MEPS Old Public Related Insurance 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.

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

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

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.

{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 PR03 FOR SELECTED RU MEMBER.

{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.

{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.

{PERSON’S 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

{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
{{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.

{PERSON’S 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.

{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} {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 ‘{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.

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]

SPECIFY:

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

{PERSON’S 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.

{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

{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.

{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}

{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).

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]

SPECIFY:

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

{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}

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

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

{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 36.

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 36.

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.

{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 36.

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 36.

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.’

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.

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

{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 36.

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

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 36.

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.

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.

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.

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

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

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
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

{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 {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 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 36.

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

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.

{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 36.

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.

{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 36.

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.

{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 36.

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’.

IF ROUND 2, ROUND 3 OR ROUND 4, CONTINUE WITH
PR16

OTHERWISE, (I.E., IF ROUND 5), GO TO BOX_05

{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 {BOX_04B}
YES, SOME COVERED PAY .................. 2 {PR16A}
NO, NO ONE COVERED PAYS ................ 3 {BOX_05}
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 ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS,
SUBSTITUTING THE REAL STATE NAME FOR PROGRAM.
FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE
ATTACHMENT 36.

IF CODED ‘1’ (YES, EVERYONE COVERED PAYS), FLAG
ALL PERSONS AT PR16A AS ‘PAYS FOR COVERAGE DURING
CURRENT ROUND.’ IF CODED ‘3’ (NO, NO ONE COVERED
PAYS), FLAG ALL PERSONS AT PR16A AS ‘DOES NOT PAY
FOR COVERAGE DURING CURRENT ROUND.’

(AHRQ WILL DECIDE ON FLAGS FOR ‘-7’, ‘-8’ AND ‘-9’
VALUES AFTER DETERMINING FREQUENCY IN FY2012.)

{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 BOX_04B

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 ARE COVERED
BY MEDICAID/SCHIP DURING THE CURRENT ROUND.

IF ROUND 3, CONTINUE WITH PR17

OTHERWISE, GO TO PR17A

{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.

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]

SPECIFY:

[Enter Other Specify] .................. {PR17A}
REF ................................... -7 {PR17A}
DK .................................... -8 {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 {BOX_05}
NO ..................................... 2 {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}

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.

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

OTHERWISE, GO TO BOX_08

{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.

{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

{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.

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.

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

{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

{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]

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.

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.

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.

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.

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

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
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

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

{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.

{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.

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.

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

{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

{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.

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.

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.

{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.

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

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
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

{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 {PR29}
NO ..................................... 2 {BOX_10A}
REF ................................... -7 {BOX_10A}
DK .................................... -8 {BOX_10A}

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.

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.

{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.

{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 {BOX_10A}
REF ................................... -7 {BOX_10A}
DK .................................... -8 {BOX_10A}

[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.

{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] ..................... {BOX_10A}
REF ................................... -7 {BOX_10A}
DK .................................... -8 {BOX_10A}

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.’

IF ROUND 2, ROUND 3 OR ROUND 4, CONTINUE WITH PR32

OTHERWISE, (I.E., IF ROUND 5), GO TO BOX_11

{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 {BOX_10B}
YES, SOME COVERED PAY .................. 2 {PR32A}
NO, NO ONE COVERED PAYS ................ 3 {BOX_11}
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.

IF CODED ‘1’ (YES, EVERYONE COVERED PAYS), FLAG
ALL PERSONS AT PR32A AS ‘PAYS FOR COVERAGE DURING
CURRENT ROUND.’ IF CODED ‘3’ (NO, NO ONE COVERED
PAYS), FLAG ALL PERSONS AT PR32A AS ‘DOES NOT PAY
FOR COVERAGE DURING CURRENT ROUND.’

(AHRQ WILL DECIDE ON FLAGS FOR ‘-7’, ‘-8’ AND ‘-9’
VALUES AFTER DETERMINING FREQUENCY IN FY2012.)

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 BOX_10B

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 ARE COVERED BY
GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND.

IF ROUND 3, CONTINUE WITH PR33

OTHERWISE, GO TO PR33A

{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.

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]

SPECIFY:

[Enter Other Specify] .................. {PR33A}
REF ................................... -7 {PR33A}
DK .................................... -8 {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 {BOX_10C}
NO ..................................... 2 {BOX_10C}
REF ................................... -7 {BOX_10C}
DK .................................... -8 {BOX_10C}

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.

IF ROUND 3
AND
IF HX15A WAS CODED ‘1’ (YES, PLAN IS EXCHANGE) THE
ROUND THE GOV’T-HOSPITAL/PHYSICIAN INSURANCE WAS
CREATED
AND
PR32 IS CODED ‘1’ (YES, EVERYONE COVERED PAYS) OR
‘2’ (YES, SOME COVERED PAY),
CONTINUE WITH PR34

OTHERWISE, GO TO BOX_11

{STR-DT}
{END-DT}
Is {the {NAME OF PLAN FROM PR31} plan/this plan} a platinum,
gold, silver, bronze or catastrophic plan?

PLATINUM PLAN .......................... 1 {BOX_11}
GOLD PLAN .............................. 2 {BOX_11}
SILVER PLAN ............................ 3 {BOX_11}
BRONZE PLAN ............................ 4 {BOX_11}
CATASTROPHIC PLAN ...................... 5 {BOX_11}
IF VOLUNTEERED: SOMETHING ELSE ......... 6 {BOX_11}
REF ................................... -7 {BOX_11}
DK .................................... -8 {BOX_11}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

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

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

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

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.

{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 36) 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.

{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.

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.

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

{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

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.’

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.

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.

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.

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

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
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

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

{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.

{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.

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.

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

{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

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.’

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.

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.

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.

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

AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP06

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

Old Public Related Insurance (PR) Section