‘During .... benefits.’) |
| IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY. |
| |
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
HX14A =====
What is the name of the plan?
[Enter text] ...........................
----------------------------------------------------
| IF HX14 IS CODED ‘1’ (YES) AND SINGLE-PERSON RU, |
| SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND |
| GO TO LOOP_07 |
----------------------------------------------------
----------------------------------------------------
| IF HX14 IS CODED ‘1’ (YES) AND MULTI-PERSON RU, |
| CONTINUE WITH HX15 |
----------------------------------------------------
----------------------------------------------------
| NOTE: ‘GOVT-HOSPITAL/PHYSICIAN’ SHOULD BE USED |
| FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER |
| (WHERE APPROPRIATE). |
----------------------------------------------------
HX15 ====
{STR-DT}
{END-DT}
Who is covered by a program sponsored by a state or local
government agency which provided hospital and physician
benefits?
PROBE: Who else is covered by a program sponsored by a state
or local government agency which provided hospital and
physician benefits?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS THE |
| RU-MEMBERS-ROSTER. |
----------------------------------------------------
LOOP_07 =======
----------------------------------------------------
| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER, ASK BOX_18-END_LP07 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_07 COLLECTS TIME PERIOD |
| COVERAGE DETAIL FOR RU MEMBERS COVERED BY GOVT- |
| HOSPITAL/PHYSICIAN. THIS LOOP CYCLES ON |
| ESTABLISHMENT-PERSON-PAIRS THAT MEET THE |
| FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN |
| AND |
| - PERSON IS FLAGGED AS BEING COVERED BY GOVT- |
| HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND |
| (I.E., SELECTED AT HX15) |
----------------------------------------------------
BOX_18 ======
----------------------------------------------------
| ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION |
| FOR THIS PERSON. |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |
| END_LP07 |
----------------------------------------------------
END_LP07 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON THE RU-ESTABLISHMENT- |
| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |
| STATED IN THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |
| END LOOP_07 AND CONTINUE WITH BOX_19 |
----------------------------------------------------
BOX_19 ======
----------------------------------------------------
| IF ANY TYPE OF OTHER PUBLIC INSURANCE PROVIDED TO |
| ANY RU MEMBER AT ANY TIME DURING THE PREVIOUS |
| ROUND, GO TO HX21 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX16 |
----------------------------------------------------
HX16 ====
{STR-DT}
{END-DT}
{During the last interview, we recorded that no one in the
family/Some people} receive{d} health benefits from other state
programs such as (READ PROGRAM NAMES BELOW) or other public
programs that provide coverage for health care services.
{STATE NAME FOR PROGRAM #1..................}
{STATE NAME FOR PROGRAM #2..................}
{STATE NAME FOR PROGRAM #3..................}
{STATE NAME FOR PROGRAM #4..................}
At any time since (START DATE), has anyone in the family been
covered by any program like this?
YES .................................... 1
NO ..................................... 2 {HX21}
REF ................................... -7 {HX21}
DK .................................... -8 {HX21}
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
| DISPLAY ‘During the last interview, we recorded |
| that no one in the family’ AND THE ‘d’ ON |
| ‘receive’ IF NOT ROUND 1. OTHERWISE, DISPLAY |
| ‘Some people’. |
| |
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
| |
| DISPLAY THE LIST OF UP TO FOUR ACTUAL NAMES OF |
| STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR ‘STATE |
| NAME FOR PROGRAM #N’ IF STATE HAS OTHER STATE |
| PROGRAMS. OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| STATE OTHER PUBLIC PROGRAM(S) |
| |
| ALASKA Chronic and Acute Medical |
| Assistance (CAMA) |
| Alaska Breast and Cervical Cancer |
| Early Detection Program |
| Senior Care |
| ALABAMA Alabama Breast and Cervical Cancer |
| Early Detection Program |
| ARIZONA Arizona Breast and Cervical Cancer |
| Early Detection Program |
| ARKANSAS Arkansas Breast and Cervical Cancer|
| Early Detection Program |
| Arkansas Health Care Access |
| Foundation |
| CALIFORNIA AIDS Drug Assistance Program (ADAP)|
| CA Breast and Cervical Cancer Early|
| Detection Program |
| Assistance to Infants and Mothers |
| General Relief or General Aid |
| COLORADO Colorado Breast and Cervical Cancer|
| Early Detection Program |
| Colorado Indigent Care Program |
| (CICP) |
| CONNECTICUT ConnPACE |
| CT AIDS Drug Assistance Program |
| (CADAP) |
| CT Pharmaceutical Assist. Contract |
| CT Breast and Cervical Cancer Early|
| Detection Program |
| DELAWARE Delaware Pharmacy Assistance |
| Program |
| Chronic Renal Disease Program |
| DE Breast and Cervical Cancer Early|
| Detection Program |
| DISTRICT OF |
| COLUMBIA DC Healthcare Alliance |
| DC Breast and Cervical Cancer Early|
| Detection Program |
| DC Free Clinics |
| FLORIDA FL Breast and Cervical Cancer Early|
| Detection Program |
| AIDS Disease Management Program |
| GEORGIA GA Breast and Cervical Cancer Early|
| Detection Program |
| HAWAII Hawaii Rx Plus |
| Breast and Cervical Cancer Control |
| Program |
----------------------------------------------------
----------------------------------------------------
| STATE OTHER PUBLIC PROGRAM(S) |
| |
| IDAHO ID Breast and Cervical Cancer Early|
| Detection Program |
| Rx Idaho |
| ILLINOIS Illinois Breast and Cervical Cancer|
| Early Detection Program |
| Chronic Renal Disease Program |
| Illinois Cares Rx |
| INDIANA Hoosier Rx |
| Children’s Special Health Care |
| Services |
| IN Breast and Cervical Cancer Early|
| Detection Program |
| IN Comprehensive Health Insurance |
| Association |
| IOWA Iowa Breast and Cervical Cancer |
| Early Detection Program |
| KANSAS KS AIDS Drug Assistance Program |
| MediKan |
| Kansas Breast and Cervical Cancer |
| Early Detection Program |
| KENTUCKY KY Breast and Cervical Cancer Early|
| Detection Program |
| State Employee KY Children’s Health|
| Insurance Program |
| LOUISIANA LA Breast and Cervical Cancer Early|
| Detection Program |
| MAINE Maine Breast and Cervical Cancer |
| Early Detection Program |
| Drugs for the Elderly |
| MARYLAND Kidney Disease Program |
| MD AIDS Drug Assistance Program |
| Maryland Breast and Cervical Cancer|
| Early Detection Program |
| Maryland Pharmacy Assistance |
| Program |
| MASSACHUSETTS Prescription Advantage Plan |
| MA HIV Drug Assistance Program |
| MA Breast and Cervical Cancer Early|
| Detection Program |
| MICHIGAN Michigan AIDS Drug Assistance |
| Program (ADAP) |
| Adult Medical Program |
| EPIC (Elderly Prescription |
| Insurance Coverage) |
| MI Rx Prescription Savings Program |
----------------------------------------------------
----------------------------------------------------
| STATE OTHER PUBLIC PROGRAM(S) |
| |
| MINNESOTA The Prescription Drug Program |
| MN AIDS Drug Assistance Program |
| (ADAP) |
| MinnesotaCare |
| MISSISSIPPI Mississippi Breast and Cervical |
| Cancer Early Detection Program |
| MISSOURI Missouri Senior Rx Program |
| MO Breast and Cervical Cancer Early|
| Detection Program |
| MONTANA End-Stage Renal Disease Program |
| Montana Breast and Cervical Cancer |
| Early Detection Program |
| The Mental Health Services Plan |
| NEBRASKA Nebraska Breast and Cervical Cancer|
| Early Detection Program |
| NEW HAMPSHIRE Catastrophic Illness Program |
| New Hampshire Breast and Cervical |
| Cancer Early Detection Program |
| NH AIDS Drug Assistance Program |
| Care Program |
| NEVADA Senior Rx Insurance Subsidy for |
| Prescription Drugs |
| Nevada Breast and Cervical Cancer |
| Early Detection Program |
| NEW JERSEY Pharmaceutical Assistance for the |
| Aged and Disabled (PAAD) |
| NJ AIDS Drug Assistance Program |
| (ADAP) |
| General Assistance Prescription |
| Drug Plan |
| General Assistance Medical Services|
| NEW MEXICO Breast and Cervical Cancer Early |
| Detection Program |
| NEW YORK Elderly Pharmaceutical Insure |
| Program (EPIC) |
| NY AIDS Drug Assistance Program |
| (ADAP) |
| Healthy Women Partnership |
| Cancer Services Program |
| NORTH |
| CAROLINA State Kidney Program |
| School Health Fund |
| Sickle Cell Program |
| NC Breast and Cervical Cancer Early|
| Detection Program |
| NORTH DAKOTA ND Breast and Cervical Cancer Early|
| Detection Program |
| ND AIDS Drug Assistance Program |
----------------------------------------------------
----------------------------------------------------
| STATE OTHER PUBLIC PROGRAM(S) |
| |
| OHIO Ohio Disability Assistance Medical |
| Program |
| Ohio’s Best Prescription Discount |
| Card |
| General Assistance |
| Ohio Breast and Cervical Cancer |
| Early Detection Program |
| OKLAHOMA AIDS Drug Assistance Programs |
| (ADAP) |
| Oklahoma Breast and Cervical Cancer|
| Early Detection Program |
| End Stage Renal Disease Program |
| Part A |
| End Stage Renal Disease Program |
| Part B |
| OREGON Senior Prescription Drug Assistance|
| Program-discounts |
| Oregon Breast and Cervical Cancer |
| Program |
| Car Assist (HIV) |
| PENNSYLVANIA AdultBasic |
| Pharmacy Assistance Contract for |
| Elderly (PACE)/PACE NET) |
| Chronic Renal Disease Program |
| RHODE ISLAND General Public Assistance Medical |
| Program |
| Rhode Island Pharmacy Assistance |
| for Elderly (RIPAE) |
| Rhode Island Women’s Cancer |
| Screening Program |
| RI AIDS Drug Assistance Program |
| SOUTH |
| CAROLINA SC Breast and Cervical Cancer Early|
| Detection Program |
| Gap Assistance Pharmacy Program for|
| Service |
| Medically Indigent Assistance |
| Program |
| SOUTH DAKOTA SD Chronic Renal Disease Program |
| Prescription Access |
| SD Breast and Cervical Cancer Early|
| Detection Program |
| TENNESSEE Tennessee Renal Disease Program |
| Tennessee Breast and Cervical |
| Cancer Screening Program |
| Prescription Outreach |
| Express Access Drug Discount Card |
----------------------------------------------------
----------------------------------------------------
| STATE OTHER PUBLIC PROGRAM(S) |
| |
| TEXAS Division of Kidney Health Care |
| Program |
| Texas HIV Medication Program (THMP)|
| Breast and Cervical Cancer Control |
| Children with Special Health Care |
| Needs |
| UTAH Utah Children with Special Health |
| Care Needs (CSHCN) |
| Utah Breast and Cervical Cancer |
| Early Detection Program |
| Primary Care Network of Utah |
| VIRGINIA State and Local Hospitalization |
| Program |
| Virginia Breast and Cervical Cancer|
| Early Detection Program |
| VERMONT Vermont End Stage Renal Disease |
| Program |
| VT Breast and Cervical Cancer Early|
| Detection Program |
| Vpharm |
| General Assistance Medical Services|
| WASHINGTON WA State Kidney Disease Program |
| WA HIV Drug Assistance Program |
| General Assistance |
| WA Breast and Cervical Cancer Early|
| Detection Program |
| WEST VIRGINIA Children with Special Health Care |
| Needs |
| Prenatal Care Program |
| WV Breast and Cervical Cancer Early|
| Detection Program |
| WISCONSIN WI AIDS Drug Reimbursement Program |
| Wisconsin Chronic Renal Disease |
| Program |
| Well-Woman Program |
| Health Insurance Risk Sharing |
| Program |
| WYOMING Prescription Drug Assistance |
| Program |
| WY HIV/AIDS/Hepatitis Program |
| WY End Stage Renal Disease Program |
| WY Breast and Cervical Cancer Early|
| Detection Program |
----------------------------------------------------
LOOP_08 =======
----------------------------------------------------
| FOR EACH OF THE FOLLOWING: |
| |
| GROUP 1 |
| GROUP 2 |
| |
| ASK BOX_20-END_LP08 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_08 COLLECTS INFORMATION ON |
| OTHER STATE OR PUBLIC PROGRAMS. THE FIRST CYCLE |
| OF THIS LOOP COLLECTS GROUP 1 OTHER PUBLIC |
| INSURANCE PROGRAMS OR, IF NO GROUP 1, GROUP 2 |
| OTHER PUBLIC INSURANCE PROGRAMS. |
| |
| THIS LOOP CAN CYCLE A MAXIMUM OF TWICE. THE |
| SUBSEQUENT CYCLE OF THE LOOP IS DETERMINED BY THE |
| RESPONSE AT HX20. IF HX20 IS CODED ‘1’ (YES), |
| THE LOOP CYCLES AGAIN TO COLLECT GROUP 2 PUBLIC |
| INSURANCE INFORMATION. IF HX20 IS CODED ‘2’ (NO), |
| ‘-7’ (REFUSED), ‘-8’ (DON’T KNOW), OR IS NOT |
| ASKED, THE LOOP ENDS. |
----------------------------------------------------
BOX_20 ======
----------------------------------------------------
| IF FIRST CYCLE OF LOOP_08, CONTINUE WITH HX17 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (I.E., IF SECOND CYCLE OF LOOP_08), GO |
| TO HX18 |
----------------------------------------------------
HX17 ====
{STR-DT}
{END-DT}
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY TANF, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA
IS MENTIONED, CODE 95.
