Old Public Related Insurance (PR) Section

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

BOX_00

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

BOX_01

IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS MEET
BOTH OF THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS MEDICARE
AND
- PERSON WAS COVERED BY MEDICARE DURING THE
PREVIOUS ROUND,
CONTINUE WITH LOOP_01

OTHERWISE, GO TO BOX_02

LOOP_01

FOR EACH ELEMENT ON THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_PR01 - END_LP01

LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION
ABOUT THE COVERAGE PROVIDED THROUGH MEDICARE.
THIS LOOP CYCLES ON ESTABLISHMENT-PERSON-PAIRS
THAT MEET BOTH OF THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS MEDICARE
AND
- PERSON WAS COVERED BY MEDICARE AT ANY TIME
DURING THE PREVIOUS ROUND

NAVIGATOR DETAILS: LOOP_01 USES NAV_PR01 TO
TO CONTROL THE FLOW OF THE LOOP.

NAV_PR01

{STR-DT}

SERIES: Review of Medicare Managed Care Plan Coverage from a
Previous Round

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 BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS MEDICARE
AND
- PERSON WAS COVERED BY MEDICARE AT ANY TIME
DURING THE PREVIOUS ROUND

CONTINUE WITH BOX_01B FOR SELECTED RU MEMBER.

BOX_01A

OMITTED.

PR01

OMITTED.

PR01A

OMITTED.
MOVED AND RENUMBERED TO PRO6B

BOX_01B

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

IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED
DOES NOT OFFER A MEDICARE MANAGED CARE PLAN, CODE
PR02 AND PR03 ‘2’ (NO) AUTOMATICALLY BY CAPI AND
GO TO PR06B

IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED
DOES OFFER A MEDICARE MANAGED CARE PLAN, CONTINUE
WITH PR02

PR02

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

SHOW CARD HX-5.

During the last interview, it was recorded that {you/{PERSON}}
{were/was} enrolled in Medicare. We would like to update information
about {your/his/her} Medicare coverage.

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

YES .................................... 1 {PR02OV}
NO ..................................... 2 {PR03}
REF ................................... -7 {PR03}
DK .................................... -8 {PR03}

HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED CARE.

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

PR02OV

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

CODE LETTER OF PLAN FROM SHOW CARD.

[Enter Plan Letter From Card] ......... {PR05}

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

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

WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY
THE FOLLOWING MESSAGE: "PLEASE VERIFY PLAN
SELECTED: {DISPLAY PLAN NAME SELECTED}." WHEN
INTERVIEWER PRESSES ENTER TO CLEAR THE MESSAGE,
PROCEED TO THE NEXT LOGICAL SCREEN.

IN THE MESSAGE FOR ‘DISPLAY PLAN NAME SELECTED’
DISPLAY THE ACTUAL PLAN NAME THAT CORRESPONDS TO
THE LETTER ENTERED FOR THAT STATE.

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

PR03

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

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

YES .................................... 1 {PR04}
NO ..................................... 2 {PR06B}
REF ................................... -7 {PR06B}
DK .................................... -8 {PR06B}

HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED CARE.

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

PR03A

OMITTED.

PR04

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

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

[Enter Plan Name] ..................... {PR05}
REF ................................... -7 {PR05}
DK .................................... -8 {PR05}

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

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

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

PR05

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

{{Do/Does}/Did} {you/{PERSON}} have prescribed medicine coverage through
{{{PLAN NAME ENTERED AT PR02OV-50}/{NAME OF PLAN FROM PR04}}/
{your/his/her} Medicare managed care plan} {as of {END DATE}}?

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

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

DISPLAY ‘{{PLAN NAME ENTERED AT PR02OV-50}/{NAME
OF PLAN FROM PR04}}’ IF A PLAN NAME WAS CODED AT
PR02OV OR PR04. DISPLAY {your/his/her} Medicare
managed care plan’ IF PR04 IS CODED ‘-7’ (REF)
OR ‘-8’ (DK).

DISPLAY ‘{PLAN NAME ENTERED AT PR02OV-50}’ IF A
PLAN LETTER WAS ENTERED AT PR04OV. DISPLAY THE
ACTUAL PLAN NAME THAT CORRESPONDS TO THE LETTER
ENTERED AT PR02OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR04 FOR
‘NAME OF PLAN FROM PR04’ IF A PLAN NAME WAS
ENTERED.

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

IF ROUND 3, CONTINUE WITH PR06

OTHERWISE, GO TO END_LP01

PR06

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

Most Medicare beneficiaries pay their Part B premiums through their
Social Security checks. In addition, {do/does} {you/{PERSON}} (or
anyone in the family) pay anything else for {the coverage with
{{PLAN NAME ENTERED AT PR02OV}/{NAME OF PLAN FROM PR04}}/this
Medicare managed care plan}?

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

YES .................................... 1 {PR06A}
NO ..................................... 2 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

[Code One]

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

DISPLAY ‘the coverage with {{PLAN NAME ENTERED AT
PR02OV}/{NAME OF PLAN FROM PR04}}’ IF A MEDICARE
PLAN NAME WAS SELECTED AT PR02OV OR ENTERED AT
PR04. DISPLAY ‘this Medicare managed care plan’
IF PR04 WAS CODED ‘-7’ (REF) OR ‘-8’ (DK).

DISPLAY ‘{PLAN NAME ENTERED AT PR02OV}’ IF A PLAN
LETTER WAS ENTERED AT PR02OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT PR02OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR04 FOR
‘NAME OF PLAN FROM PR04’ IF A PLAN NAME WAS
ENTERED.

PR06A

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

How {do/does} {you/{PERSON}} pay for {your/his/her} {{PLAN NAME ENTERED
AT PR02OV}/{NAME OF PLAN FROM PR04}}/Medicare managed care} premium?

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

DEDUCTED FROM SOCIAL SECURITY .......... 1 {PR06AA}
PAY DIRECTLY ........................... 2 {PR06AA}
BOTH ................................... 3 {PR06AA}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

DISPLAY ‘{{PLAN NAME ENTERED AT PR02OV}/{NAME OF
PLAN FROM PR04}} IF A MEDICARE PLAN NAME WAS
SELECTED AT PR02OV OR ENTERED AT PR04. DISPLAY
‘Medicare managed care’ IF PR04 WAS CODED ‘-7’
(REF) OR ‘-8’ (DK).

DISPLAY ‘{PLAN NAME ENTERED AT PR02OV}’ IF A PLAN
LETTER WAS ENTERED AT PR02OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT PR02OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR04 FOR
‘NAME OF PLAN FROM PR04’ IF A PLAN NAME WAS
ENTERED.

PR06AA

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

How much {is {your/{PERSON}’s} Social Security deduction/{do/does}
{you/{PERSON}} pay in premiums} for {your/his/her} {{PLAN NAME ENTERED
AT PR02OV}/{NAME OF PLAN FROM PR04}} plan?

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

[Enter Amount in Dollars] .............. {PR06AAOV1}
REF ................................... -7 {PR06AAA}
DK .................................... -8 {PR06AAA}

DISPLAY ‘is {your/{PERSON}’s} Social Security
deduction’ IF PR06AA IS CODED ‘1’ (DEDUCTED FROM
SOCIAL SECURITY’. DISPLAY ‘{do/does} {you/
{PERSON}} pay in premiums’ IF PR06AA IS CODED ‘2’
(PAY DIRECTLY) OR ‘3’ (BOTH).

