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 MEMBERS 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 PR03 FOR SELECTED RU MEMBER.
BOX_01A
OMITTED.
PR01
OMITTED.
PR01A
OMITTED.
BOX_01B
OMITTED.
PR02
OMITTED.
PR02OV
OMITTED.
PR03
{PERSONS 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
{PERSONS 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 RDS
MEDICARE INSURER FOR THIS ESTABLISHMENT-PERSON-
PAIR.
PR05
{PERSONS FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{{Do/Does}/Did} {you/{PERSON}} have prescribed
medicine coverage
through {{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 ‘{NAME OF PLAN FROM PR04} IF A PLAN NAME
WAS ENTERED AT PR04. DISPLAY {your/his/her}
Medicare managed care plan IF PR04 IS CODED ‘-7
(REF) OR ‘-8 (DK).
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
{PERSONS 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
{{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 {NAME OF PLAN FROM
PR04} IF A MEDICARE PLAN NAME WAS ENTERED AT
PR04. DISPLAY ‘this Medicare managed care plan
IF PR04 WAS CODED ‘-7 (REF) OR ‘-8 (DK).
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR04 FOR
‘NAME OF PLAN FROM PR04 IF A PLAN NAME WAS
ENTERED.
PR06A
{PERSONS FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
How {do/does} {you/{PERSON}} pay for {your/his/her}
{{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 ‘{NAME OF PLAN FROM PR04} IF A MEDICARE
PLAN NAME WAS ENTERED AT PR04. DISPLAY ‘Medicare
managed care IF PR04 WAS CODED ‘-7 (REF) OR
‘-8 (DK).
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR04 FOR
‘NAME OF PLAN FROM PR04 IF A PLAN NAME WAS
ENTERED.
PR06AA
{PERSONS 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}
{NAME OF PLAN
FROM PR04} plan?
IF RESPONDENT IS NOT SURE, DO NOT PROBE. CODE ‘DONT
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 ‘{NAME OF PLAN FROM PR04} IF A MEDICARE
PLAN NAME WAS ENTERED AT PR04. OTHERWISE (I.E.,
IF PR04 WAS CODED ‘-7 (REF) OR ‘-8 (DK)), USE
A NULL DISPLAY.
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
{PERSONS FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{PLAN NAME: {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: {NAME OF PLAN FROM PR04} IF
A MEDICARE PLAN NAME WAS ENTERED AT PR04.
OTHERWISE (I.E., IF PR04 WAS CODED ‘-7 (REF) OR
‘-8 (DK)), USE A NULL DISPLAY.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR04 FOR
‘NAME OF PLAN FROM PR04 IF A PLAN NAME WAS
ENTERED.
PR06B
{PERSONS 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
{PERSONS 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
{PERSONS 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
{PERSONS 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 ‘DONT
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
{PERSONS 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 MEMBERS 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 MEMBERS 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 weve 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 ‘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 TO DISPLAY BY STATE, SEE ATTACHMENT 37.
DISPLAY ‘or STATE CHIP NAME UNDER ALL CONDITIONS,
SUBSTITUTING THE REAL STATE NAME FOR PROGRAM.
FOR THE SPECIFIC NAME TO 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 (DONT
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 (DONT
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 ‘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 TO DISPLAY BY STATE, SEE ATTACHMENT 37.
DISPLAY ‘or STATE CHIP NAME UNDER ALL CONDITIONS,
SUBSTITUTING THE REAL STATE NAME FOR PROGRAM.
FOR THE SPECIFIC NAME TO 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
MEMBERS 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 [Persons Name-65] through
MEDICAID/SCHIP] [Status-25]
[2. Coverage duration for [Persons Name-65] through
MEDICAID/SCHIP] [Status-25]
[3. Coverage duration for [Persons Name-65] through
MEDICAID/SCHIP] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBERS 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 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 RDS 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 {PR13}
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 RDS
MEDICAID/SCHIP INSURER FOR RU}. IF THERE IS AN
INSURER ASSOCIATED WITH MEDICAID/SCHIP IN THE
PREVIOUS ROUND.
FOR ‘NAME OF PREV RDS 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 ‘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 TO DISPLAY BY STATE, SEE ATTACHMENT 37.
DISPLAY ‘or STATE CHIP NAME UNDER ALL CONDITIONS,
SUBSTITUTING THE REAL STATE NAME FOR PROGRAM.
FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE
ATTACHMENT 37.
IF CODED ‘2 (NO), ‘-7 (REFUSED), OR ‘-8 (DONT
KNOW), FLAG PREVIOUS ROUNDS INSURER AS ‘CURRENT
RDS MEDICAID/SCHIP INSURER
ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1
COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBERS 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
OMITTED.
PR12OV
OMITTED.
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 ‘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 TO DISPLAY BY STATE, SEE ATTACHMENT 37.
DISPLAY ‘or STATE CHIP NAME UNDER ALL CONDITIONS,
SUBSTITUTING THE REAL STATE NAME FOR PROGRAM.
FOR THE SPECIFIC NAME TO 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 MEMBERS 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 ‘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 TO DISPLAY BY STATE, SEE ATTACHMENT 37.
DISPLAY ‘or STATE CHIP NAME UNDER ALL CONDITIONS,
SUBSTITUTING THE REAL STATE NAME FOR PROGRAM.
FOR THE SPECIFIC NAME TO 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 (DONT 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 MEMBERS 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 ‘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 TO DISPLAY BY STATE, SEE ATTACHMENT 37.
DISPLAY ‘or STATE CHIP NAME UNDER ALL CONDITIONS,
SUBSTITUTING THE REAL STATE NAME FOR PROGRAM.
FOR THE SPECIFIC NAME TO 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 ROUNDS
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}
Is there a monthly premium {for anyone in the family}
for the
coverage through {{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.]
READ IF NECESSARY: A monthly premium is a fixed amount
of money
people pay each month to have health coverage. It does
not include
copays or other expenses such as prescription costs.
YES, EVERYONE COVERED PAYS ............. 1 {PR17}
YES, SOME COVERED PAY .................. 2 {PR16A}
NO, NO ONE COVERED PAYS ................ 3 {PR18}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
[Code One]
HELP AVAILABLE FOR DEFINITION OF
PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
DISPLAY ‘{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 ‘{NAME OF PLAN FROM PR15} IF A PLAN NAME
WAS ENTERED AT PR15. DISPLAY THE ACTUAL PLAN NAME
THAT WAS ENTERED.
DISPLAY ‘for anyone in the family IF MORE THAN
ONE RU MEMBER SELECTED AS COVERED BY MEDICAID/SCHIP
INSURANCE. OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘Medicaid IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘Medicaid. DISPLAY
‘STATE NAME FOR MEDICAID (SUBSTITUTING THE 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 TO DISPLAY BY STATE, SEE ATTACHMENT 37.
DISPLAY ‘or STATE CHIP NAME UNDER ALL CONDITIONS,
SUBSTITUTING THE REAL STATE NAME FOR PROGRAM.
FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE
ATTACHMENT 37.
PR16A
{STR-DT}
{END-DT}
Which family members have a monthly premium for that
coverage?
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]
FLAG ALL PERSONS SELECTED AS ‘PAYS FOR COVERAGE
DURING CURRENT ROUND. FLAG ALL PERSONS NOT
SELECTED AS ‘DOES NOT PAY FOR COVERAGE DURING
CURRENT ROUND.
CONTINUE WITH PR17
ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1
COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBERS 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 ARE COVERED
BY MEDICAID/SCHIP DURING THE CURRENT ROUND.
PR17
{STR-DT}
{END-DT}
How much is the premium for {the {NAME OF PLAN FROM
PR15}/that}
coverage?
[Enter Amount in Dollars] .............. {PR17OV1}
REF ................................... -7 {PR17A}
DK .................................... -8 {PR17A}
DISPLAY ‘the {NAME OF PLAN FROM PR15} IF THERE IS
A CURRENT ROUND INSURER ASSOCIATED WITH THE
MEDICAID/SCHIP INSURANCE. OTHERWISE, DISPLAY
‘that.
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 {PR17A}
QUARTERLY/EVERY 3 MONTHS ............... 2 {PR17A}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {PR17A}
PER MONTH .............................. 4 {PR17A}
PER WEEK ............................... 5 {PR17A}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {PR17A}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {PR17A}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {PR17A}
OTHER ................................. 91 {PR17OV2}
REF ................................... -7 {PR17A}
DK
.................................... -8 {PR17A}
[Code One]
PR17OV2
SPECIFY:
[Enter Other Specify] .................. {PR17A}
REF ................................... -7 {PR17A}
DK .................................... -8 {PR17A}
PR17A
{STR-DT}
{END-DT}
{PLAN NAME: {NAME OF PLAN FROM PR15}}
Is the cost of the premium subsidized based on family
income?
