Old Employment and Private Related Insurance (OE) 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} FOR ROUNDS 2-5. FOR
MOST PERSONS, THE END DATE FOR ROUNDS 2-4 WILL BE
THE INTERVIEW DATE. FOR MOST PERSONS, THE END
FOR ROUND 5 WILL BE DECEMBER 31 OF THE SECOND
YEAR OF THE PANEL.

BOX_00

CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME, ESTB.ESTBNAME,
PRND.BEGREFMM, PRND.BEGREFDD, PRND.BEGREFYY,
PRND.ENDREFMM, PRND.ENDREFDD, PRND.ENDREFYY

BOX_01

IF ONE OR MORE RU MEMBERS STILL HOLDS A ‘CURRENT
MAIN’ OR ‘CURRENT MISCELLANEOUS’ JOB THIS ROUND
THAT WAS REPORTED DURING THE PREVIOUS ROUND AS
PROVIDING HEALTH INSURANCE ON THE DATE OF THE
PREVIOUS ROUND’S INTERVIEW, THAT IS:

IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS IN THE
RU MEET THE FOLLOWING CONDITIONS:
- RJ01 OR RJ06 WAS CODED ‘1’ (YES) DURING THIS
ROUND FOR THIS PAIR, AND
- PERSON IS A JOBHOLDER AT ESTABLISHMENT, AND
- PERSON IS FLAGGED AS THE POLICYHOLDER OF THIS
INSURANCE, AND
- ESTABLISHMENT IS AN EMPLOYER FLAGGED DURING
THE PREVIOUS ROUND AS ‘PROVIDES HEALTH
INSURANCE’ AND,
- THE HEALTH INSURANCE PROVIDED BY ESTABLISHMENT
COVERED PERSON ON THE DATE OF THE PREVIOUS
ROUND’S INTERVIEW (HQ01 WAS CODED ‘1’ (WHOLE
TIME) OR HQ02 WAS CODED ‘1’ (YES) IN THE
PREVIOUS ROUND), AND
- JOB AT ESTABLISHMENT IS NOT FLAGGED AS ‘SELF-
EMPLOYED’ WITH A FIRM-SIZE-1,

CONTINUE WITH LOOP_01

NOTE: IF POLICYHOLDER WAS NOT PHYSICALLY PRESENT
IN THE RU ON THE PREVIOUS ROUND’S INTERVIEW DATE,
THE FIFTH CONDITION ABOVE CAN BE MET IF AT LEAST
ONE DEPENDENT WAS COVERED BY POLICYHOLDER’S
INSURANCE ON THE PREVIOUS ROUND’S INTERVIEW DATE.
THE LOOP WILL CYCLE ON THE POLICYHOLDER’S NAME.

OTHERWISE, GO TO BOX_10

NOTE: ESTABLISHMENT-PERSON-PAIRS WHERE THE
POLICYHOLDER IS OUT-OF-SCOPE (E.G., DECEASED,
INSTITUTIONALIZED, OUT OF COUNTRY) ON THE CURRENT
ROUND’S INTERVIEW DATE, BUT WHERE THE
ESTABLISHMENT-PERSON-PAIR COVERED DEPENDENTS WHO
ARE STILL RU MEMBERS MAY STILL QUALIFY FOR
LOOP_01.

LOOP_01

FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_OE01A - END_LP01

LOOP DEFINITION:

LOOP_01 COLLECTS INFORMATION ABOUT THE
CONTINUATION OF INSURANCE COVERAGE THROUGH A
‘CURRENT MAIN’ OR ‘CURRENT MISCELLANEOUS’ JOB THAT
WAS COLLECTED IN THE PREVIOUS ROUND. THIS LOOP
CYCLES ON ESTABLISHMENT-PERSON-PAIRS THAT MEET THE
FOLLOWING CONDITIONS:

- RJ01 OR RJ06 WAS CODED ‘1’ (YES) DURING THIS
ROUND FOR THIS PAIR, AND
- PERSON IS A JOBHOLDER AT ESTABLISHMENT, AND
- PERSON IS FLAGGED AS THE POLICYHOLDER OF THIS
INSURANCE, AND
- ESTABLISHMENT IS AN EMPLOYER FLAGGED DURING
THE PREVIOUS ROUND AS ‘PROVIDES HEALTH
INSURANCE’ AND,
- THE HEALTH INSURANCE PROVIDED BY ESTABLISHMENT
COVERED PERSON ON THE DATE OF THE PREVIOUS
ROUND’S INTERVIEW (HQ01 WAS CODED ‘1’ (WHOLE
TIME) OR HQ02 WAS CODED ‘1’ (YES) IN THE
PREVIOUS ROUND), AND
- JOB AT ESTABLISHMENT IS NOT FLAGGED AS ‘SELF-
EMPLOYED’ WITH A FIRM-SIZE-1

NAVIGATOR DETAILS: LOOP_01 USES BOTH NAV_OE01A
AND OE01B TO CONTROL THE FLOW OF THE LOOP.

NAV_OE01A

SERIES: Confirming Insurance from a Previous Round through a
Current Employer (i.e., probing for who is still covered, any
change in plan name, etc.)

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_OE01B

SERIES: Confirming Insurance from a Previous Round through a
Current Employer (i.e., probing for who is still covered, any
change in plan name, etc.)

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.

Policyholder...Employer Providing Insurance

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

ROSTER DETAILS:
COL # 1 HEADER: POLICYHOLDER...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 OE01 FOR SELECTED PAIR.

OE01

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

Now think about {your/{POLICYHOLDER}’s} health insurance through
{ESTABLISHMENT}. {{Are/Is}/{Were/Was}} {you/he/she} or anyone in
the family covered by this insurance as of {today,} {END DATE}?

YES ................................... 1 {BOX_02}
NO .................................... 2 {OE02}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

DISPLAY ‘{Are/Is}’ IF NOT ROUND 5. DISPLAY
‘{Were/Was}’ IF ROUND 5.

DISPLAY ‘today,’ IF NOT ROUND 5. OTHERWISE, USE A
NULL DISPLAY.

OE02

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

On what date did {your/{POLICYHOLDER}’s} health insurance through
{ESTABLISHMENT} end?

{IF INSURANCE ENDED AFTER 12/31/{YEAR}, BACK-UP TO OE01
AND SELECT ‘YES’.}

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}

DISPLAY ‘IF INSURANCE ENDED... SELECT ‘YES’.’ IF
ROUND 5. OTHERWISE, USE A NULL DISPLAY.

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE02OV

OTHERWISE, GO TO BOX_02

OE02OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_02}
PART OF THE MONTH ..................... 2 {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}

[Code One]

BOX_02

IF THE POLICYHOLDER IS THE ONLY PERSON COVERED AT
THE PREVIOUS ROUND’S INTERVIEW DATE BY THE
INSURANCE FROM THIS ESTABLISHMENT-PERSON-PAIR,
AUTOMATICALLY CODE OE03 AS ‘1’ (YES) AND GO TO
BOX_03

OTHERWISE, CONTINUE WITH OE03

OE03

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

{Are/Were} (READ NAMES BELOW) all covered by {your/{POLICYHOLDER}’s}
health insurance through {ESTABLISHMENT} {until {{OE02 DATE}/it
ended}/on {END DATE}}?

{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}
{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}
{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}

YES ................................... 1 {BOX_03}
NO .................................... 2 {BOX_03}
REF ................................... -7 {BOX_03}
DK .................................... -8 {BOX_03}

DISPLAY ‘Are’ IF OE01 IS CODED ‘1’ (YES).
DISPLAY ‘Were’ IF OE01 IS CODED ‘2’ (NO) OR IF
CURRENT ROUND IS ROUND 5.

DISPLAY ‘until {OE02 DATE}’ IF OE01 IS CODED ‘2’
(NO).
DISPLAY ‘on {END DATE}’ IF OE01 IS CODED ‘1’
(YES).

DISPLAY THE DATE RECORDED AT OE02 FOR ‘OE02 DATE’.
IF THE MONTH OR YEAR FIELD AT OE02 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY ‘it ended’
FOR ‘OE02 DATE’.

ROSTER DETAILS:
TITLE: RU_ESTB_PLCYHLDR_COVRD_PERS_TRPLS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY COVERED PERSONS’ NAMES
(PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER FOR DISPLAY.

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

ROSTER FILTER:
1. PERSON WAS COVERED AT PREVIOUS ROUND’S
INTERVIEW DATE BY THE INSURANCE FROM THIS
ESTABLISHMENT-PERSON-PAIR, INCLUDING THE
POLICYHOLDER
2. PERSON IS AN RU MEMBER

BOX_03

IF COVERAGE IS CONTINUOUS FROM THE PREVIOUS ROUND
TO THE END DATE OF THE CURRENT ROUND, THAT IS:

IF OE01 IS CODED ‘1’ (YES) AND OE03 IS CODED ‘1’
(YES),

FLAG INSURANCE FOR ALL COVERED PERSONS (INCLUDING
THE POLICYHOLDER) AS ‘CONTINUOUS COVERAGE’ THROUGH
THE REFERENCE PERIOD END DATE AND

GO TO BOX_05

IF COVERAGE IS CONTINUOUS FROM THE PREVIOUS ROUND
TO PART OF THE CURRENT ROUND, THAT IS:

IF OE01 IS CODED ‘2’ (NO) AND OE03 IS CODED ‘1’
(YES),

FLAG INSURANCE FOR ALL COVERED PERSONS (INCLUDING
THE POLICYHOLDER) AS ‘CONTINUOUS COVERAGE’ THROUGH
THE DATE RECORDED AT OE02 AND

GO TO BOX_05

OTHERWISE (I.E., OE03 CODED ‘2’ (NO), ‘-7’
(REFUSED), OR ‘-8’ (DON’T KNOW)),
CONTINUE WITH OE04

OE04

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

Who {is/was} no longer covered by {your/{POLICYHOLDER}’s} health
insurance through {ESTABLISHMENT} {until {{OE02 DATE}/it ended}/on
{END DATE}}?

[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 ‘is’ IF OE01 IS CODED ‘1’ (YES).
DISPLAY ‘was’ IF OE01 IS CODED ‘2’ (NO) OR IF
CURRENT ROUND IS ROUND 5.

DISPLAY ‘until {OE02 DATE}’ IF OE01 IS CODED ‘2’
(NO).
DISPLAY ‘on {END DATE}’ IF OE01 IS CODED ‘1’
(YES).

DISPLAY THE DATE RECORDED AT OE02 FOR ‘OE02 DATE’.
IF THE MONTH OR YEAR FIELD AT OE02 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY ‘it ended’
FOR ‘OE02 DATE’.

IF FAMILY STILL HAS INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR (OE01 IS CODED ‘1’
(YES)), FLAG INSURANCE FOR ALL PERSONS NOT
SELECTED AT OE04 AS ‘CONTINUOUS COVERAGE’ FROM THE
REFERENCE PERIOD START DATE UNTIL THE REFERENCE
PERIOD END DATE.

IF FAMILY DOES NOT STILL HAVE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON-PAIR (OE01 IS CODED ‘2’
(NO), FLAG INSURANCE FOR ALL PERSONS NOT SELECTED
AT OE04 AS ‘CONTINUOUS COVERAGE’ FROM THE
REFERENCE PERIOD START DATE UNTIL DATE RECORDED
AT OE02.

GO TO LOOP_02

ROSTER DETAILS:
TITLE: RU_ESTB_PLCYHLDR_COVRD_PERS_TRPLS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY COVERED PERSONS’ NAMES
(PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER FOR SELECTION.

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

ROSTER FILTER:
1. PERSON WAS COVERED AT PREVIOUS ROUND’S
INTERVIEW DATE BY THE INSURANCE FROM THIS
ESTABLISHMENT-PERSON-PAIR, INCLUDING THE
POLICYHOLDER
2. PERSON IS AN RU MEMBER

LOOP_02

FOR EACH ELEMENT IN THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER, ASK NAV_OE02 - END_LP02

LOOP DEFINITION: LOOP_02 COLLECTS THE DATE ON
WHICH THE INSURANCE COVERAGE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR ENDED FOR EACH RU MEMBER
WHOSE COVERAGE ENDED EITHER PRIOR TO THE REFERENCE
PERIOD END DATE OR THE DATE REPORTED IN OE02.
THIS LOOP CYCLES ON PERSONS SELECTED AT OE04.

NAVIGATOR DETAILS: LOOP_02 USES NAV_OE02 TO
CONTROL THE FLOW OF THE LOOP.

NAV_OE02

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

SERIES: End Date of Insurance from {POLICYHOLDER}’s
{ESTABLISHMENT} plan.

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 DEFINITION:
THIS ITEM DISPLAYS RU-ESTB-PLCYHLDR-COVRD-PERS-
TRPLS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

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

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT OE04.

CONTINUE WITH OE05 FOR SELECTED RU MEMBER.

OE05

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

On what date did the health insurance through {ESTABLISHMENT}
end for {you/{PERSON}}?

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7 {BOX_04}
DK .................................... -8 {BOX_04}

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE05OV

OTHERWISE, GO TO BOX_04

OE05OV

Can you just tell me if {you/he/she} {were/was} was covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_04}
PART OF THE MONTH ..................... 2 {BOX_04}
REF ................................... -7 {BOX_04}
DK .................................... -8 {BOX_04}

[Code One]

BOX_04

FLAG INSURANCE FOR PERSON AS ‘CONTINUOUS COVERAGE’
THROUGH THE COMPLETE DATE RECORDED AT OE05 AND
OE05OV.

