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Health Insurance (HX) Section
----------------------------------------------------
THROUGHOUT THE SPECIFICATIONS FOR THIS CAPI
SECTION, FOR SCREENS THAT SPECIFY THE REFERENCE
PERIOD {END DATE} AS PART OF THE CONTEXT HEADER,
CAPI DISPLAYS THE {END DATE} ONLY FOR ROUND 5. IN
ANY OTHER ROUND, CAPI DOES NOT DISPLAY THE {END
DATE} IN THE CONTEXT HEADER. FOR MOST PERSONS, THE
END DATE FOR ROUND 5 WILL BE DECEMBER 31 OF THE
SECOND YEAR OF THE PANEL.
----------------------------------------------------
BOX_00
======
----------------------------------------------------
CONTEXT HEADER DISPLAY INSTRUCTIONS:
FOR MONTH DISPLAY 3 CHAR MONTH (EG. JAN, FEB)
ROUNDS 1-4, DISPLAY ONLY THE BEGIN DATE RATHER
THAN BOTH THE BEGIN AND END DATE. IF ROUND 5 THEN
DISPLAY BOTH THE BEGIN AND END DATE.
DISPLAY PERS.FULLNAME, ESTB.ESTBNAME,
PRND.BEGREFMM, PRND.BEGREFDD, PRND.BEGREFYY,
PRND.ENDREFMM, PRND.ENDREFDD, PRND.ENDREFYY
----------------------------------------------------
HX01
====
{STR-DT}
{END-DT}
Now I’d like to talk with you about health insurance,
an
important topic for most persons. We want to know
about all
the health coverage that anyone in the family may have
had to
help pay the costs of medical care at any time {since
(START
DATE)/between (START DATE) and (END DATE)}.
{ASK RESPONDENT TO GET INSURANCE CARDS/IDENTIFYING
INFORMATION
IF NOT ALREADY AVAILABLE.}
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
----------------------------------------------------
DISPLAY ‘ASK....AVAILABLE.’ IF ROUND 1.
OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
----------------------------------------------------
IF ROUND 1, GO TO BOX_03
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH BOX_01
----------------------------------------------------
BOX_01
======
----------------------------------------------------
ASK THE OLD EMPLOYMENT AND PRIVATE RELATED
INSURANCE (OE) SECTION.
----------------------------------------------------
----------------------------------------------------
AT COMPLETION OF OE SECTION, CONTINUE WITH BOX_02
----------------------------------------------------
BOX_02
======
----------------------------------------------------
ASK THE OLD PUBLIC RELATED INSURANCE (PR) SECTION.
----------------------------------------------------
----------------------------------------------------
AT COMPLETION OF PR SECTION, CONTINUE WITH BOX_03
----------------------------------------------------
BOX_03
======
----------------------------------------------------
IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS MEET THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS
PROVIDING HEALTH INSURANCE
AND
- ESTABLISHMENT IS AN EMPLOYER
AND
- PERSON IS OR WAS A JOBHOLDER AT ESTABLISHMENT
AND
- ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’
OR IS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM-
SIZE-GREATER-THAN-1,
CONTINUE WITH LOOP_01
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_05
----------------------------------------------------
LOOP_01
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-PAIRS-
ROSTER, ASK HX02-END_LP01
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION
ABOUT PRIVATE HEALTH INSURANCE OBTAINED THROUGH
AN EMPLOYER. THIS LOOP CYCLES ON ESTABLISHMENT-
PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS
PROVIDING HEALTH INSURANCE
AND
- ESTABLISHMENT IS AN EMPLOYER
AND
- PERSON IS OR WAS A JOBHOLDER AT ESTABLISHMENT
AND
- ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’
OR IS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM-
SIZE-GREATER-THAN-1.
----------------------------------------------------
HX02
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
You mentioned that (PERSON) (were/was) covered by
health
insurance from (ESTABLISHMENT) {at some point after
(START
DATE)/between (START DATE) and (END DATE)}.
SELECT ‘CONTINUE’ UNLESS RESPONDENT VOLUNTEERS
INSURANCE
REPORTED IN ERROR.
CONTINUE ............................... 1 {BOX_04}
INSURANCE REPORTED IN ERROR ............ 2 {END_LP01}
[Code One]
----------------------------------------------------
IF ROUND 1 THROUGH ROUND 4, DISPLAY ‘at some point
after (START DATE)’. IF ROUND 5, DISPLAY
‘between
(START DATE) and (END DATE)’.
----------------------------------------------------
----------------------------------------------------
‘(ESTABLISHMENT)’ AND ‘(START DATE)’ IN RESPONSE
LABELS SHOULD BE PURPLE.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘2’ (INSURANCE REPORTED IN ERROR) FLAG
THIS ESTABLISHMENT-PERSON-PAIR AS ‘NOT SEPARATE
SOURCE OF INSURANCE’ AND GO TO END_LP01
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH BOX_04
----------------------------------------------------
BOX_04
======
----------------------------------------------------
ASK THE PRIVATE HEALTH INSURANCE DETAIL (HP)
SECTION FOR THIS ESTABLISHMENT-PERSON-PAIR.
----------------------------------------------------
----------------------------------------------------
AT COMPLETION OF HP SECTION, CONTINUE WITH
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_05
----------------------------------------------------
BOX_05
======
----------------------------------------------------
IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS MEET
THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS
PROVIDING HEALTH INSURANCE
AND
- ESTABLISHMENT IS AN EMPLOYER
AND
- PERSON IS A JOBHOLDER AT ESTABLISHMENT
AND
- ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’
AND
- FIRM SIZE OF ESTABLISHMENT = 1,
CONTINUE WITH LOOP_02
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_07
----------------------------------------------------
LOOP_02
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-PAIRS-
ROSTER, ASK LOOP_03-END_LP02
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_02 COLLECTS INFORMATION
ABOUT THE SOURCES OF DIRECTLY PURCHASED HEALTH
INSURANCE ASSOCIATED WITH A SELF-EMPLOYED JOB
WHERE FIRM SIZE = 1. THIS LOOP CYCLES ON
ESTABLISHMENT-PERSON-PAIRS THAT MEET THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS
PROVIDING HEALTH INSURANCE
AND
- ESTABLISHMENT IS AN EMPLOYER
AND
- PERSON IS A JOBHOLDER AT ESTABLISHMENT
AND
- ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’
- FIRM SIZE OF ESTABLISHMENT = 1
----------------------------------------------------
LOOP_03
=======
----------------------------------------------------
For each of the following:
INSURANCE CATEGORY 1
INSURANCE CATEGORY 2
INSURANCE CATEGORY 3
INSURANCE CATEGORY 4
INSURANCE CATEGORY 5
INSURANCE CATEGORY 6
ask HX03 - END_LP03
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_03 COLLECTS INFORMATION
ABOUT THE WAYS PERSON PURCHASED HEALTH INSURANCE
(INSURANCE CATEGORIES AT HX03) ASSOCIATED WITH A
SELF-EMPLOYED JOB WITH FIRM-SIZE = 1. THE FIRST
CYCLE OF THIS LOOP COLLECTS THE MAIN WAY PERSON
PURCHASES INSURANCE. SUBSEQUENT CYCLES COLLECT
ADDITIONAL WAYS PERSON PURCHASES INSURANCE.
THE RESPONSE AT HX04 DETERMINES WHETHER THE LOOP
CYCLES AGAIN. IF HX04 IS CODED ‘1’ (YES), THE
LOOP CYCLES TO COLLECT THE NEXT INSURANCE
CATEGORY. IF HX04 IS CODED ‘2’ (NO), ‘-7’
(REFUSED), OR ‘-8’ (DON’T KNOW), THE LOOP ENDS.
----------------------------------------------------
HX03
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
SHOW CARD HX-1.
{You mentioned that (PERSON) {(are/is)/(were/was)}
self-employed
and had health insurance through that business.} Which
category on this card comes closest to {the main/another}
way
(PERSON) (purchase/purchases) this insurance?
FROM A PROFESSIONAL ASSOCIATION ........ 1 {BOX_06}
FROM A SMALL BUSINESS GROUP ............ 2 {BOX_06}
FROM A UNION ........................... 3 {BOX_06}
DIRECTLY FROM AN INSURANCE AGENT ....... 5 {BOX_06}
DIRECTLY FROM INSURANCE COMPANY ........ 6 {BOX_06}
DIRECTLY FROM AN HMO ................... 7 {BOX_06}
FROM A PREVIOUS EMPLOYER ............... 8 {BOX_06}
FROM A PREVIOUS EMPLOYER (COBRA) ....... 9 {BOX_06}
OTHER ................................. 91 {HX03OV}
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
STARTING IN PANEL 12 ROUND 2, CATEGORY ‘4’ (FROM
A HEALTH INSURANCE PURCHASING ALLIANCE) WAS
OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘you mentioned that (PERSON) {(are/is)/
(were/was)} self-employed and had health insurance
through that business.’ IF FIRST CYCLE THROUGH
LOOP_03. OTHERWISE USE A NULL DISPLAY.