DISPLAY ‘{{PLAN NAME ENTERED AT PR02OV}/{NAME OF
PLAN FROM PR04}}’ IF A MEDICARE PLAN NAME WAS
SELECTED AT PR02OV OR ENTERED AT PR04. OTHERWISE
(I.E., IF PR04 WAS CODED ‘-7’ (REF) OR ‘-8’ (DK)),
USE A NULL DISPLAY.

DISPLAY ‘{PLAN NAME ENTERED AT PR02OV}’ IF A PLAN
LETTER WAS ENTERED AT PR02OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT PR02OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR04 FOR
‘NAME OF PLAN FROM PR04’ IF A PLAN NAME WAS
ENTERED.

PR06AAOV1

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

UNIT OF COVERAGE:

PER YEAR ............................... 1 {END_LP01}
QUARTERLY/EVERY 3 MONTHS ............... 2 {END_LP01}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {END_LP01}
PER MONTH .............................. 4 {END_LP01}
PER WEEK ............................... 5 {END_LP01}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {END_LP01}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {END_LP01}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {END_LP01}
OTHER ................................. 91 {PR06AAOV2}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

[Code One]

PR06AAOV2

SPECIFY:

[Enter Other Specify] .................. {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

PR06AAA

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

{PLAN NAME: {{PLAN NAME ENTERED AT PR02OV}/{NAME OF PLAN FROM PR04}}}

SHOW CARD HX-6.

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

1 - 50 ................................. 1 {END_LP01}
51 - 100 ............................... 2 {END_LP01}
101 - 200 .............................. 3 {END_LP01}
201 - 300 .............................. 4 {END_LP01}
301 OR MORE ............................ 5 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

DISPLAY ‘PLAN NAME: {{PLAN NAME ENTERED AT
PR02OV}/{NAME OF PLAN FROM PR04}}’ IF A MEDICARE
PLAN NAME WAS SELECTED AT PR02OV OR ENTERED AT
PR04. OTHERWISE (I.E., IF PR04 WAS CODED ‘-7’
(REF) OR ‘-8’ (DK)), USE A NULL DISPLAY.

DISPLAY ‘{PLAN NAME ENTERED AT PR02OV}’ IF A PLAN
LETTER WAS ENTERED AT PR02OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT PR02OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR04 FOR
‘NAME OF PLAN FROM PR04’ IF A PLAN NAME WAS
ENTERED.

PR06B

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

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

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

HELP AVAILABLE FOR DEFINITION OF MEDICARE PART D.

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

IF CODED ‘1’ (YES) AND ROUND 3, CONTINUE WITH
PR06C

OTHERWISE, GO TO END_LP01

PR06C

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

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

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

YES .................................... 1 {PR06D}
NO ..................................... 2 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

[Code One]

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

PR06D

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

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

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

DEDUCTED FROM SOCIAL SECURITY .......... 1 {PR06E}
PAY DIRECTLY ........................... 2 {PR06E}
BOTH ................................... 3 {PR06E}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

PR06E

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

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

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

[Enter Amount in Dollars] .............. {PR06EOV1}
REF ................................... -7 {PR06F}
DK .................................... -8 {PR06F}

DISPLAY ‘is {your/{PERSON}’s} Social Security
deduction’ IF PR06D IS CODED ‘1’ (DEDUCTED FROM
SOCIAL SECURITY’. DISPLAY ‘{do/does} {you/
{PERSON}} pay in premiums’ IF PR06D IS CODED ‘2’
(PAY DIRECTLY) OR ‘3’ (BOTH).

PR06EOV1

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

UNIT OF COVERAGE:

PER YEAR ............................... 1 {END_LP01}
QUARTERLY/EVERY 3 MONTHS ............... 2 {END_LP01}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {END_LP01}
PER MONTH .............................. 4 {END_LP01}
PER WEEK ............................... 5 {END_LP01}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {END_LP01}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {END_LP01}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {END_LP01}
OTHER ................................. 91 {PR06EOV2}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

[Code One]

PR06EOV2

SPECIFY:

[Enter Other Specify] .................. {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

PR06F

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

SHOW CARD HX-7.

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

1 - 30 ................................. 1 {END_LP01}
31 - 60 ................................ 2 {END_LP01}
61 - 90 ................................ 3 {END_LP01}
91 - 120 ............................... 4 {END_LP01}
121 OR MORE ............................ 5 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

END_LP01

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

IF NO MORE PAIRS MEET THE STATED CONDITIONS,
END LOOP_01 AND CONTINUE WITH BOX_02

BOX_02

IF ANY RU MEMBER HAD MEDICAID/SCHIP AS A SOURCE
OF INSURANCE AT ANY TIME DURING THE PREVIOUS
ROUND, CONTINUE WITH PR07

OTHERWISE, GO TO BOX_05

PR07

{STR-DT}
{END-DT}

During the last interview, we recorded that (READ NAME(S)
BELOW) (was/were) covered by {Medicaid/{STATE NAME FOR
MEDICAID}} or {STATE CHIP NAME}.

Have all of these people been covered by {Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME} at any time {since {START
DATE}/between {START DATE} and {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]

YES, ALL .............................. 1 {BOX_03}
NO, ONLY SOME ......................... 2 {PR08}
NO, NONE .............................. 3
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}

DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘Medicaid’ DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE STATE
NAME FOR THE PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM
NAME BY STATE TO DISPLAY, SEE ATTACHMENT 37.

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

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

IF CODED ‘1’ (YES, ALL), FLAG ALL RU MEMBERS
LISTED HERE AS ‘COVERED BY MEDICAID/SCHIP DURING
CURRENT ROUND.’

IF CODED ‘3’ (NO, NONE), FLAG ALL RU MEMBERS
LISTED HERE AS ‘NOT COVERED BY MEDICAID/SCHIP
DURING CURRENT ROUND.’

IF CODED ‘3’ (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR07,
GO TO PR09

IF CODED ‘3’ (NO, NONE)
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR07,
GO TO BOX_05

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
1. DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED
BY MEDICAID/SCHIP AT ANY TIME DURING THE
PREVIOUS ROUND.

PR08

{STR-DT}
{END-DT}

Who has been covered by {Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME} {since {START DATE}/between {START DATE} and
{END DATE}}?

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 ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘Medicaid’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE STATE
NAME FOR THE PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM
NAME BY STATE TO DISPLAY, SEE ATTACHMENT 37.

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

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY MEDICAID/
SCHIP DURING CURRENT ROUND.’ FLAG ALL PERSONS NOT
SELECTED AS ‘NOT COVERED BY MEDICAID/SCHIP DURING
CURRENT ROUND.’

GO TO BOX_03

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
1. DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED
BY MEDICAID/SCHIP AT ANY TIME DURING THE
PREVIOUS ROUND.

BOX_03

IF ALL CURRENT RU MEMBERS ARE ALREADY FLAGGED AS
COVERED OR NOT COVERED BY MEDICAID/SCHIP DURING
CURRENT ROUND (I.E., ALL CURRENT RU MEMBERS WERE
LISTED AT PR07), GO TO LOOP_02

OTHERWISE, CONTINUE WITH PR09

PR09

{STR-DT}
{END-DT}

Besides the family members we’ve just talked about, have any
additional family members been covered by {Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME} {since {START DATE}/between
{START DATE} and {END DATE}}?

YES ................................... 1 {PR10}
NO .................................... 2
REF ................................... -7
DK .................................... -8

HELP AVAILABLE FOR DEFINITION OF MEDICAID/SCHIP.

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

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

IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘8’ (DON’T
KNOW) AND AT LEAST ONE RU MEMBER IS FLAGGED AS
‘COVERED BY MEDICAID/SCHIP DURING CURRENT ROUND,’
GO TO LOOP_02

IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW) AND NO RU MEMBERS ARE FLAGGED AS ‘COVERED
BY MEDICAID/SCHIP DURING CURRENT ROUND,’ GO TO
BOX_05

PR10

{STR-DT}
{END-DT}

Who has been covered by {Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME} {since {START DATE}/between {START DATE} and
{END DATE}}?

