Health Insurance (HX) Section

THROUGHOUT THE SPECIFICATIONS FOR THIS CAPI
SECTION, FOR SCREENS THAT SPECIFY THE REFERENCE
PERIOD {END DATE} AS PART OF THE CONTEXT HEADER,
CAPI DISPLAYS THE {END DATE} ONLY FOR ROUND 5. IN
ANY OTHER ROUND, CAPI DOES NOT DISPLAY THE {END
DATE} IN THE CONTEXT HEADER. FOR MOST PERSONS, THE
END DATE FOR ROUND 5 WILL BE DECEMBER 31 OF THE
SECOND YEAR OF THE PANEL.

BOX_00

CONTEXT HEADER DISPLAY INSTRUCTIONS:
FOR MONTH DISPLAY 3 CHAR MONTH (EG. JAN, FEB)

ROUNDS 1-4, DISPLAY ONLY THE BEGIN DATE RATHER
THAN BOTH THE BEGIN AND END DATE. IF ROUND 5 THEN
DISPLAY BOTH THE BEGIN AND END DATE.

DISPLAY PERS.FULLNAME, ESTB.ESTBNAME,
PRND.BEGREFMM, PRND.BEGREFDD, PRND.BEGREFYY,
PRND.ENDREFMM, PRND.ENDREFDD, PRND.ENDREFYY

HX01

{STR-DT}
{END-DT}

Let’s talk (again) about all the health insurance coverage the
family may have to help pay for the costs of medical care {since
{START DATE}/between {START DATE} and {END DATE}}.

{ASK RESPONDENT TO GET INSURANCE CARDS/IDENTIFYING INFORMATION
IF NOT ALREADY AVAILABLE.}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

DISPLAY ‘ASK....AVAILABLE.’ IF 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.

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 NAV_HX01A - 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.

NAVIGATOR DETAILS: LOOP_01 USES BOTH NAV_HX01A
AND NAV_HX01B TO CONTROL THE FLOW OF THE LOOP.

NAV_HX01A

{STR-DT}

SERIES: Health Insurance Through Establishments

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH RU MEMBER EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS-
ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE CONDITIONS
STATED AT THE LOOP_01 DEFINITION.

CONTINUE WITH NAV_OE01B FOR SELECTED RU MEMBER

NAV_HX01B

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

SERIES: Verifying Insurance during the Reference Period
(including selecting a Policyholder)

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member...Employer Providing Insurance

[1. Person’s Name-65]...[Establishment Name-30] [Status-25]
[2. Person’s Name-65]...[Establishment Name-30] [Status-25]
[3. Person’s Name-65]...[Establishment Name-30] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER...EMPLOYER PROVIDING
INSURANCE
INSTRUCTIONS: DISPLAY RU-ESTABLISHMENT-PERSON-
PAIR
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH PAIR EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL EMPLOYERS THAT MEET THE CONDITIONS
STATED AT THE LOOP_01 DEFINITION.

CONTINUE WITH HX02 FOR SELECTED PAIR

HX02

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}

You mentioned that {you/{PERSON}} {were/was} covered by health
insurance from {ESTABLISHMENT} {at some point after {START
DATE}/between {START DATE} and {END DATE}}.

SELECT ‘CONTINUE’ UNLESS RESPONDENT VOLUNTEERS INSURANCE
REPORTED IN ERROR.

CONTINUE ............................... 1 {BOX_04}
INSURANCE REPORTED IN ERROR ............ 2 {END_LP01}

[Code One]

IF ROUND 1 THROUGH ROUND 4, DISPLAY ‘at some point
after {START DATE}’. IF ROUND 5, DISPLAY ‘between
{START DATE} and {END DATE}’.

IF CODED ‘2’ (INSURANCE REPORTED IN ERROR) 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 {you/{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
{you/{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}
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}
DIRECTLY FROM A HIGH RISK POOL {/{STATE
NAME FOR HIGH RISK POOL}} ........... 10 {BOX_06}
OTHER ................................. 91 {HX03OV}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

STARTING IN PANEL 12 ROUND 2, CATEGORY ‘4’ (FROM
A HEALTH INSURANCE PURCHASING ALLIANCE) WAS
OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.

STARTING IN PANEL 14 ROUND 5, PANEL 15 ROUND 3 AND
PANEL 16 ROUND 1, CATEGORY ‘10’ (DIRECTLY FROM A
HIGH RISK POOL{/{STATE NAME FOR HIGH RISK POOL}})
WAS ADDED AND WILL BE ADDED IN ALL FUTURE ROUNDS.

DISPLAY ‘you mentioned that {you/{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’.

DISPLAY ‘/{STATE NAME FOR HIGH RISK POOL}’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED OFFERS
A HIGH RISK POOL HEALTH INSURANCE PLAN. THIS
INCLUDES ALL STATES EXCEPT: AZ, DE, DC, GA, HI,
ME, MA, MI, NV, NJ, NY, OH, PA, RI, VT, VA. IF
INTERVIEW STATE IS ONE OF THESE STATES, USE A NULL
DISPLAY.

FOR ‘STATE NAME FOR HIGH RISK POOL’ DISPLAY THE
HIGH RISK POOL PLAN NAME ASSOCIATED WITH THE STATE
IN WHICH INTERVIEW IS BEING CONDUCTED.

HX03OV

OTHER:

[Enter Other Specify] .................. {BOX_06}
DK .................................... -8 {BOX_06}

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 {you/{PERSON}}
{purchase/purchases} health insurance for {ESTABLISHMENT}?

YES .................................... 1 {END_LP03}
NO ..................................... 2 {END_LP03}
REF ................................... -7 {END_LP03}
DK .................................... -8 {END_LP03}

HELP AVAILABLE 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}

We show that (READ NAMES BELOW) {(are/is)} {either} {65 years old
or older} {or} {joined the household since our last interview}.

[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}

HELP AVAILABLE 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.

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

ROSTER DETAILS:
Title: RU_MEMBERS_1

COL #1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR DISPLAY
OF RU-MEMBERS.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
OTHERWISE, DISPLAY RU-MEMBERS WHO MEET ONE OF THE
FOLLOWING CONDITIONS:
1. PERSON IS A NEW RU MEMBER THIS ROUND,

2. PERSON TURNED 65 YEARS OLD THIS ROUND AND IS
NOT FLAGGED AS COVERED BY MEDICARE DURING ANY
ROUND,

3. OR PERSON >= 65 (OR IN AGE CATEGORY 9) LAST
ROUND AND NOT FLAGGED AS COVERED BY MEDICARE
DURING ANY ROUND.

HX06

{STR-DT}

SHOW CARD HX-2.

Medicare is a health insurance program for persons 65 years or
over and for some disabled persons. 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

HELP AVAILABLE FOR DEFINITION OF MEDICARE.

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

HX07

{STR-DT}
{END-DT}

Who is covered by Medicare?

PROBE: Who else is covered by Medicare?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65] {LOOP_04}

ROSTER DETAILS:
TITLE: RU_MEMBERS_SELECTONE

COL # 1 HEADER: PERSON-TYPE-PROVIDER
INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
ONE OR MORE FROM THE LISTED MEMBERS.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
IN ROUND 1, NONE. DISPLAY ALL.
IN ROUNDS 2-5, DISPLAY RU MEMBERS WHO MEET ONE OF
THE FOLLOWING CONDITIONS:
1. PERSON IS A NEW RU MEMBER THIS ROUND,

2. PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT
FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND,

3. 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.

NAVIGATOR DETAILS: LOOP_04 USES EITHER NAV_HX04A
OR NAV_HX04B TO CONTROL THE FLOW OF THE LOOP.

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 NAV_HX04B

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
NAV_HX04A

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 NAV_HX04B

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 NAV_HX04B

NAV_HX04A

{STR-DT}

SERIES: Medicare for RU Members Under 65

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. Reason for Medicare [Person’s Name-65]] [Status-25]
[2. Reason for Medicare [Person’s Name-65]] [Status-25]
[3. Reason for Medicare [Person’s Name-65]] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT HX07 AND WHO
ARE < 65 YEARS OLD (OR IN AGE CATEGORIES 1-8).

GO TO HX08 FOR SELECTED RU MEMBER.

NAV_HX04B

SERIES: Receive Social Security for Someone 65+ Without Medicare

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

Question Series

[1. Receive Social Security...[Person’s Name-65]] [Status-25]
[2. Receive Social Security...[Person’s Name-65]] [Status-25]
[3. Receive Social Security...[Person’s Name-65]] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: QUESTION SERIES
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH RU MEMBER EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED WHO MEET THE
FOLLOWING CONDITIONS (SEE BOX_10 AND BOX_11):

- HX05 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR
‘-8’ (DON’T KNOW) AND RU MEMBER TURNED 65 THIS
ROUND
OR
- PERSON IS NOT SELECTED AT HX07 AND IS = > 65
YEARS OLD (OR IN AGE CATEGORY 9)
OR
- 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 FOR SELECTED RU MEMBER.