DISPLAY ‘(are/is)’ IF ESTABLISHMENT IS FLAGGED AS
A CURRENT EMPLOYER. DISPLAY ‘(were/was)’ IF
ESTABLISHMENT IS NOT FLAGGED AS A CURRENT
EMPLOYER, OR IF CURRENT ROUND IS ROUND 5.
DISPLAY ‘the main’ IF FIRST CYCLE THROUGH
LOOP_03.
OTHERWISE (I.E., NOT FIRST CYCLE), DISPLAY
‘another’.
----------------------------------------------------
HX03OV
======
OTHER:
[Enter Other Specify] .................. {BOX_06}
DK .................................... -8 {BOX_06}
BOX_06
======
----------------------------------------------------
ASK PRIVATE HEALTH INSURANCE DETAIL (HP) SECTION
FOR THE RESPONSE CATEGORY SELECTED AT HX03.
----------------------------------------------------
----------------------------------------------------
AT COMPLETION OF HP SECTION, CONTINUE WITH HX04
----------------------------------------------------
HX04
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
SHOW CARD HX-1.
Aside from what you already told me about, is there
another
category on this card which describes the way (PERSON)
(purchase/purchases) health insurance for
(ESTABLISHMENT)?
YES .................................... 1 {END_LP03}
NO ..................................... 2 {END_LP03}
REF ................................... -7 {END_LP03}
DK .................................... -8 {END_LP03}
HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.
END_LP03
========
----------------------------------------------------
IF HX04 IS CODED ‘1’ (YES), CYCLE TO COLLECT THE
NEXT WAY OF PURCHASING INSURANCE.
----------------------------------------------------
----------------------------------------------------
OTHERWISE, END LOOP_03 AND CONTINUE WITH END_LP02
----------------------------------------------------
END_LP02
========
----------------------------------------------------
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_02 AND CONTINUE WITH BOX_07
----------------------------------------------------
BOX_07
======
----------------------------------------------------
IF ROUND 1, GO TO HX06
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH BOX_08
----------------------------------------------------
BOX_08
======
----------------------------------------------------
IF:
ANY NEW RU MEMBERS ADDED TO RU THIS ROUND,
OR
ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING
MEDICARE TURNED 65 SINCE START DATE (USE REAL
DATE OF BIRTH ONLY),
OR
ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING
MEDICARE WERE = OR > 65 (OR IN AGE CATEGORY 9) IN
PREVIOUS ROUND,
CONTINUE WITH HX05
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_12
----------------------------------------------------
HX05
====
{STR-DT}
{END-DT}
My records indicate that (READ NAMES BELOW) {(are/is)}
{either} {65 years old or older} {or} {joined the
household
since our last interview}.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
(Has (READ NAME ABOVE)/Have any of these people) been
covered
by Medicare {since (START DATE)/between (START DATE)
and (END DATE)}?
YES .................................... 1
NO ..................................... 2 {LOOP_04}
REF ................................... -7 {LOOP_04}
DK .................................... -8 {LOOP_04}
HELP AVAILABLE FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY ‘(are/is)’ AND ‘65 years old’ IF ANY RU
MEMBERS NOT ALREADY FLAGGED AS RECEIVING
MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU
MEMBERS NOT ALREADY FLAGGED AS RECEIVING
MEDICARE WERE = OR > 65 PREVIOUS ROUND.
DISPLAY ‘joined the household since our last
interview’ IF ANY NEW RU MEMBERS ADDED TO THE RU
THIS ROUND.
DISPLAY ‘either’ AND ‘or’ IF ANY NEW RU MEMBERS
ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS
NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED
65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY
FLAGGED AS RECEIVING MEDICARE WERE = OR > 65
PREVIOUS ROUND.
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED ‘1’ (YES) AND ONLY ONE RU MEMBER
ELIGIBLE FOR HX05, SELECT THAT PERSON
AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED ‘1’ (YES) AND MORE THAN ONE RU
MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
----------------------------------------------------
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 DISPLAY
OF RU-MEMBERS.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
OTHERWISE, DISPLAY RU-MEMBERS WHO MEET ONE OF THE
FOLLOWING CONDITIONS:
1. PERSON IS A NEW RU MEMBER THIS ROUND,
2. PERSON TURNED 65 YEARS OLD THIS ROUND AND IS
NOT FLAGGED AS COVERED BY MEDICARE DURING ANY
ROUND,
3. OR PERSON >= 65 (OR IN AGE CATEGORY 9) LAST
ROUND AND NOT FLAGGED AS COVERED BY MEDICARE
DURING ANY ROUND.
----------------------------------------------------
HX06
====
{STR-DT}
There are several large public health insurance
programs {with
similar names} that are easily confused.
Medicare is a health insurance program for persons 65
years or
over and for disabled persons. Other programs, such as
{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP
NAME}, are
state programs which cover low income families and
individuals
or children who do not have private health insurance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by
Medicare
usually have a card that looks like this.
At any time since (START DATE), has anyone in the
family been
covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
HELP AVAILABLE FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY ‘or Denali KidCare’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
ALASKA.
DISPLAY ‘or ALL Kids’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
ALABAMA.
DISPLAY ‘or KidsCare’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
ARIZONA.
DISPLAY ‘or ARKids First’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
ARKANSAS.
DISPLAY ‘or Healthy Families’ FOR ‘STATE CHIP
NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS CALIFORNIA.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or Child Health Plan Plus (CHP+)’ FOR
‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS COLORADO.
DISPLAY ‘or HUSKY’ FOR ‘STATE CHIP NAME’ IF STATE
IN WHICH INTERVIEW IS BEING CONDUCTED IS
CONNECTICUT.
DISPLAY ‘or DC Healthy Families’ FOR ‘STATE
CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS WASHINGTON, DC.
DISPLAY ‘or DE Healthy Children Program’ FOR
‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS DELAWARE.
DISPLAY ‘or Florida KidCare’ FOR ‘STATE CHIP
NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS FLORIDA.
DISPLAY ‘or PeachCare for Kids’ FOR ‘STATE CHIP
NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS GEORGIA.
DISPLAY ‘or QUEST’ FOR ‘STATE CHIP NAME’ IF STATE
IN WHICH INTERVIEW IS BEING CONDUCTED IS HAWAII.
DISPLAY ‘or hawk-i’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW
IS BEING CONDUCTED IS IOWA.
DISPLAY ‘or Children’s Health Insurance Program’
FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW
IS BEING CONDUCTED IS IDAHO.
DISPLAY ‘or All Kids’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
ILLINOIS.
DISPLAY ‘or Hoosier Healthwise’ FOR ‘STATE CHIP
NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS INDIANA.
DISPLAY ‘or Heathwave 21’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED
IS KANSAS.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or KY Children’s Hlth Insurance
Prgm (KCHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN
WHICH INTERVIEW IS BEING CONDUCTED IS KENTUCKY.
DISPLAY ‘or LaCHIP’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
LOUISIANA.
DISPLAY ‘or Maryland Children’s Health Program’
FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW
IS BEING CONDUCTED IS MARYLAND.
DISPLAY ‘or Children’s Medical Sec. Plan’
FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW
IS BEING CONDUCTED IS MASSACHUSETTS.
DISPLAY ‘or MIChild’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
MICHIGAN.
DISPLAY ‘or MO HealthNet for Kids’ FOR ‘STATE
CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS MISSOURI.
DISPLAY ‘or Children’s Health Insurance Program’
FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW
IS BEING CONDUCTED IS MISSISSIPPI.
DISPLAY ‘or Healthy Montana Kids Plan’ FOR ‘STATE
CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS MONTANA.
DISPLAY ‘or Kids Connection’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
NEBRASKA.
DISPLAY ‘or Nevada Check Up’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
NEVADA.
DISPLAY ‘or NH Healthy Kids’ FOR ‘STATE CHIP
NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS NEW HAMPSHIRE.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or NJ Family Care’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
NEW JERSEY.
DISPLAY ‘or New MexiKids’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
NEW MEXICO.
DISPLAY ‘or Child Health Plus (CHPlus)’ FOR
‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS NEW YORK.
DISPLAY ‘or NC Health Choice for Children’ FOR
‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS NORTH CAROLINA.
DISPLAY ‘or Healthy Steps’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
NORTH DAKOTA.
DISPLAY ‘or Healthy Start’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
OHIO.
DISPLAY ‘or PA Children’s Health Insurance
Program’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH
INTERVIEW IS BEING CONDUCTED IS PENNSYLVANIA.
DISPLAY ‘or RIte Care’ FOR ‘STATE CHIP
NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS RHODE ISLAND.
DISPLAY ‘or Healthy Connections Kids’ FOR ‘STATE
CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS SOUTH CAROLINA.
DISPLAY ‘or Children’s Health Insurance Program’
FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW
IS BEING CONDUCTED IS SOUTH DAKOTA.
DISPLAY ‘or CoverKids’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
TENNESSEE.
DISPLAY ‘or Children’s Health Insurance Program
(SCHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH
INTERVIEW IS BEING CONDUCTED IS TEXAS.