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

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY MEDICAID/
SCHIP’ DURING CURRENT ROUND. FLAG ALL PERSONS
NOT SELECTED AS ‘NOT COVERED BY MEDICAID/SCHIP’
DURING CURRENT ROUND.

GO TO LOOP_02

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.
1. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
1. RU MEMBERS NOT FLAGGED AS COVERED BY MEDICAID/
SCHIP AT ANY TIME DURING THE PREVIOUS ROUND.

LOOP_02

FOR EACH ELEMENT ON THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_PR02 - END_LP02

LOOP DEFINITION: LOOP_02 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY MEDICAID/
SCHIP. THIS LOOP CYCLES ON ESTABLISHMENT-PERSON-
PAIRS THAT MEET BOTH OF THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS MEDICAID/SCHIP
AND
- PERSON IS COVERED BY MEDICAID/SCHIP DURING THE
CURRENT ROUND

NAVIGATOR DETAILS: LOOP_02 USES NAV_PR02 TO
TO CONTROL THE FLOW OF THE LOOP.

NAV_PR02

MEDICAID/SCHIP {STR-DT}

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

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

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

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

RU Member

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

ROSTER DEFINITION:
THIS ITEM DISPLAYS 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 BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS MEDICAID
AND
- PERSON IS COVERED BY MEDICAID/SCHIP DURING
THE CURRENT ROUND

CONTINUE WITH BOX_04 FOR SELECTED RU MEMBER

BOX_04

ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PAIR.

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP02

END_LP02

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

IF NO MORE PAIRS MEET THE STATED CONDITIONS, END
LOOP_02 AND CONTINUE WITH PR11

PR11

{STR-DT}
{END-DT}

{Last time we recorded that (READ NAME(S) BELOW) may be
covered by {NAME OF PREV RD’S MEDICAID/SCHIP INSURER FOR RU}.}

{Since {START DATE}/Between {START DATE} and {END DATE}}, has
there been any change in the plan name of the health insurance
the family has through {Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}?

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

YES .................................... 1
NO ..................................... 2 {BOX_04A}
REF ................................... -7 {BOX_04A}
DK .................................... -8 {BOX_04A}

HELP AVAILABLE FOR A DEFINITION OF MEDICAID/SCHIP.

DISPLAY ‘Last time... {NAME OF PREV RD’S
MEDICAID/SCHIP INSURER FOR RU}.’ IF THERE IS AN
INSURER ASSOCIATED WITH MEDICAID/SCHIP IN THE
PREVIOUS ROUND.

FOR ‘NAME OF PREV RD’S MEDICAID/SCHIP INSURER FOR
RU’, DISPLAY THE INSURER RECORDED FOR MEDICAID/
SCHIP DURING THE PREVIOUS ROUND.

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

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

IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW), FLAG PREVIOUS ROUND’S INSURER AS ‘CURRENT
RD’S MEDICAID/SCHIP INSURER’

NOTE: STATES THAT DO NOT OFFER MEDICAID MANAGED
CARE PLANS ARE ALASKA, MISSISSIPPI, AND WYOMING

IF CODED ‘1’ (YES) AND IF STATE IN WHICH THE
INTERVIEW IS BEING CONDUCTED DOES NOT OFFER A
MEDICAID/SCHIP MANAGED CARE PLAN, CODE PR12 ‘2’
(NO) AUTOMATICALLY BY CAPI AND GO TO PR13

IF CODED ‘1’ (YES) AND IF STATE IN WHICH THE
INTERVIEW IS BEING CONDUCTED DOES OFFER A
A MEDICAID/SCHIP MANAGED CARE PLAN, CONTINUE WITH
PR12

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
1. DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED
BY MEDICAID/SCHIP DURING THE CURRENT ROUND.

PR12

{STR-DT}
{END-DT}

SHOW CARD HX-8.

Is the name of the health insurance through {Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME} {, between {START DATE}
and {END DATE},} listed on this card?

YES .................................... 1 {PR12OV}
NO ..................................... 2 {PR13}
REF ................................... -7 {PR13}
DK .................................... -8 {PR13}

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

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

PR12OV

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

CODE LETTER OF PLAN FROM SHOW CARD.

[Enter Plan Letter From Card] ......... {BOX_04A}

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

WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY
THE FOLLOWING MESSAGE: "PLEASE VERIFY PLAN
SELECTED: {DISPLAY PLAN NAME SELECTED}." WHEN
INTERVIEWER CLEARS THE MESSAGE, PROCEED TO THE
NEXT LOGICAL SCREEN.

FOR ‘DISPLAY PLAN NAME SELECTED’ IN THIS MESSAGE,
DISPLAY THE PLAN NAME THAT CORRESPONDS TO THE
LETTER ENTERED FOR THIS STATE.

FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S
INSURER FOR MEDICAID/SCHIP.’

PR13

{STR-DT}
{END-DT}

Under {Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP NAME}
{(are/is)/(were/was)} (READ NAME(S) BELOW) enrolled in an HMO,
that is a Health Maintenance Organization {between {START DATE}
and {END DATE}}?

[With an HMO, you must generally receive care from HMO
physicians. If another doctor is seen, the expense is not
covered unless you were referred by the HMO, or there was a
medical emergency.]

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

YES, ALL ARE ........................... 1 {PR15}
YES, SOME ARE .......................... 2 {PR15}
NO, NONE ARE ........................... 3 {PR14}
REF ................................... -7 {PR14}
DK .................................... -8 {PR14}

[Code One]

HELP AVAILABLE FOR DEFINITION OF HMO.

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

DISPLAY ‘(are/is)’ IF NOT ROUND 5. DISPLAY
‘(were/was)’ IF ROUND 5.

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

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
1. DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED
BY MEDICAID/SCHIP DURING THE CURRENT ROUND.

PR14

{STR-DT}
{END-DT}

{Does/Between {START DATE} and {END DATE, did} {Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME} require (READ NAME(S) BELOW)
to sign up with a certain primary care doctor, group of doctors, or
with a certain clinic which they must go to for all of their routine
care?

PROBE: Do not include emergency care or care from a specialist
they were referred to.

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

YES, ALL REQUIRED ...................... 1 {PR15}
YES, SOME REQUIRED ..................... 2 {PR15}
NO, NONE REQUIRED ...................... 3 {BOX_04A}
REF ................................... -7 {BOX_04A}
DK .................................... -8 {BOX_04A}

[Code One]

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

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

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

IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED),
OR ‘-8’ (DON’T KNOW), THERE IS NO INSURER
ASSOCIATED WITH THE CURRENT ROUND FOR MEDICAID/
SCHIP.

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
1. DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED
BY MEDICAID/SCHIP DURING THE CURRENT ROUND.

PR15

{STR-DT}
{END-DT}

What is the name of the {Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME} {HMO/health insurance}?

[Enter Plan Name] ..................... {BOX_04A}
REF ................................... -7 {BOX_04A}
DK .................................... -8 {BOX_04A}

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

DISPLAY ‘HMO’ IF PR13 IS CODED ‘1’ (YES, ALL ARE)
OR ‘2’ (YES, SOME ARE). DISPLAY ‘health
insurance’ IF PR14 IS CODED ‘1’ (YES, ALL
REQUIRED) OR ‘2’ (YES, SOME REQUIRED).

FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S
MEDICAID/SCHIP INSURER’.