END_LP02

CYCLE ON NEXT PERSON IN THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_02 AND CONTINUE WITH BOX_05

BOX_05

IF AT LEAST ONE CURRENT RU MEMBER NOT COVERED BY
THE INSURANCE FROM THIS ESTABLISHMENT-PERSON-PAIR,
(THIS INCLUDES ALL NEW RU MEMBERS AND PREVIOUS RU
MEMBERS NOT COVERED BY THIS INSURANCE ON THE
PREVIOUS ROUND’S INTERVIEW DATE, BUT EXCLUDES RU
MEMBERS JUST MARKED AS NO LONGER COVERED IN OE04),
CONTINUE WITH OE06

OTHERWISE, GO TO OE08A

OE06

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

{Since {START DATE}/Between {START DATE} and {END DATE}}, have
any persons living here, we have not yet mentioned, been covered
by {your/{POLICYHOLDER}’s} health insurance through {ESTABLISHMENT}?

YES ................................... 1 {OE07}
NO .................................... 2 {OE08A}
REF ................................... -7 {OE08A}
DK .................................... -8 {OE08A}

HELP AVAILABLE FOR DEFINITION OF DEPENDENT.

DISPLAY ‘Since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘Between {START DATE} and {END DATE}’ IF
ROUND 5.

OE07

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

Who {has been/was} covered by {your/{POLICYHOLDER}’s} health insurance
through {ESTABLISHMENT} {since {START DATE}/between {START DATE} and
{END DATE}} that we have not yet mentioned?

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]

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

WRITE PERSONS SELECTED TO THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER.

IF ‘PERSON NOT LISTED IN RU’ IS SELECTED, FLAG
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
AS ‘COVERING PERSON NOT LISTED IN RU’.

GO TO LOOP_03

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 ONE OR MORE FROM THE LISTED MEMBERS.
2. ADD, DELETE, AND EDIT DISALLOWED.
3. DISPLAY ‘PERSON NOT LISTED IN RU’ AS LAST ENTRY
ON THIS ROSTER.

ROSTER FILTER:
DISPLAY PERSONS WHO WERE NOT COVERED BY THE
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
ON THE PREVIOUS ROUND’S INTERVIEW DATE.

LOOP_03

FOR EACH ELEMENT IN THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER, ASK NAV_OE03 - END_LP03

LOOP DEFINITION: LOOP_03 COLLECTS THE COVERAGE
START DATE FOR ALL PERSONS NEWLY COVERED DURING
THE CURRENT ROUND BY THE INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR. THIS LOOP CYCLES ON
PERSONS SELECTED AT OE07.

NAVIGATOR DETAILS: LOOP_03 USES NAV_OE03 TO
CONTROL THE FLOW OF THE LOOP.

NAV_OE03

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

SERIES: Begin Date of Insurance from {POLICYHOLDER}’s
{ESTABLISHMENT} plan.

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 DEFINITION:
THIS ITEM DISPLAYS RU-ESTB-PLCYHLDR-COVRD-PERS-
TRPLS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

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

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT OE07.

CONTINUE WITH OE08 FOR SELECTED RU MEMBER.

OE08

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

On what date did the health insurance through {ESTABLISHMENT}
begin for {you/{PERSON}}?

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE08OV

OTHERWISE, GO TO BOX_06

OE08OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_06}
PART OF THE MONTH ..................... 2 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}

[Code One]

HARD CHECK:
COMPLETE DATE AT OE08 MUST BE < THAN COMPLETE
DATE AT OE02 IF A DATE IS RECORDED AT OE02
OR < THAN REFERENCE PERIOD END DATE IF NO DATE
IS RECORDED AT OE02.

BOX_06

IF FAMILY STILL HAS INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR (OE01 IS CODED ‘1’
(YES)), FLAG INSURANCE FOR THIS PERSON AS
‘CONTINUOUS COVERAGE’ FROM DATE RECORDED AT OE08
UNTIL THE REFERENCE PERIOD END DATE.

IF FAMILY DOES NOT STILL HAVE INSURANCE THROUGH
ESTABLISHMENT-PERSON-PAIR (OE01 IS CODED ‘2’ (NO))
FLAG INSURANCE FOR THIS PERSON AS ‘CONTINUOUS
COVERAGE’ FROM DATE RECORDED AT OE08 UNTIL DATE
RECORDED AT OE02.

END_LP03

CYCLE ON NEXT PERSON IN RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER WHO MEETS THE CONDITIONS STATED
IN THE LOOP DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_03 AND GO TO BOX_07

OE08A

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

{Does/Between {START DATE} and {END DATE}, did} {your/{POLICYHOLDER}’s}
health coverage through {ESTABLISHMENT} cover as dependents any
persons who do not live here?

YES .................................... 1 {BOX_07}
NO ..................................... 2 {BOX_07}
REF ................................... -7 {BOX_07}
DK .................................... -8 {BOX_07}

HELP AVAILABLE FOR DEFINITION OF DEPENDENT.

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

IF CODED ‘1’ (YES), FLAG INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR AS ‘COVERING PERSON NOT
LISTED IN RU’ IN OE07

BOX_07

IF ONE OR MORE RU MEMBERS ARE STILL COVERED BY THE
INSURANCE THROUGH THE ESTABLISHMENT-PERSON-PAIR
ON THE CURRENT ROUND’S INTERVIEW DATE, THAT IS,
OE01 IS CODED ‘1’ (YES), CONTINUE WITH BOX_07A

OTHERWISE, GO TO END_LP01

BOX_07A

IF ROUND 3, CONTINUE WITH OE09A

OTHERWISE, GO TO OE09

OE09A

{POLICYHOLDER’S 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 {OE09AA}
YES, PAY SOME OF PREMIUM/COST .......... 2 {OE09AA}
YES, BUT DON’T KNOW IF PAY ALL OR SOME
OF PREMIUM/COST ........................ 3 {OE09AA}
NO, DO NOT PAY ......................... 4 {OE09AAA}
REF ................................... -7 {BOX_08AA}
DK .................................... -8 {BOX_08AA}

[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.

OE09AA

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

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

[Enter Amount in Dollars] ..............
REF ................................... -7 {BOX_08A}
DK .................................... -8 {BOX_08A}

CONTINUE WITH OE09AAOV1

OE09AAOV1

UNIT OF COVERAGE:

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

PER YEAR ............................... 1 {BOX_08A}
QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_08A}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_08A}
PER MONTH .............................. 4 {BOX_08A}
PER WEEK ............................... 5 {BOX_08A}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_08A}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_08A}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_08A}
OTHER ................................. 91 {OE09AAOV2}
REF ................................... -7 {BOX_08A}
DK .................................... -8 {BOX_08A}

[Code One]

OE09AAOV2

SPECIFY:

[Enter Other Specify] .................. {BOX_08A}
REF ................................... -7 {BOX_08A}
DK .................................... -8 {BOX_08A}

BOX_08A

IF OE09A IS CODED ‘1’ (YES, PAY ALL OF PREMIUM/
COST), GO TO BOX_08AA

OTHERWISE, CONTINUE WITH OE09AAA

OE09AAA

{POLICYHOLDER’S 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 {OE09AAAOV}
REF ................................... -7 {BOX_08AA}
DK .................................... -8 {BOX_08AA}

[Code All That Apply]

DISPLAY ‘else’ IF OE09A 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 OE09A 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 OE09A 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 OE09AAAOV

OTHERWISE, GO TO BOX_08AA

OE09AAAOV

SPECIFY:

[Enter Other Specify] .................. {BOX_08AA}
REF ................................... -7 {BOX_08AA}
DK .................................... -8 {BOX_08AA}

BOX_08AA

IF INSURANCE BEING ASKED ABOUT PROVIDES MEDICARE
SUPPLEMENT/MEDIGAP COVERAGE (I.E., HX48 OR OE10
OR OE24 OR OE37 WAS CODED ‘5’ (MEDICARE SUPPLEMENT
/MEDIGAP) EITHER ALONE OR WITH ANY COMBINATION OF
CODES IN THE PREVIOUS ROUND FOR THIS ESTABLISHMENT
-PERSON-PAIR), GO TO OE09

OTHERWISE, CONTINUE WITH OE09B

OE09B

{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 {OE09}
{$1,250/$2,500} OR MORE ................ 2 {OE09C}
NO ANNUAL DEDUCTIBLE ................... 3 {OE09}
REF ................................... -7 {OE09}
DK .................................... -8 {OE09}

[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 (OE08A 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 OE08A 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 OE08A 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 OE08A 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.

OE09C

{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 {OE09}
NO ..................................... 2 {OE09}
REF ................................... -7 {OE09}
DK .................................... -8 {OE09}

[Code One]

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

OE09

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

{Last time we recorded that {you/{POLICYHOLDER}} {were/was} covered
by {INSURER OF ESTAB-PERS-INSURER TRIPLE ON PREV RD INT DT}.}

{Since {START DATE}, has there been/Between {START DATE} and
{END DATE}, was there} any change in the plan name of the health
insurance {you/{POLICYHOLDER}} {have/has} through {ESTABLISHMENT}?

YES ................................... 1 {OE10}
NO .................................... 2 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

DISPLAY FIRST PARAGRAPH IF THE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON- PAIR HAD ANY INSURERS
FLAGGED AS PROVIDING MEDIGAP OR HOSPITAL/PHYSICIAN
BENEFITS AT ANY TIME DURING THE PREVIOUS ROUND.

FOR ‘NAME OF INSURER BEING LOOPED ON’, DISPLAY
THE NAME OF THIS POLICYHOLDER'S CURRENT ROUND’S
PRIVATE OR MEDIGAP INSURER FOR PLAN NAME. THAT IS,
DISPLAY THE NAME OF THE PLAN (PROVIDING MEDICARE
SUPPLEMENT / MEDIGAP BENEFITS OR HOSPITAL/
PHYSICIAN BENEFITS) ENTERED AT HX49, HX51, OE11,
OE25, OE36, OR OE38.

DISPLAY ‘Since {START DATE}, has there been’ AND
‘{have/has}’ IF NOT ROUND 5. DISPLAY ‘Between
{START DATE} and {END DATE}, was there’ AND ‘had’
IF ROUND 5.

IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW), FLAG PREVIOUS ROUND’S INSURER AS CURRENT
ROUND’S INSURER FOR THIS ESTABLISHMENT-PERSON-
PAIR.

OE10

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

SHOW CARD HX-9.

Looking at this card, what type of health insurance coverage
{{do/does}/did} {you/{POLICYHOLDER}} {now} have through
{ESTABLISHMENT}’s new plan {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 {OE10OV}
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}

[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 NOT ROUND 5. DISPLAY ‘did’
IF ROUND 5.

DISPLAY ‘now’ IF NOT ROUND 5. OTHERWISE, USE A
NULL DISPLAY.

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

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 CODES, CONTINUE WITH OE10OV

OTHERWISE, GO TO BOX_08

OE10OV

SPECIFY:

[Enter Other Specify] .................. {BOX_08}
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}

HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.

BOX_08

NOTE: ALL ESTABLISHMENTS WHICH ARE BEING LOOPED
ON HERE ARE EMPLOYERS. THEREFORE, IT IS NOT
NECESSARY TO AUTOMATICALLY CODE OE11 IF THE
ESTABLISHMENT IS AN INSURANCE COMPANY OR HMO.

IF OE10 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN
BENEFITS) OR ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP),
ALONE OR WITH ANY OTHER COMBINATION OF CODES,
CONTINUE WITH OE11

OTHERWISE, GO TO END_LP01

OE11

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

What is the new plan name for {your/{POLICYHOLDER}’s} health
insurance through {ESTABLISHMENT} which provides the {hospital
and physician benefits/Medicare Supplement or Medigap benefits}?

IF MORE THAN ONE NAME, PROBE: What is the main new plan name?

RECORD THE NAME OF THE MAIN INSURER THAT PROVIDES THE {HOSPITAL
AND PHYSICIAN/MEDIGAP} BENEFITS FOR THIS PAIR.

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

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

TYPE:

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

[Code One]

HELP AVAILABLE FOR DEFINITION OF INSURANCE CO/HMO/SELF-INSURED CO.

DISPLAY ‘hospital and physician benefits’ AND
‘HOSPITAL AND PHYSICIAN’ IF OE10 IS CODED ‘1’
(HOSPITAL AND PHYSICIAN BENEFITS), BUT NOT CODED
‘5’ (MEDICARE SUPPLEMENT/MEDIGAP). DISPLAY
‘Medicare supplement or Medigap benefits’ AND
‘MEDIGAP’ IF OE10 IS CODED ‘5’ (MEDICARE
SUPPLEMENT/MEDIGAP).

WRITE INSURER(S) TO THE RU-ESTAB-PERSON-INSURER-
TRIPLES-ROSTER FOR THE INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR.

FLAG INSURER(S) COLLECTED AT OE11 AS CURRENT
ROUND’S INSURER(S) FOR THIS ESTABLISHMENT-PERSON-
PAIR.

IF OE10 IS CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP)
FLAG INSURANCE CO./HMO AS ‘SUPPLYING MEDICARE
SUPPLEMENT/MEDIGAP BENEFITS (WHICH INCLUDES
HOSPITAL/PHYSICIAN BENEFITS)’ FOR THE CURRENT
ROUND.

IF OE10 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN
BENEFITS), BUT NOT ‘5’ (MEDICARE SUPPLEMENT/
MEDIGAP), FLAG INSURANCE CO./HMO AS ‘SUPPLYING
HOSPITAL/PHYSICIAN BENEFITS’ FOR THE CURRENT
ROUND.

LOOP_04

FOR EACH ELEMENT ON THE RU-ESTAB-PERSON-INSURER-
TRIPLES-ROSTER, ASK BOX_08B - END_LP04.