{STATE SPECIFIC PLAN 1} ................ 1
{STATE SPECIFIC PLAN 2} ................ 2
{STATE SPECIFIC PLAN 3} ................ 3
{STATE SPECIFIC PLAN 4} ................ 4
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
| FOR ‘STATE SPECIFIC PLAN N’, DISPLAY AN ACTUAL |
| NAME OF A STATE PLAN WHEN INTERVIEW IS BEING |
| CONDUCTED IN A STATE THAT HAS OTHER STATE |
| PROGRAMS. FOR THE SPECIFIC NAMES OF PROGRAMS BY |
| STATE, SEE BOX ON HX16. |
----------------------------------------------------
----------------------------------------------------
| ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP|
| 1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED |
| ABOUT IN HX19. |
----------------------------------------------------
----------------------------------------------------
| CODES ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, AND ‘6’ ARE |
| RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE |
| HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER |
| CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC |
| PLANS, CODES WOULD START WITH ‘91’ AT HX17 OR ‘7’ |
| AT HX18.) |
----------------------------------------------------
----------------------------------------------------
| EDIT: CODE ‘95’ (NONE OF THESE) CANNOT BE ENTERED|
| WITH ANY OTHER CODES. IF CODED ‘95’ (NONE OF |
| THESE) WITH ANY OTHER CODES, DISPLAY THE |
| FOLLOWING MESSAGE: ‘95 CANNOT BE CODED WITH ANY |
| OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS |
| ENTER TO CONTINUE.’ |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |
| WITH ANY OTHER CODE, CONTINUE WITH HX17OV |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘95’ (NONE OF THESE), GO TO HX18 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_21 |
----------------------------------------------------
HX17OV ======
ENTER OTHER:
[Enter Other Specify] .................. {BOX_21}
REF ................................... -7 {BOX_21}
DK .................................... -8 {BOX_21}
HX18 ====
{STR-DT}
{END-DT}
What is the name of the program?
PROBE: Any other state program?
TANF (TEMPORARY ASSISTANCE FOR
NEEDY FAMILIES) ........................ 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
| ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A |
| GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN |
| ASKED ABOUT IN HX19 |
----------------------------------------------------
----------------------------------------------------
| IF: |
| NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- |
| HOSPITAL/PHYSICIAN DURING CURRENT ROUND |
| AND |
| HX18 IS CODED ‘7’ (TANF), ‘8’ (SSI), OR ‘9’ |
| (WIC), ALONE OR WITH ANY OTHER COMBINATION OF |
| CODES, CONTINUE WITH BOX_21 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO END_LP08 |
----------------------------------------------------
BOX_21 ======
----------------------------------------------------
| IF SINGLE-PERSON RU, SELECT PERSON AT HX19 |
| AUTOMATICALLY BY CAPI AND GO TO LOOP_09 |
----------------------------------------------------
----------------------------------------------------
| IF MULTI-PERSON RU, CONTINUE WITH HX19 |
----------------------------------------------------
HX19 ====
{STR-DT}
{END-DT}
PROGRAM:
{STATE PROGRAM PROVIDING COVERAGE}
{STATE PROGRAM PROVIDING COVERAGE}
{STATE PROGRAM PROVIDING COVERAGE}
{STATE PROGRAM PROVIDING COVERAGE}
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
| IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED|
| AT HX17. IF COMING FROM HX18, DISPLAY ALL |
| PROGRAMS SELECTED AT HX18. |
----------------------------------------------------
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- |
| MEMBERS-ROSTER. |
----------------------------------------------------
LOOP_09 =======
----------------------------------------------------
| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |
| PAIRS ROSTER, ASK BOX_22-END_LP09 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_09 COLLECTS TIME PERIOD |
| COVERAGE DETAIL FOR RU MEMBERS COVERED BY OTHER |
| PUBLIC PROGRAMS. THIS LOOP CYCLES ON ESTABLISHMENT|
| -PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS GROUP 1 OR GROUP 2 OTHER |
| PUBLIC PROGRAM |
| AND |
| - PERSON IS FLAGGED AS BEING COVERED BY GROUP 1 |
| OR GROUP 2 OTHER PUBLIC PROGRAM DURING THE |
| CURRENT ROUND (I.E., SELECTED IN HX19) |
----------------------------------------------------
----------------------------------------------------
| IF FIRST TIME THROUGH LOOP_08 AND HX17 IS NOT |
| CODED ‘95’ (NONE OF THESE), THIS LOOP CYCLES ON A |
| ESTABLISHMENT-PERSON-PAIR WHERE ESTABLISHMENT IS A|
| GROUP 1 OTHER PUBLIC PROGRAM. |
----------------------------------------------------
----------------------------------------------------
| IF HX17 IS CODED ‘95’ (NONE OF THESE) OR IF SECOND|
| CYCLE OF LOOP_08, THEN THE ESTABLISHMENT IS A |
| GROUP 2 OTHER PUBLIC PROGRAM. |
----------------------------------------------------
BOX_22 ======
----------------------------------------------------
| ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION |
| FOR THIS PERSON. |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |
| END_LP09 |
----------------------------------------------------
END_LP09 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT- |
| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |
| STATED IN THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |
| END LOOP_09 AND CONTINUE WITH BOX_23 |
----------------------------------------------------
BOX_23 ======
----------------------------------------------------
| IF HX17 IS CODED ‘95’ (NONE OF THESE) OR IF ON |
| SECOND CYCLE OF LOOP_08, GO TO END_LP08 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX20 |
----------------------------------------------------
HX20 ====
{STR-DT}
{END-DT}
Are there any other state programs that provide coverage for
health care services to anyone else in the family?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
END_LP08 ========
----------------------------------------------------
| IF HX20 IS CODED ‘1’ (YES), CYCLE TO COLLECT GROUP|
| 2 PUBLIC INSURANCE INFORMATION. |
----------------------------------------------------
----------------------------------------------------
| IF HX20 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), ‘-8’ |
| (DON’T KNOW), OR IS NOT ASKED, END LOOP_08 AND |
| CONTINUE WITH HX21 |
----------------------------------------------------
HX21 ====
{STR-DT}
{END-DT}
Next, I have some questions about other sources of health
insurance anyone in the family may have had {since (START
DATE)/between (START DATE) and (END DATE)} to help pay hospital
and doctor bills and other health expenses such as nursing home
care or prescribed medicines. {This includes Medigap or
Medicare Supplements, plans through a private insurance carrier,
which some people who are eligible for Medicare have as
additional coverage.}
PRESS ENTER TO CONTINUE.
----------------------------------------------------
| DISPLAY ‘This includes...coverage.’ IF ANYONE IN |
| RU HAS MEDICARE AS A SOURCE OF INSURANCE DURING |
| THE CURRENT ROUND. |
| |
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
HX22 ====
{STR-DT}
{END-DT}
SHOW CARD HX-4.
Please look at this card. It lists various ways people can
obtain insurance.
{Not counting insurance you already told me about, at/At} any
time {since (START DATE)/between (START DATE) and (END DATE)},
was anyone in the family covered by health insurance from any
{other} source, such as those listed on the card?
YES .................................... 1
NO ..................................... 2 {BOX_25}
REF ................................... -7 {BOX_25}
DK .................................... -8 {BOX_25}
PRESS F1 FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
| DISPLAY ‘Not counting insurance you already told |
| me about, at’ AND ‘other’ IF ANY SOURCES OF |
| INSURANCE ARE RECORDED FOR THIS RU. |
| |
| IF NO SOURCES OF INSURANCE ARE RECORDED FOR THIS |
| RU, DISPLAY ‘At’. |
| |
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
LOOP_10 =======
----------------------------------------------------
| FOR EACH OF THE FOLLOWING: |
| |
| PRIVATELY PURCHASED INSURANCE CATEGORY 1 |
| PRIVATELY PURCHASED INSURANCE CATEGORY 2 |
| PRIVATELY PURCHASED INSURANCE CATEGORY 3 |
| PRIVATELY PURCHASED INSURANCE CATEGORY 4 |
| PRIVATELY PURCHASED INSURANCE CATEGORY 5 |
| PRIVATELY PURCHASED INSURANCE CATEGORY 6 |
| |
| ASK HX23 - END_LP10 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_10 COLLECTS INFORMATION |
| ABOUT PRIVATELY PURCHASED HEALTH INSURANCE NOT |
| OBTAINED THROUGH AN EMPLOYER. THIS LOOP CYCLES ON|
| SOURCES OF PRIVATELY PURCHASED INSURANCE LISTED |
| AT HX23. THE FIRST CYCLE OF THIS LOOP COLLECTS |
| THE FIRST SOURCE OF PRIVATELY PURCHASED INSURANCE.|
| SUBSEQUENT CYCLES OF THE LOOP ARE DETERMINED BY |
| THE RESPONSE AT HX24. IF HX24 IS CODED ‘1’ |
| (YES), THE LOOP CYCLES AGAIN TO COLLECT THE NEXT |
| SOURCE OF PRIVATELY PURCHASED INSURANCE. IF HX24 |
| IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ |
| (DON’T KNOW), THE LOOP ENDS. |
----------------------------------------------------
HX23 ====
{STR-DT}
{END-DT}
SHOW CARD HX-4.
From which of the sources on this card did anyone in the family
purchase health insurance?
FROM A GROUP OR ASSOCIATION .............. 1 {BOX_24}
FROM A HEALTH INSURANCE PURCHASING
ALLIANCE ............................... 2 {BOX_24}
DIRECTLY THROUGH A SCHOOL ................ 3 {BOX_24}
DIRECTLY FROM AN INSURANCE AGENT ......... 4 {BOX_24}
DIRECTLY FROM INSURANCE COMPANY .......... 5 {BOX_24}
DIRECTLY FROM AN HMO ..................... 6 {BOX_24}
FROM A UNION ............................. 7 {BOX_24}
FROM ANYONE’S PREVIOUS EMPLOYER (COBRA) .. 8 {BOX_24}
FROM ANYONE’S PREVIOUS EMPLOYER
(NOT COBRA) ............................ 9 {BOX_24}
FROM SPOUSE’S/DECEASED SPOUSE’ SPREVIOUS
EMPLOYER .............................. 10 {BOX_24}
FROM SOME OTHER EMPLOYER ................ 11 {BOX_24}
UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 {BOX_24}
OTHER SOURCE ............................ 91
REF ..................................... -7 {BOX_24}
DK ...................................... -8 {BOX_24}
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
HX23OV
======
ENTER OTHER:
[Enter Other Specify] ..................