YES .................................... 1 {PR18}
NO ..................................... 2 {PR18}
REF ................................... -7 {PR18}
DK .................................... -8 {PR18}
DISPLAY ‘PLAN NAME: ... IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
INSURANCE. OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘{NAME OF PLAN FROM PR15} IF A PLAN NAME
WAS ENTERED AT PR15. DISPLAY THE ACTUAL PLAN NAME
THAT WAS ENTERED.
PR18
{STR-DT}
{END-DT}
{PLAN NAME: {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 ‘{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, EVERYONE
COVERED PAYS) OR ‘2 (YES, SOME COVERED PAY).
OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘some of IF PR16 IS CODED ‘1 (YES,
EVERYONE COVERED PAYS) OR ‘2 (YES, SOME COVERED
PAY).
DISPLAY ‘for IF PR16 IS CODED ‘3 (NO, NO ONE
COVERED PAYS).
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7 (REFUSED) OR ‘-8 (DONT 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 MEMBERS 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 MEMBERS 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 weve 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 (DONT
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 (DONT
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
MEMBERS 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 [Persons Name-65] through
TRICARE OR CHAMPVA] [Status-25]
[2. Coverage duration for [Persons Name-65] through
TRICARE OR CHAMPVA] [Status-25]
[3. Coverage duration for [Persons Name-65] through
TRICARE OR CHAMPVA] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBERS 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 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_08
BOX_07A
OMITTED.
PR22A
OMITTED.
PR22B
OMITTED.
PR22BOV1
OMITTED.
PR22BOV2
OMITTED.
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 MEMBERS 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 MEMBERS 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 weve 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 (DONT
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 (DONT
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
MEMBERS 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 RDS GOVT-HOSPITAL/PHYSICIAN INSURER FOR
RU}
{STR-DT}
SERIES: Time Covered by {NAME OF PREV RDS
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 [Persons Name-65] through
{NAME OF PREV RDS GOVT-HOSPITAL/PHYSICIAN INSURER
FOR RU}] [Status-25]
[2. Coverage duration for [Persons Name-65] through
{NAME OF PREV RDS GOVT-HOSPITAL/PHYSICIAN INSURER
FOR RU}] [Status-25]
[3. Coverage duration for [Person’s Name-65] through
{NAME OF PREV RDS GOVT-HOSPITAL/PHYSICIAN INSURER
FOR RU}] [Status-25]
FOR ‘NAME OF PREV RDS GOVT-HOSPITAL/PHYSICIAN
INSURER FOR RU, DISPLAY THE INSURER RECORDED FOR
GOVT-HOSPITAL/PHYSICIAN AT ANY TIME DURING THE
PREVIOUS ROUND.
ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBERS 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 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 RDS 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 {PR29}
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 RDS GOVT-
HOSPITAL/PHYSICIAN INSURER FOR RU}. IF THERE IS
AN INSURER ASSOCIATED WITH GOVT-HOSPITAL/
PHYSICIAN IN THE PREVIOUS ROUND.
FOR ‘NAME OF PREV RDS 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 (DONT
KNOW), FLAG PREVIOUS ROUNDS INSURER AS CURRENT
ROUNDS INSURER FOR GOVT-HOSPITAL/PHYSICIAN.
ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1
COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBERS 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
OMITTED.
PR28OV
OMITTED.
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 MEMBERS 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 (DONT 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 MEMBERS 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 ROUNDS
INSURER FOR GOVT-HOSPITAL/PHYSICIAN.
PR32
{STR-DT}
{END-DT}
Is there a monthly premium {for anyone in the family}
for the
coverage through {{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.]
READ IF NECESSARY: A monthly premium is a fixed amount
of money
people pay each month to have health coverage. It does
not include
copays or other expenses such as prescription costs.
