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BOX_00
CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME, ESTB.ESTBNAME,
PRND.BEGREFMM, PRND.BEGREFDD, PRND.BEGREFYY,
PRND.ENDREFMM, PRND.ENDREFDD, PRND.ENDREFYY.
MC01
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
{Is/Was} {your/{POLICYHOLDER}’s} {NAME OF INSURER
BEING LOOPED ON} an
HMO {as of {END DATE}}? {When answering this question,
do not consider
{your/his/her} insurance through Medicare.}
[With an HMO, you must generally receive care from HMO
physicians.
For other doctors, the expense is not covered unless
you were
referred by the HMO or there was a medical emergency.]
YES .................................... 1 {MC05}
NO ..................................... 2 {MC02}
REF ................................... -7 {MC02}
DK .................................... -8 {MC02}
HELP AVAILABLE FOR DEFINITION OF HMO.
DISPLAY ‘Is’ IF NOT ROUND 5. DISPLAY ‘Was’ IF
ROUND 5.
DISPLAY ‘as of {END DATE}’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.
DISPLAY ‘When answering this question, do not
consider {your/his/her} insurance through
Medicare.’ IF POLICYHOLDER BEING ASKED ABOUT IS
ALSO COVERED BY MEDICARE. OTHERWISE, USE A NULL
DISPLAY.
MC02
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
{Does/As of {END DATE}, did} {your/{POLICYHOLDER}’s}
insurance
plan require {you/him/her} to sign up with a
certain primary
care doctor, group of doctors, or a certain clinic
which
{you/he/she} must go to for all of {your/his/her}
routine
care?
PROBE: Do not include emergency care or care from a
specialist
you were referred to.
YES .................................... 1 {MC04}
NO ..................................... 2 {MC03}
REF ................................... -7 {MC03}
DK .................................... -8 {MC03}
HELP AVAILABLE FOR DEFINITION OF PRIMARY CARE DOCTOR
AND ROUTINE CARE.
DISPLAY ‘Does’ IF NOT ROUND 5. DISPLAY ‘As of
{END DATE}, did’ IF ROUND 5.
MC03
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
{Is/As of {END DATE}, was} there a book or list of
doctors
associated with the plan?
YES .................................... 1 {MC04}
NO ..................................... 2 {BOX_01}
REF ................................... -7 {BOX_01}
DK .................................... -8 {BOX_01}
DISPLAY ‘Is’ IF NOT ROUND 5. DISPLAY ‘As of {END
DATE}, was’ IF ROUND 5.
MC04
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
{Will/As of {END DATE}, would} {your/{POLICYHOLDER}’s}
plan pay for any
of the costs of visits to doctors who are not
associated with
{your/his/her} plan, even if {you/he/she}
{{do/does}/did}
not have a referral?
YES .................................... 1 {BOX_01}
NO ..................................... 2 {BOX_01}
REF ................................... -7 {BOX_01}
DK .................................... -8 {BOX_01}
DISPLAY ‘Will’ AND ‘{do/does}’ IF NOT ROUND 5.
DISPLAY ‘As of {END DATE}, would’ AND ‘did’ IF
ROUND 5.
MC05
{POLICYHOLDER’S FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
{Will/As of {END DATE}, would} {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}/did} not have
a referral?
YES .................................... 1 {BOX_01}
NO ..................................... 2 {BOX_01}
REF ................................... -7 {BOX_01}
DK .................................... -8 {BOX_01}
DISPLAY ‘Will’ AND ‘{do/does}’ IF NOT ROUND 5.
DISPLAY ‘As of {END DATE}, would’ AND ‘did’ IF
ROUND 5.
BOX_01
RETURN TO ORIGINAL QUESTIONNAIRE SECTION IN HX OR
OE.
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