HX08

{PERSON’S FIRST MIDDLE AND LAST NAME}

{Do/Does} {you/{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}

HELP AVAILABLE FOR DEFINITION OF CONDITION/DISABILITY.

HX09

{PERSON’S FIRST MIDDLE AND LAST NAME}

People with Social Security usually get Medicare. {Do/Does}
{you/{PERSON}} receive Social Security?

YES .................................... 1 {END_LP04}
NO ..................................... 2 {END_LP04}
REF ................................... -7 {END_LP04}
DK .................................... -8 {END_LP04}

HELP AVAILABLE 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}

SHOW CARD HX-3.

{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP NAME} are state
programs that pay for health care for persons in need. People covered
by {Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP NAME} may have
a (piece of paper/card) that looks something like this.

At any time {since {START DATE}/between {START DATE} and {END DATE}},
has anyone in the family been covered by {Medicaid/{STATE NAME FOR
MEDICAID}} or {STATE CHIP NAME}?

YES .................................... 1
NO ..................................... 2 {BOX_14}
REF ................................... -7 {BOX_14}
DK .................................... -8 {BOX_14}

HELP AVAILABLE FOR DEFINITION OF MEDICAID/SCHIP.

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 ATTACHMENT 37.

DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
SUBSTITUTING THE REAL NAME FOR PROGRAM. FOR THE
SPECIFIC NAME TO USE BY STATE, SEE ATTACHMENT 37.

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}?

[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 ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
SUBSTITUTING THE REAL NAME FOR PROGRAM. FOR THE
SPECIFIC NAME TO USE BY STATE, SEE ATTACHMENT 37.

GO TO LOOP_05

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
FROM THE LISTED MEMBERS.

2. ADD, DELETE, AND EDIT DISALLOLWED.

ROSTER FILTER:
NONE, DISPLAY ALL.

LOOP_05

FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_HX05 - 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)

NAVIGATOR DETAILS: LOOP_05 USES NAV_HX05 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HX05

MEDICAID/SCHIP {STR-DT}

SERIES: Time Covered by MEDICAID/SCHIP during Reference Period.

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. Coverage duration for [Person’s Name-65] through
MEDICAID/SCHIP] [Status-25]
[2. Coverage duration for [Person’s Name-65] through
MEDICAID/SCHIP] [Status-25]
[3. Coverage duration for [Person’s Name-65] through
MEDICAID/SCHIP] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT HX11.

CONTINUE WITH BOX_13 FOR SELECTED RU MEMBER.

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}

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 {HX12A}
NO ..................................... 2 {BOX_16}
REF ................................... -7 {BOX_16}
DK .................................... -8 {BOX_16}

HELP AVAILABLE FOR DEFINITION OF TRICARE/CHAMPVA.

DISPLAY ‘since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘between {START DATE} and {END DATE}’ IF
ROUND 5.

HX12A

{STR-DT}
{END-DT}

Which plan is it? Is it…

INTERVIEWER:
CODE MORE THAN ONE PLAN ONLY IF DIFFERENT RU MEMBERS
HAVE DIFFERENT PLANS.

CHECK ALL THAT APPLY.

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?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

GO TO LOOP_06

ROSTER DETAILS:
Title: RU_MEMBERS_1

COL #1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR SELECTION
OF RU-MEMBERS.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
FROM THE LISTED MEMBERS.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
NONE, DISPLAY ALL.

LOOP_06

FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_HX06 - 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)

NAVIGATOR DETAILS: LOOP_06 USES NAV_HX06 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HX06

TRICARE OR CHAMPVA {STR-DT}

SERIES: Time Covered by TRICARE OR CHAMPVA during Reference
Period.

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. Coverage duration for [Person’s Name-65] through
TRICARE OR CHAMPVA] [Status-25]
[2. Coverage duration for [Person’s Name-65] through
TRICARE OR CHAMPVA] [Status-25]
[3. Coverage duration for [Person’s Name-65] through
TRICARE OR CHAMPVA] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT HX13.

CONTINUE WITH BOX_15 FOR SELECTED RU MEMBER.

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}

At any time {since {START DATE}/between {START DATE} and
{END DATE}}, has anyone in the family had any other type of health
insurance from any state or local government agency which provided
hospital and physician benefits?

YES .................................... 1 {HX14A}
NO ..................................... 2 {BOX_19}
REF ................................... -7 {BOX_19}
DK .................................... -8 {BOX_19}

HELP AVAILABLE FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.

DISPLAY ‘since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘between {START DATE} and {END DATE}’ IF
ROUND 5.

HX14A

{STR-DT}

What is the name of the plan?

[Enter text] ...........................

NOTE: ‘GOVT-HOSPITAL/PHYSICIAN’ SHOULD BE USED
FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER
(WHERE APPROPRIATE).

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

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?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

GO TO LOOP_07

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
FROM THE LISTED MEMBERS.

2. ADD, DELETE, AND EDIT DISALLOLWED.

ROSTER FILTER:
NONE, DISPLAY ALL.

LOOP_07

FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_HX07 - 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)

NAVIGATOR DETAILS: LOOP_07 USES NAV_HX07 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HX07

{PLAN NAME FROM HX14A.....} {STR-DT}

SERIES: Time Covered by {PLAN NAME FROM HX14A.....} during
Reference Period.

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. Coverage duration for [Person’s Name-65] through
{PLAN NAME FROM HX14A.....}] [Status-25]
[2. Coverage duration for [Person’s Name-65] through
{PLAN NAME FROM HX14A.....}] [Status-25]
[3. Coverage duration for [Person’s Name-65] through
{PLAN NAME FROM HX14A.....}] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT HX15.

CONTINUE WITH BOX_18 FOR SELECTED RU MEMBER.

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}

Some people receive 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}/between {START DATE} and {END
DATE}}, has anyone in the family been covered by any program like
this?

YES .................................... 1 {LOOP_08}
NO ..................................... 2 {HX21}
REF ................................... -7 {HX21}
DK .................................... -8 {HX21}

HELP AVAILABLE FOR A LIST OF OTHER STATE PROGRAMS.

DISPLAY THE LIST OF UP TO FOUR ACTUAL NAMES OF
STATE PROGRAMS (AS LISTED IN ATTACHMENT 37) FOR
‘STATE NAME FOR PROGRAM #N’ IF STATE HAS OTHER
STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘between {START DATE} and {END DATE}’ IF
ROUND 5.

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, SELECT ‘NONE OF THESE’.

{STATE SPECIFIC PLAN 1} ................ 1
{STATE SPECIFIC PLAN 2} ................ 2
{STATE SPECIFIC PLAN 3} ................ 3
{STATE SPECIFIC PLAN 4} ................ 4
OTHER ................................. 91 {HX17OV}
NONE OF THESE ......................... 95 {HX18}
REF ................................... -7 {BOX_21}
DK .................................... -8 {BOX_21}

HELP AVAILABLE 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 ATTACHMENT 37.

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.)

FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.

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

HARD CHECK:
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. CONTINUE."

HX17OV

SPECIFY:

[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 {END_LP08}
DK .................................... -8 {END_LP08}

HELP AVAILABLE 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)?

[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 DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
FROM THE LISTED MEMBERS.

2. ADD, DELETE, AND EDIT DISALLOLWED.

ROSTER FILTER:
NONE, DISPLAY ALL.

LOOP_09

FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS ROSTER, ASK BOX_21A - 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)

NAVIGATOR DETAILS: LOOP_09 USES EITHER NAV_HX09A
OR NAV_HX09B TO CONTROL THE FLOW OF THE LOOP.

BOX_21A

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. CONTINUE WITH
NAV_HX09A

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. GO TO NAV_HX09B

NAV_HX09A

STATE SPECIFIC PROGRAM {STR-DT}

SERIES: Time Covered by STATE SPECIFIC PROGRAM during Reference
Period.

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. Coverage duration for [Person’s Name-65] through
STATE SPECIFIC PROGRAM] [Status-25]
[2. Coverage duration for [Person’s Name-65] through
STATE SPECIFIC PROGRAM] [Status-25]
[3. Coverage duration for [Person’s Name-65] through
STATE SPECIFIC PROGRAM] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT HX19 AND
FLAGGED AS BEING COVERED BY A GROUP 1 OTHER PUBLIC
PROGRAM DURING THE CURRENT ROUND.

GO TO BOX_22 FOR SELECTED RU MEMBER.

NAV_HX09B

STATE: TANF/SSI/WIC/IHS/PHC/VA {STR-DT}

SERIES: Time Covered by STATE: TANF/SSI/WIC/IHS/PHC/VA during
Reference Period.

