Managed Care (MC) Section
MC01
====
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT........} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
Now I will ask you a few questions about how (POLICYHOLDER)'s
health insurance through (ESTABLISHMENT) {works/worked} for
non-emergency care {on (END DATE)}.
We are interested in knowing if (POLICYHOLDER)'s (ESTABLISHMENT)
plan is an HMO, that is, a Health Maintenance Organization.
With an HMO, you must generally receive care from HMO physicians.
For other doctors, the expense is not covered unless you were
referred by the HMO or there was a medical emergency.
{When answering this question, do not consider (POLICYHOLDER)’s
insurance through Medicare.}
{Is/Was} (POLICYHOLDER)’s (INSURER NAME) an HMO {on (END DATE)}?
YES .................................... 1 {MC05}
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF HMO.
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| DISPLAY ‘works’ AND ‘Was’ IF NOT ROUND 5. DISPLAY|
| ‘worked’ AND ‘Is’ IF ROUND 5. |
| |
| DISPLAY ‘on (END DATE)’ IF ROUND 5. OTHERWISE, |
| USE A NULL DISPLAY. |
| |
| DISPLAY ‘When answering this question, do not |
| consider (POLICYHOLDER)’s insurance through |
| Medicare.’ IF POLICYHOLDER BEING ASKED ABOUT IS |
| ALSO COVERED BY MEDICARE. OTHERWISE, USE A NULL |
| DISPLAY. |
----------------------------------------------------
MC02
====
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT........} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
{(Do/Does)/As of (END DATE), did} (POLICYHOLDER)’s insurance
plan require (POLICYHOLDER) to sign up with a certain primary
care doctor, group of doctors, or a certain clinic which
(POLICYHOLDER) must go to for all of (POLICYHOLDER)’s routine
care?
PROBE: Do not include emergency care or care from a specialist
you were referred to.
YES .................................... 1 {MC04}
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF PRIMARY CARE DOCTOR AND ROUTINE CARE.
----------------------------------------------------
| DISPLAY ‘(Do/Does)’ IF NOT ROUND 5. DISPLAY ‘As |
| of (END DATE), did’ IF ROUND 5. |
----------------------------------------------------
MC03
====
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT........} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
{Is/As of (END DATE), was} there a book or list of doctors
associated with the plan?
YES .................................... 1
NO ..................................... 2 {BOX_01}
REF ................................... -7 {BOX_01}
DK .................................... -8 {BOX_01}
----------------------------------------------------
| DISPLAY ‘Is’ IF NOT ROUND 5. DISPLAY ‘As of (END |
| DATE), was’ IF ROUND 5. |
----------------------------------------------------
MC04
====
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT........} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
{Will/As of (END DATE), would} (POLICYHOLDER)’s plan pay for any
of the costs of visits to doctors who are not associated with
(POLICYHOLDER)’s plan, even if (POLICYHOLDER) {(do/does)/did}
not have a referral?
YES .................................... 1 {BOX_01}
NO ..................................... 2 {BOX_01}
REF ................................... -7 {BOX_01}
DK .................................... -8 {BOX_01}
----------------------------------------------------
| DISPLAY ‘Will’ AND ‘(do/does)’ IF NOT ROUND 5. |
| DISPLAY ‘As of (END DATE), would’ AND ‘did’ IF |
| ROUND 5. |
----------------------------------------------------
MC05
====
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT........} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
{Will/As of (END DATE), would} (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)/did} not
have a referral?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| DISPLAY ‘Will’ AND ‘(do/does)’ IF NOT ROUND 5. |
| DISPLAY ‘As of (END DATE), would’ AND ‘did’ IF |
| ROUND 5. |
----------------------------------------------------
BOX_01
======
----------------------------------------------------
| RETURN TO ORIGINAL QUESTIONNAIRE SECTION IN HX OR |
| OE. |
----------------------------------------------------
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