DISPLAY ‘or Children’s Health Insurance Program
(SCHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH
INTERVIEW IS BEING CONDUCTED IS UTAH.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or Dr. Dynasaur’ FOR ‘STATE CHIP NAME’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED
IS VERMONT.
DISPLAY ‘or FAMIS’ FOR ‘STATE CHIP NAME’ IF STATE
IN WHICH INTERVIEW IS BEING CONDUCTED IS VIRGINIA.
DISPLAY ‘or West Virginia Children’s Health
Insurance Program’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
WEST VIRGINIA.
DISPLAY ‘or BadgerCare’ FOR ‘STATE CHIP NAME’ IF
STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
WISCONSIN.
DISPLAY ‘or Wyoming Kid Care (CHIP)’ FOR ‘STATE
CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS WYOMING.
OTHERWISE (I.E., STATE IS ME, MN, OK, OR, WA)
DISPLAY ‘or State Children’s Health Insurance
Program’ FOR ‘STATE CHIP NAME.’
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘with similar names’ IF STATE IN WHICH
INTERVIEW IS BEING CONDUCTED USES ‘MEDICAID’ OR A
NAME SIMILAR TO MEDICARE (WHICH INCLUDES CA:
MEDI-CAL AND ME: MAINECARE).
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA LOUISIANA OHIO
ALABAMA MICHIGAN SOUTH CAROLINA
ARKANSAS MISSISSIPPI TEXAS
COLORADO MONTANA UTAH
DELAWARE NEBRASKA VERMONT
FLORIDA NEVADA VIRGINIA
GEORGIA NEW HAMPSHIRE WASHINGTON
IDAHO NEW JERSEY WEST VIRGINIA
ILLINOIS NEW MEXICO WISCONSIN
INDIANA NEW YORK
IOWA NORTH CAROLINA
KANSAS NORTH DAKOTA
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘Medical Assistance’ FOR ‘STATE NAME FOR
MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS ONE OF THE FOLLOWING:
CONNECTICUT MARYLAND RHODE ISLAND
DISTRICT OF COLUMBIA MINNESOTA SOUTH DAKOTA
HAWAII PENNSYLVANIA
DISPLAY ‘AZ Hlth Care Cost Containment System’
FOR ‘STATE NAME FOR MEDICAID’ IF STATE IN WHICH
INTERVIEW IS BEING CONDUCTED IS ARIZONA.
DISPLAY ‘Medi-Cal’ FOR ‘STATE NAME FOR MEDICAID’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
CALIFORNIA.
DISPLAY ‘KYHealth Choices’ FOR ‘STATE NAME FOR
MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS KENTUCKY.
DISPLAY ‘MaineCare’ FOR ‘STATE NAME FOR MEDICAID’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
MAINE.
DISPLAY ‘MassHealth’ FOR ‘STATE NAME FOR MEDICAID’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
MASSACHUSETTS.
DISPLAY ‘MO HealthNet’ FOR ‘STATE NAME FOR
MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS MISSOURI.
DISPLAY ‘OR Health Plan’ FOR ‘STATE NAME FOR
MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS OREGON.
DISPLAY ‘SoonerCare’ FOR ‘STATE NAME FOR MEDICAID’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
OKLAHOMA.
DISPLAY ‘TennCare’ FOR ‘STATE NAME FOR MEDICAID’
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS
TENNESSEE.
DISPLAY ‘EqualityCare’ FOR ‘STATE NAME FOR
MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING
CONDUCTED IS WYOMING.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘1’ (YES) AND SINGLE-PERSON RU, SELECT
PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO
LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED ‘1’ (YES) AND MULTI-PERSON RU, CONTINUE
WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW) AND ONE OR MORE RU MEMBER = > 65 YEARS OLD,
GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW) AND NO RU MEMBER = > 65 YEARS OLD, GO
TO BOX_12
----------------------------------------------------
HX07
====
{STR-DT}
{END-DT}
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65] {LOOP_04}
----------------------------------------------------
ROSTER DETAILS:
TITLE: RU_MEMBERS_SELECTONE
COL # 1 HEADER: PERSON-TYPE-PROVIDER
INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
ONE OR MORE FROM THE LISTED MEMBERS.
2. ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
IN ROUND 1, NONE. DISPLAY ALL.
IN ROUNDS 2-5, DISPLAY RU MEMBERS WHO MEET ONE OF
THE FOLLOWING CONDITIONS:
1. PERSON IS A NEW RU MEMBER THIS ROUND,
2. PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT
FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND,
3. OR PERSON >= 65 YEARS OLD (OR IN AGE CATEGORY
9) LAST ROUND AND NOT FLAGGED AS COVERED BY
MEDICARE DURING ANY ROUND.
----------------------------------------------------
LOOP_04
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK
BOX_09-END_LP04
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_04 DETERMINES IF REASON FOR
MEDICARE IS CONDITION/DISABILITY FOR PERSONS < 65
WHO RECEIVE MEDICARE AND COLLECTS SOCIAL SECURITY
STATUS FOR PERSONS = > 65 WHO ARE NOT COVERED BY
MEDICARE. THIS LOOP CYCLES ON PERSONS WHO MEET
ANY OF THE FOLLOWING CONDITIONS:
- IF ROUND 1: ALL CURRENT RU MEMBERS
- IF NOT ROUND 1: ALL CURRENT RU MEMBERS WHO
MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND,
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT
FLAGGED AS COVERED BY MEDICARE DURING ANY
ROUND
OR
- PERSON => 65 YEARS OLD (OR IN AGE CATEGORY 9)
LAST ROUND AND NOT FLAGGED AS COVERED BY
MEDICARE DURING ANY ROUND.
----------------------------------------------------
BOX_09
======
----------------------------------------------------
IF ROUND 1, GO TO BOX_11
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH BOX_10
----------------------------------------------------
BOX_10
======
----------------------------------------------------
IF PERSON ADDED THIS ROUND, CONTINUE WITH BOX_11
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR
‘-8’ (DON’T KNOW) AND RU MEMBER TURNED 65 THIS
ROUND, GO TO HX09
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP04
----------------------------------------------------
----------------------------------------------------
NOTE: HX09 IS NOT RE-ASKED OF PERSONS WHO WERE
OVER 65 DURING THE PREVIOUS ROUND AND DID NOT
RECEIVE MEDICARE AND WHO CONTINUE NOT RECEIVING
MEDICARE DURING THE CURRENT ROUND.
----------------------------------------------------
BOX_11
======
----------------------------------------------------
IF PERSON IS SELECTED AT HX07 AND IS < 65 YEARS
OLD (OR IN AGE CATEGORIES 1-8), CONTINUE WITH HX08
----------------------------------------------------
----------------------------------------------------
IF PERSON IS SELECTED AT HX07 AND IS = > 65 YEARS
OLD (OR IN AGE CATEGORY 9), GO TO END_LP04
----------------------------------------------------
----------------------------------------------------
IF PERSON IS NOT SELECTED AT HX07 AND IS < 65
YEARS OLD (OR IN AGE CATEGORIES 1-8), GO TO
END_LP04
----------------------------------------------------
----------------------------------------------------
IF PERSON IS NOT SELECTED AT HX07 AND IS = > 65
YEARS OLD (OR IN AGE CATEGORY 9), GO TO HX09
----------------------------------------------------
----------------------------------------------------
IF HX07 IS NOT ASKED (I.E., HX05 OR HX06 IS CODED
‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW))
AND PERSON IS < 65 YEARS OLD (OR IN AGE CATEGORIES
1-8), GO TO END_LP04
----------------------------------------------------
----------------------------------------------------
IF HX07 IS NOT ASKED (I.E., HX05 OR HX06 IS CODED
‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW))
AND PERSON IS = > 65 YEARS OLD (OR IN AGE CATEGORY
9), GO TO HX09
----------------------------------------------------
HX08
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
(Do/Does) (PERSON) receive Medicare because of
a medical
condition or a disability?
YES .................................... 1 {END_LP04}
NO ..................................... 2 {END_LP04}
REF ................................... -7 {END_LP04}
DK .................................... -8 {END_LP04}
HELP AVAILABLE FOR DEFINITION OF CONDITION/DISABILITY.
HX09
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
People with Social Security usually get Medicare.
(Do/Does)
(PERSON) receive Social Security?
YES .................................... 1 {END_LP04}
NO ..................................... 2 {END_LP04}
REF ................................... -7 {END_LP04}
DK .................................... -8 {END_LP04}
HELP AVAILABLE FOR DEFINITION OF SOCIAL SECURITY.
END_LP04
========
----------------------------------------------------
CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION
----------------------------------------------------
----------------------------------------------------
IF NO MORE PERSONS MEET THE STATED CONDITIONS,
END LOOP_04 AND CONTINUE WITH BOX_12
----------------------------------------------------
BOX_12
======
----------------------------------------------------
IF MEDICAID/SCHIP PROVIDED TO ANY RU MEMBER
DURING THE PREVIOUS ROUND, GO TO BOX_14
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH BOX_12A
----------------------------------------------------
BOX_12A
=======
----------------------------------------------------
IF GOVT-HOSPITAL/PHYSICIAN IS A SOURCE OF
INSURANCE FOR ANY RU MEMBER DURING THE CURRENT
ROUND, GO TO BOX_14
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH HX10
----------------------------------------------------
HX10
====
{STR-DT}
{END-DT}
{Some people are covered by programs called {Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME}.