REF .................................... -7
DK ..................................... -8
BOX_24 ======
----------------------------------------------------
| ASK PRIVATE HEALTH INSURANCE DETAIL (HP) SECTION |
| FOR THE RESPONSE CATEGORY SELECTED AT HX23 AND |
| FLAGGED THIS ROUND AS PROVIDING HEALTH INSURANCE. |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF THE HP SECTION, CONTINUE WITH |
| HX24 |
----------------------------------------------------
HX24 ====
{STR-DT}
{END-DT}
SHOW CARD HX-4.
Aside from what you already told me about, at any time {since
(START DATE)/between (START DATE) and (END DATE)}, was anyone in
the family covered by health insurance from any other source
listed on this card?
PROBE: Please include any type of health insurance anyone in
the family is covered by which has not been discussed yet. This
includes health insurance that was obtained from a source not
listed on this card.
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
END_LP10 ========
----------------------------------------------------
| IF HX24 IS CODED ‘1’ (YES), CYCLE TO COLLECT THE |
| NEXT INSURANCE CATEGORY. |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE END LOOP_10, AND CONTINUE WITH BOX_25 |
----------------------------------------------------
BOX_25 ======
----------------------------------------------------
| IF NO PUBLIC OR PRIVATE INSURANCE RECORDED FOR ANY|
| CURRENT RU MEMBER, GO TO BOX_45 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH BOX_26 |
----------------------------------------------------
BOX_26 ======
----------------------------------------------------
| IF ANY RU MEMBER HAS MEDICARE AS A SOURCE OF |
| INSURANCE DURING THE CURRENT ROUND, CONTINUE WITH |
| BOX_27 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_29 |
----------------------------------------------------
BOX_27 ======
----------------------------------------------------
| IF ROUND 1, GO TO LOOP_11 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH BOX_28 |
----------------------------------------------------
BOX_28 ======
----------------------------------------------------
| IF NOT ROUND 1, CONTINUE WITH LOOP_11 ONLY FOR RU |
| MEMBERS WHERE MEDICARE WAS RECORDED AS BEING |
| RECEIVED THIS ROUND. THAT IS, CONTINUE WITH |
| LOOP_11 ONLY IF THERE IS AT LEAST ONE |
| ESTABLISHMENT-PERSON-PAIR WHERE THE ESTABLISHMENT |
| IS MEDICARE AND THE PAIR WAS CREATED THIS ROUND. |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_29 |
----------------------------------------------------
LOOP_11 =======
----------------------------------------------------
| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER, ASK HX25-END_LP11 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_11 COLLECTS MEDICARE CARD |
| AND MANAGED CARE INFORMATION FOR RU MEMBERS |
| COVERED BY MEDICARE. THIS LOOP CYCLES ON |
| ESTABLISHMENT-PERSON-PAIRS THAT MEET THE FOLLOWING|
| CONDITIONS: |
| IF ROUND 1: |
| - ESTABLISHMENT IS MEDICARE |
| AND |
| - PERSON IS AN RU MEMBER FLAGGED AS COVERED BY |
| MEDICARE DURING THE ROUND |
| IF NOT ROUND 1: |
| - ESTABLISHMENT IS MEDICARE |
| AND |
| - PERSON IS AN RU MEMBER |
| AND |
| - ESTABLISHMENT-PERSON-PAIR WAS CREATED THIS ROUND|
----------------------------------------------------
HX25 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
In this study, we are asking the participants for their
Medicare numbers, so that their Medicare records can be easily
and accurately located and identified for statistical research
purposes. Under Section 903(c) of the Public Health Service
Act, providing us with the number is a voluntary decision and
the benefits (PERSON) may be receiving under this program will
not be affected by your decision. This study is being
conducted under the authority of Section 902(a) of the Public
Health Service Act.
CODE WITHOUT ASKING IF ANSWER IS KNOWN.
May I please see (PERSON)’s Medicare card?
CARD AVAILABLE ......................... 1
CARD NOT AVAILABLE ..................... 2 {HX29}
REF ................................... -7 {HX29}
DK .................................... -8 {HX29}
[Code One]
HX26 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
INTERVIEWER:
CODE MEDICARE CARD(S) SHOWN/AVAILABLE.
MEDICARE CARD (RED, WHITE AND BLUE) .... 1
RAILROAD RETIREMENT BOARD CARD (RED,
WHITE AND BLUE) ........................ 2
SOME OTHER CARD ........................ 3
[Code All That Apply]
----------------------------------------------------
| NOTE: INTERVIEWERS WILL BE TRAINED TO CODE ANY |
| TYPE OF MANAGED CARE CARD COLLECTED HERE AS SOME |
| OTHER CARD. THE NAME OF THE MANAGED CARE |
| ORGANIZATION WILL BE COLLECTED AT HX28. |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘1’ (MEDICARE CARD) OR ‘2’ (RAILROAD |
| RETIREMENT BOARD CARD), CONTINUE WITH HX27 |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘3’ (SOME OTHER CARD) ONLY, GO TO HX28 |
----------------------------------------------------
HX27 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
INTERVIEWER:
RECORD THE FOLLOWING INFORMATION FROM THE CARD:
{MEDICARE} CLAIM NUMBER:
[Enter Large Number] ...................
REF ................................... -7
DK .................................... -8
EFFECTIVE DATE:
[Enter Month,Day,Year-4]
TYPE OF COVERAGE (IS ENTITLED TO):
HOSPITAL ONLY .......................... 1
MEDICAL AND HOSPITAL ................... 2
MEDICAL ONLY ........................... 3
[Code One]
----------------------------------------------------
| DISPLAY ‘MEDICARE’ IF HX26 IS CODED ‘1’ (MEDICARE |
| CARD). |
----------------------------------------------------
----------------------------------------------------
| CHECK EFFECTIVE DATE. DATE MUST BE ON OR BEFORE |
| (I.E., < OR =) THE END DATE. IF EFFECTIVE DATE |
| IS ON OR BEFORE JANUARY 1, 2005, FLAG RU MEMBER AS|
| ‘WITH HEALTH INSURANCE COVERAGE ON JAN 1, 2005’. |
----------------------------------------------------
----------------------------------------------------
| SOFT RANGE CHECK: MEDICARE EFFECTIVE DATE MUST |
| BE = OR > BIRTH DATE OF PERSON. |
----------------------------------------------------
----------------------------------------------------
| IF HX26 IS CODED ‘3’ (SOME OTHER CARD), CONTINUE |
| WITH HX28 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO HX30A |
----------------------------------------------------
HX28 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
INTERVIEWER:
RECORD THE INFORMATION FROM THE {OTHER} CARD:
[Enter Text]
----------------------------------------------------
| DISPLAY ‘OTHER’ IF HX26 IS CODED ‘1’ (MEDICARE |
| CARD) OR ‘2’ (RAILROAD RETIREMENT BOARD CARD). |
----------------------------------------------------
----------------------------------------------------
| IF HX26 IS CODED ‘3’ (SOME OTHER CARD) ONLY, |
| CONTINUE WITH HX29 |
----------------------------------------------------
----------------------------------------------------
| IF HX26 IS CODED ‘1’ (MEDICARE CARD) OR ‘2’ |
| (RAILROAD RETIREMENT BOARD CARD) (IN ADDITION TO |
| ‘3’ (SOME OTHER CARD)), GO TO HX30A |
----------------------------------------------------
HX29 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
When did (PERSON)’s Medicare coverage start?
[Enter Month,Year-4] .................. {HX30}
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| DATE MUST BE ON OR BEFORE (I.E., < OR =) INTERVIEW|
| DATE OR 12/31/2005 IF ROUND 5. ‘-7’ (REFUSED) AND|
| ‘-8’ (DON’T KNOW) ARE ALLOWED ON THE MONTH AND |
| YEAR FIELDS. |
----------------------------------------------------
----------------------------------------------------
| IF EFFECTIVE DATE IS: |
| A VALID DATE (I.E., NOT ‘7’ (REFUSED) OR ‘-8’ |
| (DON’T KNOW) IN THE MONTH OR YEAR FIELD) |
| AND |
| ON OR BEFORE JANUARY 1, 2005. |
| THEN FLAG RU MEMBER AS ‘WITH HEALTH INSURANCE |
| COVERAGE ON JANUARY 1, 2005. |
----------------------------------------------------
----------------------------------------------------
| SOFT RANGE CHECK: MEDICARE EFFECTIVE DATE MUST |
| BE = OR > BIRTH DATE OF PERSON. |
----------------------------------------------------
HX29OV ======
Did (PERSON) have Medicare coverage on January 1, 2005?
YES ................................... 1 {HX30}
NO .................................... 2 {HX30}
REF ................................... -7 {HX30}
DK .................................... -8 {HX30}
----------------------------------------------------
| IF HX29OV CODED ‘1’ (YES), FLAG PERSON AS ‘WITH |
| HEALTH INSURANCE COVERAGE ON JAN 1, 2005’. |
----------------------------------------------------
HX29OV2
=======
OMITTED.
HX30 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD HX-2.
(Do/Does) (PERSON) have a Medicare card that looks like this?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
HX30A =====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{At any time since (START DATE)/{Between (START DATE) and
(END DATE)}, {(have/has)/(were/was)} (PERSON) {been} covered
by the new Medicare prescribed drug coverage (also called
Part D)?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE PART D.
----------------------------------------------------
| DISPLAY ‘At any time since (START DATE)’ AND |
| ‘(have/has)’ IF NOT ROUND 5. DISPLAY ‘Between |
| (START DATE) and (END DATE)’ AND ‘(were/was)’ |
| IF ROUND 5. |
| |
| DISPLAY ‘been’ IF NOT ROUND 5. OTHERWISE, USE A |
| NULL DISPLAY. |
----------------------------------------------------
BOX_28A =======
----------------------------------------------------
| NOTE: CURRENTLY ALL STATES OFFER MEDICARE |
| MANAGED CARE PLANS |
----------------------------------------------------
----------------------------------------------------
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |
| DOES NOT OFFER A MEDICARE MANAGED CARE PLAN, CODE |
| HX31 OR HX32 ‘2’ (NO) AUTOMATICALLY BY CAPI AND |
| GO TO END_LP11. |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX31 |
----------------------------------------------------
HX31 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
SHOW CARD HX-5.
As you may know, Medicare allows beneficiaries in certain parts
of the country to enroll in managed care plans, such as HMOs
(health maintenance organizations) or PPOs (preferred provider
organizations) to receive their Medicare-funded health care.
These plans have names like those listed on this card.
Is the name of (PERSON)’s insurance through Medicare{, between
(START DATE) and (END DATE),} listed on this card?
YES .................................... 1
NO ..................................... 2 {HX32}
REF ................................... -7 {HX32}
DK .................................... -8 {HX32}
PRESS F1 FOR DEFINITION OF MEDICARE MANAGED CARE.
----------------------------------------------------
| DISPLAY ‘, between (START DATE) and (END DATE),’ |
| IF ROUND 5. OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
HX31OV ======
Which insurance plan is (PERSON)’s Medicare managed care plan?
CODE LETTER OF PLAN FROM SHOW CARD.
[Enter Plan Letter From Card] .........
----------------------------------------------------
| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |
| THE FOLLOWING MESSAGE: ‘PLEASE VERIFY PLAN |
| SELECTED: {DISPLAY PLAN NAME SELECTED}.’ WHEN |
| INTERVIEWER PRESSES ENTER TO CLEAR THE MESSAGE, |
| PROCEED TO THE NEXT LOGICAL SCREEN. |
| |
| FOR ‘DISPLAY PLAN NAME SELECTED’, DISPLAY THE |
| ACTUAL PLAN NAME THAT CORRESPONDS TO THE LETTER |
| ENTERED FOR THIS STATE. |
----------------------------------------------------
----------------------------------------------------
| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |
| MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON- |
| PAIR. |
----------------------------------------------------
----------------------------------------------------
| IF ROUND 1, GO TO HX34 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO END_LP11 |
----------------------------------------------------
HX32 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Even though (PERSON)’s Medicare plan was not listed on the card,
{(are/is) (PERSON) currently/between (START DATE) and (END DATE),
(were/was) (PERSON)} enrolled in a Medicare managed care plan such
as an HMO (health maintenance organization) or PPO (preferred
provider organization)? (When answering this question, please
include only insurance from Medicare, not any privately purchased
insurance.)