BOX_04A

IF ROUND 3, CONTINUE WITH PR16

OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO
BOX_05

PR16

{STR-DT}
{END-DT}

Does anyone in the family pay anything for the coverage through {{{PLAN
NAME ENTERED AT PR12OV}/{NAME OF PLAN FROM PR15}}/{Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME}}?

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

YES .................................... 1 {PR17}
NO ..................................... 2 {PR18}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}

[Code One]

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

DISPLAY ‘{{PLAN NAME ENTERED AT PR12OV}/{NAME OF
PLAN FROM PR15}}’ IF THERE IS A CURRENT ROUND
INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
INSURANCE. OTHERWISE, DISPLAY ‘{Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME}’

DISPLAY ‘(PLAN NAME ENTERED AT PR12OV)’ IF A PLAN
WAS ENTERED AT PR12OV. DISPLAY THE ACTUAL PLAN
NAME THAT CORRESPONDS TO THE LETTER ENTERED AT
PR12OV FOR THIS STATE.

DISPLAY ‘(NAME OF PLAN FROM PR15)’ IF A PLAN NAME
WAS ENTERED AT PR15. DISPLAY THE ACTUAL PLAN NAME
THAT WAS ENTERED.

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

PR17

{STR-DT}
{END-DT}

How much does anyone in the family pay for {the {{PLAN NAME
ENTERED AT PR12OV}/{NAME OF PLAN FROM PR15}}/that} coverage?

[Enter Amount in Dollars] .............. {PR17OV1}
REF ................................... -7 {PR18}
DK .................................... -8 {PR18}

DISPLAY ‘the {{PLAN NAME ENTERED AT PR12OV}/{NAME
OF PLAN FROM PR15}}’ IF THERE IS A CURRENT ROUND
INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
INSURANCE. OTHERWISE, DISPLAY ‘that’.

DISPLAY ‘(PLAN NAME ENTERED AT PR12OV)’ IF A PLAN
WAS ENTERED AT PR12OV. DISPLAY THE ACTUAL PLAN
NAME THAT CORRESPONDS TO THE LETTER ENTERED AT
PR12OV FOR THIS STATE.

DISPLAY ‘(NAME OF PLAN FROM PR15)’ IF A PLAN NAME
WAS ENTERED AT PR15. DISPLAY THE ACTUAL PLAN NAME
THAT WAS ENTERED.

PR17OV1

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

ENTER UNIT OF COVERAGE:

PER YEAR ............................... 1 {PR18}
QUARTERLY/EVERY 3 MONTHS ............... 2 {PR18}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {PR18}
PER MONTH .............................. 4 {PR18}
PER WEEK ............................... 5 {PR18}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {PR18}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {PR18}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {PR18}
OTHER ................................. 91 {PR17OV2}
REF ................................... -7 {PR18}
DK .................................... -8 {PR18}

[Code One]

PR17OV2

SPECIFY:

[Enter Other Specify] .................. {PR18}
REF ................................... -7 {PR18}
DK .................................... -8 {PR18}

PR18

{STR-DT}
{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT PR12OV}/{NAME OF PLAN
FROM PR15}}}

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
OTHER ................................. 91 {PR18OV}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}

[Code All That Apply)

DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
INSURANCE. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘(PLAN NAME ENTERED AT PR12OV)’ IF A PLAN
WAS ENTERED AT PR12OV. DISPLAY THE ACTUAL PLAN
NAME THAT CORRESPONDS TO THE LETTER ENTERED AT
PR12OV FOR THIS STATE.

DISPLAY ‘(NAME OF PLAN FROM PR15)’ IF A PLAN NAME
WAS ENTERED AT PR15. DISPLAY THE ACTUAL PLAN NAME
THAT WAS ENTERED.

DISPLAY ‘else’ IF PR16 IS CODED ‘1’ (YES).
OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘some of’ IF PR16 IS CODED ‘1’ (YES).
DISPLAY ‘for’ IF PR16 IS CODED ‘2’ (NO).

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

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH PR18OV

OTHERWISE, GO TO BOX_05

PR18OV

SPECIFY:

[Enter Other Specify] .................. {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}

BOX_05

IF ANY RU MEMBER HAD TRICARE/CHAMPVA AS A SOURCE
OF INSURANCE DURING PREVIOUS ROUND, CONTINUE WITH
PR19

OTHERWISE, GO TO BOX_08

PR19

{STR-DT}
{END-DT}

During the last interview, we recorded that (READ NAME(S)
BELOW) (was/were) covered by TRICARE or CHAMPVA.

Have all of these people been covered by TRICARE or CHAMPVA at
any time {since {START DATE}/between {START DATE} and {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]

YES, ALL .............................. 1 {PR19A}
NO, ONLY SOME ......................... 2 {PR19A}
NO, NONE .............................. 3
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}

HELP AVAILABLE FOR DEFINITION OF TRICARE/CHAMPVA.

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

IF CODED ‘3’ (NO, NONE), FLAG ALL RU MEMBERS
LISTED HERE AS ‘NOT COVERED BY TRICARE/CHAMPVA
DURING CURRENT ROUND.’

IF CODED ‘3’ (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED IN PR19,
GO TO PR21

IF CODED ‘3’ (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED IN PR19,
GO TO BOX_08

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY
TRICARE/CHAMPVA AT ANY TIME DURING THE PREVIOUS
ROUND.

PR19A

{STR-DT}
{END-DT}

Which plan is it? Is it...

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

CHECK ALL THAT APPLY.

TRICARE Standard; ...................... 1
TRICARE Prime; ......................... 2
TRICARE Extra; ......................... 3
TRICARE for Life; or ................... 4
CHAMPVA? ............................... 5
REF ................................... -7
DK .................................... -8

[Code All That Apply]

IF PR19 IS CODED ‘1’ (YES, ALL), FLAG ALL RU
MEMBERS LISTED HERE AS ‘COVERED BY TRICARE/CHAMPVA
DURING CURRENT ROUND.’ THEN GO TO BOX_06

IF PR19 IS CODED ‘2’ (NO, ONLY SOME), CONTINUE
WITH PR20

PR20

{STR-DT}
{END-DT}

Who has been covered by TRICARE or CHAMPVA {since {START DATE}/
between {START DATE} and {END DATE}}?

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY TRICARE/
CHAMPVA’ DURING CURRENT ROUND. FLAG ALL PERSONS
NOT SELECTED AS ‘NOT COVERED BY TRICARE/CHAMPVA ‘
DURING CURRENT ROUND.

GO TO BOX_06

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY
TRICARE/CHAMPVA AT ANY TIME DURING THE PREVIOUS
ROUND.

BOX_06

IF ALL CURRENT RU MEMBERS ALREADY FLAGGED AS
COVERED OR NOT COVERED BY TRICARE/CHAMPVA DURING
CURRENT ROUND (I.E., ALL CURRENT RU MEMBERS WERE
LISTED IN PR19), GO TO LOOP_03

OTHERWISE, CONTINUE WITH PR21

PR21

{STR-DT}
{END-DT}

Besides the family members we’ve just talked about, have any
additional family members been covered by TRICARE or CHAMPVA
{since {START DATE}/between {START DATE} and {END DATE}}?

YES ................................... 1 {PR21A}
NO .................................... 2
REF ................................... -7
DK .................................... -8

HELP AVAILABLE FOR DEFINITION OF TRICARE/CHAMPVA.

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

IF CODED ‘2’ (NO), ‘-7’ (REFUSED) OR ‘8’ (DON’T
KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS
COVERED BY TRICARE/CHAMPVA DURING CURRENT ROUND,
GO TO LOOP_03

IF CODED ‘2’ (NO), ‘-7’ (REFUSED) OR ‘8’ (DON’T
KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY
TRICARE/CHAMPVA DURING CURRENT ROUND, GO TO BOX_08

PR21A

{STR-DT}
{END-DT}

Which plan is it? Is it...