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. Coverage duration for [Person’s Name-65] through
STATE: TANF/SSI/WIC/IHS/PHC/VA] [Status-25]
[2. Coverage duration for [Person’s Name-65] through
STATE: TANF/SSI/WIC/IHS/PHC/VA] [Status-25]
[3. Coverage duration for [Person’s Name-65] through
STATE: TANF/SSI/WIC/IHS/PHC/VA] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT HX19 AND
FLAGGED AS BEING COVERED BY A GROUP 2 OTHER PUBLIC
PROGRAM DURING THE CURRENT ROUND.

GO TO BOX_22 FOR SELECTED RU MEMBER

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 {END_LP08}
NO ..................................... 2 {END_LP08}
REF ................................... -7 {END_LP08}
DK .................................... -8 {END_LP08}

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.}

{Since {START DATE}/Between {START DATE} and {END DATE}} we show the
family has had the following health insurance:

HX21_01. ESTABLISHMENT NAME (INSURER)	HX21_02. COVERED RU MEMBERS
[Display Establishment Name (Display Insurer Name)]	[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]	[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]	[Display First and Last Names of All Covered RU Members]

PRESS ENTER OR SELECT NEXT PAGE 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.

DISPLAY ‘So far, ... and {END DATE}}:’ AND THE
REPORT OF CURRENT ROUND HEALTH INSURANCE IF ANY
SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.

HX22

{STR-DT}
{END-DT}

SHOW CARD HX-4.

Please look at this card. It lists various ways people can
obtain health 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 {LOOP_10}
NO ..................................... 2 {BOX_25}
REF ................................... -7 {BOX_25}
DK .................................... -8 {BOX_25}

HELP AVAILABLE 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
OBTAINED FROM SOURCES OTHER THAN EMPLOYERS
MENTIONED IN THE EMPLOYMENT SECTION OF THE
INTERVIEW. 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}
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’S PREVIOUS
EMPLOYER .............................. 10 {BOX_24}
FROM SOME OTHER EMPLOYER ................ 11 {BOX_24}
UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 {BOX_24}
DIRECTLY FROM A HIGH RISK POOL {/{STATE
NAME FOR HIGH RISK POOL}} ............. 13 {BOX_24}
OTHER SOURCE ............................ 91 {HX23OV}
REF ..................................... -7 {BOX_24}
DK ...................................... -8 {BOX_24}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

STARTING IN PANEL 12 ROUND 2, CATEGORY ‘2’ (FROM
A HEALTH INSURANCE PURCHASING ALLIANCE) WAS
OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.

STARTING IN PANEL 14 ROUND 5, PANEL 15 ROUND 3 AND
PANEL 16 ROUND 1, CATEGORY ‘13’ (DIRECTLY FROM A
HIGH RISK POOL {/{STATE NAME FOR HIGH RISK POOL}})
WAS ADDED AS A CATEGORY AND WILL BE ADDED IN ALL
FUTURE ROUNDS.

DISPLAY ‘/{STATE NAME FOR HIGH RISK POOL}’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED OFFERS
A HIGH RISK POOL HEALTH INSURANCE PLAN. THIS
INCLUDES ALL STATES EXCEPT: AZ, DE, DC, GA, HI,
ME, MA, MI, NV, NJ, NY, OH, PA, RI, VT, VA. IF
INTERVIEW STATE IS ONE OF THESE STATES, USE A NULL
DISPLAY.

FOR ‘STATE NAME FOR HIGH RISK POOL’ DISPLAY THE
HIGH RISK POOL PLAN NAME ASSOCIATED WITH THE STATE
IN WHICH INTERVIEW IS BEING CONDUCTED.

DISPLAY AN ‘ADD OTHER SOURCE’ BUTTON ON THIS
SCREEN.

IF ‘ADD OTHER SOURCE’ IS SELECTED, PRESENT ‘ADD
OTHER SOURCE’ POP-UP (HX23OV) AND THEN GO TO
BOX_24.

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 {END_LP10}
NO ..................................... 2 {END_LP10}
REF ................................... -7 {END_LP10}
DK .................................... -8 {END_LP10}

HELP AVAILABLE 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} {STR-DT}
{END-DT}

CODE WITHOUT ASKING IF ANSWER IS KNOWN.

Can you please take out {your/{PERSON}’s} Medicare card?

We do not need {your/his/her} Medicare number, but
would like to record the exact date {your/his/her} Medicare coverage
became effective and what type of coverage {you/he/she} {have/has}
through Medicare.

CARD AVAILABLE ......................... 1 {HX26}
CARD NOT AVAILABLE ..................... 2 {HX28A}
REF ................................... -7 {HX28A}
DK .................................... -8 {HX28A}

[Code One]

STARTING IN PANEL 13 ROUND 1/PANEL 12 ROUND 3,
CAPI NO LONGER COLLECTS MEDICARE NUMBERS (SSN).

HX26

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

Is that card a regular Medicare card, a Railroad Retirement
Board card, or some other Medicare card?

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.

IF CODED ‘1’ (MEDICARE CARD) OR ‘2’ (RAILROAD
RETIREMENT BOARD CARD), CONTINUE WITH HX27

IF CODED ‘3’ (SOME OTHER CARD) ONLY, GO TO HX28A

HX27

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HX-2.

Please tell me the effective date listed on the card.

{Are/Is} {you/{PERSON}} entitled to hospital (Part A), medical
(Part B), or both?

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]

STARTING IN PANEL 13, ROUND 1/PANEL 12, ROUND 3,
CAPI NO LONGER COLLECTS MEDICARE NUMBERS (SSN).

GO TO BOX_28A

HARD CHECK:
CHECK EFFECTIVE DATE. DATE MUST BE ON OR BEFORE
(I.E., < OR =) THE INTERVIEW DATE. IF EFFECTIVE
DATE IS ON OR BEFORE JANUARY 1, {YEAR}, WHERE
‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL,
FLAG RU MEMBER AS ‘WITH HEALTH INSURANCE COVERAGE
ON JAN 1, {YEAR}’.

SOFT RANGE CHECK: MEDICARE EFFECTIVE DATE MUST
BE = OR > BIRTH DATE OF PERSON.

HX28

OMITTED.

HX28A

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

Part A of Medicare covers most hospital expenses. Part B covers
many doctors’ expenses, including doctor visits, and the premium
is usually deducted from {your/{PERSON}’s} Social Security.

{Are/Is} {you/he/she} covered under Part B of Medicare?

YES ................................... 1 {HX29}
NO .................................... 2 {HX29}
REF ................................... -7 {HX29}
DK .................................... -8 {HX29}

HX29

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

When did {your/{PERSON}’s} Medicare coverage start?

[Enter Month,Year-4] .................. {HX30}
REF ................................... -7 {HX29OV}
DK .................................... -8 {HX29OV}

IF EFFECTIVE DATE IS:
- A VALID DATE (I.E., NOT ‘RF’ (REFUSED) OR ‘DK’
(DON’T KNOW) IN THE MONTH OR YEAR FIELDS
AND
- ON OR BEFORE JANUARY 1, {YEAR}, WHERE ‘YEAR’ IS
THE FIRST CALENDAR YEAR OF THE PANEL,
THEN FLAG RU MEMBER AS ‘WITH HEALTH INSURANCE
COVERAGE ON JAN 1, {YEAR}.

HARD CHECK:
DATE MUST BE ON OR BEFORE (I.E., < OR =) INTERVIEW
DATE OR 12/31/{YEAR}, WHERE YEAR IS THE SECOND
CALENDAR YEAR OF THE PANEL, IF ROUND 5. ‘-7’
(REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED ON THE
MONTH AND YEAR FIELDS.

MEDICARE EFFECTIVE DATE MUST BE = OR > BIRTH DATE
OF PERSON.

HX29OV

Did {you/he/she} have Medicare coverage on January 1, {YEAR}?

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, {YEAR}, WHERE
‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL.

HX29OV2

OMITTED.

HX30

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HX-2.

{Do/Does} {you/{PERSON}} have a Medicare card that looks like this?

YES .................................... 1 {BOX_28A}
NO ..................................... 2 {BOX_28A}
REF ................................... -7 {BOX_28A}
DK .................................... -8 {BOX_28A}

HX30A

OMITTED.
MOVED AND RENUMBERED TO HX35A

BOX_28A

NOTE: STATES THAT DO NOT OFFER MEDICARE MANAGED
CARE PLANS INCLUDE THE FOLLOWING:
ALASKA

IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED
DOES NOT OFFER A MEDICARE MANAGED CARE PLAN, CODE
HX31 AND HX32 ‘2’ (NO) AUTOMATICALLY BY CAPI AND
GO TO HX35A

OTHERWISE, CONTINUE WITH HX31

HX31

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HX-5.