YES .................................... 1 {HX33}
NO ..................................... 2 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
PRESS F1 FOR DEFINITION OF MEDICARE MANAGED CARE.
----------------------------------------------------
| DISPLAY ‘(are/is)... currently’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE), |
| (were/was) (PERSON)’ IF ROUND 5. |
----------------------------------------------------
HX32A
=====
OMITTED.
HX33 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
What is the name of the (PERSON)’s Medicare managed care plan?
[Enter Plan Name] .....................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |
| MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON- |
| PAIR. |
----------------------------------------------------
----------------------------------------------------
| IF ROUND 1, CONTINUE WITH HX34 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO END_LP11 |
----------------------------------------------------
HX34 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
PLAN NAME: {{PLAN NAME ENTERED AT HX31OV}/{NAME OF PLAN FROM HX33}}
Medicare beneficiaries pay their Part B premiums through their
Social Security checks. In addition, (do/does) (PERSON) (or
anyone in the family) pay anything directly to (PLAN NAME) for
this coverage?
[Do not include the cost of any copayments, coinsurance or
deductibles anyone in the family may have had to pay.]
YES .................................... 1
NO ..................................... 2 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
[Code One]
PRESS F1 FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
----------------------------------------------------
| DISPLAY ‘{PLAN NAME ENTERED AT HX31OV}’ IF A PLAN |
| LETTER WAS ENTERED AT HX31OV. DISPLAY THE ACTUAL |
| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |
| AT HX31OV FOR THIS STATE. |
| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR |
| ‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS |
| ENTERED. |
----------------------------------------------------
HX35 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
PLAN NAME: {{PLAN NAME ENTERED AT HX31OV}/{NAME OF PLAN FROM HX33}}
How much (do/does) (PERSON) pay for the (PLAN NAME) coverage?
PROBE: Is that per year, per month, per week, or what?
[Enter Amount in Dollars] ..............
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
----------------------------------------------------
| DISPLAY ‘{PLAN NAME ENTERED AT HX31OV}’ IF A PLAN |
| LETTER WAS ENTERED AT HX31OV. DISPLAY THE ACTUAL |
| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |
| AT HX31OV FOR THIS STATE. |
| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR |
| ‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS |
| ENTERED. |
----------------------------------------------------
HX35OV1 =======
ENTER UNIT OF COVERAGE:
PER YEAR ............................... 1 {END_LP11}
QUARTERLY/EVERY 3 MONTHS ............... 2 {END_LP11}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {END_LP11}
PER MONTH .............................. 4 {END_LP11}
PER WEEK ............................... 5 {END_LP11}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {END_LP11}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {END_LP11}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {END_LP11}
OTHER ................................. 91
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
[Code One]
HX35OV2 =======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
END_LP11 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |
| THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |
| END LOOP_11 AND CONTINUE WITH BOX_29 |
----------------------------------------------------
BOX_29 ======
----------------------------------------------------
| IF ANY RU MEMBER HAS MEDICAID/SCHIP OR GOVT- |
| HOSPITAL/PHYSICIAN AS A SOURCE OF INSURANCE |
| DURING THE CURRENT ROUND, CONTINUE WITH BOX_30 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_32 |
----------------------------------------------------
BOX_30 ======
----------------------------------------------------
| IF NO ONE IN THE RU WAS COVERED BY MEDICAID/SCHIP |
| OR GOVT-HOSPITAL/PHYSICIAN DURING THE PREVIOUS |
| ROUND AND AT LEAST ONE RU MEMBER IS COVERED BY |
| MEDICAID/SCHIP DURING THE CURRENT ROUND |
| OR |
| IF NO ONE IN THE RU WAS COVERED BY MEDICAID/SCHIP |
| OR GOVT-HOSPITAL/ PHYSICIAN DURING THE PREVIOUS |
| ROUND AND AT LEAST ONE RU MEMBER IS COVERED BY |
| GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND, |
| GO TO BOX_31AA |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_32 |
----------------------------------------------------
----------------------------------------------------
| NOTE: SINCE AN RU CANNOT HAVE BOTH MEDICAID/SCHIP|
| AND GOVT-HOSPITAL/PHYSICIAN, HX41-HX47OV WILL BE |
| ASKED ONLY ONCE; EITHER FOR A ‘YES’ TO HX10 |
| (MEDICAID/SCHIP) OR A ‘YES’ TO HX14 (GOVT- |
| HOSPITAL/PHYSICIAN). |
----------------------------------------------------
HX36
====
OMITTED.
BOX_31
======
OMITTED.
HX37
====
OMITTED.
HX38
====
OMITTED.
HX38OV1
=======
OMITTED.
HX38OV2
=======
OMITTED.
HX39
====
OMITTED.
HX40
====
OMITTED.
BOX_31AA ========
----------------------------------------------------
| NOTE: STATES THAT DO NOT OFFER MEDICAID MANAGED |
| CARE PLANS INCLUDE THE FOLLOWING: |
| ALASKA NEW HAMPSHIRE |
| ARKANSAS WYOMING |
| MISSISSIPPI |
----------------------------------------------------
----------------------------------------------------
| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |
| DOES NOT OFFER A MEDICAID MANAGED CARE PLAN, CODE |
| HX41 ‘2’ (NO) AUTOMATICALLY BY CAPI AND GO TO HX42|
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX41 |
----------------------------------------------------
HX41 ====
{STR-DT}
{END-DT}
SHOW CARD HX-6.
{Some people on {Medicaid/{STATE NAME FOR MEDICAID}} or {STATE
CHIP NAME} can enroll in plans called HMOs. These plans have
names like those listed on this card.}
Is the name of the health insurance through {{Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME}/the program sponsored
by a state or local government agency which provides hospital
and physician benefits}{, between (START DATE) and (END DATE),}
listed on this card?
YES .................................... 1
NO ..................................... 2 {HX42}
REF ................................... -7 {HX42}
DK .................................... -8 {HX42}
----------------------------------------------------
| DISPLAY ‘Some people on...on this card.’ IF |
| ASKING ABOUT MEDICAID/SCHIP. OTHERWISE, USE A |
| NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or |
| {STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/ |
| SCHIP. DISPLAY ‘the program....benefits’ IF |
| ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘, between (START DATE) and (END DATE),’ |
| IF ROUND 5. OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|
| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |
| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|
| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |
| STATE, SEE BOX ON HX06. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |
| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |
| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |
| ON HX06. |
----------------------------------------------------
HX41OV ======
Which plan is the health insurance through {{Medicaid/{STATE NAME
FOR MEDICAID} or {STATE CHIP NAME}}/that program)?
CODE LETTER OF PLAN FROM SHOW CARD.
[Enter Plan Letter From Card] .........
----------------------------------------------------
| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}}’ |
| IF ASKING ABOUT MEDICAID/SCHIP. |
| DISPLAY ‘that program’ IF ASKING ABOUT GOVT- |
| HOSPITAL/PHYSICIAN. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|
| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |
| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|
| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |
| STATE, SEE BOX ON HX06. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or STATE CHIP NAME’ (SUBSTITUTING THE |
| REAL STATE NAME FOR PROGRAM). FOR THE SPECIFIC |
| NAME TO USE BY STATE, SEE BOX ON HX06. |
----------------------------------------------------
----------------------------------------------------
| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |
| INSURER FOR MEDICAID/SCHIP OR GOVT-HOSPITAL/ |
| PHYSICIAN’. |
----------------------------------------------------
----------------------------------------------------
| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |
| THE FOLLOWING MESSAGE: ‘PLEASE VERIFY PLAN |
| SELECTED: {DISPLAY PLAN NAME SELECTED}.’ WHEN |
| INTERVIEWER PRESSES ENTER TO CLEAR THE MESSAGE, |
| PROCEED TO THE NEXT LOGICAL SCREEN. |
| |
| FOR ‘DISPLAY PLAN NAME SELECTED’, DISPLAY THE |
| ACTUAL PLAN NAME THAT CORRESPONDS TO THE LETTER |
| ENTERED FOR THIS STATE. |
----------------------------------------------------
----------------------------------------------------
| IF ASKING ABOUT MEDICAID/SCHIP, GO TO BOX_32 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO HX45 |
----------------------------------------------------
HX42 ====
{STR-DT}
{END-DT}
Under {{Medicaid/{STATE NAME FOR MEDICAID} or {STATE CHIP NAME}}/
the program sponsored by a state or local government agency which
provides hospital and physician benefits} {(are/is)/(were/was)}
(READ NAME(S) FROM BELOW) signed up with an HMO, that is a Health
Maintenance Organization {between (START DATE) and (END DATE)}?
[With an HMO, you must generally receive care from HMO
physicians. If another doctor is seen, the expense is not
covered unless you were referred by the HMO, or there was a
medical emergency.]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
YES, ALL ARE ........................... 1 {HX44}
YES, SOME ARE .......................... 2 {HX44}
NO, NONE ARE ........................... 3
REF ................................... -7
DK .................................... -8
[Code One]
PRESS F1 FOR DEFINITION OF HMO.
----------------------------------------------------
| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}/or |
| {STATE CHIP NAME}}’ IF ASKING ABOUT MEDICAID/ |
| SCHIP. DISPLAY ‘the program....benefits’ IF |
| ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘(are/is)’ IF NOT ROUND 5. DISPLAY |
| ‘(were/was)’ IF ROUND 5. |
| |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|
| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |
| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|
| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |
| STATE, SEE BOX ON HX06. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |
| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |
| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |
| ON HX06. |
----------------------------------------------------
----------------------------------------------------
| ROSTER DEFINITION: THIS ROSTER DISPLAYS ITEMS IN |
| THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER THAT MEET|
| THE FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS MEDICAID/SCHIP OR GOVT- |
| HOSPITAL/PHYSICIAN |
| AND |
| - PERSON IS AN RU MEMBER FLAGGED AS COVERED |
| BY MEDICAID/SCHIP OR GOVT-HOSPITAL/PHYSICIAN |
| DURING THE CURRENT ROUND |
----------------------------------------------------
HX43 ====
{STR-DT}
{END-DT}
{Does/Between (START DATE) and (END DATE), did} {{Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME}/the program sponsored by
a state or local government agency which provides hospital and
physician benefits} require (READ NAME(S) BELOW) to sign up with
a certain primary care doctor, group of doctors, or with a certain
clinic which they must go to for all of their routine care?
PROBE: Do not include emergency care or care from a specialist
they were referred to.
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
YES, ALL REQUIRED ...................... 1
YES, SOME REQUIRED ..................... 2
NO, NONE REQUIRED ...................... 3
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF PRIMARY CARE DOCTOR AND ROUTINE CARE.