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

CHECK ALL THAT APPLY.

TRICARE Standard; ...................... 1 {PR22}
TRICARE Prime; ......................... 2 {PR22}
TRICARE Extra; ......................... 3 {PR22}
TRICARE for Life; or ................... 4 {PR22}
CHAMPVA? ............................... 5 {PR22}
REF ................................... -7 {PR22}
DK .................................... -8 {PR22}

[Code All That Apply]

PR22

{STR-DT}
{END-DT}

Who has been covered by TRICARE or CHAMPVA {since {START DATE}/
between {START DATE} and {END DATE}}?

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY TRICARE/
CHAMPVA’ DURING CURRENT ROUND. FLAG ALL PERSONS
NOT SELECTED AS ‘NOT COVERED BY TRICARE/CHAMPVA’
DURING CURRENT ROUND.

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.
1. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE NOT FLAGGED
AS COVERED BY TRICARE/CHAMPVA AT ANY TIME DURING
THE PREVIOUS ROUND.

LOOP_03

FOR EACH ELEMENT ON THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_PR03 - END_LP03

LOOP DEFINITION: LOOP_03 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY TRICARE/
CHAMPVA. THIS LOOP CYCLES ON ESTABLISHMENT-PERSON-
PAIRS THAT MEET BOTH OF THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS TRICARE/CHAMPVA
AND
- PERSON IS COVERED BY TRICARE/CHAMPVA DURING THE
CURRENT ROUND

NAVIGATOR DETAILS: LOOP_03 USES NAV_PR03 TO
TO CONTROL THE FLOW OF THE LOOP.

NAV_PR03

TRICARE OR CHAMPVA {STR-DT}

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

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

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

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

RU Member

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

ROSTER DEFINITION:
THIS ITEM DISPLAYS 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 BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS TRICARE/CHAMPVA
AND
- PERSON IS COVERED BY TRICARE/CHAMPVA DURING
THE CURRENT ROUND

CONTINUE WITH BOX_07 FOR SELECTED RU MEMBER.

BOX_07

ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PAIR.

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP03

END_LP03

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

IF NO MORE PAIRS MEET THE STATED CONDITIONS,
END LOOP_03 AND CONTINUE WITH BOX_07A

BOX_07A

IF ROUND 1 OR ROUND 3, CONTINUE WITH PR22A

OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO
BOX_08

PR22A

{STR-DT}
{END-DT}

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

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

YES .................................... 1 {PR22B}
NO ..................................... 2 {BOX_08}
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}

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

PR22B

{STR-DT}
{END-DT}

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

[Enter Amount in Dollars] .............. {PR22BOV1}
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}

PR22BOV1

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

UNIT OF COVERAGE:

PER YEAR ............................... 1 {BOX_08}
QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_08}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_08}
PER MONTH .............................. 4 {BOX_08}
PER WEEK ............................... 5 {BOX_08}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_08}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_08}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_08}
OTHER ................................. 91 {PR22BOV2}
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}

[Code One]

PR22BOV2

SPECIFY:

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

BOX_08

IF ANY RU MEMBER HAD GOVT-HOSPITAL/PHYSICIAN AS A
SOURCE OF INSURANCE AT ANY TIME DURING PREVIOUS
ROUND, CONTINUE WITH PR23

OTHERWISE, GO TO BOX_11

PR23

{STR-DT}
{END-DT}

During the last interview, we recorded that (READ NAME(S)
BELOW) (was/were) covered by a program sponsored by a
state or local government agency which provided hospital and
physician benefits.

Have all of these people been covered by a program sponsored by a
state or local government agency at any time {since {START DATE}/
between {START DATE} and {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]

YES, ALL .............................. 1 {BOX_09}
NO, ONLY SOME ......................... 2 {PR24}
NO, NONE .............................. 3
REF ................................... -7 {BOX_11}
DK .................................... -8 {BOX_11}

HELP AVAILABLE FOR DEFINITION OF THIS TYPE OF PROGRAM.

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

IF CODED ‘3’ (NO, NONE), FLAG ALL RU MEMBERS
LISTED HERE AS ‘NOT COVERED BY GOVT-HOSPITAL/
PHYSICIAN’ DURING CURRENT ROUND.

IF CODED ‘1’ (YES, ALL), FLAG ALL RU MEMBERS
LISTED HERE AS ‘COVERED BY GOVT-HOSPITAL/
PHYSICIAN’ DURING CURRENT ROUND.

IF CODED ‘3’ (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR23,
GO TO PR25

IF CODED ‘3’ (NO, NONE)
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR23,
GO TO BOX_11

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE FLAGGED AS
COVERED BY GOVT-HOSPITAL/PHYSICIAN AT ANY TIME
DURING THE PREVIOUS ROUND.

PR24

{STR-DT}
{END-DT}

Who has been covered by this program {since {START DATE}/between
{START DATE} and {END DATE}}?

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY
GOVT-HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY
GOVT-HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND.

GO TO BOX_09

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY
GOVT-HOSPITAL/PHYSICIAN AT ANY TIME DURING THE
PREVIOUS ROUND.

BOX_09

IF ALL CURRENT RU MEMBERS ALREADY FLAGGED AS
COVERED OR NOT COVERED BY THE GOVT-HOSPITAL/
PHYSICIAN DURING CURRENT ROUND (I.E., ALL CURRENT
RU MEMBERS WERE LISTED IN PR23), GO TO LOOP_04

OTHERWISE, CONTINUE WITH PR25

PR25

{STR-DT}
{END-DT}

Besides the family members we’ve just talked about, have any
additional family members been covered by this program {since
{START DATE}/between {START DATE} and {END DATE}}?

YES ................................... 1 {PR26}
NO .................................... 2
REF ................................... -7
DK .................................... -8

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

IF CODED ‘2’ (NO), ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS
‘COVERED BY GOVT-HOSPITAL/PHYSICIAN’ DURING
CURRENT ROUND, GO TO LOOP_04

IF CODED ‘2’ (NO), ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND NO RU MEMBERS FLAGGED AS ‘COVERED
BY GOVT-HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND,
GO TO BOX_11

PR26

{STR-DT}
{END-DT}

Who has been covered by this program?

PROBE: Who else has been covered by a program sponsored by a
state or local government agency which provides hospital and
physician benefits {since {START DATE}/between {START DATE} and
{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 ‘since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘between {START DATE} and {END DATE}’ IF
ROUND 5.

FLAG ALL PERSONS SELECTED AS ‘COVERED BY GOVT-
HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND. FLAG
ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY
GOVT-HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND.

GO TO LOOP_04

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.
1. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE NOT FLAGGED
AS COVERED BY GOVT-HOSPITAL/PHYSICIAN AT ANY TIME
DURING THE PREVIOUS ROUND.

LOOP_04

FOR EACH ELEMENT ON THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_PR04 - END_LP04

LOOP DEFINITION: LOOP_04 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY GOVT-
HOSPITAL/PHYSICIAN. THIS LOOP CYCLES ON
ESTABLISHMENT-PERSON-PAIRS THAT MEET BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN
AND
- PERSON IS FLAGGED AS COVERED BY GOVT-HOSPITAL/
PHYSICIAN DURING THE CURRENT ROUND

NAVIGATOR DETAILS: LOOP_04 USES NAV_PR04 TO
TO CONTROL THE FLOW OF THE LOOP.