Is the name of {your/{PERSON}’s} insurance plan through Medicare{,
as of {END DATE},} listed on this card?

YES .................................... 1 {HX31OV}
NO ..................................... 2 {HX32}
REF ................................... -7 {HX32}
DK .................................... -8 {HX32}

HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED CARE.

DISPLAY ‘, as of {END DATE},’ IF ROUND 5.
OTHERWISE, USE A NULL DISPLAY.

HX31OV

Which insurance plan {is/was} {your/his/her} Medicare managed care
plan {as of {END DATE}}?

CODE LETTER OF PLAN FROM SHOW CARD:

[Enter Plan Letter From Card] ......... {HX33A}

DISPLAY ‘is’ IF NOT ROUND 5. DISPLAY ‘was’ IF
ROUND 5.

DISPLAY ‘as of {END DATE}’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.

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.

HX32

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

{{Are/Is} {you/{PERSON}} currently/As of {END DATE}, {were/was}
{you/{PERSON}} enrolled in a Medicare Advantage or managed care plan,
such as an HMO (Health Maintenance Organization) or PPO (Preferred
Provider Organization) to receive {your/his/her} Medicare-funded
health care? When answering, please include only insurance from
Medicare, not any privately purchased or job-related insurance.

YES .................................... 1 {HX33}
NO ..................................... 2 {HX35A}
REF ................................... -7 {HX35A}
DK .................................... -8 {HX35A}

HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED CARE.

DISPLAY ‘{Are/Is} {you/{PERSON} currently’ IF NOT
ROUND 5. DISPLAY ‘as of {END DATE}, {were/was}
{you/{PERSON}’ IF ROUND 5.

HX32A

OMITTED.

HX33

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

What {is/was} the name of {your/{PERSON}’s} Medicare managed care
plan {as of {END DATE}}?

[Enter Plan Name] ..................... {HX33A}
REF ................................... -7 {HX33A}
DK .................................... -8 {HX33A}

DISPLAY ‘is’ IF NOT ROUND 5. DISPLAY ‘was’ IF
ROUND 5.

DISPLAY ‘as of {END DATE}’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.

FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S
MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON-
PAIR.

HX33A

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

{{Do/Does}/Did} {you/{PERSON}} have prescribed medicine coverage
through {{{PLAN NAME ENTERED AT HX31OV-50}/{NAME OF PLAN FROM
HX33}}/{your/his/her} Medicare managed care plan} {as of {END DATE}}?

YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8

DISPLAY ‘{Do/Does}’ IF NOT ROUND 5. DISPLAY ‘Did’
IF ROUND 5.

DISPLAY ‘{{PLAN NAME ENTERED AT HX31OV-50}/{NAME
OF PLAN FROM HX33}}’ IF A PLAN NAME WAS CODED AT
HX31OV OR HX33. DISPLAY ‘{your/his/her} Medicare
managed care plan’ IF HX33 IS CODED ‘-7’ (REF)
OR ‘-8’ (DK).

DISPLAY ‘{PLAN NAME ENTERED AT HX31OV-50}’ 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.

DISPLAY ‘as of {END DATE}’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.

IF ROUND 1 OR ROUND 3, CONTINUE WITH HX34

OTHERWISE, GO TO END_LP11

HX34

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

Most Medicare beneficiaries pay their Part B premiums through their
Social Security checks. In addition, {do/does} {you/{PERSON}} (or
anyone in the family) pay anything else for {the coverage with
{{PLAN NAME ENTERED AT HX310V}/{NAME OF PLAN FROM HX33}}/this
Medicare Managed Care plan}?

[Do not include the cost of any copayments, coinsurance or
deductibles anyone in the family may have had to pay.]

YES .................................... 1 {HX34A}
NO ..................................... 2 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

[Code One]

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

DISPLAY ‘the coverage with {{PLAN NAME ENTERED AT
HX31OV}/{NAME OF PLAN FROM HX33}}’ IF A MEDICARE
PLAN NAME WAS SELECTED AT HX31OV OR ENTERED AT
HX33. DISPLAY ‘this Medicare managed care plan’
IF HX33 WAS CODED ‘-7’ (REF) OR ‘-8’ (DK).

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.

HX34A

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

How {do/does} {you/{PERSON}} pay for {your/his/her} {{{PLAN NAME
ENTERED AT HX31OV}/{NAME OF PLAN FROM HX33}}/Medicare managed care}
premium?

IF NECESSARY, SAY: Is the Medicare Advantage premium paid through
{your/his/her} Social Security check, paid directly to the provider,
or paid both ways?

DEDUCTED FROM SOCIAL SECURITY .......... 1 {HX35}
PAY DIRECTLY ........................... 2 {HX35}
BOTH ................................... 3 {HX35}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

DISPLAY ‘{{PLAN NAME ENTERED AT HX31OV}/{NAME OF
PLAN FROM HX33}} IF A MEDICARE PLAN NAME WAS
SELECTED AT HX31OV OR ENTERED AT HX33. DISPLAY
‘Medicare managed care’ IF HX33 WAS CODED ‘-7’
(REF) OR ‘-8’ (DK).

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} {STR-DT}
{END-DT}

How much {is {your/{PERSON}’s Social Security deduction/{do/does}
{you/{PERSON}} pay in premiums} for {your/his/her} {{PLAN NAME
ENTERED AT HX31OV}/{NAME OF PLAN FROM HX33}} plan?

IF RESPONDENT IS NOT SURE, DO NOT PROBE. CODE ‘DON’T KNOW’.

[Enter Amount in Dollars] .............. {HX35OV1}
REF ................................... -7 {HX35AA}
DK .................................... -8 {HX35AA}

DISPLAY ‘is {your/{PERSON}’s} Social Security
deduction’ IF HX34A IS CODED ‘1’ (DEDUCTED FROM
SOCIAL SECURITY’. DISPLAY ‘{do/does} {you/
{PERSON}} pay in premiums’ IF HX34A IS CODED ‘2’
(PAY DIRECTLY) OR ‘3’ (BOTH).

DISPLAY ‘{{PLAN NAME ENTERED AT HX31OV}/{NAME OF
PLAN FROM HX33}}’ IF A MEDICARE PLAN NAME WAS
SELECTED AT HX31OV OR ENTERED AT HX33. OTHERWISE
(I.E., IF HX33 WAS CODED ‘-7’ (REF) OR ‘-8’ (DK)),
USE A NULL DISPLAY.

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

Is that per year, per month, per week, or what?

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 {HX35OV2}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

[Code One]

HX35OV2

SPECIFY:

[Enter Other Specify] .................. {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

HX35AA

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT HX31OV}/{NAME OF PLAN FROM HX33}}}

SHOW CARD HX-6.

Which category on the card best indicates the cost of this
plan per month?

1 - 50 ................................. 1 {END_LP11}
51 - 100 ............................... 2 {END_LP11}
101 - 200 .............................. 3 {END_LP11}
201 - 300 .............................. 4 {END_LP11}
301 OR MORE ............................ 5 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

DISPLAY ‘PLAN NAME: {{PLAN NAME ENTERED AT
HX31OV}/{NAME OF PLAN FROM HX33}}’ IF A MEDICARE
PLAN NAME WAS SELECTED AT HX31OV OR ENTERED AT
HX33. OTHERWISE (I.E., IF HX33 WAS CODED ‘-7’
(REF) OR ‘-8’ (DK)), USE A NULL DISPLAY.

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.

HX35A

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

{{Are/Is}/{Were/Was}} {you/{PERSON}} enrolled in Medicare Part D,
also known as the Medicare Prescription Drug Plan {as of
{END DATE}}?

YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8

HELP AVAILABLE FOR DEFINITION OF MEDICARE PART D.

DISPLAY ‘{Are/Is}’ IF NOT ROUND 5. DISPLAY
‘{Were/Was}’ IF ROUND 5.
DISPLAY ‘as of {END DATE}’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.

IF CODED ‘1’ (YES) AND ROUND 1 OR ROUND 3,
CONTINUE WITH HX35B

OTHERWISE, GO TO END_LP11

HX35B

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

Most Medicare beneficiaries pay their Part B premiums through their
Social Security checks. In addition, {do/does} {you/{PERSON}} (or
anyone in the family) pay anything else for {your/his/her} Medicare
Prescription Drug Plan (also known as Part D)?

[Do not include the cost of any copayments, coinsurance or
deductibles anyone in the family may have had to pay.]

YES .................................... 1 {HX35C}
NO ..................................... 2 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

[Code One]

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

HX35C

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

How {do/does} {your/{PERSON}} pay for {your/his/her} Part D premium?