----------------------------------------------------
| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or |
| {STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/SCHIP.|
| DISPLAY ‘the program....benefits’ IF ASKING ABOUT |
| GOVT-HOSPITAL/PHYSICIAN. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Does’ IF NOT ROUND 5. DISPLAY ‘Between |
| (START DATE) and (END DATE), did’ IF ROUND 5. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|
| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |
| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|
| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |
| STATE, SEE BOX ON HX06. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |
| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |
| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |
| ON HX06. |
----------------------------------------------------
----------------------------------------------------
| ROSTER DEFINITION: THIS ROSTER DISPLAYS ITEMS IN |
| THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER THAT MEET|
| THE FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS MEDICAID/SCHIP OR GOVT- |
| HOSPITAL/PHYSICIAN |
| AND |
| - PERSON IS AN RU MEMBER FLAGGED AS COVERED |
| BY MEDICAID/SCHIP OR GOVT-HOSPITAL/PHYSICIAN |
| DURING THE CURRENT ROUND |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED), |
| OR ‘-8’ (DON’T KNOW), THERE IS NO INSURER |
| ASSOCIATED WITH THE CURRENT ROUND FOR MEDICAID/ |
| SCHIP OR GOVT-HOSPITAL/PHYSICIAN. |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED), |
| OR ‘-8’ (DON’T KNOW) AND IF ASKING ABOUT MEDICAID/|
| SCHIP, GO TO BOX_32 |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED), |
| OR ‘-8’ (DON’T KNOW) AND ASKING ABOUT GOVT- |
| HOSPITAL/PHYSICIAN, GO TO HX45 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, (I.E., IF CODED ‘1’ (YES, ALL REQUIRED)|
| OR ‘2’ (YES, SOME REQUIRED)), CONTINUE WITH HX44 |
----------------------------------------------------
HX44 ====
{STR-DT}
{END-DT}
What is the name of the {{Medicaid/{STATE NAME FOR MEDICAID} or
{STATE CHIP NAME}}} {HMO/health insurance} {from the program
sponsored by a state or local government agency which provides
hospital and physician benefits}?
[Enter Plan Name] .....................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}/or |
| {STATE CHIP NAME}}’ IF ASKING ABOUT MEDICAID/ |
| SCHIP. IF ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN, |
| USE A NULL DISPLAY. |
| DISPLAY ‘from the....benefits’ IF ASKING ABOUT |
| GOVT-HOSPITAL/PHYSICIAN. IF ASKING ABOUT MEDICAID/|
| SCHIP, USE A NULL DISPLAY. |
| |
| DISPLAY ‘HMO’ IF HX42 IS CODED ‘1’ (YES, ALL ARE) |
| OR ‘2’ (YES, SOME ARE). |
| DISPLAY ‘health insurance’ IF HX43 IS CODED ‘1’ |
| (YES, ALL REQUIRED) OR ‘2’ (YES, SOME REQUIRED). |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |
| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|
| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |
| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |
| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|
| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |
| STATE, SEE BOX ON HX06. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |
| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |
| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |
| ON HX06. |
----------------------------------------------------
----------------------------------------------------
| FLAG INSURER CODED ABOVE AS CURRENT ROUND’S |
| INSURER FOR MEDICAID/SCHIP OR GOVT-HOSPITAL/ |
| PHYSICIAN. |
----------------------------------------------------
----------------------------------------------------
| IF ASKING ABOUT MEDICAID/SCHIP, GO TO BOX_32 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX45 |
----------------------------------------------------
HX45 ====
{STR-DT}
{END-DT}
{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF PLAN FROM
HX44}}}
Does anyone in the family pay anything for the coverage through
{(PLAN NAME)/the program sponsored by a state or local
government agency which provides hospital and physician
benefits}?
[Do not include the cost of any copayments, coinsurance or
deductibles anyone in the family may have had to pay.]
YES .................................... 1
NO ..................................... 2 {HX47}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}
[Code One]
PRESS F1 FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
----------------------------------------------------
| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |
| ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |
| PHYSICIAN INSURANCE. OTHERWISE, USE A NULL |
| DISPLAY. |
| |
| DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN |
| LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL |
| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |
| AT HX41OV FOR THIS STATE. |
| |
| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR |
| ‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS |
| ENTERED. |
| |
| DISPLAY ‘(PLAN NAME)’ IF THERE IS A CURRENT ROUND |
| INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |
| PHYSICIAN INSURANCE. OTHERWISE, DISPLAY, ‘the |
| program sponsored ...’. |
----------------------------------------------------
HX46 ====
{STR-DT}
{END-DT}
{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF PLAN FROM
HX44}}}
How much does anyone in the family pay for {the (PLAN NAME)/
that} coverage?
PROBE: Is that per year, per month, per week, or what?
[Enter Amount in Dollars] ..............
REF ................................... -7 {HX47}
DK .................................... -8 {HX47}
----------------------------------------------------
| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |
| ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |
| PHYSICIAN INSURANCE. OTHERWISE, USE A NULL |
| DISPLAY. |
| |
| DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN |
| LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL |
| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |
| AT HX41OV FOR THIS STATE. |
| |
| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR |
| ‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS |
| ENTERED. |
| |
| DISPLAY ‘the (PLAN NAME)’ IF THERE IS A CURRENT |
| ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |
| PHYSICIAN INSURANCE. OTHERWISE, DISPLAY, ‘that’. |
----------------------------------------------------
HX46OV1 =======
ENTER UNIT OF COVERAGE:
PER YEAR ............................... 1 {HX47}
QUARTERLY/EVERY 3 MONTHS ............... 2 {HX47}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {HX47}
PER MONTH .............................. 4 {HX47}
PER WEEK ............................... 5 {HX47}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {HX47}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {HX47}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {HX47}
OTHER ................................. 91
REF ................................... -7 {HX47}
DK .................................... -8 {HX47}
[Code One]
HX46OV2 =======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
BOX_31A ======= OMITTED.
HX47 ====
{STR-DT}
{END-DT}
{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF PLAN FROM
HX44}}}
Who {else} pays {some of/for} the premium or cost
of this insurance?
FEDERAL GOVERNMENT .................... 1
STATE GOVERNMENT ...................... 2
LOCAL GOVERNMENT ...................... 3
SOME GOVERNMENT ....................... 4
OTHER ................................. 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |
| ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |
| PHYSICIAN INSURANCE. OTHERWISE, USE A NULL |
| DISPLAY. |
| |
| DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN |
| LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL |
| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |
| AT HX41OV FOR THIS STATE. |
| |
| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR |
| ‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS |
| ENTERED. |
| |
| DISPLAY ‘else’ IF HX45 IS CODED ‘1’ (YES). |
| OTHERWISE, USE A NULL DISPLAY. |
| |
| DISPLAY ‘some of’ IF HX45 IS CODED ‘1’ (YES). |
| DISPLAY ‘for’ IF HX45 IS CODED ‘2’ (NO). |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |
| WITH ANY OTHER CODE, CONTINUE WITH HX47OV |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_32 |
----------------------------------------------------
HX47OV ======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
BOX_32 ======
-----------------------------------------------------
| IF ANY ESTABLISHMENT RECORDED AS PROVIDING PRIVATE |
| INSURANCE (THAT WAS CREATED DURING THE CURRENT |
| ROUND) TO A CURRENT RU MEMBER, CONTINUE WITH |
| LOOP_12 |
-----------------------------------------------------
-----------------------------------------------------
| OTHERWISE, GO TO BOX_45 |
-----------------------------------------------------
LOOP_12 =======
-----------------------------------------------------
| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER, ASK HX48-END_LP12 |
-----------------------------------------------------
-----------------------------------------------------
| LOOP DEFINITION: LOOP_12 COLLECTS PRIVATE HEALTH |
| INSURANCE INFORMATION. THIS LOOP CYCLES ON |
| ESTABLISHMENT-PERSON-PAIRS THAT MEET THE |
| FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS PROVIDER OF PRIVATE HEALTH |
| INSURANCE TO A CURRENT RU MEMBER |
| AND |
| - THE INSURANCE COVERAGE PROVIDED BY THE |
| ESTABLISHMENT IS CREATED DURING THE CURRENT ROUND|
-----------------------------------------------------
HX48 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
{END-DT}
SHOW CARD HX-7.
Now I’d like to ask a few questions about (POLICYHOLDER)’s health
insurance through (ESTABLISHMENT). What type of health insurance
{(do/does)/did} (POLICYHOLDER) get through (ESTABLISHMENT) {on
(END DATE)}?
CODE ALL THAT APPLY.
HOSPITAL AND PHYSICIAN BENEFITS,
INCLUDING COVERAGE THROUGH AN HMO ...... 1
DENTAL ................................. 2
PRESCRIPTION DRUGS ..................... 3
VISION ................................. 4
MEDICARE SUPPLEMENT/MEDIGAP ............ 5
LONG TERM CARE IN A NURSING HOME ....... 6
EXTRA CASH FOR HOSPITAL STAYS .......... 7
SERIOUS DISEASE OR DREAD DISEASE ....... 8
DISABILITY ............................. 9
WORKER’S COMPENSATION ................. 10
ACCIDENT .............................. 11
OTHER ................................. 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITION OF ANSWER CATEGORIES.
----------------------------------------------------
| DISPLAY ‘(do/does)’ IF INSURANCE BEING ASKED |
| ABOUT IS CURRENT (I.E., HQ02 IS CODED ‘1’ (YES, |
| COVERED NOW) FOR THE POLICYHOLDER AND THE CURRENT |
| ROUND IS NOT ROUND 5. OTHERWISE, DISPLAY ‘did’. |
| |
| DISPLAY ‘on (END DATE)’ IF ROUND 5. OTHERWISE, |
| USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |
| WITH ANY OTHER CODE, CONTINUE WITH HX48OV |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_33 |
----------------------------------------------------
----------------------------------------------------
| NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE |
| SHOW CARD. |
----------------------------------------------------
HX48OV ======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
BOX_33 ======
----------------------------------------------------
| IF ESTABLISHMENT TYPE IS NOT INSURANCE CO. OR HMO |
| AND HX48 IS CODED ‘5’ (MEDICARE SUPPLEMENT OR |
| MEDIGAP) ONLY OR ‘5’ AND ANY OTHER CODES, CONTINUE|
| WITH HX49 |
----------------------------------------------------
----------------------------------------------------
| IF ESTABLISHMENT TYPE IS INSURANCE CO. OR HMO AND |
| HX48 IS CODED ‘5’ (MEDICARE SUPPLEMENT OR MEDIGAP)|
| ONLY OR ‘5’ AND ANY OTHER CODES, AUTOMATICALLY |
| CODE HX49 WITH APPROPRIATE RESPONSES BY CAPI AND |
| THEN GO TO LOOP_13 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (I.E., HX48 IS NOT CODED ‘5’ (MEDICARE |
| SUPPLEMENT OR MEDIGAP)), GO TO BOX_35 |
----------------------------------------------------
HX49 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
{END-DT}
What is the name of the insurance company or HMO from which
(POLICYHOLDER) receives the Medicare Supplement or Medigap
benefits?
IF MORE THAN ONE NAME, PROBE: What is the main insurance company
or HMO from which (POLICYHOLDER) receives the Medicare Supplement
or Medigap benefits?
IF RESPONDENT SAYS BOTH INSURANCE COMPANY AND HMO, CODE 2 (HMO).
| NAME OF INSURER | TYPE |
|---|---|
| [Enter Insurer] | 1 = INSURANCE COMPANY 2 = HMO 3 = SELF-INSURED COMPANY |
PRESS F1 FOR DEFINITION OF INSURANCE CO/HMO/SELF-INSURED CO.
----------------------------------------------------
| FLAG INSURANCE CO./HMO AS ‘SUPPLYING MEDICARE |
| SUPPLEMENT/MEDIGAP BENEFITS’. ALSO FLAG AS |
| CURRENT ROUND’S INSURER(S) FOR THIS ESTABLISHMENT-|
| PERSON-PAIR. |
----------------------------------------------------
BOX_34
======
OMITTED.
LOOP_13 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON- |
| INSURER-TRIPLES-ROSTER, ASK HX50-END_LP13 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_13 COLLECTS OTHER POLICY |
| NAMES FOR THE HEALTH INSURANCE COMPANIES OR HMOs |
| PROVIDING MEDICARE SUPPLEMENT/MEDIGAP BENEFITS |
| (THAT IS, INSURERS ENUMERATED AT HX49). |
| THIS LOOP CYCLES ON TRIPLES THAT MEET THE |
| FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS PROVIDER OF PRIVATE INSURANCE |
| WHICH PROVIDES MEDICARE SUPPLEMENT/MEDIGAP |
| BENEFITS |
| AND |
| - PERSON IS THE POLICYHOLDER FOR THE INSURANCE |
| PROVIDED THROUGH THIS ESTABLISHMENT |
| AND |
| - INSURER IS THE SOURCE OF THE BENEFITS PROVIDED |
| TO PERSON THROUGH THE ESTABLISHMENT (I.E., THE |
| INSURANCE COMPANY, HMO, OR SELF-INSURED COMPANY)|
----------------------------------------------------
HX50 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
Is there any other name for the {INSURANCE COMPANY OR HMO
NAME.} policy, such as Option A, $100 Deductible Plan, 90/80
Plan, Gold Plan, or High Option Plan?