These are state
programs for low income families and individuals or
children
who do not have private health insurance. They
sometimes
cover persons with very large medical bills or those
in
nursing homes.}
{SHOW CARD HX-3.}
{People covered by {Medicaid/{STATE NAME FOR
MEDICAID}} or
{STATE CHIP NAME} usually have a (piece of
paper/card) that
looks something like this.}
{During the last interview, we recorded that no one in
the
family was covered by {Medicaid/{STATE NAME FOR
MEDICAID}} or
{STATE CHIP NAME}.}
Has anyone in the family been covered by
{Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME} at any time {since
(START
DATE)/between (START DATE) and (END DATE)}?
YES .................................... 1
NO ..................................... 2 {BOX_14}
REF ................................... -7 {BOX_14}
DK .................................... -8 {BOX_14}
HELP AVAILABLE FOR DEFINITION OF MEDICAID/SCHIP.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH (‘Some .... homes.’) ONLY
IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO
SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO
MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES
EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING
CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH (‘During... CHIP NAME}}.’)
ONLY IF NOT ROUND 1. 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 REAL
STATE NAME FOR PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
SUBSTITUTING THE REAL NAME FOR PROGRAM. FOR THE
SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘1’ (YES) AND SINGLE-PERSON RU, SELECT
PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED ‘1’ (YES) AND MULTI-PERSON RU, CONTINUE
WITH HX11
----------------------------------------------------
HX11
====
{STR-DT}
{END-DT}
Who is covered by {Medicaid/{STATE NAME FOR
MEDICAID}} or
{STATE CHIP NAME}?
PROBE: Who else is covered by {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]
-----------------------------------------------------
DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL
STATE NAME FOR PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
-----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
SUBSTITUTING THE REAL NAME FOR PROGRAM. FOR THE
SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: RU_MEMBERS_1
COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
FROM THE LISTED MEMBERS.
2. ADD, DELETE, AND EDIT DISALLOLWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
NONE, DISPLAY ALL.
----------------------------------------------------
LOOP_05
=======
-----------------------------------------------------
FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK BOX_13 - END_LP05
-----------------------------------------------------
-----------------------------------------------------
LOOP DEFINITION: LOOP_05 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY MEDICAID/
SCHIP. THIS LOOP CYCLES ON ESTABLISHMENT-PERSON-
PAIRS THAT MEET THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS MEDICAID/SCHIP
AND
- PERSON IS FLAGGED AS COVERED BY MEDICAID/SCHIP
DURING THE CURRENT ROUND (I.E., SELECTED IN
HX11)
-----------------------------------------------------
BOX_13
======
-----------------------------------------------------
ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PERSON.
-----------------------------------------------------
-----------------------------------------------------
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_14
----------------------------------------------------
BOX_14
======
----------------------------------------------------
IF TRICARE/CHAMPVA PROVIDED TO ANY RU MEMBER
DURING THE PREVIOUS ROUND, GO TO BOX_16
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH HX12
----------------------------------------------------
HX12
====
{STR-DT}
{END-DT}
{During the last interview, we recorded that no one in
the
family was covered by TRICARE or CHAMPVA.}
At any time {since (START DATE)/between (START DATE)
and
(END DATE)}, has anyone in the family been covered by
TRICARE
or CHAMPVA?
YES .................................... 1 {HX12A}
NO ..................................... 2 {BOX_16}
REF ................................... -7 {BOX_16}
DK .................................... -8 {BOX_16}
HELP AVAILABLE FOR DEFINITION OF TRICARE/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH (‘During .... TRICARE or
CHAMPVA.’) IF NOT ROUND 1. OTHERWISE, USE A
NULL DISPLAY.
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
HX12A
=====
{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
[Code All That Apply]
----------------------------------------------------
IF HX12 IS CODED ‘1’ (YES) AND SINGLE-PERSON RU,
SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND
GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF HX12 IS CODED ‘1’ (YES) AND MULTI-PERSON RU,
CONTINUE WITH HX13
----------------------------------------------------
HX13
====
{STR-DT}
{END-DT}
Who is covered by TRICARE or CHAMPVA?
PROBE: Who else is covered by TRICARE or CHAMPVA?
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
Title: RU_MEMBERS_1
COL #1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE
AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR SELECTION
OF RU-MEMBERS.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
FROM THE LISTED MEMBERS.
2. ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
NONE, DISPLAY ALL.
----------------------------------------------------
LOOP_06
=======
----------------------------------------------------
FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK BOX_15-END_LP06
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_06 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY TRICARE
OR CHAMPVA. THIS LOOP CYCLES ON ESTABLISHMENT-
PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS TRICARE/CHAMPVA
AND
- PERSON IS FLAGGED AS COVERED BY TRICARE/CHAMPVA
DURING THE CURRENT ROUND (I.E., SELECTED AT
HX13)
----------------------------------------------------
BOX_15
======
----------------------------------------------------
ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PERSON.
----------------------------------------------------
----------------------------------------------------
AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP06
----------------------------------------------------
END_LP06
========
----------------------------------------------------
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_06 AND CONTINUE WITH BOX_16
----------------------------------------------------
BOX_16
======
----------------------------------------------------
IF MEDICAID/SCHIP IS A SOURCE OF INSURANCE FOR
ANY RU MEMBER DURING CURRENT ROUND, GO TO BOX_19
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH BOX_17
----------------------------------------------------
BOX_17
======
----------------------------------------------------
IF GOVT-HOSPITAL/PHYSICIAN PROVIDED TO ANY RU
MEMBER DURING THE PREVIOUS ROUND, GO TO BOX_19
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH HX14
----------------------------------------------------
HX14
====
{STR-DT}
{END-DT}
{During the last interview, we recorded that no one in
the
family was covered by any other state sponsored
program which
provided hospital and physician benefits.}
At any time {since (START DATE)/between (START DATE)
and
(END DATE)}, has anyone in the family had any other
type of health
insurance obtained through any state or local
government agency
which provided hospital and physician benefits?
YES .................................... 1 {HX14A}
NO ..................................... 2 {BOX_19}
REF ................................... -7 {BOX_19}
DK .................................... -8 {BOX_19}
HELP AVAILABLE FOR DESCRIPTION OF INSURANCE TYPES TO
INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH (‘During .... benefits.’)
IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
HX14A
=====
{STR-DT}
What is the name of the plan?
[Enter text] ...........................
----------------------------------------------------
NOTE: ‘GOVT-HOSPITAL/PHYSICIAN’ SHOULD BE USED
FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER
(WHERE APPROPRIATE).
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED ‘1’ (YES) AND SINGLE-PERSON RU,
SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND
GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED ‘1’ (YES) AND MULTI-PERSON RU,
CONTINUE WITH HX15
----------------------------------------------------
HX15
====
{STR-DT}
{END-DT}
Who is covered by a program sponsored by a state or
local
government agency which provided hospital and
physician
benefits?
PROBE: Who else is covered by a program sponsored by a
state
or local government agency which provided 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]
----------------------------------------------------
GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: RU_MEMBERS_1
COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
FROM THE LISTED MEMBERS.
2. ADD, DELETE, AND EDIT DISALLOLWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
NONE, DISPLAY ALL.
----------------------------------------------------
LOOP_07
=======
----------------------------------------------------
FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK BOX_18-END_LP07
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_07 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY GOVT-
HOSPITAL/PHYSICIAN. THIS LOOP CYCLES ON
ESTABLISHMENT-PERSON-PAIRS THAT MEET THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN
AND
- PERSON IS FLAGGED AS BEING COVERED BY GOVT-
HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND
(I.E., SELECTED AT HX15)
----------------------------------------------------
BOX_18
======
----------------------------------------------------
ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PERSON.
----------------------------------------------------
----------------------------------------------------
AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP07
----------------------------------------------------
END_LP07
========
----------------------------------------------------
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_07 AND CONTINUE WITH BOX_19
----------------------------------------------------
BOX_19
======
----------------------------------------------------
IF ANY TYPE OF OTHER PUBLIC INSURANCE PROVIDED TO
ANY RU MEMBER AT ANY TIME DURING THE PREVIOUS
ROUND, GO TO HX21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH HX16
----------------------------------------------------
HX16
====
{STR-DT}
{END-DT}
{During the last interview, we recorded that no one in
the
family/Some people} receive{d} health benefits from
other state
programs such as (READ PROGRAM NAMES BELOW) or other
public
programs that provide coverage for health care
services.
{STATE NAME FOR PROGRAM #1..................}
{STATE NAME FOR PROGRAM #2..................}
{STATE NAME FOR PROGRAM #3..................}
{STATE NAME FOR PROGRAM #4..................}
At any time {since (START DATE)/between (START DATE)
and (END
DATE)}, has anyone in the family been covered by any
program like
this?