LOOP DEFINITION: LOOP_04 COLLECTS OTHER POLICY
NAMES AND MANAGED CARE INFORMATION FOR INSURERS
COLLECTED AT OE11. THIS LOOP CYCLES ON TRIPLES
THAT MEET THE FOLLOWING CONDITIONS:

- ESTABLISHMENT-PERSON-PAIR PROVIDES THE INSURANCE
BEING ASKED ABOUT
- INSURER IS ENTERED AT OE11

BOX_08B

IF AN INSURER NAME IS ENTERED AT OE11, CONTINUE
WITH OE11A

IF INSURER NAME IS CODED ‘-7’ (REF) OR ‘-8’ (DK)
AT OE11, GO TO BOX_09A

OE11A

{POLICYHOLDER’S 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 {OE11AOV}
NO OTHER NAME .......................... 2 {BOX_09A}
REF ................................... -7 {BOX_09A}
DK .................................... -8 {BOX_09A}

HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH OPTION.

[Code One]

DISPLAY THE NAME OF THE INSURANCE CO/HMO
RECORDED IN OE11 WHICH IS BEING LOOPED ON FOR
‘INSURANCE...NAME’.

OE11AOV

SPECIFY:

[Enter Policy Name] .................... {BOX_09A}
REF ................................... -7 {BOX_09A}
DK .................................... -8 {BOX_09A}

HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH OPTION.

BOX_09A

IF INSURER BEING LOOPED ON IS CODED ‘2’ (HMO) IN
OE11, CONTINUE WITH OE11B

OTHERWISE, GO TO BOX_09

OE11B

{POLICYHOLDER’S 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_LP04}
NO ..................................... 2 {END_LP04}
REF ................................... -7 {END_LP04}
DK .................................... -8 {END_LP04}

BOX_09

ASK THE MANAGED CARE (MC) SECTION FOR THIS INSURER

AT COMPLETION OF MANAGED CARE (MC) SECTION,
CONTINUE WITH END_LP04

END_LP04

CYCLE ON NEXT INSURER IN THE RU-ESTAB-PERSON-
INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER INSURERS MEET THE STATED CONDITIONS,
END LOOP_04 AND CONTINUE WITH END_LP01

END_LP01

CYCLE ON NEXT PAIR IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.

IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END
LOOP_01 AND CONTINUE WITH BOX_10

BOX_10

IF ONE OR MORE RU MEMBERS DOES NOT STILL HOLD A
‘CURRENT MAIN’ OR ‘CURRENT MISCELLANEOUS’ JOB THIS
ROUND THAT WAS REPORTED DURING THE PREVIOUS ROUND
AS PROVIDING HEALTH INSURANCE ON THE DATE OF THE
PREVIOUS ROUND’S INTERVIEW, THAT IS:

IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS IN THE
RU MEET THE FOLLOWING CONDITIONS:
- RJ01 OR RJ06 WAS CODED ‘2’ (NO), ‘-7’ (REFUSED),
‘-8’ (DON’T KNOW) DURING THIS ROUND FOR THIS
PAIR, AND
- PERSON WAS A JOBHOLDER AT ESTABLISHMENT, AND
- PERSON IS FLAGGED AS THE POLICYHOLDER OF THIS
INSURANCE, AND
- ESTABLISHMENT IS AN EMPLOYER FLAGGED DURING
THE PREVIOUS ROUND AS ‘PROVIDES HEALTH
INSURANCE’ AND,
- THE HEALTH INSURANCE PROVIDED BY ESTABLISHMENT
COVERED PERSON ON THE DATE OF THE PREVIOUS
ROUND’S INTERVIEW (HQ01 WAS CODED ‘1’ (WHOLE
TIME) OR HQ02 WAS CODED ‘1’ (YES) IN THE
PREVIOUS ROUND), AND
- JOB AT ESTABLISHMENT IS NOT FLAGGED AS ‘SELF-
EMPLOYED’ WITH A FIRM-SIZE-1,

CONTINUE WITH LOOP_05

OTHERWISE, GO TO BOX_19

NOTE: IF POLICYHOLDER WAS NOT PHYSICALLY PRESENT
IN THE RU ON THE PREVIOUS ROUND’S INTERVIEW DATE,
THE FIFTH CONDITION IN THE ABOVE BOX CAN BE MET
IF AT LEAST ONE DEPENDENT WAS COVERED BY
POLICYHOLDER’S INSURANCE ON THE PREVIOUS ROUND’S
INTERVIEW DATE. COVERAGE FOR THE POLICYHOLDER IS
ASSUMED IN THAT CASE AND THE LOOP WILL CYCLE ON
THE POLICYHOLDER’S NAME.

LOOP_05

FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_OE05A - END_LP05

LOOP DEFINITION:

LOOP_05 COLLECTS INFORMATION ABOUT THE
CONTINUATION OF INSURANCE COVERAGE THROUGH A
NO LONGER HELD ‘CURRENT MAIN’ OR ‘CURRENT
MISCELLANEOUS’ JOB THAT WAS COLLECTED IN THE
PREVIOUS ROUND. THIS LOOP CYCLES ON
ESTABLISHMENT-PERSON-PAIRS THAT MEET THE
FOLLOWING CONDITIONS:

- RJ01 OR RJ06 WAS CODED ‘2’ (NO), ‘-7’ (REFUSED),
‘-8’ (DON’T KNOW) DURING THIS ROUND FOR THIS
PAIR, AND
- PERSON WAS A JOBHOLDER AT ESTABLISHMENT, AND
- PERSON IS FLAGGED AS THE POLICYHOLDER OF THIS
INSURANCE, AND
- ESTABLISHMENT IS AN EMPLOYER FLAGGED DURING
THE PREVIOUS ROUND AS ‘PROVIDES HEALTH
INSURANCE’ AND,
- THE HEALTH INSURANCE PROVIDED BY ESTABLISHMENT
COVERED PERSON ON THE DATE OF THE PREVIOUS
ROUND’S INTERVIEW (HQ01 WAS CODED ‘1’ (WHOLE
TIME) OR HQ02 WAS CODED ‘1’ (YES) IN THE
PREVIOUS ROUND), AND
- JOB AT ESTABLISHMENT IS NOT FLAGGED AS ‘SELF-
EMPLOYED’ WITH A FIRM-SIZE-1.

NAVIGATOR DETAILS: LOOP_05 USES BOTH NAV_OE05A
AND OE05B TO CONTROL THE FLOW OF THE LOOP.

NAV_OE05A

SERIES: Confirming Insurance from a Previous Round through a
Former Employer (i.e., probing for who is still covered, any
change in plan name, etc.)

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 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_05 DEFINITION.

CONTINUE WITH NAV_OE05B FOR SELECTED RU MEMBER.

NAV_OE05B

SERIES: Confirming Insurance from a Previous Round through a
Former Employer (i.e., probing for who is still covered, any
change in plan name, etc.)

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.

Policyholder...Former Employer Providing Insurance

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

ROSTER DETAILS:
COL # 1 HEADER: POLICYHOLDER...FORMER 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_05 DEFINITION.

CONTINUE WITH OE12 FOR SELECTED PAIR.

OE12

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

Now think about {your/{POLICYHOLDER}’s} health insurance through
{ESTABLISHMENT}. {{Are/Is}/{Were/Was}} {you/he/she} or anyone in
the family covered by this insurance as of {today,} {END DATE}?

YES ................................... 1 {OE16}
NO .................................... 2 {OE13}
REF ................................... -7 {END_LP05}
DK .................................... -8 {END_LP05}

DISPLAY ‘{Are/Is}’ IF NOT ROUND 5. DISPLAY
‘{Were/Was}’ IF ROUND 5.

DISPLAY ‘today,’ IF NOT ROUND 5. OTHERWISE, USE A
NULL DISPLAY.

OE13

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

Did the health insurance {you/{POLICYHOLDER}} had through
{ESTABLISHMENT} continue for any period of time after
{you/he/she} stopped working at {ESTABLISHMENT}?

YES ................................... 1 {OE14}
NO .................................... 2 {OE15}
REF ................................... -7 {OE15}
DK .................................... -8 {OE15}

OE14

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

Did that health insurance continue through COBRA?

YES ................................... 1 {OE15}
NO .................................... 2 {OE15}
REF ................................... -7 {OE15}
DK .................................... -8 {OE15}

HELP AVAILABLE FOR DEFINITION OF COBRA.

OE15

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

On what date did {your/{POLICYHOLDER}’s} health insurance through
{ESTABLISHMENT} end?

{IF INSURANCE ENDED ATER 12/31/{YEAR}, BACK-UP TO OE12
AND SELECT ‘YES’.}

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7
DK .................................... -8

DISPLAY ‘IF INSURANCE ENDED... SELECT ‘YES’.’ IF
ROUND 5. OTHERWISE, USE A NULL DISPLAY.

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE15OV

OTHERWISE, GO TO BOX_11

OE15OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_11}
PART OF THE MONTH ..................... 2 {BOX_11}
REF ................................... -7 {BOX_11}
DK .................................... -8 {BOX_11}

[Code One]

OE16

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

Is {your/{POLICYHOLDER}’s} health insurance through {ESTABLISHMENT}
now extended through COBRA?

YES ................................... 1 {BOX_11}
NO .................................... 2 {BOX_11}
REF ................................... -7 {BOX_11}
DK .................................... -8 {BOX_11}

HELP AVAILABLE FOR DEFINITION OF COBRA.

BOX_11

IF THE POLICYHOLDER IS THE ONLY PERSON COVERED AT
THE PREVIOUS ROUND’S INTERVIEW DATE BY THE
INSURANCE FROM THIS ESTABLISHMENT-PERSON-PAIR,
AUTOMATICALLY CODE OE17 AS ‘1’ (YES) AND GO TO
BOX_12

OTHERWISE, CONTINUE WITH OE17

OE17

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

{Are/Were} (READ NAMES BELOW) all covered by {your/{POLICYHOLDER}’s}
health insurance through {ESTABLISHMENT} {until {{OE15 DATE}/it
ended}/on {END DATE}}?

{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}
{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}
{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}

YES ................................... 1 {BOX_12}
NO .................................... 2 {BOX_12}
REF ................................... -7 {BOX_12}
DK .................................... -8 {BOX_12}

DISPLAY ‘Are’ IF OE12 IS CODED ‘1’ (YES).
DISPLAY ‘Were’ IF OE12 IS CODED ‘2’ (NO) OR IF
CURRENT ROUND IS ROUND 5.

DISPLAY ‘until {OE15 DATE}’ IF OE12 IS CODED ‘2’
(NO). DISPLAY ‘on {END DATE}’ IF OE12 IS CODED ‘1’
(YES).

DISPLAY THE DATE RECORDED AT OE15 FOR ‘OE15 DATE’.
IF THE MONTH OR YEAR FIELD AT OE15 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY ‘it ended’
FOR ‘OE15 DATE’.

ROSTER DETAILS:
TITLE: RU_ESTB_PLCYHLDR_COVRD_PERS_TRPLS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY COVERED PERSONS’ NAMES
(PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSONS ON THE RU-ESTB-
PLCYHLDR-COVRD-PERS-TRPLS-ROSTER FOR DISPLAY.

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

ROSTER FILTER:
1. PERSON WAS COVERED AT PREVIOUS ROUND’S
INTERVIEW DATE BY THE INSURANCE FROM THIS
ESTABLISHMENT-PERSON-PAIR, INCLUDING THE
POLICYHOLDER AND
2. PERSON IS AN RU MBMBER

BOX_12

IF COVERAGE IS CONTINUOUS FROM THE PREVIOUS ROUND
TO THE END DATE OF THE CURRENT ROUND, THAT IS:

IF OE12 IS CODED ‘1’ (YES) AND OE17 IS CODED ‘1’
(YES),

FLAG INSURANCE FOR ALL COVERED PERSONS (INCLUDING
THE POLICYHOLDER) AS ‘CONTINUOUS COVERAGE’ THROUGH
THE REFERENCE PERIOD END DATE AND

GO TO BOX_14

IF COVERAGE IS CONTINUOUS FROM THE PREVIOUS ROUND
TO PART OF THE CURRENT ROUND, THAT IS:

IF OE12 IS CODED ‘2’ (NO) AND OE17 IS CODED ‘1’
(YES),

FLAG INSURANCE FOR ALL COVERED PERSONS (INCLUDING
THE POLICYHOLDER) AS ‘CONTINUOUS COVERAGE’ THROUGH
THE DATE RECORDED AT OE15 AND

GO TO BOX_14

OTHERWISE (I.E., OE17 CODED ‘2’ (NO), ‘-7’
(REFUSED), OR ‘-8’ (DON’T KNOW)), CONTINUE WITH
OE18

OE18

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

Who {is/was} no longer covered by {your/{POLICYHOLDER}’s} health
insurance through {ESTABLISHMENT} {until {{OE15 DATE}/it ended}/
on {END DATE}}?

[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 ‘is’ IF OE12 IS CODED ‘1’ (YES).
DISPLAY ‘was’ IF OE12 IS CODED ‘2’ (NO) OR IF
CURRENT ROUND IS ROUND 5.

DISPLAY ‘until {OE15 DATE}’ IF OE12 IS CODED ‘2’
(NO). DISPLAY ‘on {END DATE}’ IF OE12 IS CODED
‘1’ (YES).

DISPLAY THE DATE RECORDED AT OE15 FOR ‘OE15 DATE’.
IF THE MONTH OR YEAR FIELD AT OE15 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY ‘it ended’
FOR ‘OE15 DATE’.

IF FAMILY STILL HAS INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR (OE12 IS CODED ‘1’
(YES)), FLAG INSURANCE FOR ALL PERSONS NOT
SELECTED AT OE18 AS ‘CONTINUOUS COVERAGE’ FROM THE
REFERENCE PERIOD START DATE UNTIL THE REFERENCE
PERIOD END DATE.