YES, ANOTHER NAME ...................... 1
NO OTHER NAMES ......................... 2 {END_LP13}
REF ................................... -7 {END_LP13}
DK .................................... -8 {END_LP13}
PRESS F1 FOR DEFINITION OF LOW OPTION/HIGH OPTION.
[Code One]
----------------------------------------------------
| DISPLAY THE NAME OF THE INSURANCE CO/HMO |
| RECORDED IN HX49_01 WHICH IS BEING LOOPED ON FOR |
| ‘INSURANCE...NAME.’ |
----------------------------------------------------
HX50OV ======
ENTER OTHER NAME:
[Enter Insurance Company or HMO] .......
REF ................................... -7
DK .................................... -8
END_LP13 ========
----------------------------------------------------
| CYCLE ON NEXT TRIPLE ON THE RU-ESTABLISHMENT- |
| PERSON-INSURER-TRIPLES-ROSTER THAT MEETS THE |
| CONDITIONS STATED IN THE LOOP DEFINITION |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE TRIPLES MEET THE STATED CONDITIONS, |
| END LOOP_13 AND CONTINUE WITH BOX_35 |
----------------------------------------------------
BOX_35 ======
----------------------------------------------------
| IF ESTABLISHMENT TYPE IS INSURANCE COMPANY, |
| INSURANCE COMPANY - FROM AGENT, OR HMO, |
| AND HX48 IS CODED ‘1’ (HOSPITAL AND |
| PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN |
| HMO) (BUT NOT ‘5’ (MEDIGAP)), FLAG INSURANCE |
| COMPANY/HMO AS ‘SUPPLYING HOSPITAL AND PHYSICIAN |
| BENEFITS’ AND AUTOMATICALLY CODE HX51 WITH |
| APPROPRIATE RESPONSES BY CAPI AND GO TO LOOP_14 |
----------------------------------------------------
----------------------------------------------------
| IF ESTABLISHMENT TYPE IS NOT INSURANCE COMPANY, |
| INSURANCE COMPANY - FROM AGENT, OR HMO, |
| AND HX48 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN |
| BENEFITS, INCLUDING COVERAGE THROUGH AN HMO) AND |
| NOT ALSO CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP), |
| CONTINUE WITH HX51 |
----------------------------------------------------
----------------------------------------------------
| IF HX48 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN |
| BENEFITS, INCLUDING COVERAGE THROUGH AN HMO) AND |
| ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP) (IN COMBINATION |
| WITH ANY OTHER CODES), GO TO BOX_38 |
----------------------------------------------------
----------------------------------------------------
| IF HX48 IS NOT CODED ‘1’ (HOSPITAL AND PHYSICIAN |
| BENEFITS, INCLUDING COVERAGE THROUGH AN HMO) BUT |
| IS CODED ‘2’ (DENTAL), ‘3’ (PRESCRIPTION DRUGS), |
| ‘4’ (VISION), ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP), |
| ‘6’ (LONG TERM CARE IN A NURSING HOME), ‘7’ (EXTRA|
| CASH FOR HOSPITAL STAYS), ‘8’ (SERIOUS DISEASE OR |
| DREAD DISEASE), OR ‘91’ (OTHER), GO TO BOX_38 |
----------------------------------------------------
----------------------------------------------------
| IF HX48 IS CODED ANY COMBINATION OF ONLY CODES ‘9’|
| (DISABILITY), ‘10’ (WORKER’S COMPENSATION) OR ‘11’|
| (ACCIDENT), GO TO END_LP12 |
----------------------------------------------------
----------------------------------------------------
| IF HX48 IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T |
| KNOW), GO TO BOX_38 |
----------------------------------------------------
HX51 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
{END-DT}
What is the name of the insurance company or HMO from which
(POLICYHOLDER) receives hospital and physician benefits?
IF MORE THAN ONE NAME, PROBE: What is the main insurance company
or HMO from which (POLICYHOLDER) receives hospital and physician
benefits?
IF RESPONDENT SAYS BOTH INSURANCE COMPANY AND HMO, CODE 2 (HMO).
| NAME OF INSURER | TYPE |
|---|---|
| [Enter Insurer] | 1 = INSURANCE COMPANY 2 = HMO 3 = SELF-INSURED COMPANY |
PRESS F1 FOR DEFINITION OF INSURANCE CO/HMO/SELF-INSURED CO.
----------------------------------------------------
| FLAG INSURANCE CO./HMO AS ‘SUPPLYING HOSPITAL AND |
| PHYSICIAN BENEFITS’. ALSO FLAG AS CURRENT ROUND’S|
| INSURER(S) FOR THIS ESTABLISHMENT-PERSON-PAIR. |
----------------------------------------------------
BOX_36
======
OMITTED.
LOOP_14 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON- |
| INSURER-TRIPLES-ROSTER, ASK HX52-END_LP14 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_14 COLLECTS OTHER POLICY |
| NAMES FOR THE HEALTH INSURANCE COMPANIES OR HMOS |
| PROVIDING HOSPITAL/PHYSICIAN BENEFITS BUT NOT |
| MEDICARE SUPPLEMENT OR MEDIGAP. THIS LOOP CYCLES |
| ON TRIPLES THAT MEET THE FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS PROVIDER OF PRIVATE INSURANCE |
| WHICH PROVIDES HOSPITAL/PHYSICIAN BENEFITS BUT |
| NOT MEDICARE SUPPLEMENT OR MEDIGAP |
| AND |
| - PERSON IS THE POLICYHOLDER FOR THE INSURANCE |
| PROVIDED THROUGH THIS ESTABLISHMENT |
| AND |
| - INSURER IS THE SOURCE OF THE BENEFITS PROVIDED |
| TO PERSON THROUGH THE ESTABLISHMENT (I.E., THE |
| INSURANCE COMPANY, HMO OR SELF-INSURED COMPANY) |
----------------------------------------------------
HX52 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
Is there any other name for the {INSURANCE COMPANY OR HMO
NAME.} policy, such as Option A, $100 Deductible Plan, 90/80
Plan, Gold Plan, or High Option Plan?
YES, ANOTHER NAME ...................... 1
NO OTHER NAMES ......................... 2 {END_LP14}
REF ................................... -7 {END_LP14}
DK .................................... -8 {END_LP14}
PRESS F1 FOR DEFINITION OF LOW OPTION/HIGH OPTION.
[Code One]
----------------------------------------------------
| DISPLAY THE NAME OF THE INSURANCE CO/HMO |
| RECORDED IN HX51_01 WHICH IS BEING LOOPED ON FOR |
| ‘INSURANCE...NAME.’ |
----------------------------------------------------
HX52OV ======
ENTER OTHER NAME:
[Enter Insurance Company or HMO] .......
REF ................................... -7
DK .................................... -8
END_LP14 ========
----------------------------------------------------
| CYCLE ON NEXT TRIPLE ON RU-ESTABLISHMENT-PERSON- |
| INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS |
| STATED IN THE LOOP DEFINITION |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE TRIPLES MEET THE STATED CONDITIONS, |
| END LOOP_14 AND CONTINUE WITH BOX_38 |
----------------------------------------------------
BOX_37
======
OMITTED.
HX53
====
OMITTED.
HX54
====
OMITTED.
LOOP_15
=======
OMITTED.
HX55
====
OMITTED.
HX55OV
======
OMITTED.
END_LP15
========
OMITTED.
BOX_38 ======
----------------------------------------------------
| IF ROUND 1, CONTINUE WITH BOX_39 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_40 |
----------------------------------------------------
HX56
====
OMITTED.
LOOP_16
=======
OMITTED.
HX57
====
OMITTED.
HX57OV
======
OMITTED.
HX58
====
OMITTED.
END_LP16
========
OMITTED.
BOX_39 ======
----------------------------------------------------
| IF ESTABLISHMENT-PERSON-PAIR BEING ASKED ABOUT |
| IS FLAGGED AS THROUGH THE FEDERAL GOVERNMENT |
| (EM96 IS CODED ‘2’ (THE FEDERAL GOVERNMENT) OR |
| HP13 IS CODED ‘1’ (YES)), |
| CONTINUE WITH HX59 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_40 |
----------------------------------------------------
HX59 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
SHOW CARD HX-8.
Is the name of (POLICYHOLDER)’s insurance plan through
(ESTABLISHMENT) listed on this card?
YES .................................... 1
NO ..................................... 2 {BOX_40}
REF ................................... -7 {BOX_40}
DK .................................... -8 {BOX_40}
HX59OV ======
Which insurance plan is (POLICYHOLDER)’s (ESTABLISHMENT)
insurance?
CODE LETTER OF PLAN FROM SHOW CARD.
[Enter Plan Letter From Card] .........
----------------------------------------------------
| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |
| THE FOLLOWING MESSAGE: ‘PLEASE VERIFY PLAN |
| ENTERED.’ WHEN INTERVIEWER PRESSES ENTER TO CLEAR|
| THE MESSAGE, PROCEED TO THE NEXT LOGICAL SCREEN. |
----------------------------------------------------
BOX_40 ======
----------------------------------------------------
| IF THIS ESTABLISHMENT-PERSON-PAIR HAS AT LEAST ONE|
| INSURER THAT PROVIDES HOSPITAL AND PHYSICIAN |
| BENEFITS OR THAT PROVIDES MEDICARE SUPPLEMENT/ |
| MEDIGAP COVERAGE AND THE POLICYHOLDER IS NOT |
| LISTED AS A COVERED PERSON WITH MEDICAID OR GOVT- |
| HOSPITAL/PHYSICIAN FOR THE CURRENT ROUND, |
| CONTINUE WITH LOOP_17 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_42 |
----------------------------------------------------
LOOP_17 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON- |
| INSURER-TRIPLES-ROSTER, ASK BOX_41 - END_LP17 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_17 COLLECTS INFORMATION ON |
| PLANS THAT PROVIDE HOSPITAL/PHYSICIAN BENEFITS OR |
| MEDICARE SUPPLEMENT/MEDIGAP COVERAGE TO EACH |
| POLICYHOLDER NOT ALSO COVERED BY MEDICAID OR GOVT-|
| HOSPITAL/PHYSICIAN TO DETERMINE IF THAT PLAN IS AN|
| HMO. THIS LOOP CYCLES ON TRIPLES THAT MEET THE |
| FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS PROVIDER OF HOSPITAL/PHYSICIAN |
| BENEFITS OR MEDICARE SUPPLEMENT/MEDIGAP COVERAGE|
| AND |
| - PERSON IS NOT LISTED AS A COVERED PERSON WITH |
| MEDICAID OR GOVT-HOSPITAL/PHYSICIAN |
| AND |
| - INSURER IS THE SOURCE OF THE HOSPITAL AND |
| PHYSICIAN BENEFITS PROVIDED TO PERSON THROUGH |
| THE ESTABLISHMENT (I.E., THE INSURANCE COMPANY |
| OR SELF-INSURED COMPANY) |
----------------------------------------------------
BOX_40A =======
----------------------------------------------------
| IF INSURER IS AN HMO, CONTINUE WITH HX60A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (I.E., IF INSURER IS NOT AN HMO), GO |
| TO BOX_41 |
----------------------------------------------------
HX60A =====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
Will (POLICYHOLDER)’s plan pay for any of the costs of
visits to doctors who are not part of (POLICYHOLDER)’s
HMO, even if (POLICYHOLDER) (do/does) not have a referral?