YES .................................... 1 {LOOP_08}
NO ..................................... 2 {HX21}
REF ................................... -7 {HX21}
DK .................................... -8 {HX21}
HELP AVAILABLE FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY ‘During the last interview, we recorded
that no one in the family’ AND THE ‘d’ ON
‘receive’ IF NOT ROUND 1. OTHERWISE, DISPLAY
‘Some people’.
DISPLAY THE LIST OF UP TO FOUR ACTUAL NAMES OF
STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR ‘STATE
NAME FOR PROGRAM #N’ IF STATE HAS OTHER STATE
PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALASKA Chronic and Acute Medical
Assistance
AK AIDS Drug Assistance Program
AK Breast and Cervical Health Check
Senior Benefits Program
ALABAMA Senior Rx
AL AIDS Drug Assistance Program
(ADAP)
Breast/Cervical Cancer Early Detect
Alabama Perinatal Hepatitis B Prog
ARIZONA CoppeRx Card
Non-Renal Transplant Medication
Prgm
AZ AIDS Drug Assistance Program
Well Woman HealthCheck Program
ARKANSAS Arkansas Kidney Disease Commission
AR AIDS Drug Assistance Program
Breast Care
CALIFORNIA AIDS Drug Assistance Program
CA Discount Rx Drug Program
Cancer Detection Programs: Every
Woman Counts
COLORADO Colorado Indigent Care Program
Women’s Wellness Connection
CO AIDS Drug Assistance Program
CONNECTICUT ConnPACE
CT AIDS Drug Assistance Program
Healthy Start
Breast/Cervical Cancer Early
Detect.
DELAWARE DE Prescription Assistance Program
DE AIDS Drug Assistance Program
Chronic Renal Disease Program
Breast and Cervical Cancer Program
DISTRICT OF
COLUMBIA DC AIDS Drug Assistance Program
Breast/Cervical Cancer Early
Detect.
FLORIDA AIDS Drug Assistance Program
Breast/Cervical Cancer Early
Detect.
Positive Healthcare
Florida Discount Drug Card Program
GEORGIA AIDS Drug Assistance Program
Cancer Screening Program
----------------------------------------------------
----------------------------------------------------
HAWAII HIV Drug Assistance Program
Breast/Cervical Cancer Control Pgrm
Hawaii Rx Plus
IDAHO ID AIDS Drug Assistance Program
Family Support 360 Project
Women’s Health Check
Rx Idaho
ILLINOIS Chronic Renal Disease Program
IL Breast and Cervical Cancer
Program
IL AID Drug Assistance Program
Illinois Cares Rx
INDIANA Hoosier Rx
Children’s Special Hlth Care
Service
IN AIDS Drug Assistance Program
IN Breast and Cervical Cancer
Program
IOWA AIDS Drug Assistance Program
Care for Yourself BCCED Pgrm
KANSAS MediKan
KS AIDS Drug Assistance Program
Early Detection Works Program
KENTUCKY KY AIDS Drug Assistance Program
Kentucky Rx Drug Assistance Prgm
KY Women’s Cancer Screening
Program
LOUISIANA Breast and Cervical Cancer
Screening Program
LA AIDS Drug Assistance Program
MAINE Maine AIDS Drug Assistance Program
Maine Breast and Cervical Health
Program
Drugs for the Elderly
Medical Eye Care
MARYLAND Kidney Disease Program
MD AIDS Drug Assistance Program
Breast/Cervical Cancer Early
Detect.
Maryland Primary Adult Care Program
MASSACHUSETTS Prescription Advantage Plan
MA HIV Drug Assistance Program
Women’s Health Network
MICHIGAN MiRx Card
Adult Medical Program
MI Rx Prescription Savings Program
Breast/Cervical Cancer Control
Prgm
----------------------------------------------------
----------------------------------------------------
MINNESOTA MN AIDS Drug Assistance
Program
Sage Screening Program
MISSISSIPPI MS AIDS Drug Assistance Program
Breast/Cervical Cancer Early
Detect.
First Steps: Early Intervention
Program
MISSOURI MO AIDS Drug Assistance Program
Show Me Healthy Women
Extended Women’s Health
MoRx
MONTANA End-Stage Renal Disease Program
MT AIDS Drug Assistance Program
MT Breast and Cervical Health
Program
The Mental Health Services Plan
NEBRASKA Chronic Renal Disease Program
NE AIDS Drug Assistance Program
Every Woman Matters Program
NEW HAMPSHIRE Catastrophic Illness Program
Ryan White CARE Program
Let No Woman Be Overlooked
NEVADA Senior Rx
NV AIDS Drug Assistance Program
Women’s Health Connection Program
Children w/Special Hlth Care Needs
NEW JERSEY Rx Assist. for the Aged and
Disabled
NJ AIDS Drug Distribution Program
End Stage Renal Disease Ptnt
Assist.
NJ Cancer Education/Early Detection
NEW MEXICO NM AIDS Drug Assistance Program
Family Infant Toddler Program
Breast/Cervical Cancer Early
Detect.
Discount Prescription Drug Program
NEW YORK Elderly Pharmaceutical Insurance
Coverage Program
APIC
NY AIDS Drugs Assistance Program
Cancer Services Prgm Partnerships
NORTH
CAROLINA State Kidney Program
Breast/Cervical Cancer Control
Prgm
School Health Fund
Sickle Cell Syndrome Program
----------------------------------------------------
----------------------------------------------------
NORTH DAKOTA Women’s Way
ND AIDS Drug Assistance Program
Health Tracks
Children’s Special Health Services
OHIO OH Disability Assist Medical Prgm
Ohio HIV Drug Assistance Program
Ohio’s Best Rx Discount Card
Breast and Cervical Cancer Project
OKLAHOMA HIV Drug Assistance Program
Take Charge!
Oklahoma Family Planning Program
OREGON CAREAssit/AIDS Drug Assist Prgm
Senior Rx Drug Assist Prgm
OR Breast/Cervical Cancer Program
PENNSYLVANIA Special Pharmaceutical Benefits
Prgm
Pharma. Assist Contract for
Elderly
The Healthy Woman Program
Chronic Renal Disease Program
RHODE ISLAND General Public Assistance Program
RI Pharma. Assist to the Elderly
RI AIDS Drug Assistance Program
RI Women’s Cancer Screening Prgm
SOUTH
CAROLINA Best Chance Network
Gap Assist. Pharmacy Prog for
Seniors
Medically Indigent Assistance Prog.
Family Planning Program
SOUTH DAKOTA SD Chronic Renal Disease Program
All Women Count! Program
Rx Access
AIDS Drug Assistance Program
TENNESSEE Tennessee Renal Disease Program
Breast/Cervical Cancer Screen
Prgm
CoverRx
HIV Drug Assistance Program
TEXAS Kidney Health Care Program
Texas HIV Medication Program
Breast and Cervical Cancer Services
Children w/Special Hlth Care Needs
UTAH Children w/Special Hlth Care Needs
Utah AIDS Drug Assistance Program
Utah Cancer Control Program
Primary Care Network of Utah
----------------------------------------------------
----------------------------------------------------
VIRGINIA VA AIDS Drug Assistance Program
Every Woman’s Life
Child Development Services Program
State/Local Hospitalization
Program
VERMONT Ladies First
VT End Stage Renal Disease Program
General Assistance
Vpharm
WASHINGTON WA State Kidney Disease Program
Early Intervention Program
WA Breast and Cervical Health
Program
General Assistance
WEST VIRGINIA WV AIDS Drug Assistance Program
Children w/Special Hlth Care Needs
WV Breast/Cervical Cancer Scrng
Pgrm
Right from the Start Project
WISCONSIN WI Sr. Care Rx Drug Assistance
Program
WI AIDS Drug Assistance Program
WI Chronic Renal Disease Program
Well-Woman Program
WYOMING Prescription Drug Assistance
Program
WY HIV/AIDS/Hepatitis Program
WY End Stage Renal Disease Program
Breast/Cervical Cancer Early
Detect.
----------------------------------------------------
LOOP_08
=======
----------------------------------------------------
For each of the following:
GROUP 1
GROUP 2
ask BOX_20-END_LP08
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_08 COLLECTS INFORMATION ON
OTHER STATE OR PUBLIC PROGRAMS. THE FIRST CYCLE
OF THIS LOOP COLLECTS GROUP 1 OTHER PUBLIC
INSURANCE PROGRAMS OR, IF NO GROUP 1, GROUP 2
OTHER PUBLIC INSURANCE PROGRAMS.
THIS LOOP CAN CYCLE A MAXIMUM OF TWICE. THE
SUBSEQUENT CYCLE OF THE LOOP IS DETERMINED BY THE
RESPONSE AT HX20. IF HX20 IS CODED ‘1’ (YES),
THE LOOP CYCLES AGAIN TO COLLECT GROUP 2 PUBLIC
INSURANCE INFORMATION. IF HX20 IS CODED ‘2’ (NO),
‘-7’ (REFUSED), ‘-8’ (DON’T KNOW), OR IS NOT
ASKED, THE LOOP ENDS.