NAV_PR04

{NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN INSURER FOR RU}
{STR-DT}

SERIES: Time Covered by {NAME OF PREV RD’S GOVT-HOSPITAL/
PHYSICIAN INSURER FOR RU} during Reference Period.

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

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

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

RU Member

[1. Coverage duration for [Person’s Name-65] through
{NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN INSURER
FOR RU}] [Status-25]
[2. Coverage duration for [Person’s Name-65] through
{NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN INSURER
FOR RU}] [Status-25]
[3. Coverage duration for [Person’s Name-65] through
{NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN INSURER
FOR RU}] [Status-25]

FOR ‘NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN
INSURER FOR RU’, DISPLAY THE INSURER RECORDED FOR
GOVT-HOSPITAL/PHYSICIAN AT ANY TIME DURING THE
PREVIOUS ROUND.

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 BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN
AND
- PERSON IS FLAGGED AS COVERED BY GOVT-HOSPITAL/
PHYSICIAN DURING THE CURRENT ROUND

CONTINUE WITH BOX_10 FOR SELECTED RU MEMBER.

BOX_10

ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PAIR.

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP04

END_LP04

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

IF NO MORE PAIRS MEET THE STATED CONDITIONS, END
LOOP_04 AND CONTINUE WITH PR27

PR27

{STR-DT}
{END-DT}

{Last time we recorded that (READ NAME(S) BELOW) may be covered by
{NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN INSURER FOR RU}.}

{Since {START DATE}/Between {START DATE} and {END DATE}}, has
there been any change in the plan name of the health insurance
the family has through the program sponsored by a state or local
government agency which provides hospital and physician benefits?

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

YES .................................... 1
NO ..................................... 2 {PR32}
REF ................................... -7 {PR32}
DK .................................... -8 {PR32}

HELP AVAILABLE FOR A DEFINITION OF THIS TYPE OF PROGRAM.

DISPLAY ‘Last time .... {NAME OF PREV RD’S GOVT-
HOSPITAL/PHYSICIAN INSURER FOR RU}.’ IF THERE IS
AN INSURER ASSOCIATED WITH GOVT-HOSPITAL/
PHYSICIAN IN THE PREVIOUS ROUND.

FOR ‘NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN
INSURER FOR RU’, DISPLAY THE INSURER RECORDED FOR
GOVT-HOSPITAL/PHYSICIAN AT ANY TIME DURING THE
PREVIOUS ROUND.

DISPLAY ‘Since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘Between {START DATE} and {END DATE}’ 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 GOVT-HOSPITAL/PHYSICIAN.

NOTE: STATES THAT DO NOT OFFER GOVT-HOSPITAL/
PHYSICIAN (MEDICAID/SCHIP) MANAGED CARE PLANS ARE
ALASKA, MISSISSIPPI, AND WYOMING.

IF CODED ‘1’ (YES) AND IF STATE IN WHICH THE
INTERVIEW IS BEING CONDUCTED DOES NOT OFFER A
GOVT-HOSPITAL/PHYSICIAN (MEDICAID/SCHIP) MANAGED
CARE PLAN, CODE PR28 ‘2’ (NO) AUTOMATICALLY BY
CAPI AND GO TO PR29

IF CODED ‘1’ (YES) AND IF STATE IN WHICH THE
INTERVIEW IS BEING CONDUCTED DOES OFFER A GOVT-
HOSPITAL/PHYSICIAN (MEDICAID/SCHIP) MANAGED CARE
PLAN, CONTINUE WITH PR28

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO ARE FLAGGED AS
COVERED BY GOVT-HOSPITAL/PHYSICIAN DURING THE
CURRENT ROUND.

PR28

{STR-DT}
{END-DT}

SHOW CARD HX-8.

Is the name of the health insurance through the program
sponsored by a state or local government agency which provides
hospital and physician benefits{, between {START DATE} and
{END DATE},} listed on this card?

YES .................................... 1 {PR28OV}
NO ..................................... 2 {PR29}
REF ................................... -7 {PR29}
DK .................................... -8 {PR29}

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

PR28OV

Which plan is the health insurance through this program?

CODE LETTER OF PLAN FROM SHOW CARD.

[Enter Plan Letter From Card] ......... {PR32}

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

WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY
THE FOLLOWING MESSAGE: "PLEASE VERIFY PLAN
SELECTED: {DISPLAY PLAN NAME SELECTED}." WHEN
INTERVIEWER CLEARS THE MESSAGE, PROCEED TO THE
NEXT LOGICAL SCREEN.

IN THIS MESSAGE FOR ‘DISPLAY PLAN NAME SELECTED’,
DISPLAY THE ACTUAL PLAN NAME THAT CORRESPONDS TO
THE LETTER ENTERED FOR THIS STATE.

PR29

{STR-DT}
{END-DT}

Under the program sponsored by a state or local government agency
which provides hospital and physician benefits {(are/is)/(were/was)}
(READ NAME(S) BELOW) enrolled in an HMO, that is a Health Maintenance
Organization {between {START DATE} and {END DATE}}?

[With an HMO, you must generally receive care from HMO physicians.
If another doctor is seen, the expense is not covered unless you were
referred by the HMO, or there was a medical emergency.]

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

YES, ALL ARE ........................... 1 {PR31}
YES, SOME ARE .......................... 2 {PR31}
NO, NONE ARE ........................... 3 {PR30}
REF ................................... -7 {PR30}
DK .................................... -8 {PR30}

[Code One]

HELP AVAILABLE FOR DEFINITION OF HMO.

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

DISPLAY ‘(are/is)’ IF NOT ROUND 5. DISPLAY
‘(were/was)’ IF ROUND 5.

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED BY
GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND.

PR30

{STR-DT}
{END-DT}

{Does/Between {START DATE} and {END DATE}, did} the program
sponsored by a state or local government agency which provides
hospital and physician benefits require (READ NAME(S) BELOW) to
sign up with a certain primary care doctor, group of doctors, or
with a certain clinic which they must go to for all of their
routine care?

PROBE: Do not include emergency care or care from a specialist
they were referred to.

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

YES, ALL REQUIRED ...................... 1 {PR31}
YES, SOME REQUIRED ..................... 2 {PR31}
NO, NONE REQUIRED ...................... 3 {PR32}
REF ................................... -7 {PR32}
DK .................................... -8 {PR32}

[Code One]

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

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

IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED),
OR ‘-8’ (DON’T KNOW), THERE IS NO INSURER
ASSOCIATED WITH THE CURRENT ROUND FOR
GOVT-HOSPITAL/PHYSICIAN.

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED BY
GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND.

PR31

{STR-DT}
{END-DT}

What is the name of the {HMO/health insurance} from the program
sponsored by a state or local government agency which provides
hospital and physician benefits?

[Enter Plan Name] ..................... {PR32}
REF ................................... -7 {PR32}
DK .................................... -8 {PR32}

DISPLAY ‘HMO’ IF PR29 IS CODED ‘1’ (YES, ALL ARE)
OR ‘2’ (YES, SOME ARE). DISPLAY ‘health
insurance’ IF PR30 CODED ‘1’ (YES, ALL REQUIRED)
OR ‘2’ (YES, SOME REQUIRED).

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

PR32

{STR-DT}
{END-DT}

Does anyone in the family pay anything for the coverage through
{{{PLAN NAME ENTERED AT PR28OV}/{NAME OF PLAN FROM PR31}}/the program
sponsored by a state or local government agency which provides hospital
and physician benefits}?