YES .................................... 1 {END_LP17}
NO ..................................... 2 {END_LP17}
REF ................................... -7 {END_LP17}
DK .................................... -8 {END_LP17}
BOX_41 ======
----------------------------------------------------
| PRESENT MANAGED CARE (MC) SECTION FOR THIS INSURER|
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF THE MC SECTION, CONTINUE WITH |
| END_LP17 |
----------------------------------------------------
END_LP17 ========
----------------------------------------------------
| CYCLE ON NEXT TRIPLE ON RU-ESTABLISHMENT-PERSON- |
| INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS |
| STATED IN THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO MORE TRIPLES MEET THE STATED CONDITIONS, |
| END LOOP_17 AND CONTINUE WITH BOX_42 |
----------------------------------------------------
BOX_42 ======
----------------------------------------------------
| IF ROUND 1 OR ROUND 3 AND IF HX48 IS CODED ‘5’ |
| (MEDICARE SUPPLEMENT/MEDIGAP), CONTINUE WITH HX60 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_43 |
----------------------------------------------------
HX60 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
CODE WITHOUT ASKING IF ANSWER IS KNOWN.
Many Medicare Supplemental or Medigap Plans are referred to by
a Plan Letter. Do you know the Plan Letter for (PERSON)’s
plan?
PROBE: What is it?
[Enter Plan Letter] ....................
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF PLAN LETTER.
BOX_43 ======
----------------------------------------------------
| IF ROUND 1 OR ROUND 3, CONTINUE WITH HX61 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO |
| END_LP12 |
----------------------------------------------------
BOX_44
======
OMITTED.
HX61 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
For the coverage through (ESTABLISHMENT), does anyone in the
family pay all of the premium or cost, some of the premium or
cost, or none of the premium or cost?
[Do not include the cost of any copayments, coinsurance or
deductibles anyone in the family may have had to pay.]
[Do include any contribution made to the plan as part of a
paycheck.]
YES, PAY ALL OF PREMIUM/COST ........... 1
YES, PAY SOME OF PREMIUM/COST .......... 2
YES, BUT DON’T KNOW IF PAY ALL OR SOME
OF PREMIUM/COST ........................ 3
NO, DO NOT PAY ......................... 4 {HX63}
REF ................................... -7 {END_LP12}
DK .................................... -8 {END_LP12}
[Code One]
PRESS F1 FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
----------------------------------------------------
| NOTE: THE ESTABLISHMENT NAME WHICH SHOULD BE |
| DISPLAYED HERE FOR THE INSURANCE FROM A |
| SELF-EMPLOYED-FIRM-SIZE-1 AND INSURANCE FROM |
| DIRECTLY PURCHASED SOURCES, SHOULD BE THE NAME OF |
| THE SOURCE, NOT THE NAME OF THE EMPLOYER OR |
| DIRECTLY PURCHASED CATEGORY. |
----------------------------------------------------
HX62 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
How much {(do/does)/did} (POLICYHOLDER) pay for the
(ESTABLISHMENT) coverage?
PROBE: {Is/Was} that per year, per month, per week, or what?
[Enter Amount in Dollars] ..............
REF ................................... -7 {BOX_44A}
DK .................................... -8 {BOX_44A}
----------------------------------------------------
| DISPLAY ‘(do/does)’ AND ‘Is’ IF INSURANCE BEING |
| ASKED ABOUT IS CURRENT (I.E., HQ02 IS CODED ‘1’ |
| (YES, COVERED NOW)) FOR THE POLICYHOLDER. |
| OTHERWISE, DISPLAY ‘did’ AND ‘Was’. |
----------------------------------------------------
----------------------------------------------------
| NOTE: THE ESTABLISHMENT NAME WHICH SHOULD BE |
| DISPLAYED HERE FOR THE INSURANCE FROM A |
| SELF-EMPLOYED-FIRM-SIZE-1 AND INSURANCE FROM |
| DIRECTLY PURCHASED SOURCES, SHOULD BE THE NAME OF |
| THE SOURCE, NOT THE NAME OF THE EMPLOYER OR |
| DIRECTLY PURCHASED CATEGORY. |
----------------------------------------------------
HX62OV1 =======
ENTER UNIT OF COVERAGE:
PER YEAR ............................... 1 {BOX_44A}
QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_44A}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_44A}
PER MONTH .............................. 4 {BOX_44A}
PER WEEK ............................... 5 {BOX_44A}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_44A}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_44A}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_44A}
OTHER ................................. 91
REF ................................... -7 {BOX_44A}
DK .................................... -8 {BOX_44A}
[Code One]
HX62OV2 =======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
BOX_44A =======
-----------------------------------------------------
| IF HX61 IS CODED ‘1’ (YES, PAY ALL OF PREMIUM/ |
| COST), GO TO END_LP12 |
-----------------------------------------------------
-----------------------------------------------------
| OTHERWISE, CONTINUE WITH HX63 |
-----------------------------------------------------
HX63 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT.........} {STR-DT}
Who {else} pays {some of/for} the premium or cost
of this insurance?
FEDERAL GOVERNMENT .................... 1
STATE GOVERNMENT ...................... 2
LOCAL GOVERNMENT ...................... 3
SOME GOVERNMENT ....................... 4
EMPLOYER .............................. 5
UNION ................................. 6
OTHER ................................. 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
| DISPLAY ‘else’ IF HX61 IS CODED ‘2’ (YES, PAY SOME|
| OF PREMIUM/COST) OR ‘3’ (YES, BUT DON’T KNOW IF |
| PAY ALL OR SOME OF PREMIUM/COST). OTHERWISE, USE |
| A NULL DISPLAY |
| |
| DISPLAY ‘some of’ IF HX61 IS CODED ‘2’ (YES, PAY |
| SOME OF PREMIUM/COST) OR ‘3’ (YES, BUT DON’T KNOW |
| IF PAY ALL OR SOME OF PREMIUM/COST). DISPLAY ‘for’|
| IF HX61 IS CODED ‘4’ (NO, DO NOT PAY). |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |
| WITH ANY OTHER CODE, CONTINUE WITH HX63OV |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO END_LP12 |
----------------------------------------------------
HX63OV ======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
END_LP12 ========
------------------------------------------------------
| CYCLE ON NEXT PAIR IN RU-ESTABLISHMENT-PERSON- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |
| THE LOOP DEFINITION. |
------------------------------------------------------
------------------------------------------------------
| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |
| END LOOP_12 AND CONTINUE WITH BOX_45 |
------------------------------------------------------
BOX_45 ======
------------------------------------------------------
| IF ROUND 1, CONTINUE WITH BOX_46 |
------------------------------------------------------
------------------------------------------------------
| OTHERWISE, GO TO BOX_50 |
------------------------------------------------------
BOX_46 ======
------------------------------------------------------
| IF ALL PERSONS IN RU HAVE HEALTH INSURANCE (I.E., |
| FLAGGED AS HAVING MEDICARE, MEDICAID, GOVT-HOSPITAL/|
| PHYSICIAN, TRICARE, OTHER PUBLIC OR PRIVATE |
| INSURANCE) COVERAGE ON JANUARY 1, 2005, GO TO |
| BOX_48 |
------------------------------------------------------
------------------------------------------------------
| OTHERWISE (AT LEAST ONE RU MEMBER BORN BEFORE |
| 12/31/2004 IS WITHOUT HEALTH INSURANCE ON JANUARY 1,|
| 2005), CONTINUE WITH LOOP_18 |
------------------------------------------------------
LOOP_18 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK |
| HX64-END_LP18 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_18 COLLECTS INFORMATION |
| ABOUT RU MEMBERS WITH NO HEALTH INSURANCE ON |
| JANUARY 1, 2005. THIS LOOP CYCLES ON RU MEMBERS |
| WHO ARE NOT A COVERED PERSON IN ANY ESTABLISHMENT-|
| POLICYHOLDER-COVERED-PERSON-TRIPLE THAT MEETS THE |
| FOLLOWING CONDITIONS: |
| - ESTABLISHMENT IS MEDICARE, MEDICAID, GOVT- |
| HOSPITAL/PHYSICIAN, OTHER PUBLIC, TRICARE, |
| OR PRIVATE INSURANCE |
| AND |
| - PERSON IS A CURRENT RU MEMBER (PART OF THE |
| RU ON 1/1/2005) WITH A BIRTH DATE PRIOR TO |
| DECEMBER 31, 2004 (OR AGE CATEGORY > 1) |
| AND |
| - PERIOD OF COVERAGE INCLUDES JANUARY 1, 2005 |
----------------------------------------------------
HX64 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
I have recorded that (PERSON) (were/was) without insurance on
January 1, 2005. (Were/Was) (PERSON) covered by a health
insurance plan or program at any time in the years 2003 or
2004?
YES .................................... 1
NO ..................................... 2 {END_LP18}
REF ................................... -7 {END_LP18}
DK .................................... -8 {END_LP18}
HX65 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
When (were/was) (PERSON) most recently covered by health
insurance? That is, in what month and year did that health
insurance end for the last time in 2003 or 2004?
[Enter Month,Year-4] ...................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED |
| ON THE MONTH AND YEAR FIELDS. |
----------------------------------------------------
HX66 ====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
Was (PERSON)’s health insurance that ended in {MONTH AND YEAR
FROM HX65/in 2003 or 2004} obtained through an employer or a
union, was it a government program such as Medicaid or a State
Children’s Health Insurance Program, or what?
CODE ALL THAT APPLY.
OBTAINED THROUGH UNION, PRIVATE
EMPLOYER OR PUBLIC EMPLOYER (FEDERAL,
STATE, OR LOCAL GOVT.) ................. 1
MEDICARE ............................... 2
MEDICAID/SCHIP ......................... 3
TRICARE/CHAMPVA ........................ 4
VA OR MILITARY HEALTH CARE ............. 5
PURCHASED DIRECTLY FROM GROUP, ASSOC.,
OR INS. AGENT, INS. CO. OR HMO ......... 6
OTHER TYPE OF GOVERNMENT SPONSORED
PROGRAM ................................ 7
OTHER PUBLIC PROGRAM:
TANF ................................ 8
SSI ................................. 9
{STATE PROGRAM 1} .................. 10
{STATE PROGRAM 2} .................. 11
{STATE PROGRAM 3} .................. 12
{STATE PROGRAM 4} .................. 13
OTHER ................................. 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITION OF ANSWER CATEGORIES.
----------------------------------------------------
| IF HX65 IS NOT CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T|
| KNOW), DISPLAY THE DATE ENTERED AT HX65 FOR ‘MONTH|
| AND YEAR FROM HX65’. DISPLAY ‘2003 or 2004’ IF |
| HX65 IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW).|
----------------------------------------------------
----------------------------------------------------
| FOR ‘STATE PROGRAM N’, DISPLAY AN ACTUAL NAME OF |
| STATE PLAN. FOR THE SPECIFIC NAMES OF PROGRAMS |
| BY STATE, SEE BOX ON HX16. |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |
| WITH OTHER CODES, CONTINUE WITH HX66OV |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO END_LP18 |
----------------------------------------------------
HX66OV ======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
HX67
====
OMITTED.
HX68
====
OMITTED.
HX68OV
======
OMITTED.
BOX_47
======
OMITTED.
HX69
====
OMITTED.