IF NECESSARY, SAY: Is the Medicare drug coverage premium paid
through {your/his/her} Social Security check, paid directly to the
provider, or paid both ways?

DEDUCTED FROM SOCIAL SECURITY .......... 1 {HX35D}
PAY DIRECTLY ........................... 2 {HX35D}
BOTH ................................... 3 {HX35D}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

HX35D

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

How much {is {your/{PERSON}’s} Social Security deduction/{do/does}
{you/{PERSON}} pay in premiums} for {your/his/her} Part D plan?

IF RESPONDENT IS NOT SURE, DO NOT PROBE. CODE ‘DON’T KNOW’.

[Enter Amount in Dollars] .............. {HX35DOV1}
REF ................................... -7 {HX35E}
DK .................................... -8 {HX35E}

DISPLAY ‘is {your/{PERSON}’s} Social Security
deduction’ IF HX35C IS CODED ‘1’ (DEDUCTED FROM
SOCIAL SECURITY’. DISPLAY ‘{do/does} {you/
{PERSON}} pay in premiums’ IF HX35C IS CODED ‘2’
(PAY DIRECTLY) OR ‘3’ (BOTH).

HX35DOV1

Is that per year, per month, per week, or what?

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 {HX35DOV2}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

[Code One]

HX35DOV2

SPECIFY:

[Enter Other Specify] .................. {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

HX35E

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HX-7.

Which category on the card best indicates the cost of this
plan per month?

1 - 30 ................................. 1 {END_LP11}
31 - 60 ................................ 2 {END_LP11}
61 - 90 ................................ 3 {END_LP11}
91 - 120 ............................... 4 {END_LP11}
121 OR MORE ............................ 5 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

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_31C

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_31C

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 MISSISSIPPI
WYOMING

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-8.

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 {HX41OV}
NO ..................................... 2 {HX42}
REF ................................... -7 {HX42}
DK .................................... -8 {HX42}

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 ATTACHMENT 37.

DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE
ATTACHMENT 37.

HX41OV

Which plan is the health insurance through {{Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME}/that program)}?

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 ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE
ATTACHMENT 37.

FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S
INSURER FOR MEDICAID/SCHIP OR GOVT-HOSPITAL/
PHYSICIAN’.

IF ASKING ABOUT MEDICAID/SCHIP, GO TO BOX _31B

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) BELOW) enrolled in 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.]

[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 {HX43}
REF ................................... -7 {HX43}
DK .................................... -8 {HX43}

[Code One]

HELP AVAILABLE 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 ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE
ATTACHMENT 37.

DISPLAY ‘between {START DATE} and {END DATE}’ IF
ROUND 5. OTHERWISE, USE A NULL DISPLAY.

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS-
ROSTER FOR SELECTION OF RU MEMBERS.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
1. ESTABLISHMENT IS MEDICAID/SCHIP OR GOVT-
HOSPITAL/PHYSICIAN,
AND
2. PERSON IS AN RU MBMBER 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.

[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 {HX44}
YES, SOME REQUIRED ..................... 2 {HX44}
NO, NONE REQUIRED ...................... 3
REF ................................... -7
DK .................................... -8

HELP AVAILABLE FOR DEFINITION OF PRIMARY CARE DOCTOR AND ROUTINE CARE.

DISPLAY ‘Does’ IF NOT ROUND 5. DISPLAY ‘Between
{START DATE} and {END DATE}, did’ IF ROUND 5.

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 ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE
ATTACHMENT 37.

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_31B

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

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS-
ROSTER FOR SELECTION OF RU-MEMBERS.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
1. ESTABLISHMENT IS MEDICAID/SCHIP OR GOVT-
HOSPITAL/PHYSICIAN,
AND
2. PERSON IS AN RU MBMBER FLAGGED AS COVERED BY
MEDICAID/SCHIP OR GOVT-HOSPITAL/PHYSICIAN DURING
THE CURRENT ROUND.

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 ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE
ATTACHMENT 37.

FLAG INSURER CODED ABOVE AS CURRENT ROUND’S
INSURER FOR MEDICAID/SCHIP OR GOVT-HOSPITAL/
PHYSICIAN.

IF ASKING ABOUT MEDICAID/SCHIP, CONTINUE WITH
BOX_31B

OTHERWISE, GO TO HX45

BOX_31B

IF ROUND 1 OR ROUND 3 (AND ASKING ABOUT MEDICAID/
SCHIP), CONTINUE WITH HX45

OTHERWISE (I.E., IF ROUNDS 2, 4, OR 5 AND ASKING
ABOUT MEDICAID/SCHIP), GO TO BOX_31C

HX45

{STR-DT}
{END-DT}

Does anyone in the family pay anything for the coverage through
{{{PLAN NAME ENTERED AT HX41OV}/{NAME OF PLAN FROM HX44}}/
{{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}?

[Do not include the cost of any copayments, coinsurance or
deductibles anyone in the family may have had to pay.]

YES .................................... 1 {HX46}
NO ..................................... 2 {HX47}
REF ................................... -7 {BOX_31C}
DK .................................... -8 {BOX_31C}

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

DISPLAY ‘{{PLAN NAME ENTERED AT HX41OV}/{NAME OF
PLAN FROM HX44}}’ IF THERE IS A CURRENT ROUND
INSURER ASSOCIATED WITH THE MEDICAID/SCHIP OR
GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE,
DISPLAY, {{Medicaid/... and physician benefits}’.
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 ‘{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 ‘Medicaid’ IF STATE IN WHCH 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 ATTACHMENT 37.

DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE
ATTACHMENT 37.

HX46

{STR-DT}
{END-DT}

How much does anyone in the family pay for {the {{PLAN NAME
ENTERED AT HX41OV}/{NAME OF PLAN FROM HX44}}/that} coverage?

[Enter Amount in Dollars] .............. {HX46OV1}
REF ................................... -7 {HX47}
DK .................................... -8 {HX47}

DISPLAY ‘the {{PLAN NAME ENTERED AT HX41OV}/{NAME
OF PLAN FROM HX44}}’ IF THERE IS A CURRENT ROUND
INSURER ASSOCIATED WITH THE MEDICAID/SCHIP OR
GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE,
DISPLAY, ‘that’.

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.

HX46OV1

Is that per year, per month, per week, or what?

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 {HX46OV2}
REF ................................... -7 {HX47}
DK .................................... -8 {HX47}

[Code One]

HX46OV2

SPECIFY:

[Enter Other Specify] .................. {HX47}
REF ................................... -7 {HX47}
DK .................................... -8 {HX47}

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 {HX47OV}
REF ................................... -7 {BOX_31C}
DK .................................... -8 {BOX_31C}

[Code All That Apply]

DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
OR 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).

FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH HX47OV

OTHERWISE, GO TO BOX_31C

HX47OV

SPECIFY:

[Enter Other Specify] .................. {BOX_31C}
REF ................................... -7 {BOX_31C}
DK .................................... -8 {BOX_31C}

BOX_31C

IF ROUND 1 OR ROUND 3, CONTINUE WITH BOX_31D

OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO
BOX_32

BOX_31D

IF ANY RU MEMBER HAS TRICARE/CHAMPVA AS A SOURCE
OF INSURANCE DURING THE CURRENT ROUND, CONTINUE
WITH BOX_31E

OTHERWISE, GO TO BOX_32

BOX_31E

IF NO ONE IN THE RU WAS COVERED BY TRICARE/CHAMPVA
DURING THE PREVIOUS ROUND AND AT LEAST ONE RU
MEMBER IS COVERED BY TRICARE/CHAMPVA DURING THE
CURRENT ROUND CONTINUE WITH HX47A

OTHERWISE, GO TO BOX_32

HX47A

{STR-DT}
{END-DT}

[Now, let’s talk about the coverage someone in the family has
through TRICARE or CHAMPVA.]

Does anyone in the family pay anything for the coverage through
TRICARE or CHAMPVA?

[Do not include the cost of any copayments, coinsurance or
deductibles anyone in the family may have had to pay.]

YES .................................... 1 {HX47B}
NO ..................................... 2 {BOX_32}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

HX47B

{STR-DT}
{END-DT}

How much does anyone in the family pay for the coverage through
TRICARE or CHAMPVA?

[Enter Amount in Dollars] .............. {HX47BOV1}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}

HX47BOV1

Is that per year, per month, per week, or what?

UNIT OF COVERAGE:

PER YEAR ............................... 1 {BOX_32}
QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_32}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_32}
PER MONTH .............................. 4 {BOX_32}
PER WEEK ............................... 5 {BOX_32}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_32}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_32}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_32}
OTHER ................................. 91 {HX47BOV2}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}

[Code One]

HX47BOV2

SPECIFY:

[Enter Other Specify] .................. {BOX_32}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}

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_44C

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-9.