----------------------------------------------------
BOX_20
======
----------------------------------------------------
IF FIRST CYCLE OF LOOP_08, CONTINUE WITH HX17
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF SECOND CYCLE OF LOOP_08), GO
TO HX18
----------------------------------------------------
HX17
====
{STR-DT}
{END-DT}
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY TANF, SSI, WIC, IHS, PUBLIC HEALTH
CLINIC, OR VA
IS MENTIONED, CODE 95.
{STATE SPECIFIC PLAN 1} ................ 1
{STATE SPECIFIC PLAN 2} ................ 2
{STATE SPECIFIC PLAN 3} ................ 3
{STATE SPECIFIC PLAN 4} ................ 4
OTHER ................................. 91 {HX17OV}
NONE OF THESE ......................... 95 {HX18}
REF ................................... -7 {BOX_21}
DK .................................... -8 {BOX_21}
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR ‘STATE SPECIFIC PLAN N’, DISPLAY AN ACTUAL
NAME OF A STATE PLAN WHEN INTERVIEW IS BEING
CONDUCTED IN A STATE THAT HAS OTHER STATE
PROGRAMS. FOR THE SPECIFIC NAMES OF PROGRAMS BY
STATE, SEE BOX ON HX16.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED
ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, AND ‘6’ ARE
RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE
HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER
CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC
PLANS, CODES WOULD START WITH ‘91’ AT HX17 OR ‘7’
AT HX18.)
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED ‘95’ (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
----------------------------------------------------
HARD CHECK:
EDIT: CODE ‘95’ (NONE OF THESE) CANNOT BE ENTERED
WITH ANY OTHER CODES. IF CODED ‘95’ (NONE OF
THESE) WITH ANY OTHER CODES, DISPLAY THE
FOLLOWING MESSAGE: "95 CANNOT BE CODED WITH ANY
OTHER RESPONSES. VERIFY AND RE-ENTER. CONTINUE."
----------------------------------------------------
HX17OV
======
OTHER:
[Enter Other Specify] .................. {BOX_21}
REF ................................... -7 {BOX_21}
DK .................................... -8 {BOX_21}
HX18
====
{STR-DT}
{END-DT}
What is the name of the program?
PROBE: Any other state program?
TANF (TEMPORARY ASSISTANCE FOR NEEDY
FAMILIES) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7 {END_LP08}
DK .................................... -8 {END_LP08}
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A
GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN
ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT-
HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED ‘7’ (TANF), ‘8’ (SSI), OR ‘9’
(WIC), ALONE OR WITH ANY OTHER COMBINATION OF
CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
BOX_21
======
----------------------------------------------------
IF SINGLE-PERSON RU, SELECT PERSON AT HX19
AUTOMATICALLY BY CAPI AND GO TO LOOP_09
----------------------------------------------------
----------------------------------------------------
IF MULTI-PERSON RU, CONTINUE WITH HX19
----------------------------------------------------
HX19
====
{STR-DT}
{END-DT}
PROGRAM:
{STATE PROGRAM PROVIDING COVERAGE}
{STATE PROGRAM PROVIDING COVERAGE}
{STATE PROGRAM PROVIDING COVERAGE}
{STATE PROGRAM PROVIDING COVERAGE}
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED
AT HX17. IF COMING FROM HX18, DISPLAY ALL
PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: RU_MEMBERS_1
COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION OF RU MEMBERS.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT
FROM THE LISTED MEMBERS.
2. ADD, DELETE, AND EDIT DISALLOLWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
NONE, DISPLAY ALL.
----------------------------------------------------
LOOP_09
=======
----------------------------------------------------
FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS ROSTER, ASK BOX_22-END_LP09
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_09 COLLECTS TIME PERIOD
COVERAGE DETAIL FOR RU MEMBERS COVERED BY OTHER
PUBLIC PROGRAMS. THIS LOOP CYCLES ON ESTABLISHMENT
-PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS GROUP 1 OR GROUP 2 OTHER
PUBLIC PROGRAM
AND
- PERSON IS FLAGGED AS BEING COVERED BY GROUP 1
OR GROUP 2 OTHER PUBLIC PROGRAM DURING THE
CURRENT ROUND (I.E., SELECTED IN HX19)
----------------------------------------------------
----------------------------------------------------
IF FIRST TIME THROUGH LOOP_08 AND HX17 IS NOT
CODED ‘95’ (NONE OF THESE), THIS LOOP CYCLES ON A
ESTABLISHMENT-PERSON-PAIR WHERE ESTABLISHMENT IS A
GROUP 1 OTHER PUBLIC PROGRAM.
----------------------------------------------------
----------------------------------------------------
IF HX17 IS CODED ‘95’ (NONE OF THESE) OR IF SECOND
CYCLE OF LOOP_08, THEN THE ESTABLISHMENT IS A
GROUP 2 OTHER PUBLIC PROGRAM.
----------------------------------------------------
BOX_22
======
----------------------------------------------------
ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION
FOR THIS PERSON.
----------------------------------------------------
----------------------------------------------------
AT COMPLETION OF THE HQ SECTION, CONTINUE WITH
END_LP09
----------------------------------------------------
END_LP09
========
----------------------------------------------------
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_09 AND CONTINUE WITH BOX_23
----------------------------------------------------
BOX_23
======
----------------------------------------------------
IF HX17 IS CODED ‘95’ (NONE OF THESE) OR IF ON
SECOND CYCLE OF LOOP_08, GO TO END_LP08
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH HX20
----------------------------------------------------
HX20
====
{STR-DT}
{END-DT}
Are there any other state programs that provide
coverage for
health care services to anyone else in the family?
YES .................................... 1 {END_LP08}
NO ..................................... 2 {END_LP08}
REF ................................... -7 {END_LP08}
DK .................................... -8 {END_LP08}
END_LP08
========
----------------------------------------------------
IF HX20 IS CODED ‘1’ (YES), CYCLE TO COLLECT GROUP
2 PUBLIC INSURANCE INFORMATION.
----------------------------------------------------
----------------------------------------------------
IF HX20 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), ‘-8’
(DON’T KNOW), OR IS NOT ASKED, END LOOP_08 AND
CONTINUE WITH HX21
----------------------------------------------------
HX21
====
{STR-DT}
{END-DT}
Next, I have some questions about other sources of
health
insurance anyone in the family may have had {since
(START
DATE)/between (START DATE) and (END DATE)} to help pay
hospital
and doctor bills and other health expenses such as
nursing home
care or prescribed medicines. {This includes Medigap
or
Medicare Supplements, plans through a private
insurance carrier,
which some people who are eligible for Medicare have
as
additional coverage.}
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
----------------------------------------------------
DISPLAY ‘This includes...coverage.’ IF ANYONE IN
RU HAS MEDICARE AS A SOURCE OF INSURANCE DURING
THE CURRENT ROUND.
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
HX22
====
{STR-DT}
{END-DT}
SHOW CARD HX-4.
Please look at this card. It lists various ways people
can
obtain health insurance.
{Not counting insurance you already told me about,
at/At} any
time {since (START DATE)/between (START DATE) and (END
DATE)},
was anyone in the family covered by health insurance
from any
{other} source, such as those listed on the card?
YES .................................... 1 {LOOP_10}
NO ..................................... 2 {BOX_25}
REF ................................... -7 {BOX_25}
DK .................................... -8 {BOX_25}
HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
DISPLAY ‘Not counting insurance you already told
me about, at’ AND ‘other’ IF ANY SOURCES OF
INSURANCE ARE RECORDED FOR THIS RU.
IF NO SOURCES OF INSURANCE ARE RECORDED FOR THIS
RU, DISPLAY ‘At’.
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
LOOP_10
=======
----------------------------------------------------
For each of the following:
PRIVATELY PURCHASED INSURANCE CATEGORY 1
PRIVATELY PURCHASED INSURANCE CATEGORY 2
PRIVATELY PURCHASED INSURANCE CATEGORY 3
PRIVATELY PURCHASED INSURANCE CATEGORY 4
PRIVATELY PURCHASED INSURANCE CATEGORY 5
PRIVATELY PURCHASED INSURANCE CATEGORY 6
ask HX23 - END_LP10
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_10 COLLECTS INFORMATION
ABOUT PRIVATELY PURCHASED HEALTH INSURANCE
OBTAINED FROM SOURCES OTHER THAN EMPLOYERS
MENTIONED IN THE EMPLOYMENT SECTION OF THE
INTERVIEW. THIS LOOP CYCLES ON SOURCES OF
PRIVATELY PURCHASED INSURANCE LISTED AT HX23. THE
first cycle of this loop collects the first source
OF privately purchased insurance. Subsequent
cycles of the loop are determined by tHE RESPONSE
at HX24. If HX24 is coded ‘1’ (YES), the loop
cycles again to collect the next source of
privately purchased insurance. if hx24 is coded
‘2’ (no), ‘-7’ (refused), or ‘-8’ (don’t know),
the loop ends.