END_LP18 ========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER THAT |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_18 AND CONTINUE WITH BOX_48 |
----------------------------------------------------
BOX_48 ======
----------------------------------------------------
| IF NO CURRENT RU MEMBERS WHO WERE BORN BEFORE |
| DECEMBER 31, 2004 HAVE ANY TYPE OF COMPREHENSIVE |
| PUBLIC INSURANCE (I.E., MEDICARE, MEDICAID, |
| GOVT-HOSPITAL/PHYSICIAN, OR TRICARE) |
| AND |
| NO CURRENT RU MEMBERS WHO WERE BORN BEFORE |
| DECEMBER 31, 2004 HAVE ANY PRIVATE INSURANCE THAT |
| INCLUDED HOSPITAL AND PHYSICIAN BENEFITS OR |
| MEDICARE SUPPLEMENT/MEDIGAP BENEFITS ON 1/1/2005, |
| GO TO BOX_49 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH LOOP_19 |
----------------------------------------------------
LOOP_19 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK |
| HX70-END_LP19 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_19 COLLECTS INFORMATION ON |
| ALL RU MEMBERS WITH PUBLIC AND PRIVATE HEALTH |
| INSURANCE PROVIDING HOSPITAL/PHYSICIAN BENEFITS OR|
| MEDICARE SUPPLEMENT/MEDIGAP BENEFITS ON JANUARY 1,|
| 2005 TO DETERMINE PERIODS OF COVERAGE IN 2004 AND |
| POLICY LIMITATIONS DUE TO SPECIFIC PHYSICAL/MENTAL|
| HEALTH CONDITIONS. THIS LOOP CYCLES ON PERSONS |
| THAT MEET THE FOLLOWING CONDITIONS: |
| - PERSON IS A CURRENT RU MEMBER |
| AND |
| - PERSON WAS PART OF RU ON 1/1/2005 |
| AND |
| - PERSON’S DATE OF BIRTH IS BEFORE 12/31/2004 OR |
| IN AGE CATEGORIES 2-9 |
| AND |
| - PERSON HAD COMPREHENSIVE HEALTH INSURANCE |
| COVERAGE ON 1/1/2005. COMPREHENSIVE HEALTH |
| INSURANCE REFERS TO THE PERSON BEING A COVERED |
| PERSON ON AT LEAST ONE OF THE FOLLOWING |
| ESTABLISHMENT-POLICYHOLDER-COVERED PERSON- |
| TRIPLES ON 1/1/2005: |
| - ESTABLISHMENT IS MEDICARE |
| - ESTABLISHMENT IS MEDICAID/SCHIP |
| - ESTABLISHMENT IS TRICARE |
| - ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN |
| - ESTABLISHMENT IS PRIVATE WITH HOSPITAL AND |
| PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR |
| MEDIGAP (I.E., HX48 = 1 OR 5) |
----------------------------------------------------
HX70 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {STR-DT}
I have recorded that (PERSON) had health insurance coverage on
January 1, 2005. (Were/Was) (PERSON) ever without health
insurance coverage at any time in 2004?
YES .................................... 1
NO ..................................... 2 {END_LP19}
REF ................................... -7 {END_LP19}
DK .................................... -8 {END_LP19}
HX71 ====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {STR-DT}
Altogether, how many weeks or months (were/was) (PERSON)
without health insurance coverage in the year 2004?
[Enter Small Number] ...................
REF ................................... -7 {END_LP19}
DK .................................... -8 {END_LP19}
HX71OV ======
ENTER UNIT:
WEEKS .................................. 1
MONTHS ................................. 2
REF ................................... -7
DK .................................... -8
[Code One]
HX72
====
OMITTED.
HX73
====
OMITTED.
HX73OV
======
OMITTED.
HX74
====
OMITTED.
HX75
====
OMITTED.
HX75OV
======
OMITTED.
END_LP19 ========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER THAT |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_19 AND CONTINUE WITH BOX_49 |
----------------------------------------------------
BOX_49 ======
----------------------------------------------------
| IF ALL CURRENT RU MEMBERS WHO WERE BORN BEFORE |
| DECEMBER 31, 2004 HAVE ONLY PRIVATE INSURANCE |
| THAT INCLUDES HOSPITAL AND PHYSICIAN BENEFITS |
| AND/OR |
| ALL CURRENT RU MEMBERS HAVE ONLY COMPREHENSIVE |
| PUBLIC INSURANCE ON JANUARY 1, 2005, |
| GO TO BOX_50 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH LOOP_20 |
----------------------------------------------------
LOOP_20 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, |
| ASK HX76-END_LP20 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_20 COLLECTS INFORMATION FOR|
| EACH RU MEMBER WHOSE DATE OF BIRTH IS PRIOR TO |
| 12/31/2004 (OR AGE CATEGORY > 1), AND WHO IS |
| COVERED BY PRIVATE INSURANCE THAT DOES NOT INCLUDE|
| EITHER HOSPITAL/PHYSICIAN BENEFITS OR MEDICARE |
| SUPPLEMENT/MEDIGAP BENEFITS ON JANUARY 1, 2005. |
| THIS LOOP DETERMINES IF THESE PERSONS WERE EVER |
| COVERED BY A MORE COMPREHENSIVE PLAN THAT PROVIDED|
| HOSPITAL/PHYSICIAN COVERAGE DURING 2003 OR 2004. |
| THE LOOP CYCLES ON PERSONS THAT MEET THE FOLLOWING|
| CONDITIONS: |
| - PERSON IS A CURRENT RU MEMBER |
| AND |
| - PERSON WAS PART OF RU ON 1/1/2005 |
| AND |
| - PERSON’S DATE OF BIRTH IS BEFORE 12/31/2004 OR |
| IN AGE CATEGORIES 2-9 |
| AND |
| - PERSON DID NOT HAVE COMPREHENSIVE HEALTH |
| INSURANCE COVERAGE ON 1/1/2005. COMPREHENSIVE |
| HEALTH INSURANCE REFERS TO THE PERSON BEING A |
| COVERED PERSON ON AT LEAST ONE OF THE FOLLOWING |
| ESTABLISHMENT-POLICY HOLDER-COVERED PERSON- |
| TRIPLES ON 1/1/2005: |
| - ESTABLISHMENT IS MEDICARE |
| - ESTABLISHMENT IS MEDICAID/SCHIP |
| - ESTABLISHMENT IS TRICARE |
| - ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN |
| - ESTABLISHMENT IS PRIVATE WITH HOSPITAL AND |
| PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR |
| MEDIGAP (I.E., HX48 = 1 OR 5) |
| AND |
| - PERSON IS COVERED PERSON ON AT LEAST ONE OF THE |
| FOLLOWING ESTABLISHMENT-POLICYHOLDER-COVERED- |
| PERSON-TRIPLES ON 1/1/2005 |
| - ESTABLISHMENT IS GROUP 1 OR GROUP 2 OTHER |
| PUBLIC |
| - ESTABLISHMENT IS PRIVATE WITHOUT HOSPITAL AND |
| PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR |
| MEDIGAP (I.E., HX48 1 OR 5) |
----------------------------------------------------
HX76 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
I have recorded that (PERSON) {had health insurance coverage for
(READ TYPES OF INSURANCE BELOW) coverage} {and} {was covered by a
public program} on January 1, 2005. (Were/Was) (PERSON) ever covered
by a more comprehensive health insurance plan or program that
paid for medical and doctor’s bills at any time in the years
2003 or 2004?
{TYPE OF INSURANCE IN HX48} {TYPE OF INSURANCE IN HX48}
{TYPE OF INSURANCE IN HX48} {TYPE OF INSURANCE IN HX48}
{TYPE OF INSURANCE IN HX48} {TYPE OF INSURANCE IN HX48}
YES .................................... 1
NO ..................................... 2 {END_LP20}
REF ................................... -7 {END_LP20}
DK .................................... -8 {END_LP20}
----------------------------------------------------
| DISPLAY ‘had health...(BELOW)’ IF PERSON |
| CONFIRMED AS POLICYHOLDER (HP09 IS CODED ‘1’ |
| (YES)) OR SELECTED AS POLICYHOLDER (SELECTED AT |
| HP11) OR SELECTED AS A DEPENDENT (SELECTED AT |
| HP16) FOR ANY PRIVATE ESTABLISHMENT-POLICYHOLDER |
| PAIR WHERE HX48 IS NOT CODED ‘1’ (HOSPITAL AND |
| PHYSICIAN BENEFITS) AND NOT CODED ‘5’ (MEDICARE |
| SUPPLEMENT/MEDIGAP) EITHER ALONE OR WITH ANY |
| COMBINATION OF CODES FOR ALL OF THOSE PRIVATE |
| ESTABLISHMENT-POLICYHOLDER PARIS. OTHERWISE, USE |
| A NULL DISPLAY. |
| |
| DISPLAY ‘was....program’ IF PERSON SELECTED AT |
| HX19 (FOR EITHER GROUP 1 OR GROUP 2 PROGRAM). |
| OTHERWISE, USE A NULL DISPLAY. |
| |
| DISPLAY ‘and’ IF PERSON CONFIRMED AS POLICYHOLDER |
| (HP09 IS CODED ‘1’ (YES)) OR SELECTED AS |
| POLICYHOLDER (SELECTED AT HP11) OR SELECTED AS A |
| DEPENDENT (SELECTED AT HP16) FOR ANY PRIVATE |
| ESTABLISHMENT-POLICYHOLDER PAIR WHERE HX48 IS NOT |
| CODED ‘1’ (HOSPITAL AND PHYSICIAN BENEFITS) AND |
| NOT CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP) EITHER|
| ALONE OR WITH ANY COMBINATION OF CODES FOR ALL OF |
| THOSE PRIVATE ESTABLISHMENT-POLICYHOLDER PAIRS |
| AND PERSON SELECTED AT HX19 (FOR EITHER GROUP 1 |
| OR GROUP 2 PROGRAM). |
----------------------------------------------------
HX77 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
When (were/was) (PERSON) most recently covered by this kind of
health insurance? That is, in what month and year did the
health insurance that paid for medical and doctor’s bills end
for the last time in 2003 or 2004?
[Enter Month,Year-4] ...................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED |
| ON THE MONTH AND YEAR FIELDS. |
----------------------------------------------------
HX78 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Was (PERSON)’s health insurance that ended in {DATE FROM
HX77/2003 or 2004} obtained through an employer or union, was
it a government program such as Medicare or Medicaid or a State
Children’s Health Insurance Program, or what?
CODE ALL THAT APPLY.
OBTAINED THROUGH UNION, PRIVATE
EMPLOYER OR PUBLIC EMPLOYER (FEDERAL,
STATE, OR LOCAL GOVERNMENT) ............ 1
MEDICARE ............................... 2
MEDICAID/SCHIP ......................... 3
TRICARE/CHAMPVA ........................ 4
VA OR MILITARY HEALTH CARE ............. 5
PURCHASED DIRECTLY FROM GROUP,
ASSOCIATION, OR INSURANCE AGENT,
INSURANCE COMPANY OR HMO ............... 6
OTHER TYPE OF GOVERNMENT SPONSORED
PROGRAM ................................ 7
OTHER PUBLIC PROGRAM:
TANF ................................ 8
SSI ................................. 9
{STATE PROGRAM 1}................... 10
{STATE PROGRAM 2} .................. 11
{STATE PROGRAM 3} .................. 12
{STATE PROGRAM 4} .................. 13
OTHER ................................. 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITION OF ANSWER CATEGORIES.
----------------------------------------------------
| IF HX77 IS NOT CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T|
| KNOW), DISPLAY THE DATE ENTERED AT HX77 FOR ‘MONTH|
| AND YEAR FROM HX77’. DISPLAY ‘2003 or 2004’ IF |
| HX77 IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW).|
----------------------------------------------------
----------------------------------------------------
| FOR ‘STATE PROGRAM N’, DISPLAY AN ACTUAL NAME OF |
| STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A |
| STATE THAT HAS OTHER STATE PROGRAMS. FOR THE |
| SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON |
| HX16. |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |
| WITH OTHER CODES, CONTINUE WITH HX78OV |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO END_LP20 |
----------------------------------------------------
HX78OV ======
ENTER OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
HX79
====
OMITTED.
HX80
====
OMITTED.
HX80OV
======
OMITTED.
END_LP20 ========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER THAT |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_20 AND CONTINUE WITH BOX_50 |
----------------------------------------------------
BOX_50 ======
----------------------------------------------------
| IF ROUND 3, CONTINUE WITH LOOP_21 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO NEXT QUESTIONNAIRE SECTION. |
----------------------------------------------------
LOOP_21 =======
----------------------------------------------------
| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK |
| HX81_END_LP21 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_21 COLLECTS INFORMATION |
| FOR EACH RU MEMBER TO DETERMINE IF THESE PERSONS |
| HAD ANY COMPREHENSIVE COVERAGE ON DECEMBER 31, |
| 2005. |
----------------------------------------------------
HX81 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
(Were/Was) (PERSON) covered by a health insurance plan
or program that paid for medical and doctor’s bills on
December 31, 2005?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
END_LP21 ========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER THAT |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_21 AND CONTINUE WITH BOX_51 |
----------------------------------------------------
BOX_51 ======
----------------------------------------------------
| GO TO NEXT QUESTIONNAIRE SECTION |
----------------------------------------------------