IF FAMILY DOES NOT STILL HAVE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON-PAIR (OE12 IS CODED ‘2’,
(NO)), FLAG INSURANCE FOR ALL PERSONS NOT SELECTED
AT OE18 AS ‘CONTINUOUS COVERAGE’ FROM THE
REFERENCE PERIOD START DATE UNTIL DATE RECORDED
AT OE15.

ROSTER DETAILS:
TITLE: RU_ESTB_PLCYHLDR_COVRD_PERS_TRPLS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY COVERED PERSONS’ NAMES
(PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER FOR SELECTION.

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

ROSTER FILTER:
1. PERSON WAS COVERED AT THE PREVIOUS ROUND’S
INTERVIEW DATE BY THE INSURANCE FROM THIS
ESTABLISHMENT-PERSON-PAIR, INCLUDING THE
POLICYHOLDER
2. PERSON IS AN RU MBMBER

LOOP_06

FOR EACH ELEMENT IN THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER, ASK NAV_OE06 - END_LP06

LOOP DEFINITION: LOOP_06 COLLECTS THE DATE ON
WHICH THE INSURANCE COVERAGE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR ENDED FOR EACH RU MEMBER
WHOSE COVERAGE ENDED PRIOR TO THE REFERENCE PERIOD
END DATE OR THE DATE REPORTED IN OE15. THIS LOOP
CYCLES ON PERSONS SELECTED AT OE18.

NAVIGATOR DETAILS: LOOP_06 USES NAV_OE06 TO
CONTROL THE FLOW OF THE LOOP.

NAV_OE06

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

SERIES: End Date of Insurance from {POLICYHOLDER}’s
{ESTABLISHMENT} plan.

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 DEFINITION:
THIS ITEM DISPLAYS RU-ESTB-PLCYHLDR-COVRD-PERS-
TRPLS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

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

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT OE18.

CONTINUE WITH OE19 FOR SELECTED RU MEMBER.

OE19

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

On what date did the health insurance through {ESTABLISHMENT}
end for {you/{PERSON}}?

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7 {BOX_13}
DK .................................... -8 {BOX_13}

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’
(DON’T KNOW) AND MONTH FIELD IS NOT CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), CONTINUE WITH
OE19OV

OTHERWISE, GO TO BOX_13

OE19OV

Can you just tell me if {you/he/was} {were/was} was covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_13}
PART OF THE MONTH ..................... 2 {BOX_13}
REF ................................... -7 {BOX_13}
DK .................................... -8 {BOX_13}

[Code One]

BOX_13

FLAG INSURANCE FOR PERSON AS ‘CONTINUOUS COVERAGE’
THROUGH THE COMPLETE DATE RECORDED AT OE19 AND
OE19OV.

END_LP06

CYCLE ON NEXT PERSON IN THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_06 AND CONTINUE WITH BOX_14

BOX_14

OTHERWISE, GO TO OE22A

OE20

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

{Since {START DATE}/Between {START DATE} and {END DATE}}, have
any persons living here, that we have not yet mentioned, been
covered by {your/{POLICYHOLDER}’s} health insurance through
{ESTABLISHMENT}?

YES ................................... 1 {OE21}
NO .................................... 2 {OE22A}
REF ................................... -7 {OE22A}
DK .................................... -8 {OE22A}

HELP AVAILABLE FOR DEFINITION OF DEPENDENT.

DISPLAY ‘Since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘Between {START DATE} and {END DATE}’ IF
ROUND 5.

OE21

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

Who {has been/was} covered by {your/{POLICYHOLDER}’s} health insurance
through {ESTABLISHMENT} {since {START DATE}/between {START DATE}
and {END DATE}} that we have not yet mentioned?

PROBE: Any 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]

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

WRITE PERSONS SELECTED TO THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER.

IF ‘PERSON NOT LISTED IN RU’ IS SELECTED, FLAG
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
AS ‘COVERING PERSON NOT LISTED IN RU’.

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
ONE OR MORE FROM THE LISTED MEMBERS.
2. ADD, DELETE, AND EDIT DISALLOWED.
3. DISPLAY ‘PERSON NOT LISTED IN RU’ AS LAST ENTRY
ON THIS ROSTER.

ROSTER FILTER:
DISPLAY PERSONS WHO WERE NOT COVERED BY THE
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
ON THE PREVIOUS ROUND’S INTERVIEW DATE.

LOOP_07

FOR EACH ELEMENT IN THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER, ASK NAV_OE07 - END_LP07

LOOP DEFINITION: LOOP_07 COLLECTS THE COVERAGE
START DATE FOR ALL PERSONS NEWLY COVERED DURING
THE CURRENT ROUND BY THE INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR. THIS LOOP CYCLES ON
PERSONS SELECTED AT OE21.

NAVIGATOR DETAILS: LOOP_07 USES NAV_OE07 TO
CONTROL THE FLOW OF THE LOOP.

NAV_OE07

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

SERIES: Begin Date of Insurance from {POLICYHOLDER}’s
{ESTABLISHMENT} plan.

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 DEFINITION:
THIS ITEM DISPLAYS RU-ESTB-PLCYHLDR-COVRD-PERS-
TRPLS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

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

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT OE21.

CONTINUE WITH OE22 FOR SELECTED RU MEMBER.

OE22

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

On what date did the health insurance through {ESTABLISHMENT}
begin for {you/{PERSON}}?

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7
DK .................................... -8

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE22OV

OTHERWISE, GO TO BOX_15

OE22OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_15}
PART OF THE MONTH ..................... 2 {BOX_15}
REF ................................... -7 {BOX_15}
DK .................................... -8 {BOX_15}

[Code One]

HARD CHECK:
COMPLETE DATE AT OE22 MUST BE < THAN COMPLETE DATE
AT OE15 IF A DATE IS RECORDED AT OE15 OR < THAN
REFERENCE PERIOD END DATE IF NO DATE IS RECORDED
AT OE15.

BOX_15

IF FAMILY STILL HAS INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR (OE12 IS CODED ‘1’
(YES)), FLAG INSURANCE FOR THIS PERSON AS
‘CONTINUOUS COVERAGE’ FROM DATE RECORDED AT OE22
UNTIL THE REFERENCE PERIOD END DATE.

IF FAMILY DOES NOT STILL HAVE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON-PAIR (OE12 IS CODED ‘2’
(NO)), FLAG INSURANCE FOR THIS PERSON AS
‘CONTINUOUS COVERAGE’ FROM DATE RECORDED AT OE22
UNTIL DATE RECORDED AT OE15.

END_LP07

CYCLE ON NEXT PERSON IN THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_07 AND GO TO BOX_16

OE22A

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

{Does/Between {START DATE} and {END DATE}, did} {your/{POLICYHOLDER}’s}
health coverage through {ESTABLISHMENT} cover as dependents any
persons who do not live here?

YES .................................... 1 {BOX_16}
NO ..................................... 2 {BOX_16}
REF ................................... -7 {BOX_16}
DK .................................... -8 {BOX_16}

HELP AVAILABLE FOR DEFINITION OF DEPENDENT.

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

IF CODED ‘1’ (YES), FLAG INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR AS ‘COVERING PERSON NOT
LISTED IN RU’ IN OE21

BOX_16

IF ONE OR MORE RU MEMBERS ARE STILL COVERED BY THE
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
ON THE CURRENT ROUND’S INTERVIEW DATE, THAT IS,
OE12 IS CODED ‘1’(YES), CONTINUE WITH BOX_16A

OTHERWISE, GO TO END_LP05

BOX_16A

IF ROUND 3, CONTINUE WITH OE23A

OTHERWISE, GO TO OE23

OE23A

{POLICYHOLDER’S 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
YES, PAY SOME OF PREMIUM/COST .......... 2
YES, BUT DON’T KNOW IF PAY ALL OR SOME
OF PREMIUM/COST ........................ 3
NO, DO NOT PAY ......................... 4 {OE23AAA}
REF ................................... -7 {BOX_17AA}
DK .................................... -8 {BOX_17AA}

[Code One]

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

OE23AA

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

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

[Enter Amount in Dollars] .............. {OE23AAOV1}
REF ................................... -7 {BOX_17A}
DK .................................... -8 {BOX_17A}

OE23AAOV1

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

UNIT OF COVERAGE:

PER YEAR ............................... 1 {BOX_17A}
QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_17A}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_17A}
PER MONTH .............................. 4 {BOX_17A}
PER WEEK ............................... 5 {BOX_17A}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_17A}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_17A}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_17A}
OTHER ................................. 91 {OE23AAOV2}
REF ................................... -7 {BOX_17A}
DK .................................... -8 {BOX_17A}

[Code One]

OE23AAOV2

SPECIFY:

[Enter Other Specify] .................. {BOX_17A}
REF ................................... -7 {BOX_17A}
DK .................................... -8 {BOX_17A}

BOX_17A

IF OE23A IS CODED ‘1’ (YES, PAY ALL OF PREMIUM/
COST), GO TO BOX_17AA

OTHERWISE, CONTINUE WITH OE23AAA

OE23AAA

{POLICYHOLDER’S 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
REF ................................... -7 {BOX_17AA}
DK .................................... -8 {BOX_17AA}

[Code All That Apply]

DISPLAY ‘else’ IF OE23A 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 OE23A 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 OE23A IS CODED ‘4’ (NO, DO NOT PAY).

FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW -7 OR -8 IN COMBINATION WITH ANY OTHER CODE.

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH OE23AAAOV

OTHERWISE, GO TO BOX_17AA

OE23AAAOV

SPECIFY:

[Enter Other Specify] .................. {BOX_17AA}
REF ................................... -7 {BOX_17AA}
DK .................................... -8 {BOX_17AA}

BOX_17AA

OTHERWISE, CONTINUE WITH OE23B

OE23B

{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 {OE23}
{$1,250/$2,500} OR MORE ................ 2 {OE23C}
NO ANNUAL DEDUCTIBLE ................... 3 {OE23}
REF ................................... -7 {OE23}
DK .................................... -8 {OE23}

[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 (OE22A 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 OE22A 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 OE22A 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 OE22A 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.

OE23C

{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 {OE23}
NO ..................................... 2 {OE23}
REF ................................... -7 {OE23}
DK .................................... -8 {OE23}

[Code One]

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

OE23

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

{Last time we recorded that {you/{POLICYHOLDER}} {were/was} covered
by {INSURER OF ESTAB-PERS-INSURER TRIPLE ON PREV RD INT DT}.}

{Since {START DATE}, has there been/Between {START DATE} and
{END DATE}, was there} any change in the plan name of the health
insurance {you/{POLICYHOLDER}} {{have/has}/had} through {ESTABLISHMENT}?

YES ................................... 1 {OE24}
NO .................................... 2 {END_LP05}
REF ................................... -7 {END_LP05}
DK .................................... -8 {END_LP05}

DISPLAY FIRST PARAGRAPH IF THE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON- PAIR HAD ANY INSURERS
FLAGGED AS PROVIDING MEDIGAP OR HOSPITAL/PHYSICIAN
BENEFITS AT ANY TIME DURING THE PREVIOUS ROUND.

DISPLAY ‘Since {START DATE}, has there been’ AND
‘{have/has}’ IF NOT ROUND 5. DISPLAY ‘Between
{START DATE} and {END DATE}, ‘was there’ AND ‘had’
IF ROUND 5.

IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW), FLAG PREVIOUS ROUND’S INSURER AS CURRENT
ROUND’S INSURER FOR THIS ESTABLISHMENT-PERSON-
PAIR.

OE24

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

SHOW CARD HX-9.

Looking at this card, what type of health insurance coverage
{{do/does}/did} {you/{POLICYHOLDER}} {now} have through
{ESTABLISHMENT}’s new plan {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
REF ................................... -7 {BOX_17}
DK .................................... -8 {BOX_17}

[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.]

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 CODES, CONTINUE WITH OE24OV

OTHERWISE, GO TO BOX_17

OE24OV

SPECIFY:

[Enter Other Specify] .................. {BOX_17}
REF ................................... -7 {BOX_17}
DK .................................... -8 {BOX_17}

HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.

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

BOX_17

IF OE24 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN
BENEFITS) OR ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP),
ALONE OR WITH ANY OTHER COMBINATION OF CODES,
CONTINUE WITH OE25

OTHERWISE, GO TO END_LP05

NOTE: ALL ESTABLISHMENTS WHICH ARE BEING LOOPED
ON HERE ARE EMPLOYERS. THEREFORE, IT IS NOT
NECESSARY TO AUTOMATICALLY CODE OE25 IF THE
ESTABLISHMENT IS AN INSURANCE CO. OR HMO.

OE25

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

What is the new plan name for {your/{POLICYHOLDER}’s} health insurance
through {ESTABLISHMENT} which provides the {hospital and
physician benefits/Medicare supplement or Medigap benefits}?

IF MORE THAN ONE NAME, PROBE: What is the main new plan name?

RECORD THE NAME OF THE MAIN INSURER THAT PROVIDES THE {HOSPITAL
AND PHYSICIAN/MEDIGAP} BENEFITS FOR THIS PAIR.

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

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

TYPE:

INSURANCE COMPANY ...................... 1 {LOOP_08}
HMO .................................... 2 {LOOP_08}
SELF-INSURED COMPANY ................... 3 {LOOP_08}

[Code One]

HELP AVAILABLE FOR DEFINITION OF INSURANCE CO/HMO/SELF-INSURED CO.

DISPLAY ‘hospital and physician benefits’ AND
‘HOSPITAL AND PHYSICIAN’ IF OE24 IS CODED ‘1’
(HOSPITAL AND PHYSICIAN BENEFITS), BUT NOT CODED
‘5’ (MEDICARE SUPPLEMENT/MEDIGAP). DISPLAY
‘Medicare supplement or Medigap benefits’ AND
‘MEDIGAP’ IF OE24 IS CODED ‘5’ (MEDICARE SUPPLEMENT
/MEDIGAP).