Now think again about {your/{POLICYHOLDER}’s} health insurance
through {ESTABLISHMENT}. Looking at this card, what health
insurance coverage {{do/does}/did} {you/he/she} have {as of {END
DATE}}?

PROBE: Any other health coverage through this plan?

CHECK 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 {HX48OV}
REF ................................... -7 {BOX_33}
DK .................................... -8 {BOX_33}

[Code All That Apply]

HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.

[NOTE: ‘DISABILITY,’ ‘WORKER’S COMPENSATION,’ AND ‘ACCIDENT’
WILL NOT APPEAR ON THE SHOW CARD.]

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 ‘as of {END DATE}’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.

NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE
SHOW CARD.

FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH HX48OV

OTHERWISE, GO TO BOX_33

HX48OV

SPECIFY:

[Enter Other Specify] ................. {BOX_33}
REF ................................... -7 {BOX_33}
DK .................................... -8 {BOX_33}

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
{you/{POLICYHOLDER}} {receive/receives} the Medicare Supplement or
Medigap benefits?

IF MORE THAN ONE NAME, PROBE: What is the main insurance company
or HMO from which {you/he/she} {receive/receives} the Medicare
Supplement or Medigap benefits?

IF RESPONDENT SAYS BOTH INSURANCE COMPANY AND HMO, SELECT ‘HMO’.

NAME OF INSURER: [Enter Insurer] ..........
REF ...................... -7
DK ........... ........... -8

TYPE: 1 = INSURANCE COMPANY ...............
2 = HMO .............................
3 = SELF-INSURED COMPANY ............
REF ................................. -7
DK .................................. -8

HELP AVAILABLE 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.

BOTH INSURER NAME AND INSURER TYPE MUST BE
ENTERED.

IF INSURER NAME IS ENTERED, CONTINUE WITH LOOP_13

IF INSURER NAME IS CODED ‘-7’ (REF) OR ‘-8’ (DK),
GO TO BOX_35

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}
{END-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 {HX50OV}
NO OTHER NAME .......................... 2 {END_LP13}
REF ................................... -7 {END_LP13}
DK .................................... -8 {END_LP13}

HELP AVAILABLE 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

SPECIFY:

[Enter Insurance Company or HMO] ....... {END_LP13}
REF ................................... -7 {END_LP13}
DK .................................... -8 {END_LP13}

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 ROUND 1 AND 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 ROUND 1 AND HX48 IS CODED ‘-7’ (REFUSED) OR
‘-8’ (DON’T KNOW), GO TO BOX_39

IF ROUND 2, 3, 4, OR 5 AND 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
{you/{POLICYHOLDER}} {receive/receives} hospital and physician
benefits?

IF MORE THAN ONE NAME, PROBE: What is the main insurance company
or HMO from which {you/he/she} {receive/receives} hospital and
physician benefits?

IF RESPONDENT SAYS BOTH INSURANCE COMPANY AND HMO, SELECT ‘HMO’.

NAME OF INSURER: [Enter Insurer] ..........
REF ...................... -7
DK ..... ................. -8

TYPE: 1 = INSURANCE COMPANY ...............
2 = HMO .............................
3 = SELF-INSURED COMPANY ............
REF ................................. -7
DK .................................. -8

HELP AVAILABLE 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.

BOTH INSURER NAME AND INSURER TYPE MYST BE
ENTERED.

IF INSURER NAME IS ENTERED, CONTINUE WITH LOOP_14

IF INSURER NAME IS CODED ‘-7’ (REF) OR ‘-8’ (DK),
GO TO BOX_38

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}
{END-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 {HX52OV}
NO OTHER NAME .......................... 2 {END_LP14}
REF ................................... -7 {END_LP14}
DK .................................... -8 {END_LP14}

HELP AVAILABLE 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

SPECIFY:

[Enter Insurance Company or HMO] ....... {END_LP14}
REF ................................... -7 {END_LP14}
DK .................................... -8 {END_LP14}

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}
{END-DT}

SHOW CARD HX-10.

Is the name of {your/{POLICYHOLDER}’s} insurance plan through
{ESTABLISHMENT} listed on this card?

YES .................................... 1 {HX59OV}
NO ..................................... 2 {BOX_40}
REF ................................... -7 {BOX_40}
DK .................................... -8 {BOX_40}

HX59OV

Which insurance plan is {your/his/her} {ESTABLISHMENT}
insurance?

CODE LETTER OF PLAN FROM SHOW CARD:

[Enter Plan Letter From Card] ......... {BOX_40}

WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY
THE FOLLOWING MESSAGE: "PLEASE VERIFY PLAN
ENTERED." WHEN INTERVIEWER PRESSES CLEARS 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_4OA - 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/MANAGED CARE PLAN. 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 (EPIN.INSTYPE = 2), 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 {your/{POLICYHOLDER}’s} plan pay for any of the costs of
visits to doctors who are not part of {your/his/her} HMO, even if
{you/he/she} {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}
{END-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 {your/{PERSON}’s}
plan?

PROBE: What is it?

[Enter Plan Letter] .................... {BOX_43}
REF ................................... -7 {BOX_43}
DK .................................... -8 {BOX_43}

HELP AVAILABLE FOR DEFINITION OF PLAN LETTER.

HARD CHECK: MEDICARE SUPPLEMENTAL OR MEDIGAP
PLANS: MEDICARE SUPPLEMENTAL OR MEDIGAP PLAN
LETTER MUST BE 1 CHARACTER LONG, A-L, UPPER OR
LOWER CASE. IF CODED OTHER THAN A-L DISPLAY THE
FOLLOWING MESSAGE: "Medicare Supplemental or
Medigap Plan letter must be A through L. Verify
and re-enter 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}
{END-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 {HX62}
YES, PAY SOME OF PREMIUM/COST .......... 2 {HX62}
YES, BUT DON’T KNOW IF PAY ALL OR SOME
OF PREMIUM/COST ........................ 3 {HX62}
NO, DO NOT PAY ......................... 4 {HX63}
REF ................................... -7 {BOX_44B}
DK .................................... -8 {BOX_44B}

[Code One]

HELP AVAILABLE 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}
{END-DT}

How much {{do/does}/did} {you/{POLICYHOLDER}} pay for the
{ESTABLISHMENT} coverage?

[Enter Amount in Dollars] .............. {HX62OV1}
REF ................................... -7 {BOX_44A}
DK .................................... -8 {BOX_44A}

DISPLAY ‘{do/does}’ IF INSURANCE BEING ASKED
ABOUT IS CURRENT (I.E., HQ02 IS CODED ‘1’ (YES,
COVERED NOW)) FOR THE POLICYHOLDER. OTHERWISE,
DISPLAY ‘did’.

HX62OV1

{Is/Was} that per year, per month, per week, or what?

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 {HX62OV2}
REF ................................... -7 {BOX_44A}
DK .................................... -8 {BOX_44A}

[Code One]

DISPLAY ‘Is’ IF INSURANCE BEING ASKED ABOUT IS
CURRENT (I.E., HQ02 IS CODED ‘1’ (YES, COVERED
NOW)) FOR THE POLICYHOLDER. OTHERWISE, DISPLAY
‘Was’.

HX62OV2

SPECIFY:

[Enter Other Specify] .................. {BOX_44A}
REF ................................... -7 {BOX_44A}
DK .................................... -8 {BOX_44A}

BOX_44A

IF HX61 IS CODED ‘1’ (YES, PAY ALL OF PREMIUM/
COST), GO TO BOX_44B

OTHERWISE, CONTINUE WITH HX63

HX63

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}

Who {else} pays {some of/for} the premium or cost
of this insurance?

CHECK ALL THAT APPLY.

FEDERAL GOVERNMENT .................... 1
STATE GOVERNMENT ...................... 2
LOCAL GOVERNMENT ...................... 3
SOME GOVERNMENT ....................... 4
EMPLOYER .............................. 5
UNION ................................. 6
OTHER ................................. 91 {HX63OV}
REF ................................... -7 {BOX_44B}
DK .................................... -8 {BOX_44B}

[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).

FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH HX63OV

OTHERWISE, GO TO BOX_44B

HX63OV

SPECIFY:

[Enter Other Specify] .................. {BOX_44B}
REF ................................... -7 {BOX_44B}
DK .................................... -8 {BOX_44B}

BOX_44B

IF INSURANCE BEING ASKED ABOUT PROVIDES MEDICARE
SUPPLEMENT/MEDIGAP COVERAGE (I.E., HX48 IS CODED
‘5’ (MEDICARE SUPPLEMENT/MEDIGAP) EITHER ALONE
OR WITH ANY COMBINATION OF CODES), GO TO END_LP12

OTHERWISE, CONTINUE WITH HX63A

HX63A

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}

Is the {family} annual deductible for medical care for this plan
less than {$1,250 or $1,250/$2,500 or $2,500} or more? If there
is a separate deductible for prescription drugs, hospitalization,
or out-of-network care, do not include those deductible amounts
here.