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

YES .................................... 1 {PR33}
NO ..................................... 2 {PR34}
REF ................................... -7 {BOX_11}
DK .................................... -8 {BOX_11}

[Code One]

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

DISPLAY ‘{{PLAN NAME ENTERED AT PR28OV}/{NAME OF
PLAN FROM PR31}}’ IF THERE IS A CURRENT ROUND
INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/PHYSICIAN
INSURANCE. OTHERWISE, DISPLAY ‘the program
sponsored ...’.

DISPLAY ‘(PLAN NAME ENTERED AT PR28OV)’ IF A PLAN
WAS ENTERED AT PR28OV. DISPLAY THE ACTUAL PLAN
NAME THAT CORRESPONDS TO THE LETTER ENTERED AT
PR28OV FOR THIS STATE.

DISPLAY ‘(NAME OF PLAN FROM PR31)’ IF A PLAN NAME
WAS ENTERED AT PR31. DISPLAY THE ACTUAL PLAN NAME
THAT WAS ENTERED.

PR33

{STR-DT}
{END-DT}

How much does anyone in the family pay for {the {{PLAN NAME ENTERED
AT PR28OV}/{NAME OF PLAN FROM PR31}}/that} coverage?

[Enter Amount in Dollars] .............. {PR33OV1}
REF ................................... -7 {PR34}
DK .................................... -8 {PR34}

DISPLAY ‘the {{PLAN NAME ENTERED AT PR28OV}/{NAME
OF PLAN FROM PR31}}’ IF THERE IS A CURRENT ROUND
INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/PHYSICIAN
INSURANCE. OTHERWISE, DISPLAY ‘that’.

DISPLAY ‘{PLAN NAME ENTERED AT PR28OV}’ IF A PLAN
WAS ENTERED AT PR28OV. DISPLAY THE ACTUAL PLAN
NAME THAT CORRESPONDS TO THE LETTER ENTERED AT
PR28OV FOR THIS STATE.

DISPLAY ‘{NAME OF PLAN FROM PR31}’ IF A PLAN NAME
WAS ENTERED AT PR31. DISPLAY THE ACTUAL PLAN NAME
THAT WAS ENTERED.

PR33OV1

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

ENTER UNIT OF COVERAGE:

PER YEAR ............................... 1 {PR34}
QUARTERLY/EVERY 3 MONTHS ............... 2 {PR34}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {PR34}
PER MONTH .............................. 4 {PR34}
PER WEEK ............................... 5 {PR34}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {PR34}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {PR34}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {PR34}
OTHER ................................. 91 {PR33OV2}
REF ................................... -7 {PR34}
DK .................................... -8 {PR34}

[Code One]

PR33OV2

SPECIFY:

[Enter Other Specify] .................. {PR34}
REF ................................... -7 {PR34}
DK .................................... -8 {PR34}

BOX_10A

OMITTED.

PR34

{STR-DT}
{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT PR28OV}/{NAME OF PLAN
FROM PR31}}}

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
OTHER ................................. 91 {PR34OV}
REF ................................... -7 {BOX_11}
DK .................................... -8 {BOX_11}

[Code All That Apply)

DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/
PHYSICIAN INSURANCE. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘{PLAN NAME ENTERED AT PR28OV}’ IF A PLAN
WAS ENTERED AT PR28OV. DISPLAY THE ACTUAL PLAN
NAME THAT CORRESPONDS TO THE LETTER ENTERED AT
PR28OV FOR THIS STATE. DISPLAY THE ACTUAL PLAN
NAME ENTERED AT PR31 FOR ‘{NAME OF PLAN FROM PR31}’
IF A PLAN NAME WAS ENTERED.

DISPLAY ‘else’ IF PR32 IS CODED ‘1’ (YES).
OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘some of’ IF PR32 IS CODED ‘1’ (YES).
DISPLAY ‘for’ IF PR32 IS CODED ‘2’ (NO).

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

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH PR34OV

OTHERWISE, GO TO BOX_11

PR34OV

SPECIFY:

[Enter Other Specify] .................. {BOX_11}
REF ................................... -7 {BOX_11}
DK .................................... -8 {BOX_11}

BOX_11

IF ANY RU MEMBER HAD OTHER PUBLIC (GROUP 1 OR 2)
AS A SOURCE OF INSURANCE AT ANY TIME DURING
PREVIOUS ROUND, CONTINUE WITH BOX_12

OTHERWISE, GO TO BOX_18

BOX_12

IF ANY CURRENT RU MEMBER HAD ANY GROUP 1 OTHER
PUBLIC INSURANCE AT ANY TIME DURING PREVIOUS
ROUND, CONTINUE WITH PR35

OTHERWISE, GO TO BOX_15

NOTE: FOR BOTH GROUP 1 AND GROUP 2 PUBLIC
PROGRAMS, WE ASSUME THE PROGRAM IS THE SAME FROM
THE PREVIOUS ROUND. ALTHOUGH WE SHOW THE SHOW
CARD AND ASK IF THE FAMILY STILL HAD COVERAGE
FROM ANY OF THOSE PROGRAMS, WE DO NOT ASK WHICH
ONES. IF WE WERE TO ASK WHICH ONES, WE WOULD NEED
TO ADD SEVERAL QUESTIONS, LIKE THE OTHER PUBLIC
SERIES IN HX.

PR35

{STR-DT}
{END-DT}

During the last interview, we recorded that (READ NAMES BELOW)
were covered by one or more of the following programs:

{STATE NAME FOR PROGRAM #1....}
{STATE NAME FOR PROGRAM #2....}
{STATE NAME FOR PROGRAM #3....}
{STATE NAME FOR PROGRAM #4....}

Have all of these people been covered by any of these programs at
any time {since {START DATE}/between {START DATE} and {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]

YES, ALL .............................. 1 {BOX_13}
NO, ONLY SOME ......................... 2 {PR36}
NO, NONE .............................. 3
REF ................................... -7 {BOX_15}
DK .................................... -8 {BOX_15}

HELP AVAILABLE FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.

DISPLAY THE LIST OF UP TO FOUR ACTUAL NAMES OF
STATE PROGRAMS (AS LISTED IN ATTACHMENT 37) FOR
‘STATE NAME FOR PROGRAM #N’.

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

IF PR35 IS CODED ‘1’ (YES, ALL), MARK ALL RU
MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER
PUBLIC INSURANCE DURING CURRENT ROUND.

IF PR35 IS CODED ‘3’ (NO, NONE), FLAG ALL RU
MEMBERS LISTED HERE AS ‘NOT COVERED BY GROUP 1
OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND.

IF CODED ‘3’ (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35,
GO TO PR37

IF CODED ‘3’ (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35,
GO TO BOX_15

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY
GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING
THE PREVIOUS ROUND.

PR36

{STR-DT}
{END-DT}

Who has been covered by any of these programs {since {START
DATE}/between {START DATE} and {END DATE}}?

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY GROUP 1
OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY
GROUP 1 OTHER PUBLIC INSURANCE’ DURING CURRENT
ROUND.

GO TO BOX_13

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY
GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING
THE PREVIOUS ROUND.

BOX_13

IF ALL CURRENT RU MEMBERS ALREADY FLAGGED AS
COVERED OR NOT COVERED BY GROUP 1 OTHER PUBLIC
INSURANCE DURING CURRENT ROUND (I.E., ALL CURRENT
RU MEMBERS WERE LISTED IN PR35), GO TO LOOP_05

OTHERWISE, CONTINUE WITH PR37

PR37

{STR-DT}
{END-DT}

Besides the family members we’ve just talked about, have any
additional family members been covered by any of the following
programs {since {START DATE}/between {START DATE} and {END DATE}}?
(READ PROGRAM NAMES BELOW.)