----------------------------------------------------
HX23
====
{STR-DT}
{END-DT}
SHOW CARD HX-4.
From which of the sources on this card did anyone in
the family
purchase health insurance?
FROM A GROUP OR ASSOCIATION .............. 1 {BOX_24}
DIRECTLY THROUGH A SCHOOL ................ 3 {BOX_24}
DIRECTLY FROM AN INSURANCE AGENT ......... 4 {BOX_24}
DIRECTLY FROM INSURANCE COMPANY .......... 5 {BOX_24}
DIRECTLY FROM AN HMO ..................... 6 {BOX_24}
FROM A UNION ............................. 7 {BOX_24}
FROM ANYONE’S PREVIOUS EMPLOYER (COBRA) .. 8 {BOX_24}
FROM ANYONE’S PREVIOUS EMPLOYER
(NOT COBRA) ............................ 9 {BOX_24}
FROM SPOUSE’S/DECEASED SPOUSE’S PREVIOUS
EMPLOYER .............................. 10 {BOX_24}
FROM SOME OTHER EMPLOYER ................ 11 {BOX_24}
UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 {BOX_24}
OTHER SOURCE ............................ 91 {HX23OV}
REF ..................................... -7 {BOX_24}
DK ...................................... -8 {BOX_24}
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
STARTING IN PANEL 12 ROUND 2, CATEGORY ‘2’ (FROM
A HEALTH INSURANCE PURCHASING ALLIANCE) WAS
OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
DISPLAY AN ‘ADD OTHER SOURCE’ BUTTON ON THIS
SCREEN.
----------------------------------------------------
----------------------------------------------------
IF ‘ADD OTHER SOURCE’ IS SELECTED, PRESENT ‘ADD
OTHER SOURCE’ POP-UP (HX23OV) AND THEN GO TO
BOX_24.
----------------------------------------------------
HX23OV
======
ENTER OTHER:
[Enter Other Specify] ..................
REF .................................... -7
DK ..................................... -8
BOX_24
======
----------------------------------------------------
ask private HEALTH INSURANCE detail (HP) SECTION
for the response category selected at hx23 AND
FLAGGED THIS ROUND AS PROVIDING HEALTH INSURANCE.
----------------------------------------------------
----------------------------------------------------
at COMPLETION of THE hp SECTION, continue with
hx24
----------------------------------------------------
HX24
====
{STR-DT}
{END-DT}
SHOW CARD HX-4.
Aside from what you already told me about, at any time
{since
(START DATE)/between (START DATE) and (END DATE)}, was
anyone in
the family covered by health insurance from any other
source
listed on this card?
PROBE: Please include any type of health insurance
anyone in
the family is covered by which has not been discussed
yet. This
includes health insurance that was obtained from a
source not
listed on this card.
YES .................................... 1 {END_LP10}
NO ..................................... 2 {END_LP10}
REF ................................... -7 {END_LP10}
DK .................................... -8 {END_LP10}
HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
DISPLAY ‘since (START DATE)’ IF NOT ROUND 5.
DISPLAY ‘between (START DATE) and (END DATE)’ IF
ROUND 5.
----------------------------------------------------
END_LP10
========
----------------------------------------------------
If HX24 is coded ‘1’ (YES), cycle to collect the
next insurance category.
----------------------------------------------------
----------------------------------------------------
Otherwise end LOOP_10, and continue with BOX_25
----------------------------------------------------
BOX_25
======
----------------------------------------------------
IF NO PUBLIC OR PRIVATE INSURANCE RECORDED FOR ANY
CURRENT RU MEMBER, GO TO BOX_45
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH BOX_26
----------------------------------------------------
BOX_26
======
----------------------------------------------------
IF ANY RU MEMBER HAS MEDICARE AS A SOURCE OF
INSURANCE DURING THE CURRENT ROUND, CONTINUE WITH
BOX_27
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_29
----------------------------------------------------
BOX_27
======
----------------------------------------------------
IF ROUND 1, GO TO LOOP_11
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH BOX_28
----------------------------------------------------
BOX_28
======
----------------------------------------------------
IF NOT ROUND 1, CONTINUE WITH LOOP_11 ONLY FOR RU
MEMBERS WHERE MEDICARE WAS RECORDED AS BEING
RECEIVED THIS ROUND. THAT IS, CONTINUE WITH
LOOP_11 ONLY IF THERE IS AT LEAST ONE
ESTABLISHMENT-PERSON-PAIR WHERE THE ESTABLISHMENT
IS MEDICARE AND THE PAIR WAS CREATED THIS ROUND.
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_29
----------------------------------------------------
LOOP_11
=======
----------------------------------------------------
FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER, ASK HX25-END_LP11
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_11 COLLECTS MEDICARE CARD
AND MANAGED CARE INFORMATION FOR RU MEMBERS
COVERED BY MEDICARE. THIS LOOP CYCLES ON
ESTABLISHMENT-PERSON-PAIRS THAT MEET THE FOLLOWING
CONDITIONS:
IF ROUND 1:
- ESTABLISHMENT IS MEDICARE
AND
- PERSON IS AN RU MEMBER FLAGGED AS COVERED BY
MEDICARE DURING THE ROUND
IF NOT ROUND 1:
- ESTABLISHMENT IS MEDICARE
AND
- PERSON IS AN RU MEMBER
AND
- ESTABLISHMENT-PERSON-PAIR WAS CREATED THIS ROUND
----------------------------------------------------
HX25
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
CODE WITHOUT ASKING IF ANSWER IS KNOWN.
May I please see (PERSON)’s Medicare card?
IF NECESSARY, SAY: We do not need (PERSON)’s Medicare
number, but
would like to record the exact date (PERSON)’s
Medicare coverage
became effective and what type of coverage (PERSON)
has through
Medicare.
CARD AVAILABLE ......................... 1 {HX26}
CARD NOT AVAILABLE ..................... 2 {HX28A}
REF ................................... -7 {HX28A}
DK .................................... -8 {HX28A}
[Code One]
----------------------------------------------------
STARTING IN PANEL 13 ROUND 1/PANEL 12 ROUND 3,
CAPI NO LONGER COLLECTS MEDICARE NUMBERS (SSN).
----------------------------------------------------
HX26
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
INTERVIEWER:
CODE MEDICARE CARD(S) SHOWN/AVAILABLE.
MEDICARE CARD (RED, WHITE AND BLUE) .... 1
RAILROAD RETIREMENT BOARD CARD (RED,
WHITE AND BLUE) ........................ 2
SOME OTHER CARD ........................ 3
[Code All That Apply]
----------------------------------------------------
NOTE: INTERVIEWERS WILL BE TRAINED TO CODE ANY
TYPE OF MANAGED CARE CARD COLLECTED HERE AS SOME
OTHER CARD.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘1’ (MEDICARE CARD) OR ‘2’ (RAILROAD
RETIREMENT BOARD CARD), CONTINUE WITH HX27
----------------------------------------------------
----------------------------------------------------
IF CODED ‘3’ (SOME OTHER CARD) ONLY, GO TO HX28A
----------------------------------------------------
HX27
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
INTERVIEWER:
RECORD THE FOLLOWING INFORMATION FROM THE CARD:
EFFECTIVE DATE:
[Enter Month,Day,Year-4]
TYPE OF COVERAGE (IS ENTITLED TO):
HOSPITAL ONLY .......................... 1
MEDICAL AND HOSPITAL ................... 2
MEDICAL ONLY ........................... 3
[Code One]
----------------------------------------------------
STARTING IN PANEL 13, ROUND 1/PANEL 12, ROUND 3,
CAPI NO LONGER COLLECTS MEDICARE NUMBERS (SSN).
----------------------------------------------------
----------------------------------------------------
GO TO BOX_28A
----------------------------------------------------
----------------------------------------------------
HARD CHECK:
CHECK EFFECTIVE DATE. DATE MUST BE ON OR BEFORE
(I.E., < OR =) THE INTERVIEW DATE. IF EFFECTIVE
DATE IS ON OR BEFORE JANUARY 1, {YEAR}, WHERE
‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL,
FLAG RU MEMBER AS ‘WITH HEALTH INSURANCE COVERAGE
ON JAN 1, {YEAR}’.
----------------------------------------------------
----------------------------------------------------
SOFT RANGE CHECK: MEDICARE EFFECTIVE DATE MUST
BE = OR > BIRTH DATE OF PERSON.
----------------------------------------------------
HX28
=====
OMITTED.
HX28A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Part A of Medicare covers most hospital expenses. Part
B covers
many doctors’ expenses, including doctor visits, and
the premium
is usually deducted from (PERSON)’s Social Security.
(Are/Is) (PERSON) covered under Part B of Medicare?
YES ................................... 1 {HX29}
NO .................................... 2 {HX29}
REF ................................... -7 {HX29}
DK .................................... -8 {HX29}
HX29
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
When did (PERSON)’s Medicare coverage start?