WRITE INSURER(S) TO THE RU-ESTB-PERSON-INSURER-
TRIPLES-ROSTER FOR THE INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR.

FLAG INSURER(S) COLLECTED AT OE25 AS CURRENT
ROUND’S INSURER(S) FOR THIS ESTABLISHMENT-PERSON-
PAIR.

IF OE24 IS CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP)
FLAG INSURANCE CO./HMO AS ‘SUPPLYING MEDICARE
SUPPLEMENT/MEDIGAP BENEFITS (WHICH INCLUDES
HOSPITAL/PHYSICIAN BENEFITS)’ FOR THE CURRENT
ROUND.

IF OE24 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN
BENEFITS), BUT NOT ‘5’ (MEDICARE SUPPLEMENT/
MEDIGAP), FLAG INSURANCE CO./HMO AS ‘SUPPLYING
HOSPITAL/PHYSICIAN BENEFITS’ FOR THE CURRENT
ROUND.

LOOP_08

FOR EACH ELEMENT ON THE RU-ESTAB-PERSON-INSURER-
TRIPLES-ROSTER, ASK BOX_17B - END_LP08.

LOOP DEFINITION: LOOP_08 COLLECTS OTHER POLICY
NAMES AND MANAGED CARE INFORMATION FOR INSURERS
COLLECTED AT OE25. THIS LOOP CYCLES ON TRIPLES
THAT MEET THE FOLLOWING CONDITIONS:

- ESTABLISH-PERSON-PAIR PROVIDES THE INSURANCE
BEING ASKED ABOUT
- INSURER IS ENTERED AT OE25

BOX_17B

IF AN INSURER NAME IS ENTERED AT OE25, CONTINUE
WITH OE25AA

IF INSURER NAME IS CODED ‘-7’ (REF) OR ‘-8’ (DK)
AT OE25, GO TO BOX_18A

OE25AA

{POLICYHOLDER’S 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 {OE25AAOV}
NO OTHER NAME .......................... 2 {BOX_18A}
REF ................................... -7 {BOX_18A}
DK .................................... -8 {BOX_18A}

HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH OPTION.

[Code One]

DISPLAY THE NAME OF THE INSURANCE CO/HMO
RECORDED IN OE25 WHICH IS BEING LOOPED ON FOR
‘INSURANCE...NAME’.

OE25AAOV

SPECIFY:

[Enter Policy Name] .................... {BOX_18A}
REF ................................... -7 {BOX_18A}
DK .................................... -8 {BOX_18A}

HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH OPTION.

BOX_18A

IF INSURER BEING LOOPED ON IS CODED ‘2’ (HMO) IN
OE25, CONTINUE WITH OE25B

OTHERWISE, GO TO BOX_18

OE25B

{POLICYHOLDER’S 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_LP08}
NO ..................................... 2 {END_LP08}
REF ................................... -7 {END_LP08}
DK .................................... -8 {END_LP08}

BOX_18

ASK THE MANAGED CARE (MC) SECTION FOR THIS INSURER

AT COMPLETION OF MANAGED CARE (MC) SECTION,
CONTINUE WITH END_LP08

END_LP08

CYCLE ON NEXT INSURER IN THE RU-ESTAB-PERSON-
INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER INSURERS MEET THE STATED CONDITIONS,
END LOOP_08 AND CONTINUE WITH END_LP05

END_LP05

CYCLE ON NEXT PAIR IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.

IF NO OTHER PAIRS MEET THE STATED CONDITIONS,
END LOOP_05 AND CONTINUE WITH BOX_19

BOX_19

IF ONE OR MORE OF RU MEMBERS WAS COVERED BY
INSURANCE THROUGH A NON-CURRENT EMPLOYER FROM THE
PREVIOUS ROUND, AN EMPLOYER FLAGGED AS ‘SELF-
EMPLOYED’ WITH A FIRM-SIZE-1, OR A DIRECT PURCHASE
SOURCE ON THE PREVIOUS ROUND’S INTERVIEW DATE,
THAT IS:

IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS IN THE
RU MEETS THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS ONE OF THE FOLLOWING TYPES:
- FLAGGED AS A DIRECT PURCHASE SOURCE
- FLAGGED AS AN ‘EMPLOYER’ WITH FIRM-SIZE-1,
FLAGGED DURING THE PREVIOUS ROUND AS
‘PROVIDES HEALTH INSURANCE’, OR
- FLAGGED AS AN ‘EMPLOYER’ WITH FIRM-SIZE-
GREATER-THAN-1, FLAGGED DURING THE PREVIOUS
ROUND AS ‘PROVIDES HEALTH INSURANCE’, AND
HAD ONE OF THE FOLLOWING JOB SUBTYPES DURING
THE PREVIOUS ROUND:
- ‘FORMER MAIN WITHIN REFERENCE PERIOD’
- ‘FORMER MISCELLANEOUS JOB WITHIN REFERENCE
PERIOD’
- ‘LAST JOB OUTSIDE REFERENCE PERIOD’
- ‘RETIREMENT JOB’
- PERSON IS OR WAS A JOBHOLDER AT ESTABLISHMENT,
IF THE ESTABLISHMENT IS ONE OF THE SECOND 2
TYPES NOTED ABOVE;
- PERSON IS FLAGGED AS THE POLICYHOLDER OF THIS
INSURANCE;
- THE HEALTH INSURANCE PROVIDED BY ESTABLISHMENT
COVERED PERSON ON THE DATE OF THE PREVIOUS
ROUND’S INTERVIEW (HQ WAS CODED ‘1’ (WHOLE
TIME) OR HQ02 WAS CODED ‘1’ (YES) IN THE
PREVIOUS ROUND);

CONTINUE WITH LOOP_09

OTHERWISE, GO TO BOX_29

NOTE: IF POLICYHOLDER WAS NOT PHYSICALLY PRESENT
IN THE RU ON THE PREVIOUS ROUND’S INTERVIEW DATE,
THE LAST CONDITION IN THE ABOVE BOX CAN BE MET
IF AT LEAST ONE DEPENDENT WAS COVERED BY
POLICYHOLDER’S INSURANCE ON THE PREVIOUS ROUND’S
INTERVIEW DATE. THE LOOP WILL CYCLE ON THE
POLICYHOLDER’S NAME.

NOTE: FOR DIRECT PURCHASE AND SELF-EMPLOYED-FIRM-
SIZE-1, THE CONTEXT HEADER SHOULD DISPLAY THE NAME
OF THE SOURCE PROVIDING THE INSURANCE RATHER THAN
THE NAME OF THE DIRECT PURCHASE CATEGORY OR THE
SELF-EMPLOYED-FIRM-SIZE-1 EMPLOYER NAME OR TYPE OF
PURCHASE CATEGORY. FOR EMPLOYERS WHICH ARE NOT
SELF-EMPLOYED WITH FIRM-SIZE-1, USE THE JOBHOLDER
NAME AND EMPLOYER NAME IN THE CONTEXT HEADER.

LOOP_09

FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_OE09A - END_LP09

LOOP DEFINITION: LOOP_09 COLLECTS INFORMATION
ABOUT THE CONTINUATION OF INSURANCE COVERAGE
THROUGH A NON-CURRENT EMPLOYER FROM THE PREVIOUS
ROUND, AN EMPLOYER FLAGGED AS ‘SELF-EMPLOYED’ WITH
A FIRM-SIZE-1, OR A DIRECT PURCHASE SOURCE THAT
WAS COLLECTED IN THE PREVIOUS ROUND. THIS LOOP
CYCLES ON ESTABLISHMENT-PERSON-PAIRS THAT MEET
THE FOLLOWING CONDITIONS:

- ESTABLISHMENT IS ONE OF THE FOLLOWING TYPES:
- FLAGGED AS A DIRECT PURCHASE SOURCE
- FLAGGED AS AN ‘EMPLOYER’ WITH FIRM-SIZE-1,
FLAGGED DURING THE PREVIOUS ROUND AS ‘PROVIDES
HEALTH INSURANCE’, OR
- FLAGGED AS AN ‘EMPLOYER’ WITH FIRM-SIZE-
GREATER-THAN-1, FLAGGED DURING THE PREVIOUS
ROUND AS ‘PROVIDES HEALTH INSURANCE’, AND HAD
ONE OF THE FOLLOWING JOB SUBTYPES DURING THE
PREVIOUS ROUND:
- ‘FORMER MAIN WITHIN REFERENCE PERIOD’
- ‘FORMER MISCELLANEOUS JOB WITHIN REFERENCE
PERIOD’
- ‘LAST JOB OUTSIDE REFERENCE PERIOD’
- ‘RETIREMENT JOB’
- PERSON IS OR WAS A JOBHOLDER AT ESTABLISHMENT,
IF THE ESTABLISHMENT IS ONE OF THE SECOND 2
TYPES NOTED ABOVE;
- PERSON IS FLAGGED AS THE POLICYHOLDER OF THIS
INSURANCE;
- THE HEALTH INSURANCE PROVIDED BY ESTABLISHMENT
COVERED PERSON ON THE DATE OF THE PREVIOUS
ROUND’S INTERVIEW (HQ WAS CODED ‘1’ (WHOLE TIME)
OR HQ02 WAS CODED ‘1’ (YES) IN THE PREVIOUS
ROUND)

NAVIGATOR DETAILS: LOOP_09 USES BOTH NAV_OE09A
AND OE09B TO CONTROL THE FLOW OF THE LOOP.

NAV_OE09A

SERIES: Confirming Insurance Obtained by Someone in the Family
in a Previous Round (i.e., probing for who is still covered, any
change in plan name, etc.)

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 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_09 DEFINITION.

CONTINUE WITH NAV_OE09B FOR SELECTED RU MEMBER.

NAV_OE09B

SERIES: Confirming Insurance Obtained by Someone in the Family
in a Previous Round (i.e., probing for who is still covered, any
change in plan name, etc.)

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.

Policyholder...Establishment Providing Insurance

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

ROSTER DETAILS:
COL # 1 HEADER: POLICYHOLDER...ESTABLISHMENT
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 ESTABLISHMENTS THAT MEET THE
CONDITIONS STATED AT THE LOOP_09 DEFINITION.

CONTINUE WITH BOX_19A FOR SELECTED PAIR.

BOX_19A

IF THE POLICYHOLDER OF THIS ESTABLISHMENT-PERSON-
PAIR IS FLAGGED AS ‘POLICYHOLDER NOT LISTED IN RU
(DU)’ OR ‘POLICYHOLDER DECEASED’, CONTINUE WITH
OE25A

OTHERWISE, GO TO OE26

OE25A

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

INTERVIEWER: IF {POLICYHOLDER}’S NAME IS LISTED ON THE
ROSTER BELOW, SELECT IT. IF NOT, SELECT ‘NAME NOT ON ROSTER’
AND CONTINUE.

[1. First Name,[Middle Name],Last Name-35] .
[2. First Name,[Middle Name],Last Name-35] .
[3. First Name,[Middle Name],Last Name-35] .

[Code One]

IF A DU MEMBER’S NAME IS SELECTED FROM THE
ROSTER, REPLACE THIS NAME AS THE CURRENT
POLICYHOLDER OF THIS ESTABLISHMENT-PERSON-PAIR.
IF ‘NAME NOT ON ROSTER’ SELECTED LEAVE THE
POLICYHOLDER NAME OF THIS ESTABLISHMENT-PERSON-
PAIR AS IS.

ROSTER DETAILS:
TITLE: DU_MEMBERS_1

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

ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSONS ON THE DU-MEMBERS-
ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.
2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.
3. DISPLAY ‘NAME NOT ON ROSTER’ AS LAST ENTRY ON
THIS ROSTER.

ROSTER FILTER:
NO FILTER; DISPLAY ALL.

OE26

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

Now think about {your/{POLICYHOLDER}’s} health insurance through
{ESTABLISHMENT}. {{Are/Is}/{Were/Was}} {you/he/she} or anyone in
the family covered by this insurance as of {today,} {END DATE}?

YES .................................... 1
NO ..................................... 2 {OE28}
REF ................................... -7 {END_LP09}
DK .................................... -8 {END_LP09}

DISPLAY ‘{Are/Is}’ IF NOT ROUND 5. DISPLAY
‘{Were/Was}’ IF ROUND 5.

DISPLAY ‘today,’ IF NOT ROUND 5. OTHERWISE, USE A
NULL DISPLAY.

IF CODED ‘1’ (YES) AND THIS ESTABLISHMENT-PERSON-
PAIR IS AN ESTABLISHMENT FLAGGED AS ‘SELF-
EMPLOYED’ WITH FIRM-SIZE-1, CONTINUE WITH OE27

OTHERWISE (I.E., IF CODED ‘1’ (YES) AND
ESTABLISHMENT-PERSON-PAIR IS NOT AN ESTABLISHMENT
WITH FIRM-SIZE-1), GO TO BOX_20

OE27

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

Is this insurance still through {your/{POLICYHOLDER}’s} self-employed
business?

YES .................................... 1 {BOX_20}
NO ..................................... 2 {BOX_20}
REF ................................... -7 {BOX_20}
DK .................................... -8 {BOX_20}

HELP AVAILABLE FOR DEFINITION OF SELF-EMPLOYED.

OE28

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

On what date did {your/{POLICYHOLDER}’s} health insurance through
{ESTABLISHMENT} end?