{STATE NAME FOR PROGRAM #1....}
{STATE NAME FOR PROGRAM #2....}
{STATE NAME FOR PROGRAM #3....}
{STATE NAME FOR PROGRAM #4....}

YES ................................... 1 {PR38}
NO .................................... 2
REF ................................... -7
DK .................................... -8

HELP AVAILABLE FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.

DISPLAY THE LIST OF UP TO FOUR ACTUAL NAMES OF
STATE PROGRAMS (AS LISTED IN HX16) FOR ‘STATE NAME
FOR PROGRAM #N’.

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

IF CODED ‘2’ (NO), ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS
COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING
CURRENT ROUND, GO TO LOOP_05

IF CODED ‘2’ (NO), ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY
GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT
ROUND, GO TO BOX_15

PR38

{STR-DT}
{END-DT}

Who has been covered by any of these programs {since {START
DATE}/between {START DATE} and {END DATE}}?

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY GROUP 1
OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY
GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT
ROUND.’

GO TO LOOP_05

ROSTER DETAILS:
Title: RU_MEMBERS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE NOT FLAGGED
AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE
AT ANY TIME DURING THE PREVIOUS ROUND.

LOOP_05

FOR EACH ELEMENT ON THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_PR05 - END_LP05

LOOP DEFINITION: LOOP_05 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY GROUP 1
OTHER PUBLIC INSURANCE. THIS LOOP CYCLES ON
ESTABLISHMENT-PERSON-PAIRS THAT MEET BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS GROUP 1 OTHER PUBLIC INSURANCE
AND
- PERSON IS COVERED BY GROUP 1 OTHER PUBLIC
INSURANCE DURING THE CURRENT ROUND

NAVIGATOR DETAILS: LOOP_05 USES NAV_PR05 TO
TO CONTROL THE FLOW OF THE LOOP.

NAV_PR05

STATE SPECIFIC PROGRAM {STR-DT}

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

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

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

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

RU Member

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

ROSTER DEFINITION:
THIS ITEM DISPLAYS 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 BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS GROUP 1 OTHER PUBLIC INSURANCE
AND
- PERSON IS COVERED BY GROUP 1 OTHER PUBLIC
INSURANCE DURING THE CURRENT ROUND

CONTINUE WITH BOX_14 FOR SELECTED RU MEMBER.

BOX_14

ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PAIR.

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP05

END_LP05

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

IF NO MORE PAIRS MEET THE STATED CONDITIONS,
END LOOP_05 AND CONTINUE WITH BOX_15

BOX_15

IF ANY CURRENT RU MEMBER HAD ANY ELIGIBLE GROUP 2
OTHER PUBLIC INSURANCE AT ANY TIME DURING THE
PREVIOUS ROUND, CONTINUE WITH PR39

OTHERWISE, GO TO BOX_18

PR39

{STR-DT}
{END-DT}

SHOW CARD HX-11.

During the last interview, we recorded that (READ NAMES BELOW)
were covered by one or more of the public programs listed
on this card.

Have all of these people been covered by any of these programs
at any time {since {START DATE}/between {START DATE} and {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]

YES, ALL .............................. 1 {BOX_16}
NO, ONLY SOME ......................... 2 {PR40}
NO, NONE .............................. 3
REF ................................... -7 {BOX_18}
DK .................................... -8 {BOX_18}

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

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

IF CODED ‘1’ (YES, ALL), FLAG ALL RU MEMBERS
LISTED HERE AS ‘COVERED BY GROUP 2 OTHER PUBLIC
INSURANCE’ DURING CURRENT ROUND.

IF CODED ‘3’ (NO, NONE), FLAG ALL RU MEMBERS
LISTED HERE AS ‘NOT COVERED BY GROUP 2 OTHER
PUBLIC INSURANCE’ DURING CURRENT ROUND.

IF CODED ‘3’ (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR39,
GO TO PR41

IF CODED ‘3’ (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR39,
GO TO BOX_18

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY
GROUP 2 OTHER PUBLIC INSURANCE AT ANY TIME DURING
THE PREVIOUS ROUND.

PR40

{STR-DT}
{END-DT}

SHOW CARD HX-11.

Who has been covered by any of these programs {since {START
DATE}/between {START DATE} and {END DATE}}?

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]

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY GROUP 2
OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY
GROUP 2 OTHER PUBLIC INSURANCE’ DURING CURRENT
ROUND.

GO TO BOX_16

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY
GROUP 2 OTHER PUBLIC INSURANCE AT ANY TIME DURING
THE PREVIOUS ROUND.

BOX_16

IF ALL CURRENT RU MEMBERS ALREADY FLAGGED AS
COVERED OR NOT COVERED BY GROUP 2 OTHER PUBLIC
INSURANCE DURING CURRENT ROUND (I.E., ALL CURRENT
RU MEMBERS WERE LISTED AT PR39), GO TO LOOP_06

OTHERWISE, CONTINUE WITH PR41

PR41

{STR-DT}
{END-DT}

SHOW CARD HX-11.

Besides the family members we’ve just talked about, have any
additional family members been covered by any of these programs
{since {START DATE}/between {START DATE} and {END DATE}}?

YES ................................... 1 {PR42}
NO .................................... 2
REF ................................... -7
DK .................................... -8

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

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

IF CODED ‘2’ (NO), ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS
COVERED BY GROUP 2 OTHER PUBLIC INSURANCE
DURING CURRENT ROUND, GO TO LOOP_06

IF CODED ‘2’ (NO), ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY
GROUP 2 OTHER PUBLIC INSURANCE DURING CURRENT
ROUND, GO TO BOX_18

PR42

{STR-DT}
{END-DT}

SHOW CARD HX-11.

Who has been covered by any of these programs {since {START
DATE}/between {START DATE} and {END DATE}}?

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]

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

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

FLAG ALL PERSONS SELECTED AS ‘COVERED BY GROUP 2
OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY
GROUP 2 OTHER PUBLIC INSURANCE DURING CURRENT
ROUND.’

GO TO LOOP_06

ROSTER DETAILS:
Title: RU_MEMBERS_1

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

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

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

ROSTER FILTER:
DISPLAY ONLY THOSE RU MEMBERS WHO WERE NOT FLAGGED
AS COVERED BY GROUP 2 OTHER PUBLIC INSURANCE AT
ANY TIME DURING THE PREVIOUS ROUND.

LOOP_06

FOR EACH ELEMENT ON THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK NAV_PR06 - END_LP06

LOOP DEFINITION: LOOP_06 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY GROUP 2
OTHER PUBLIC INSURANCE. THIS LOOP CYCLES ON
ESTABLISHMENT-PERSON-PAIRS THAT MEET BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS GROUP 2 OTHER PUBLIC INSURANCE
AND
- PERSON IS COVERED BY GROUP 2 OTHER PUBLIC
INSURANCE DURING THE CURRENT ROUND

NAVIGATOR DETAILS: LOOP_06 USES NAV_PR06 TO
TO CONTROL THE FLOW OF THE LOOP.

NAV_PR06

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

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

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

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

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

RU Member

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

ROSTER DEFINITION:
THIS ITEM DISPLAYS 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 BOTH OF THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS GROUP 2 OTHER PUBLIC INSURANCE
AND
- PERSON IS COVERED BY GROUP 2 OTHER PUBLIC
INSURANCE DURING THE CURRENT ROUND

CONTINUE WITH BOX_17 FOR SELECTED RU MEMBER.

BOX_17

ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PAIR.

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP06

END_LP06

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

IF NO MORE PAIRS MEET THE STATED CONDITIONS, END
LOOP_06 AND CONTINUE WITH BOX_18

BOX_18

RETURN TO THE HEALTH INSURANCE (HX) SECTION.

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