YES, EVERYONE COVERED PAYS ............. 1 {PR33}
YES, SOME COVERED PAY .................. 2 {PR32A}
NO, NO ONE COVERED PAYS ................ 3 {PR34}
REF ................................... -7 {BOX_11}
DK .................................... -8 {BOX_11}
[Code One]
HELP AVAILABLE FOR DEFINITION OF
PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
DISPLAY ‘{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 ‘{NAME OF PLAN FROM PR31} IF A PLAN NAME
WAS ENTERED AT PR31. DISPLAY THE ACTUAL PLAN NAME
THAT WAS ENTERED.
DISPLAY ‘for anyone in the family IF MORE THAN
ONE RU MEMBER SELECTED AS COVERED BY GOVT-HOSPITAL/
PHYSICIAN INSURANCE. OTHERWISE, USE A NULL DISPLAY.
PR32A
{STR-DT}
{END-DT}
Which family members have a monthly premium for that
coverage?
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]
FLAG ALL PERSONS SELECTED AS ‘PAYS FOR COVERAGE
DURING CURRENT ROUND. FLAG ALL PERSONS NOT
SELECTED AS ‘DOES NOT PAY FOR COVERAGE DURING
CURRENT ROUND.
CONTINUE WITH PR33
ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1
COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBERS 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 ARE COVERED BY
GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND.
PR33
{STR-DT}
{END-DT}
How much is the premium for {the {NAME OF PLAN FROM
PR31}/that}
coverage?
[Enter Amount in Dollars] .............. {PR33OV1}
REF ................................... -7 {PR33A}
DK .................................... -8 {PR33A}
DISPLAY ‘the {NAME OF PLAN FROM PR31} IF THERE
IS A CURRENT ROUND INSURER ASSOCIATED WITH THE
GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE,
DISPLAY ‘that.
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 {PR33A}
QUARTERLY/EVERY 3 MONTHS ............... 2 {PR33A}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {PR33A}
PER MONTH .............................. 4 {PR33A}
PER WEEK ............................... 5 {PR33A}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {PR33A}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {PR33A}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {PR33A}
OTHER ................................. 91 {PR33OV2}
REF ................................... -7 {PR33A}
DK
.................................... -8 {PR33A}
[Code One]
PR33OV2
SPECIFY:
[Enter Other Specify] .................. {PR33A}
REF ................................... -7 {PR33A}
DK .................................... -8 {PR33A}
BOX_10A
OMITTED.
PR33A
{STR-DT}
{END-DT}
{PLAN NAME: {NAME OF PLAN FROM PR31}}
Is the cost of the premium subsidized based on family
income?
YES .................................... 1 {PR34}
NO ..................................... 2 {PR34}
REF ................................... -7 {PR34}
DK .................................... -8 {PR34}
DISPLAY ‘PLAN NAME: ... IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/
PHYSICIAN INSURANCE. OTHERWISE, USE A NULL DISPLAY.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT PR31 FOR
‘{NAME OF PLAN FROM PR31} IF A PLAN NAME WAS
ENTERED.
PR34
{STR-DT}
{END-DT}
{PLAN NAME: {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 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, EVERYONE
COVERED PAYS) OR ‘2 (YES, SOME COVERED PAY).
OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘some of IF PR32 IS CODED ‘1 (YES,
EVERYONE COVERED PAYS) OR ‘2 (YES, SOME COVERED
PAY).
DISPLAY ‘for IF PR32 IS CODED ‘3 (NO, NO ONE
COVERED PAYS).
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7 (REFUSED) OR ‘-8 (DONT 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 MEMBERS 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 MEMBERS 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 weve 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 (DONT
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 (DONT
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
MEMBERS 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 [Persons Name-65] through
STATE SPECIFIC PROGRAM] [Status-25]
[2. Coverage duration for [Persons Name-65] through
STATE SPECIFIC PROGRAM] [Status-25]
[3. Coverage duration for [Persons Name-65] through
STATE SPECIFIC PROGRAM] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBERS 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 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 MEMBERS 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 MEMBERS 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 weve 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 (DONT
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 (DONT
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
MEMBERS 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 [Persons Name-65] through
STATE: TANF/SSI/WIC/IHS/PHC/VA] [Status-25]
[2. Coverage duration for [Persons Name-65] through
STATE: TANF/SSI/WIC/IHS/PHC/VA] [Status-25]
[3. Coverage duration for [Persons Name-65] through
STATE: TANF/SSI/WIC/IHS/PHC/VA] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBERS 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 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.
Return to Top
|