{IF INSURANCE ENDED AFTER 12/31/{YEAR}, BACK-UP TO OE26
AND SELECT ‘YES’.}

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7 {BOX_20}
DK .................................... -8 {BOX_20}

DISPLAY ‘IF INSURANCE ENDED... SELECT ‘YES’.’ IF
ROUND 5. OTHERWISE, USE A NULL DISPLAY

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE28OV

OTHERWISE, GO TO BOX_20

OE28OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_20}
PART OF THE MONTH ..................... 2 {BOX_20}
REF ................................... -7 {BOX_20}
DK .................................... -8 {BOX_20}

[Code One]

BOX_20

IF THE POLICYHOLDER IS THE ONLY PERSON COVERED AT
THE PREVIOUS ROUND’S INTERVIEW DATE BY THE
INSURANCE FROM THIS ESTABLISHMENT-PERSON-PAIR,
AUTOMATICALLY CODE OE29 AS ‘1’ (YES) AND GO TO
BOX_21

OTHERWISE, CONTINUE WITH OE29

OE29

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

{Are/Were} (READ NAMES BELOW) all covered by {your/{POLICYHOLDER}’s}
health insurance through {ESTABLISHMENT} {until {{OE28 DATE}/it
ended}/on {END DATE}}?

{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}
{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}
{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}

YES ................................... 1 {BOX_21}
NO .................................... 2 {BOX_21}
REF ................................... -7 {BOX_21}
DK .................................... -8 {BOX_21}

DISPLAY ‘Are’ IF OE26 IS CODED ‘1’ (YES).
DISPLAY ‘Were’ IF OE26 IS CODED ‘2’ (NO) OR IF
CURRENT ROUND IS ROUND 5.

DISPLAY ‘until {OE28 DATE}’ IF OE26 IS CODED ‘2’
(NO). DISPLAY ‘on {END DATE}’ IF OE26 IS CODED
‘1’ (YES).

DISPLAY THE DATE RECORDED AT OE28 FOR ‘OE28 DATE’.
IF THE MONTH OR YEAR FIELD AT OE28 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY ‘it ended’
FOR ‘OE28 DATE’.

ROSTER DETAILS:
TITLE: RU_ESTB_PLCYHLDR_COVRD_PERS_TRPLS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY COVERED PERSONS’ NAMES
(PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER FOR DISPLAY.

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

ROSTER FILTER:
1. PERSON WAS COVERED AT PREVIOUS ROUND’S
INTERVIEW DATE BY THE INSURANCE FROM THIS
ESTABLISHMENT-PERSON-PAIR, INCLUDING THE
POLICYHOLDER
2. PERSON IS AN RU MBMBER

BOX_21

IF COVERAGE IS CONTINUOUS FROM THE PREVIOUS ROUND
TO THE END DATE OF THE CURRENT ROUND, THAT IS:

IF OE26 IS CODED ‘1’ (YES) AND OE29 IS CODED ‘1’
(YES),

FLAG INSURANCE FOR ALL COVERED PERSONS (INCLUDING
THE POLICYHOLDER) AS ‘CONTINUOUS COVERAGE’ THROUGH
THE REFERENCE PERIOD END DATE AND

GO TO BOX_23

IF COVERAGE IS CONTINUOUS FROM THE PREVIOUS ROUND
TO PART OF THE CURRENT ROUND, THAT IS:

IF OE26 IS CODED ‘2’ (NO) AND OE29 IS CODED ‘1’
(YES).

FLAG INSURANCE FOR ALL COVERED PERSONS (INCLUDING
THE POLICYHOLDER) AS ‘CONTINUOUS COVERAGE’ THROUGH
THE DATE RECORDED AT OE28 AND

GO TO BOX_23

OTHERWISE (I.E., OE29 CODED ‘2’ (NO), ‘-7’
(REFUSED), OR ‘-8’ (DON’T KNOW)), CONTINUE WITH
OE30

OE30

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

Who {is/was} no longer covered by {your/{POLICYHOLDER}’s} health
insurance through {ESTABLISHMENT} {{until {OE28 DATE}/it ended}/
on {END DATE}}?

[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 ‘is’ IF OE26 IS CODED ‘1’ (YES).
DISPLAY ‘was’ IF OE26 IS CODED ‘2’ (NO) OR IF
CURRENT ROUND IS ROUND 5.

DISPLAY ‘until {OE28 DATE}’ IF OE26 IS CODED ‘2’
(NO).
DISPLAY ‘on {END DATE}’ IF OE26 IS CODED ‘1’
(YES).

DISPLAY THE DATE RECORDED AT OE28 FOR ‘OE28 DATE’.
IF THE MONTH OR YEAR FIELD AT OE28 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY ‘it ended’
FOR ‘OE28 DATE’.

IF FAMILY STILL HAS INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR (OE26 IS CODED ‘1’
(YES)), FLAG INSURANCE FOR ALL PERSONS NOT
SELECTED AT OE30 AS ‘CONTINUOUS COVERAGE’ FROM THE
REFERENCE PERIOD START DATE UNTIL THE REFERENCE
PERIOD END DATE.

IF FAMILY DOES NOT STILL HAVE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON-PAIR (OE26 IS CODED ‘2’
(NO)), FLAG INSURANCE FOR ALL PERSONS NOT SELECTED
AT OE30 AS ‘CONTINUOUS COVERAGE’ FROM THE
REFERENCE PERIOD START DATE UNTIL DATE RECORDED
AT OE28

GO TO LOOP_10

ROSTER DETAILS:
TITLE: RU_ESTB_PLCYHLDR_COVRD_PERS_TRPLS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY COVERED PERSONS’ NAMES
(PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER FOR SELECTION.

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

ROSTER FILTER:
1. PERSON WAS COVERED AT PREVIOUS ROUND’S
INTERVIEW DATE BY THE INSURANCE FROM THIS
ESTABLISHMENT-PERSON-PAIR, INCLUDING THE
POLICYHOLDER
2. PERSON IS AN RU MBMBER

LOOP_10

FOR EACH ELEMENT IN THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER, ASK NAV_OE10 - END_LP10

LOOP DEFINITION: LOOP_10 COLLECTS THE DATE ON
WHICH THE INSURANCE COVERAGE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR ENDED FOR EACH RU MEMBER
WHOSE COVERAGE ENDED EITHER PRIOR TO THE REFERENCE
PERIOD END DATE OR THE DATE REPORTED IN OE28.
THIS LOOP CYCLES ON PERSONS SELECTED AT OE30.

NAVIGATOR DETAILS: LOOP_10 USES NAV_OE10 TO
CONTROL THE FLOW OF THE LOOP.

NAV_OE10

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

SERIES: End Date of Insurance from {POLICYHOLDER}’s
{ESTABLISHMENT} plan.

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 DEFINITION:
THIS ITEM DISPLAYS RU-ESTB-PLCYHLDR-COVRD-PERS-
TRPLS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

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

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT OE30.

CONTINUE WITH OE31 FOR SELECTED RU MEMBER.

OE31

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

On what date did the health insurance through {ESTABLISHMENT}
end for {you/{PERSON}}?

[Enter Month-2, Day-2, Year-4] ......... {OE31OV}
REF ................................... -7 {BOX_22}
DK .................................... -8 {BOX_22}

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE31OV

OTHERWISE, GO TO BOX_22

OE31OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_22}
PART OF THE MONTH ..................... 2 {BOX_22}
REF ................................... -7 {BOX_22}
DK .................................... -8 {BOX_22}

[Code One]

BOX_22

FLAG INSURANCE FOR PERSON AS ‘CONTINUOUS COVERAGE’
THROUGH THE COMPLETE DATE RECORDED AT OE31 AND
OE31OV.

END_LP10

CYCLE ON NEXT PERSON IN THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_10 AND CONTINUE WITH BOX_23

BOX_23

OTHERWISE, GO TO OE34A

OE32

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

{Since {START DATE}/Between {START DATE} and {END DATE}}, have
any persons living here, we have not yet mentioned, been covered
by {your/{POLICYHOLDER}’s} health insurance through {ESTABLISHMENT}?

YES ................................... 1 {OE33}
NO .................................... 2 {OE34A}
REF ................................... -7 {OE34A}
DK .................................... -8 {OE34A}

HELP AVAILABLE FOR DEFINITION OF DEPENDENT.

DISPLAY ‘Since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘Between {START DATE} and {END DATE}’ IF
ROUND 5.

OE33

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

Who {has been/was} covered by {your/{POLICYHOLDER}’s} health insurance
through {ESTABLISHMENT} {since {START DATE}/between {START DATE}
and {END DATE}} that we have not yet mentioned?

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]

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

WRITE PERSONS SELECTED TO THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER.

IF ‘PERSON NOT LISTED IN RU’ IS SELECTED, FLAG
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
AS ‘COVERING PERSON NOT LISTED IN RU’.

GO TO LOOP_11

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 FILTER:
DISPLAY PERSONS WHO WERE NOT COVERED BY THE
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
ON THE PREVIOUS ROUND’S INTERVIEW DATE.

LOOP_11

FOR EACH ELEMENT IN THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER, ASK NAV_OE11 - END_LP11

LOOP DEFINITION: LOOP_11 COLLECTS THE COVERAGE
START DATE FOR ALL PERSONS NEWLY COVERED DURING
THE CURRENT ROUND BY THE INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR. THIS LOOP CYCLES ON
PERSONS SELECTED AT OE33.

NAVIGATOR DETAILS: LOOP_11 USES NAV_OE11 TO
CONTROL THE FLOW OF THE LOOP.

NAV_OE11

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

SERIES: Begin Date of Insurance from {POLICYHOLDER}’s
{ESTABLISHMENT} plan.

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 DEFINITION:
THIS ITEM DISPLAYS RU-ESTB-PLCYHLDR-COVRD-PERS-
TRPLS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

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

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT OE33.

CONTINUE WITH OE34 FOR SELECTED RU MEMBER.

OE34

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

On what date did the health insurance through {ESTABLISHMENT}
begin for {you/{PERSON}}?

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7 {BOX_24}
DK .................................... -8 {BOX_24}

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE34OV

OTHERWISE, GO TO BOX_24

OE34OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_24}
PART OF THE MONTH ..................... 2 {BOX_24}
REF ................................... -7 {BOX_24}
DK .................................... -8 {BOX_24}

[Code One]

HARD CHECK:
COMPLETE DATE AT OE34 MUST BE < THAN COMPLETE
DATE AT OE28 IF A DATE IS RECORDED AT OE28 OR
< THAN REFERENCE PERIOD END DATE IF NO DATE IS
RECORDED AT OE28.

BOX_24

IF FAMILY STILL HAS INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR (OE26 IS CODED ‘1’
(YES)), FLAG INSURANCE FOR THIS PERSON AS
‘CONTINUOUS COVERAGE’ FROM DATE RECORDED AT OE34
UNTIL THE REFERENCE PERIOD END DATE.

IF FAMILY DOES NOT STILL HAVE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON-PAIR (OE26 IS CODED ‘2’
(NO)), FLAG INSURANCE FOR THIS PERSON AS
‘CONTINUOUS COVERAGE’ FROM DATE RECORDED AT OE34
UNTIL DATE RECORDED AT OE28.

END_LP11

CYCLE ON NEXT PERSON IN THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_11 AND CONTINUE WITH BOX_25

OE34A

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

{Does/Between {START DATE} and {END DATE}, did} {your/{POLICYHOLDER}’s}
health coverage through {ESTABLISHMENT} cover as dependents any
persons who do not live here?

YES .................................... 1 {BOX_25}
NO ..................................... 2 {BOX_25}
REF ................................... -7 {BOX_25}
DK .................................... -8 {BOX_25}

HELP AVAILABLE FOR DEFINITION OF DEPENDENT.

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

IF CODED ‘1’ (YES), FLAG INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR AS ‘COVERING PERSON NOT
LISTED IN RU’ IN OE33

BOX_25

IF ONE OR MORE RU MEMBERS ARE STILL COVERED BY THE
INSURANCE THROUGH THE ESTABLISHMENT-PERSON-PAIR ON
THE CURRENT ROUND’S INTERVIEW DATE, THAT IS, OE26
IS CODED ‘1’(YES), CONTINUE WITH BOX_25A

OTHERWISE, GO TO END_LP09

BOX_25A

IF ROUND 3, CONTINUE WITH OE35A

OTHERWISE, GO TO OE35

OE35A

{POLICYHOLDER’S 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 {OE35AA}
YES, PAY SOME OF PREMIUM/COST .......... 2 {OE35AA}
YES, BUT DON’T KNOW IF PAY ALL OR SOME
OF PREMIUM/COST ........................ 3 {OE35AA}
NO, DO NOT PAY ......................... 4 {OE35AAA}
REF ................................... -7 {BOX_26AA}
DK .................................... -8 {BOX_26AA}

[Code One]

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

OE35AA

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

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

[Enter Amount in Dollars] .............. {OE35AAOV1}
REF ................................... -7 {BOX_26A}
DK .................................... -8 {BOX_26A}

OE35AAOV1

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

UNIT OF COVERAGE:

PER YEAR ............................... 1 {BOX_26A}
QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_26A}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_26A}
PER MONTH .............................. 4 {BOX_26A}
PER WEEK ............................... 5 {BOX_26A}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_26A}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_26A}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_26A}
OTHER ................................. 91 {OE35AAOV2}
REF ................................... -7 {BOX_26A}
DK .................................... -8 {BOX_26A}

[Code One]

OE35AAOV2

SPECIFY:

[Enter Other Specify] .................. {BOX_26A}
REF ................................... -7 {BOX_26A}
DK .................................... -8 {BOX_26A}

BOX_26A

IF OE35A IS CODED ‘1’ (YES, PAY ALL OF PREMIUM/
COST), GO TO BOX_26AA

OTHERWISE, CONTINUE WITH OE35AAA

OE35AAA

{POLICYHOLDER’S 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 {OE35AAAOV}
REF ................................... -7 {BOX_26AA}
DK .................................... -8 {BOX_26AA}

[Code All That Apply]

DISPLAY ‘else’ IF OE35A 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 OE35A 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 OE35A 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 OE35AAAOV

OTHERWISE, GO TO BOX_26AA

OE35AAAOV

SPECIFY:

[Enter Other Specify] .................. {BOX_26AA}
REF ................................... -7 {BOX_26AA}
DK .................................... -8 {BOX_26AA}

BOX_26AA

OTHERWISE, CONTINUE WITH OE35B

OE35B

{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 {OE35}
{$1,250/$2,500} OR MORE ................ 2 {OE35C}
NO ANNUAL DEDUCTIBLE ................... 3 {OE35}
REF ................................... -7 {OE35}
DK .................................... -8 {OE35}

[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 (OE34A 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 OE34A 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 OE34A 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 OE34A 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.