LESS THAN {$1,250/$2,500} .............. 1 {END_LP12}
{$1,250/$2,500} OR MORE ................ 2 {HX63B}
NO ANNUAL DEDUCTIBLE ................... 3 {END_LP12}
REF ................................... -7 {END_LP12}
DK .................................... -8 {END_LP12}

[Code One]

HELP AVAILABLE FOR DEFINITION OF ANNUAL DEDUCTIBLE.

DISPLAY ‘$1,250 or $1,250’ IN THE QUESTION TEXT
AND ‘$1,250’ IN THE RESPONSE CATEGORY OPTIONS IF
THE POLICYHOLDER IS THE ONLY COVERED RU MEMBER AND
THERE ARE NO DEPENDENTS OUTSIDE THE RU (HP17 IS
CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW)) FOR THE PAIR BEING ASKED ABOUT. OTHERWISE
(E.G., AT LEAST ONE RU MEMBER, OTHER THAN THE
POLICYHOLDER IS LISTED AS A COVERED PERSON FOR
THIS PAIR OR HP17 IS CODED ‘1’ (YES) FOR THIS
PAIR OR THE POLICYHOLDER IS NOT IN THE RU),
DISPLAY ‘family’ and ‘$2,500 or $2,500’ IN THE
QUESTION TEXT AND ‘$2,500’ IN THE RESPONSE
CATEGORY OPTIONS.

IF POLICYHOLDER IS FLAGGED AS ‘DECEASED’ AND THE
NUMBER OF COVERED PERSONS ON RU-ESTB-PLCYHLDR-
CVRD-PERS-TRPLS-ROSTER <= 2 AND HP17 IS CODED ‘2’
(NO), ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW), THEN
DISPLAY ‘1,250 or 1,250’ IN THE QUESTION TEXT AND
‘1,250’ IN THE RESPONSE CATEGORY OPTIONS.

IF POLICYHOLDER IS FLAGGED AS ‘DECEASED’ AND THE
NUMBER OF COVERED PERSONS ON RU-ESTB-PLCYHLDR-
CVRD-PERS-TRPLS-ROSTER <= 2 AND HP17 IS CODED ‘1’
(YES), THEN DISPLAY ‘family’ AND ‘2,500 or 2,500’
IN THE QUESTION TEXT AND ‘2,500’ IN THE RESPONSE
CATEGORY OPTIONS.

IF POLICYHOLDER IS FLAGGED AS ‘DECEASED’ AND THE
NUMBER OF COVERED PERSONS ON RU-ESTB-PLCYHLDR-
CVRD-PERS-TRPLS-ROSTER > 2, THEN DISPLAY ‘family’
AND ‘2,500 or 2,500’ IN THE QUESTION TEXT AND
‘2,500’ IN THE RESPONSE CATEGORY OPTIONS.

HX63B

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}

With this plan, is there a special account or fund that can be
used to pay for medical expenses? The accounts are sometimes
referred to as Health Savings Accounts (HSAs), Health
Reimbursement Accounts (HRAs), Personal Care accounts, Personal
Medical funds, or Choice funds, and are different from Flexible
Spending Accounts.

YES .................................... 1 {END_LP12}
NO ..................................... 2 {END_LP12}
REF ................................... -7 {END_LP12}
DK .................................... -8 {END_LP12}

[Code One]

HELP AVAILABLE FOR DEFINITION OF HEALTH SAVINGS ACCOUNTS (HSAs).

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_44C

BOX_44C

IF ROUND 1 OR ROUND 3, CONTINUE WITH HX63C

OTHERWISE, GO TO BOX_45

HX63C

{STR-DT}
{END-DT}

Does anyone in the family have a Flexible Spending Account
for health expenses?

IF NECESSARY, SAY: These accounts are offered by some employers
to allow employees to set aside pre-tax dollars of their own
money for their use throughout the year to reimburse themselves
for their own or their family members’ out-of-pocket expenses for
health care. With this type of account, any money remaining in
the account at the end of the year, following a short grace
period, is lost to the employee.

YES .................................... 1 {HX63D}
NO ..................................... 2 {BOX_45}
REF ................................... -7 {BOX_45}
DK .................................... -8 {BOX_45}

HX63D

{STR-DT}
{END-DT}

Who has a Flexible Spending Account (FSA) for health expenses?

PROBE: Anyone else?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65] {HX63E}

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
ONE OR MORE FROM THE LISTED MEMBERS.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS AGE 16 OR OLDER.

HX63E

{STR-DT}
{END-DT}

How much {{do/does} {you/{PERSON}}/does your family} contribute per
year to {this FSA/these FSAs all together}?

[Amount] .............................. {BOX_45}
REF .................................... -7 {BOX_45}
DK ..................................... -8 {BOX_45}

DISPLAY ‘{do/does} {you/{PERSON}}’ AND ‘this FSA’
IF ONLY ONE RU MEMBER SELECTED AT HX63D.
OTHERWISE, DISPLAY ‘does your family’ AND ‘these
FSAs all together’.

SOFT CHECK:
RANGE CHECK: $1-$5000

BOX_45

IF ROUND 1, CONTINUE WITH BOX_46

OTHERWISE, GO TO BOX_51

BOX_46

IF ALL PERSONS IN RU HAVE HEALTH INSURANCE (I.E.,
FLAGGED AS HAVING MEDICARE, MEDICAID/SCHIP,
GOVT-HOSPITAL/PHYSICIAN, TRICARE/CHAMPVA, OTHER
PUBLIC OR PRIVATE INSURANCE) COVERAGE ON JANUARY 1,
{YEAR}, WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF
THE PANEL, GO TO BOX_48

OTHERWISE, (AT LEAST ONE RU MEMBER BORN BEFORE
12/31/{YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE
FIRST CALENDAR YEAR OF THE PANEL, IS WITHOUT HEALTH
INSURANCE ON JANUARY 1, {YEAR}, WHERE ‘YEAR’ IS THE
FIRST CALENDAR YEAR OF THE PANEL), 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, {YEAR}, WHERE YEAR IS THE FIRST
CALENDAR YEAR OF THE PANEL. 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/SCHIP, GOVT-
HOSPITAL/PHYSICIAN, OTHER PUBLIC,
TRICARE/CHAMPVA, OR PRIVATE INSURANCE
AND
- PERSON IS A CURRENT RU MEMBER WITH A BIRTH DATE
PRIOR TO DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS
THE YEAR PRIOR TO THE FIRST CALENDAR YEAR OF THE
PANEL (OR AGE CATEGORY > 1)
AND
- PERIOD OF COVERAGE INCLUDES JANUARY 1, {YEAR},
WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE
PANEL.

HX64

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

I have recorded that {you/{PERSON}} {were/was} without insurance on
January 1, {YEAR}. {Were/Was} {you/he/she} covered by a health
insurance plan or program at any time in the years {YEAR} or
{YEAR}?

YES .................................... 1 {HX65}
NO ..................................... 2 {END_LP18}
REF ................................... -7 {END_LP18}
DK .................................... -8 {END_LP18}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): IN THE QUESTION TEXT, "... on
JANUARY 1, {YEAR}," ‘YEAR’ IS THE FIRST CALENDAR
YEAR OF THE PANEL. IN THE QUESTION TEXT, "... at
any time in the years {YEAR} or {YEAR}?" CAPI
DISPLAYS THE TWO YEARS PRIOR TO THE FIRST CALENDAR
YEAR OF THE PANEL. (FOR PANEL 12 FOR EXAMPLE, THIS
WOULD BE ‘2005 or 2006?’).

HX65

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

When {were/was} {you/{PERSON}} most recently covered by health
insurance? That is, in what month and year did that health
insurance end for the last time in {YEAR} or {YEAR}?

[Enter Month,Year-4] ................... {HX66}
REF ................................... -7 {HX66}
DK .................................... -8 {HX66}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): CAPI DISPLAYS THE TWO YEARS PRIOR
TO THE FIRST CALENDAR YEAR OF THE PANEL FOR
"‘YEAR’ OR ‘YEAR’?". (FOR PANEL 12 FOR EXAMPLE,
THIS WOULD BE ‘2005 or 2006?’).

‘-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}
{END-DT}

Was {your/{PERSON}’s} health insurance that ended in {MONTH AND YEAR
FROM HX65/{YEAR} or {YEAR}} obtained through an employer or a
union, was it a government program such as Medicaid, or what?

CHECK ALL THAT APPLY.