OE35C

{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 {OE35}
NO ..................................... 2 {OE35}
REF ................................... -7 {OE35}
DK .................................... -8 {OE35}

[Code One]

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

OE35

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

{Last time we recorded that {you/{POLICYHOLDER}} {were/was} covered
by {INSURER OF ESTAB-PERS-INSURER TRIPLE ON PREV RD INT DT}.}

{Since {START DATE}, has there been/Between {START DATE} and
{END DATE}, was there} any change in the plan name of the health
insurance {you/{POLICYHOLDER}} {{have/has}/had} through {ESTABLISHMENT}?

YES ................................... 1
NO .................................... 2 {END_LP09}
REF ................................... -7 {END_LP09}
DK .................................... -8 {END_LP09}

DISPLAY FIRST PARAGRAPH IF THE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON-PAIR HAD ANY INSURERS
FLAGGED AS PROVIDING MEDIGAP OR HOSPITAL/
PHYSICIAN BENEFITS AT ANY TIME DURING THE
PREVIOUS ROUND.

DISPLAY ‘Since {START DATE}, has there been’ AND
‘{have/has}’ IF NOT ROUND 5. DISPLAY ‘Between
{START DATE} and {END DATE}, was there’ AND ‘had’
IF ROUND 5.

IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW), FLAG PREVIOUS ROUND’S INSURER AS CURRENT
ROUND’S INSURER FOR THIS ESTABLISHMENT-PERSON-
PAIR.

IF CODED ‘1’ (YES) AND ESTABLISHMENT IS FLAGGED AS
AN ‘INSURANCE CO.’, ‘INSURANCE CO.-FROM AGENT’, OR
‘HMO’, CONTINUE WITH OE36

IF CODED ‘1’ (YES) AND ESTABLISHMENT IS NOT
FLAGGED AS AN ‘INSURANCE CO.’, ‘INSURANCE CO.-FROM
AGENT’, OR ‘HMO’, GO TO OE37

OE36

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

What is the new plan name of {your/{POLICYHOLDER}’s} health insurance
through {ESTABLISHMENT}?

[Enter Plan Name/Establishment Name] .............. {OE37}

WRITE ESTABLISHMENT NAME CORRECTION TO THE RU-
ESTABLISHMENT-PERSONS-PAIRS-ROSTER. THIS IS THE
CORRECTED ESTABLISHMENT NAME.

FLAG INSURER ENTERED ABOVE AS CURRENT ROUND’S
INSURER FOR THIS POLICYHOLDER-ESTABLISHMENT PAIR.

NOTE: IF A SOURCE OF INSURANCE WAS DIRECTLY
PURCHASED FROM AN HMO, INSURANCE COMPANY, OR FROM
AN INSURANCE AGENT, THE ESTABLISHMENT NAME IS THE
SAME AS THE INSURER NAME. THEREFORE, ANY CHANGE
IN PLAN NAME AUTOMATICALLY DICTATES A CHANGE IN
THE ESTABLISHMENT NAME.

OE37

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

SHOW CARD HX-9.

Looking at this card, what type of health insurance coverage
{{do/does}/did} {you/{POLICYHOLDER}} {now} have through
{ESTABLISHMENT}’s new plan {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 {OE37OV}
REF ................................... -7 {BOX_26}
DK .................................... -8 {BOX_26}

[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.]

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 CODES, CONTINUE WITH OE37OV

OTHERWISE, GO TO BOX_26

OE37OV

SPECIFY:

[Enter Other Specify] .................. {BOX_26}
REF ................................... -7 {BOX_26}
DK .................................... -8 {BOX_26}

HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.

BOX_26

IF OE37 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN
BENEFITS) OR ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP),
ALONE OR WITH ANY OTHER COMBINATION OF CODES,
CONTINUE WITH BOX_27

OTHERWISE, GO TO END_LP09

BOX_27

IF ESTABLISHMENT ALREADY FLAGGED AS ‘INSURANCE
CO’, ‘INSURANCE CO.-FROM AGENT’, OR ‘HMO’,
AUTOMATICALLY CODE OE38 WITH APPROPRIATE RESPONSES
AND GO TO LOOP_12

OTHERWISE, CONTINUE WITH OE38

OE38

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

What is the new plan name for {your/{POLICYHOLDER}’s} health insurance
through {ESTABLISHMENT} which provides the {hospital and
physician benefits/Medicare supplement or Medigap benefits}?

IF MORE THAN ONE NAME, PROBE: What is the main new plan name?

RECORD THE NAME OF THE MAIN INSURER THAT PROVIDES THE {HOSPITAL
AND PHYSICIAN/MEDIGAP} BENEFITS FOR THIS PAIR.

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

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

TYPE:

INSURANCE COMPANY ...................... 1 {LOOP_12}
HMO .................................... 2 {LOOP_12}
SELF-INSURED COMPANY ................... 3 {LOOP_12}

[Code One]

HELP AVAILABLE FOR DEFINITION OF INSURANCE CO/HMO/SELF-INSURED CO.

DISPLAY ‘hospital and physician benefits’ AND
‘HOSPITAL AND PHYSICIAN’ IF OE37 IS CODED ‘1’
(HOSPITAL AND PHYSICIAN BENEFITS), BUT NOT CODED
‘5’ (MEDICARE SUPPLEMENT/MEDIGAP).
DISPLAY ‘Medicare supplement or Medigap benefits’
AND ‘MEDIGAP’ IF OE37 IS CODED ‘5’ (MEDICARE
SUPPLEMENT/MEDIGAP).

WRITE INSURER(S) TO THE RU-ESTAB-PERSON-INSURER-
TRIPLES-ROSTER FOR THE INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR

FLAG INSURER(S) COLLECTED AT OE38 AS CURRENT
ROUND’S INSURER(S) FOR THIS ESTABLISHMENT-PERSON-
PAIR.

IF OE37 IS CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP)
FLAG INSURANCE CO./HMO AS ‘SUPPLYING MEDICARE
SUPPLEMENT/MEDIGAP BENEFITS (WHICH INCLUDES
HOSPITAL/PHYSICIAN BENEFITS)’ FOR THE CURRENT
ROUND.

IF OE37 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN
BENEFITS), BUT NOT ‘5’ (MEDICARE SUPPLEMENT/
MEDIGAP), FLAG INSURANCE CO./HMO AS ‘SUPPLYING
HOSPITAL/PHYSICIAN BENEFITS’ FOR THE CURRENT
ROUND.

LOOP_12

FOR EACH ELEMENT ON THE RU-ESTAB-PERSON-INSURER-
TRIPLES-ROSTER, ASK BOX_27A - END_LP12.

LOOP DEFINITION: LOOP_12 COLLECTS OTHER POLICY
NAMES AND MANAGED CARE INFORMATION FOR INSURERS
COLLECTED AT OE38. THIS LOOP CYCLES ON TRIPLES
THAT MEET THE FOLLOWING CONDITIONS:

- ESTABLISHMENT-PERSON-PAIR PROVIDES THE INSURANCE
BEING ASKED ABOUT
- INSURER IS ENTERED AT OE38

BOX_27A

IF AN INSURER NAME IS ENTERED AT OE38, CONTINUE
WITH OE38A

IF INSURER NAME IS CODED ‘-7’ (REF) OR ‘-8’ (DK)
AT OE38, GO TO BOX_28A

OE38A

{POLICYHOLDER’S 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 {OE38AOV}
NO OTHER NAME .......................... 2 {BOX_28A}
REF ................................... -7 {BOX_28A}
DK .................................... -8 {BOX_28A}

HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH OPTION.

[Code One]

DISPLAY THE NAME OF THE INSURANCE CO/HMO
RECORDED IN OE38 WHICH IS BEING LOOPED ON
FOR ‘INSURANCE...NAME’.

OE38AOV

SPECIFY:

[Enter Policy Name] .................... {BOX_28A}
REF ................................... -7 {BOX_28A}
DK .................................... -8 {BOX_28A}

HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH OPTION.

BOX_28A

IF INSURER BEING LOOPED ON IS CODED ‘2’ (HMO) IN
OE38, CONTINUE WITH OE38B

OTHERWISE, GO TO BOX_28

OE38B

{POLICYHOLDER’S 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_LP12}
NO ..................................... 2 {END_LP12}
REF ................................... -7 {END_LP12}
DK .................................... -8 {END_LP12}

BOX_28

ASK THE MANAGED CARE (MC) SECTION FOR THIS INSURER

AT COMPLETION OF MANAGED CARE (MC) SECTION,
CONTINUE WITH END_LP12

END_LP12

CYCLE ON NEXT INSURER IN THE RU-ESTAB-PERSON-
INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER INSURERS MEET THE STATED CONDITIONS,
END LOOP_12 AND CONTINUE WITH END_LP09

END_LP09

CYCLE ON NEXT PAIR IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.

IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END
LOOP_09 AND CONTINUE WITH BOX_29

BOX_29

IF ONE OR MORE RU MEMBERS WAS A COVERED PERSON BY
AN ESTABLISHMENT-PERSON-PAIR ON THE PREVIOUS
ROUND’S INTERVIEW DATE WHERE THE ESTABLISHMENT IS
A PRIVATE SOURCE OF INSURANCE AND THE POLICYHOLDER
IS FLAGGED AS ‘POLICYHOLDER/DEPENDENT IN DIFFERENT
RUS’ AT THE CURRENT ROUND’S INTERVIEW DATE,
CONTINUE WITH LOOP_13

OTHERWISE, GO TO BOX_33

NOTE: WHEN A POLICYHOLDER LEAVES AN RU, WE WILL
NEVER ASK RJ AND THAT POLICYHOLDER WILL NEVER
QUALIFY FOR LOOPS 01, 05, OR 09. WE CREATED A
NEW LOOP, LOOP_13 THAT WILL HANDLE THE SITUATIONS
WHERE THE POLICYHOLDER HAS LEFT THE RU AND LEFT
DEPENDENTS BEHIND, OR THE SITUATION WHERE THE
DEPENDENTS HAVE LEFT THE RU (WITHOUT THE
POLICYHOLDER). THIS SITUATION WILL BE FLAGGED AS
‘POLICYHOLDER/DEPENDENT IN DIFFERENT RUs’. THIS
FLAG CAN BE ASSOCIATED WITH ANY ESTABLISHMENT-
PERSON-PAIR IN A PARTICULAR RU WHERE THEY ARE
COVERED PERSONS, BUT THE POLICYHOLDER IS IN
ANOTHER RU. THIS FLAG SHOULD NEVER EXIST ON A
PAIR IN AN RU WHERE THE POLICYHOLDER OF THE PAIR
IS IN THE SAME RU AS ALL OF THE DEPENDENTS OR
WHERE THE POLICYHOLDER OF THE PAIR WAS ORIGINALLY
CREATED AS ‘POLICYHOLDER NOT IN RU/DU’ OR
‘POLICYHOLDER DECEASED’.

LOOP_13

FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_OE13A - END_LP13

LOOP DEFINITION:

LOOP_13 COLLECTS INFORMATION ABOUT THE
CONTINUATION OF INSURANCE COVERAGE THROUGH AN
ESTABLISHMENT-PERSON-PAIR WHERE THE POLICYHOLDER
OR THE ELIGIBLE DEPENDENT(S) HAVE MOVED FROM THE
RU. THIS LOOP CYCLES ON ESTABLISHMENT-PERSON-PAIRS
THAT MEET THE FOLLOWING CONDITIONS:

- THE ESTABLISHMENT IS A PRIVATE SOURCE OF
INSURANCE
- THE ESTABLISHMENT-PERSON-PAIR IS FLAGGED AS
‘POLICYHOLDER/DEPENDENT MOVED’ AT THE CURRENT
ROUND’S INTERVIEW DATE FOR THIS RU
- AT LEAST ONE RU MEMBER WAS A COVERED PERSON FOR
THIS ESTABLISHMENT-PERSON-PAIR ON THE PREVIOUS
ROUND’S INTERVIEW DATE
- POLICYHOLDER IS NOT A CURRENT RU MEMBER

NAVIGATOR DETAILS: LOOP_13 USES BOTH NAV_OE13A
AND OE13B TO CONTROL THE FLOW OF THE LOOP.

NAV_OE13A

SERIES: Confirming all of the RU Member’s Insurance from a
Previous Round and Policyholder is not in the RU (i.e., probing
for who is still covered)

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.

Policyholder

[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: POLICYHOLDER
INSTRUCTIONS: DISPLAY POLICYHOLDER’S FIRST,
MIDDLE, AND LAST NAMES
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH POLICYHOLDER 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 POLICYHOLDERS WHO MEET THE CONDITIONS
STATED AT THE LOOP_13 DEFINITION.

CONTINUE WITH NAV_OE13B FOR SELECTED POLICYHOLDER.

NAV_OE13B

{POLICYHOLDER’S FIRST MIDDLE LAST NAME}

SERIES: Confirming all of the RU Member’s Insurance from a
Previous Round and Policyholder is not in the RU (i.e., probing
for who is still covered)

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.

PolicyHolder...Establishment

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

ROSTER DETAILS:
COL # 1 HEADER: POLICYHOLDER...ESTABLISHMENT
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 ESTABLISHMENTS THAT MEET THE
CONDITIONS STATED AT THE LOOP_13 DEFINITION.

CONTINUE WITH OE39 FOR SELECTED PAIR.

OE39

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

Now think about {your/{POLICYHOLDER}’s} health insurance through
{ESTABLISHMENT}. {Is/Was} anyone in the family, living here {now},
covered by this insurance as of {today,} {END DATE}?

IF RESPONDENT VOLUNTEERS THAT THIS INSURANCE HAS ALREADY BEEN
DISCUSSED, SELECT ‘INSURANCE ALREADY DISCUSSED’.

YES ................................... 1
NO .................................... 2 {OE40}
INSURANCE ALREADY DISCUSSED ........... 3 {END_LP13}
REF ................................... -7 {END_LP13}
DK .................................... -8 {END_LP13}

[Code One]

DISPLAY ‘Is’ IF NOT ROUND 5. DISPLAY ‘Was’ IF
ROUND 5.

DISPLAY ‘today,’ AND ‘ now’ IF NOT ROUND 5.
OTHERWISE, USE A NULL DISPLAY.

IF CODED ‘3’ (INSURANCE ALREADY DISCUSSED), FLAG
ITEM FOR SOURCE CLEAN-UP.

IF YES AND ONLY ONE PERSON IS FLAGGED AS COVERED
AT THE END OF THE PREVIOUS ROUND, AUTOMATICALLY
CODE OE41 AS ‘1’ (YES) AND GO TO BOX_31.

IF YES AND MORE THAN ONE PERSON FLAGGED AS COVERED
AT THE END OF THE PREVIOUS ROUND, GO TO OE41.

OE40

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

On what date did this health insurance through {ESTABLISHMENT}
end?

{IF INSURANCE ENDED AFTER 12/31/{YEAR}, BACK-UP TO OE39
AND SELECT ‘YES’.}

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7
DK .................................... -8

DISPLAY ‘IF INSURANCE ENDED... SELECT ‘YES’.’ IF
ROUND 5. OTHERWISE, USE A NULL DISPLAY

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE40OV

IF ONLY ONE PERSON COVERED AT THE END OF THE
PREVIOUS ROUND, GO TO LOOP_14

OTHERWISE, CONTINUE WITH OE41

OE40OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1
PART OF THE MONTH ..................... 2
REF ................................... -7
DK .................................... -8

[Code One]

IF ONLY ONE PERSON COVERED AT END OF PREVIOUS
ROUND, GO TO LOOP_14

OTHERWISE, CONTINUE WITH OE41

OE41

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

{Are/Were} (READ NAMES BELOW) all covered by {your/{POLICYHOLDER}’s}
health insurance through {ESTABLISHMENT} {until {{OE40 DATE}/it
ended}/on {END DATE}}?

{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}
{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}
{PERSON WITH ESTAB-PERSON-PAIR INSURANCE ON PREV RD INTV DT}

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

DISPLAY ‘Are’ IF OE39 IS CODED ‘1’ (YES).
DISPLAY ‘Were’ IF OE39 IS CODED ‘2’ (NO) OR IF
CURRENT ROUND IS ROUND 5.

DISPLAY ‘until {OE40 DATE}’ IF OE39 IS CODED ‘2’
(NO).
DISPLAY ‘on {END DATE}’ IF OE39 IS CODED ‘1’
(YES).

DISPLAY THE DATE RECORDED AT OE40 FOR ‘OE40 DATE’.
IF THE MONTH AND DAY FIELD AT OE40 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY ‘it ended’
FOR ‘OE40 DATE’.

IF OE39 IS CODED ‘1’ (YES) AND OE41 IS CODED ‘1’
(YES),

FLAG INSURANCE FOR ALL COVERED PERSONS AS
‘CONTINUOUS COVERAGE’ THROUGH THE REFERENCE PERIOD
END DATE.

IF OE39 IS CODED ‘2’ (NO) AND OE41 IS CODED ‘1’
(YES),

FLAG INSURANCE FOR ALL COVERED PERSONS AS
‘CONTINUOUS COVERAGE’ THROUGH THE DATE RECORDED
AT OE40.

IF OE41 IS CODED ‘1’ (YES) AND OE39 IS CODED ‘1’
(YES) OR ‘2’ (NO), GO TO BOX_31

OTHERWISE (I.E., OE41 CODED ‘2’ (NO), ‘-7’
(REFUSED), OR ‘-8’ (DON’T KNOW)), CONTINUE
WITH OE42

ROSTER DETAILS:
TITLE: RU_ESTB_PLCYHLDR_COVRD_PERS_TRPLS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY COVERED PERSONS’ NAMES
(PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSONS ON THE RU-ESTB-
PLCYHLDR-COVRD-PERS-TRPLS-ROSTER FOR DISPLAY.

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

ROSTER FILTER:
1. PERSON WAS COVERED AT THE PREVIOUS ROUND’S
INTERVIEW DATE BY THE INSURANCE FROM THIS
ESTABLISHMENT-PERSON-PAIR
AND
2. PERSON IS AN RU MBMBER

OE42

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

Who {is/was} no longer covered by {your/{POLICYHOLDER}’s} health
insurance through {ESTABLISHMENT} {until {{OE40 DATE}/it ended}/on
{END DATE}}?

[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 ‘is’ IF OE39 IS CODED ‘1’ (YES).
DISPLAY ‘was’ IF OE39 IS CODED ‘2’ (NO) OR IF
CURRENT ROUND IS ROUND 5.

DISPLAY ‘until {OE40 DATE}’ IF OE39 IS CODED ‘2’
(NO).
DISPLAY ‘on {END DATE}’ IF OE39 IS CODED ‘1’
(YES).

DISPLAY THE DATE RECORDED AT OE40 FOR ‘OE40 DATE’.
IF THE MONTH AND DAY FIELD AT OE40 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY ‘it ended’
FOR ‘OE40 DATE’.

IF FAMILY STILL HAS INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR (OE39 IS CODED ‘1’
(YES)), FLAG INSURANCE FOR ALL PERSONS NOT
SELECTED AT OE42 AS ‘CONTINUOUS COVERAGE’ FROM THE
REFERENCE PERIOD START DATE UNTIL THE REFERENCE
PERIOD END DATE.

IF FAMILY DOES NOT STILL HAVE INSURANCE THROUGH
THIS ESTABLISHMENT-PERSON-PAIR (OE39 IS CODED ‘2’
(NO), FLAG INSURANCE FOR ALL PERSONS NOT SELECTED
AT OE42 AS ‘CONTINUOUS COVERAGE’ FROM THE
REFERENCE PERIOD START DATE UNTIL DATE RECORDED
AT OE40.

ROSTER DETAILS:
TITLE: RU_ESTB_PLCYHLDR_COVRD_PERS_TRPLS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY COVERED PERSONS’ NAMES
(PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER FOR SELECTION.

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

ROSTER FILTER:
1. PERSON WAS COVERED AT PREVIOUS ROUND’S
INTERVIEW DATE BY THE INSURANCE FROM THIS
ESTABLISHMENT-PERSON-PAIR
AND
2. PERSON IS AN RU MBMBER

LOOP_14

FOR EACH ELEMENT IN THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER, ASK NAV_OE14 - END_LP14

LOOP DEFINITION: LOOP_14 COLLECTS THE DATE ON
WHICH THE INSURANCE COVERAGE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR ENDED FOR EACH RU MEMBER
WHOSE COVERAGE ENDED EITHER PRIOR TO THE REFERENCE
PERIOD END DATE OR THE DATE REPORTED IN OE40.
THIS LOOP CYCLES ON PERSONS SELECTED AT OE42.

NAVIGATOR DETAILS: LOOP_14 USES NAV_OE14 TO
CONTROL THE FLOW OF THE LOOP.

NAV_OE14

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

SERIES: End Date of Insurance from {POLICYHOLDER}’s
{ESTABLISHMENT} plan.

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 DEFINITION:
THIS ITEM DISPLAYS RU-ESTB-PLCYHLDR-COVRD-PERS-
TRPLS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

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

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT OE42.

CONTINUE WITH OE43 FOR SELECTED RU MEMBER.

OE43

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

On what date did the health insurance through {ESTABLISHMENT}
end for {you/{PERSON}}?

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7
DK .................................... -8

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE43OV

OTHERWISE, GO TO BOX_30

OE43OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_30}
PART OF THE MONTH ..................... 2 {BOX_30}
REF ................................... -7 {BOX_30}
DK .................................... -8 {BOX_30}

[Code One]

BOX_30

FLAG INSURANCE FOR PERSON AS ‘CONTINUOUS COVERAGE’
THROUGH THE COMPLETE DATE RECORDED AT OE43 AND
OE43OV.

END_LP14

CYCLE ON NEXT PERSON IN THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_14 AND CONTINUE WITH BOX_31

BOX_31

OTHERWISE, GO TO OE47

OE44

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

{Since {START DATE}/Between {START DATE} and {END DATE}}, have
any persons living here, we have not yet mentioned, been covered
by {your/{POLICYHOLDER}’s} health insurance through {ESTABLISHMENT}?

YES ................................... 1 {OE45}
NO .................................... 2 {OE47}
REF ................................... -7 {OE47}
DK .................................... -8 {OE47}

HELP AVAILABLE FOR DEFINITION OF DEPENDENT.

DISPLAY ‘Since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘Between {START DATE} and {END DATE}’ IF
ROUND 5.

OE45

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

Who {has been/was} covered by {your/{POLICYHOLDER}’s} health insurance
through {ESTABLISHMENT} {since {START DATE}/between {START DATE}
and {END DATE}} that we have not yet mentioned?

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]

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

WRITE PERSONS SELECTED TO THE RU-ESTB-PLCYHLDR-
COVRD-PERS-TRPLS-ROSTER.

IF ‘PERSON NOT LISTED IN RU’ IS SELECTED, FLAG
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
AS ‘COVERING PERSON NOT LISTED IN RU’.

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 FILTER:
DISPLAY PERSONS WHO WERE NOT COVERED BY THE
INSURANCE THROUGH THIS ESTABLISHMENT-PERSON-PAIR
ON THE PREVIOUS ROUND’S INTERVIEW DATE.

LOOP_15

FOR EACH ELEMENT IN THE RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER, ASK NAV_OE15 - END_LP15

LOOP DEFINITION: LOOP_15 COLLECTS THE COVERAGE
START DATE FOR ALL PERSONS NEWLY COVERED DURING
THE CURRENT ROUND BY THE INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR. THIS LOOP CYCLES ON
PERSONS SELECTED AT OE45.

NAVIGATOR DETAILS: LOOP_15 USES NAV_OE15 TO
CONTROL THE FLOW OF THE LOOP.

NAV_OE15

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

SERIES: Begin Date of Insurance from {POLICYHOLDER}’s
{ESTABLISHMENT} plan.

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 DEFINITION:
THIS ITEM DISPLAYS RU-ESTB-PLCYHLDR-COVRD-PERS-
TRPLS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

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

ROSTER FILTER:
DISPLAY ALL RU MEMBERS SELECTED AT OE45.

CONTINUE WITH OE46 FOR SELECTED RU MEMBER

OE46

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

On what date did the health insurance through {ESTABLISHMENT}
begin for {you/{PERSON}}?

[Enter Month-2, Day-2, Year-4] .........
REF ................................... -7
DK .................................... -8

IF DAY FIELD IS CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND MONTH FIELD IS NOT CODED ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW), CONTINUE WITH OE46OV

OTHERWISE, GO TO BOX_32

OE46OV

Can you just tell me if {you/he/she} {were/was} covered under that
insurance the whole month or part of the month?

WHOLE MONTH ........................... 1 {BOX_32}
PART OF THE MONTH ..................... 2 {BOX_32}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}

[Code One]

HARD CHECK:
EDIT: COMPLETE DATE AT OE46 MUST BE < THAN
COMPLETE DATE AT OE40 IF A DATE IS RECORDED AT
OE40 OR < THAN REFERENCE PERIOD END DATE IF NO
DATE IS RECORDED AT OE40.

BOX_32

IF FAMILY STILL HAS INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR (OE39 IS CODED ‘1’
(YES)), FLAG INSURANCE FOR THIS PERSON AS
‘CONTINUOUS COVERAGE’ FROM DATE RECORDED AT OE46
UNTIL THE REFERENCE PERIOD END DATE.

IF FAMILY DOES NOT STILL HAVE INSURANCE THROUGH
ESTABLISHMENT-PERSON-PAIR (OE39 IS CODED ‘2’ (NO))
FLAG INSURANCE FOR THIS PERSON AS ‘CONTINUOUS
COVERAGE’ FROM DATE RECORDED AT OE46 UNTIL DATE
RECORDED AT OE40.

END_LP15

CYCLE ON NEXT PERSON IN RU-ESTB-PLCYHLDR-COVRD-
PERS-TRPLS-ROSTER WHO MEETS THE CONDITIONS STATED
IN THE LOOP DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_15 AND GO TO END_LP13

OE47

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

{Does/Between {START DATE} and {END DATE}, did} {your/{POLICYHOLDER}’s}
health coverage through {ESTABLISHMENT} cover as dependents any
persons who do not live here?

YES .................................... 1 {END_LP13}
NO ..................................... 2 {END_LP13}
REF ................................... -7 {END_LP13}
DK .................................... -8 {END_LP13}

HELP AVAILABLE FOR DEFINITION OF DEPENDENT.

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

IF CODED ‘1’ (YES), FLAG INSURANCE THROUGH THIS
ESTABLISHMENT-PERSON-PAIR AS ‘COVERING PERSON NOT
LISTED IN RU’ IN OE45

END_LP13

CYCLE ON NEXT PAIR IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.

IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END
LOOP_13 AND CONTINUE WITH BOX_33

BOX_33

RETURN TO ORIGINAL QUESTIONNAIRE SECTION IN HX.

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