OBTAINED THROUGH UNION, PRIVATE
EMPLOYER OR PUBLIC EMPLOYER (FEDERAL,
STATE, OR LOCAL GOVT.) ................. 1
MEDICARE ............................... 2
MEDICAID ............................... 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 {HX66OV}
REF ................................... -7 {END_LP18}
DK .................................... -8 {END_LP18}

[Code All That Apply]

HELP AVAILABLE 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 ‘{YEAR} or
{YEAR}’ IF HX65 IS CODED ‘-7’ (REFUSED) OR ‘-8’
(DON’T KNOW), WHERE ‘YEAR’ AND ‘YEAR’ DISPLAYS
THE TWO YEARS PRIOR TO THE FIRST CALENDAR YEAR OF
THE PANEL. FOR PANEL 12 FOR EXAMPLE, THIS WOULD BE
‘2005’ or ‘2006’.

FOR ‘STATE PROGRAM N’, DISPLAY AN ACTUAL NAME OF
A STATE PLAN. FOR THE SPECIFIC NAMES OF PLANS
BY STATE, SEE ATTACHMENT 37.

FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH OTHER CODES, CONTINUE WITH HX66OV

OTHERWISE, GO TO END_LP18

HX66OV

SPECIFY:

[Enter Other Specify] .................. {END_LP18}
REF ................................... -7 {END_LP18}
DK .................................... -8 {END_LP18}

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, {YEAR}, WHERE ‘YEAR’ IS THE YEAR
PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL,
HAVE ANY TYPE OF COMPREHENSIVE PUBLIC INSURANCE
(I.E., MEDICARE, MEDICAID/SCHIP, GOVT-
HOSPITAL/PHYSICIAN, OR TRICARE/CHAMPVA)
AND
NO CURRENT RU MEMBERS WHO WERE BORN BEFORE
DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS THE YEAR
PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL,
HAVE ANY PRIVATE INSURANCE THAT INCLUDED HOSPITAL
AND PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT/
MEDIGAP BENEFITS ON 1/1/{YEAR}, WHERE ‘YEAR’ IS
THE FIRST CALENDAR YEAR OF THE PANEL, 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,
{YEAR}, WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF
THE PANEL, TO DETERMINE PERIODS OF COVERAGE IN
{YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE
FIRST CALENDAR YEAR OF THE PANEL. THIS LOOP CYCLES
ON PERSONS THAT MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER
AND
- PERSON’S DATE OF BIRTH IS BEFORE 12/31/{YEAR},
WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE FIRST
CALENDAR YEAR OF THE PANEL, OR PERSON’S AGE IS
AGE CATEGORIES 2-9
AND
- PERSON HAD COMPREHENSIVE HEALTH INSURANCE
COVERAGE ON 1/1/{YEAR}, WHERE ‘YEAR’ IS THE
FIRST CALENDAR YEAR OF THE PANEL. 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/{YEAR}, WHERE ‘YEAR’ IS THE FIRST
CALENDAR YEAR OF THE PANEL:
- 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}
{END-DT}

I have recorded that {you/{PERSON}} had health insurance coverage on
January 1, {YEAR}. {Were/Was} {you/he/she} ever without health
insurance coverage at any time in {YEAR}?

YES .................................... 1 {HX71}
NO ..................................... 2 {END_LP19}
REF ................................... -7 {END_LP19}
DK .................................... -8 {END_LP19}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): FOR ‘YEAR’ IN, "... on JANUARY 1,
{YEAR}," DISPLAY THE FIRST CALENDAR YEAR OF THE
PANEL. FOR ‘YEAR’ IN "... at any time in {YEAR},"
DISPLAY THE YEAR PRIOR TO THE FIRST CALENDAR YEAR
OF THE PANEL.

HX71

{POLICYHOLDER FIRST MIDDLE LAST NAME} {STR-DT}
{END-DT}

Altogether, how many weeks or months {were/was} {you/{PERSON}}
without health insurance coverage in the year {YEAR}?

[Enter Small Number] ................... {HX71OV}
REF ................................... -7 {END_LP19}
DK .................................... -8 {END_LP19}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): FOR ‘YEAR’ IN THE QUESTION TEXT,
DISPLAY THE YEAR PRIOR TO THE FIRST CALENDAR YEAR
OF THE PANEL.

HX71OV

ENTER UNIT:

WEEKS .................................. 1 {END_LP19}
MONTHS ................................. 2 {END_LP19}
REF ................................... -7 {END_LP19}
DK .................................... -8 {END_LP19}

[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, {YEAR}, WHERE ‘YEAR’ IS THE YEAR
PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL,
HAVE ONLY PRIVATE INSURANCE THAT INCLUDES HOSPITAL
AND PHYSICIAN BENEFITS
AND/OR
ALL CURRENT RU MEMBERS HAVE ONLY COMPREHENSIVE
PUBLIC INSURANCE ON JANUARY 1, {YEAR}, WHERE
‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL,
GO TO BOX_51

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/{YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO
THE FIRST CALENDAR YEAR OF THE PANEL, (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, {YEAR}, WHERE ‘YEAR’ IS THE
FIRST CALENDAR YEAR OF THE PANEL. THE LOOP CYCLES
ON PERSONS WERE EVER COVERED BY A MORE
COMPREHENSIVE PLAN THAT PROVIDED HOSPITAL/
PHYSICIAN COVERAGE DURING {YEAR}, WHERE ‘YEAR’ IS
THE YEAR PRIOR TO THE FIRST CALENDAR YEAR OF THE
PANEL, OR {YEAR}, WHERE ‘YEAR’ IS TWO YEARS PRIOR
TO THE FIRST CALENDAR YEAR OF THE PANEL. THE LOOP
CYCLES ON PERSONS THAT MEET THE FOLLOWING
CONDITIONS:
- PERSON IS A CURRENT RU MEMBER
AND
- PERSON’S DATE OF BIRTH IS BEFORE 12/31/{YEAR},
WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE FIRST
CALENDAR YEAR OF THE PANEL, OR IN AGE CATEGORIES
2-9
AND
- PERSON DID NOT HAVE COMPREHENSIVE HEALTH
INSURANCE COVERAGE ON 1/1/{YEAR}, WHERE ‘YEAR’
IS THE FIRST CALENDAR YEAR OF THE PANEL.
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/{YEAR}, WHERE
‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL:
- ESTABLISHMENT IS MEDICARE
- ESTABLISHMENT IS MEDICAID
- 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/{YEAR}, WHERE ‘YEAR’ IS
THE FIRST CALENDAR YEAR OF THE PANEL:

- 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 IS NOT CODED 1 OR 5)

HX76

{PERSON’S FIRST MIDDLE AND LAST NAME}

I have recorded that {you/{PERSON}} {had health insurance coverage
for (READ TYPES OF INSURANCE BELOW) coverage} {and} {was covered by a
public program} on January 1, {YEAR}. {Were/Was} {you/he/she} 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
{YEAR} or {YEAR}?

{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 {HX77}
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} {you/{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 {YEAR} or {YEAR}?

[Enter Month,Year-4] ................... {HX78}
REF ................................... -7 {HX78}
DK .................................... -8 {HX78}

‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED
ON THE MONTH AND YEAR FIELDS.

HX78

{PERSON’S FIRST MIDDLE AND LAST NAME}

Was {your/{PERSON}’s} health insurance that ended in {DATE FROM
HX77/{YEAR} or {YEAR}} obtained through an employer or union, was
it a government program such as Medicare or Medicaid, or what?

CHECK ALL THAT APPLY.

OBTAINED THROUGH UNION, PRIVATE
EMPLOYER OR PUBLIC EMPLOYER (FEDERAL,
STATE, OR LOCAL GOVERNMENT) ............ 1
MEDICARE ............................... 2
MEDICAID ............................... 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 {HX78OV}
REF ................................... -7 {END_LP20}
DK .................................... -8 {END_LP20}

[Code All That Apply]

HELP AVAILABLE 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 ‘in {YEAR} or
{YEAR}’ IF HX77 IS CODED ‘-7’ (REFUSED) OR ‘-8’
(DON’T KNOW), WHERE "‘YEAR’ or ‘YEAR’" DISPLAYS
THE TWO YEARS PRIOR TO THE FIRST CALENDAR YEAR OF
THE PANEL. FOR PANEL 12 FOR EXAMPLE, THIS WOULD BE
‘2005’ or ‘2006’.

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
ATTACHMENT 37.

FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH OTHER CODES, CONTINUE WITH HX78OV

OTHERWISE, GO TO END_LP20

HX78OV

SPECIFY:

[Enter Other Specify] .................. {END_LP20}
REF ................................... -7 {END_LP20}
DK .................................... -8 {END_LP20}

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_51

BOX_50

OMITTED.

LOOP_21

OMITTED.

HX81

OMITTED.

END_LP21

OMITTED.

BOX_51

GO TO NEXT QUESTIONNAIRE SECTION

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