[Enter Month,Year-4] .................. {HX30}
REF ................................... -7 {HX29OV}
DK .................................... -8 {HX29OV}
----------------------------------------------------
IF EFFECTIVE DATE IS:
- A VALID DATE (I.E., NOT ‘RF’ (REFUSED) OR ‘DK’
(DON’T KNOW) IN THE MONTH OR YEAR FIELDS
AND
- ON OR BEFORE JANUARY 1, {YEAR}, WHERE ‘YEAR’ IS
THE FIRST CALENDAR YEAR OF THE PANEL,
THEN FLAG RU MEMBER AS ‘WITH HEALTH INSURANCE
COVERAGE ON JAN 1, {YEAR}.
----------------------------------------------------
----------------------------------------------------
HARD CHECK:
DATE MUST BE ON OR BEFORE (I.E., < OR =) INTERVIEW
DATE OR 12/31/{YEAR}, WHERE YEAR IS THE SECOND
CALENDAR YEAR OF THE PANEL, IF ROUND 5. ‘-7’
(REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED ON THE
MONTH AND YEAR FIELDS.
MEDICARE EFFECTIVE DATE MUST BE = OR > BIRTH DATE
OF PERSON.
----------------------------------------------------
HX29OV
======
Did (PERSON) have Medicare coverage on January 1,
{YEAR}?
YES ................................... 1 {HX30}
NO .................................... 2 {HX30}
REF ................................... -7 {HX30}
DK .................................... -8 {HX30}
----------------------------------------------------
IF HX29OV CODED ‘1’ (YES), FLAG PERSON AS ‘WITH
HEALTH INSURANCE COVERAGE ON JAN 1, {YEAR}, WHERE
‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL.
----------------------------------------------------
HX29OV2
=======
OMITTED.
HX30
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
SHOW CARD HX-2.
(Do/Does) (PERSON) have a Medicare card that looks
like this?
YES .................................... 1 {BOX_28A}
NO ..................................... 2 {BOX_28A}
REF ................................... -7 {BOX_28A}
DK .................................... -8 {BOX_28A}
HX30A
=====
OMITTED. MOVED AND RENUMBERED TO HX35A
BOX_28A
=======
----------------------------------------------------
NOTE: CURRENTLY ALL STATES OFFER MEDICARE
MANAGED CARE PLANS.
----------------------------------------------------
----------------------------------------------------
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED
DOES NOT OFFER A MEDICARE MANAGED CARE PLAN, CODE
HX31 AND HX32 ‘2’ (NO) AUTOMATICALLY BY CAPI AND
GO TO HX35A
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH HX31
----------------------------------------------------
HX31
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
SHOW CARD HX-5.
As you may know, Medicare allows beneficiaries to
enroll in
Medicare Advantage or managed care plans, such as HMOs
(Health Maintenance Organizations) or PPOs (Preferred
Provider
Organizations) to receive their Medicare-funded health
care.
These plans have names like those listed on this card.
Is the name of (PERSON)’s insurance through Medicare{,
as of
(END DATE),} listed on this card?
YES .................................... 1 {HX31OV}
NO ..................................... 2 {HX32}
REF ................................... -7 {HX32}
DK .................................... -8 {HX32}
HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED
CARE.
----------------------------------------------------
DISPLAY ‘, as of (END DATE),’ IF ROUND 5.
OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
HX31OV
======
Which insurance plan {is/was} (PERSON)’s Medicare
managed care plan
{as of (END DATE)}?
CODE LETTER OF PLAN FROM SHOW CARD:
[Enter Plan Letter From Card] ......... {HX33A}
----------------------------------------------------
DISPLAY ‘is’ IF NOT ROUND 5. DISPLAY ‘was’ IF
ROUND 5.
DISPLAY ‘as of (END DATE)’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY
THE FOLLOWING MESSAGE: "PLEASE VERIFY PLAN
SELECTED: {DISPLAY PLAN NAME SELECTED}." WHEN
INTERVIEWER PRESSES ENTER TO CLEAR THE MESSAGE,
PROCEED TO THE NEXT LOGICAL SCREEN.
FOR ‘DISPLAY PLAN NAME SELECTED’, DISPLAY THE
ACTUAL PLAN NAME THAT CORRESPONDS TO THE LETTER
ENTERED FOR THIS STATE.
----------------------------------------------------
----------------------------------------------------
FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S
MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON-
PAIR.
----------------------------------------------------
HX32
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Even though (PERSON)’s Medicare plan is not listed on
the card,
{(are/is) (PERSON) currently/(were/was) (PERSON)}
enrolled in a
Medicare managed care plan such as an HMO (Health
Maintenance
Organization) or PPO (Preferred Provider Organization)
{as of (END
DATE)}? When answering this question, please include
only insurance
from Medicare, not any privately purchased insurance
and not any job-
related insurance.
YES .................................... 1 {HX33}
NO ..................................... 2 {HX35A}
REF ................................... -7 {HX35A}
DK .................................... -8 {HX35A}
HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED
CARE.
----------------------------------------------------
DISPLAY ‘(are/is) (PERSON) currently’ IF NOT ROUND
5. DISPLAY (were/was) (PERSON)’ IF ROUND 5.
DISPLAY ‘as of (END DATE)’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.
----------------------------------------------------
HX32A
=====
OMITTED.
HX33
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
What {is/was} the name of (PERSON)’s Medicare managed
care plan
{as of (END DATE)}?
[Enter Plan Name] ..................... {HX33A}
REF ................................... -7 {HX33A}
DK .................................... -8 {HX33A}
----------------------------------------------------
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 ROUND’S
MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON-
PAIR.
----------------------------------------------------
HX33A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{(Do/Does)/Did} (PERSON) have prescribed medicine
coverage through
{{{PLAN NAME ENTERED AT HX31OV-50}/{NAME OF PLAN FROM
HX33}}/
(PERSON)’s Medicare managed care plan} {as of (END
DATE)}?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
DISPLAY ‘(Do/Does)’ IF NOT ROUND 5. DISPLAY ‘Did’
IF ROUND 5.
DISPLAY ‘{{PLAN NAME ENTERED AT HX31OV-50}/{NAME
OF PLAN FROM HX33}}’ IF A PLAN NAME WAS CODED AT
HX31OV OR HX33. DISPLAY ‘(PERSON)’s Medicare
managed care plan’ IF HX33 IS CODED ‘-7’ (REF)
OR ‘-8’ (DK).
DISPLAY ‘{PLAN NAME ENTERED AT HX31OV-50}’ IF A
PLAN LETTER WAS ENTERED AT HX31OV. DISPLAY THE
ACTUAL PLAN NAME THAT CORRESPONDS TO THE LETTER
ENTERED AT HX31OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR
‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS
ENTERED.
DISPLAY ‘as of (END DATE)’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF ROUND 1 OR ROUND 3, CONTINUE WITH HX34
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP11
----------------------------------------------------
HX34
====
{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)
(PERSON) (or
anyone in the family) pay anything else for {the
coverage with
{{PLAN NAME ENTERED AT HX310V}/{NAME OF PLAN FROM
HX33}}/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 {HX34A}
NO ..................................... 2 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
[Code One]
HELP AVAILABLE FOR DEFINITION OF
PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
----------------------------------------------------
DISPLAY ‘the coverage with {{PLAN NAME ENTERED AT
HX31OV}/{NAME OF PLAN FROM HX33}}’ IF A MEDICARE
PLAN NAME WAS SELECTED AT HX31OV OR ENTERED AT
HX33. DISPLAY ‘this Medicare managed care plan’
IF HX33 WAS CODED ‘-7’ (REF) OR ‘-8’ (DK).
DISPLAY ‘{PLAN NAME ENTERED AT HX31OV}’ IF A PLAN
LETTER WAS ENTERED AT HX31OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT HX31OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR
‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS
ENTERED.
----------------------------------------------------
HX34A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Many Medicare beneficiaries pay the premium for their
Medicare
Advantage coverage through their Social Security
checks. Some pay
directly to the provider. How (do/does) (PERSON) pay
for
(PERSON)’s {{{PLAN NAME ENTERED AT HX31OV}/{NAME OF
PLAN FROM
HX33}}/Medicare managed care} premium?
DEDUCTED FROM SOCIAL SECURITY .......... 1 {HX35}
PAY DIRECTLY ........................... 2 {HX35}
BOTH ................................... 3 {HX35}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
----------------------------------------------------
DISPLAY ‘{{PLAN NAME ENTERED AT HX31OV}/{NAME OF
PLAN FROM HX33}} IF A MEDICARE PLAN NAME WAS
SELECTED AT HX31OV OR ENTERED AT HX33. DISPLAY
‘Medicare managed care’ IF HX33 WAS CODED ‘-7’
(REF) OR ‘-8’ (DK).
DISPLAY ‘{PLAN NAME ENTERED AT HX31OV}’ IF A PLAN
LETTER WAS ENTERED AT HX31OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT HX31OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR
‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS
ENTERED.
----------------------------------------------------
HX35
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
How much {is (PERSON)’s Social Security
deduction/(do/does)
(PERSON) pay in premiums} for (PERSON)’s {{PLAN NAME
ENTERED AT
HX31OV}/{NAME OF PLAN FROM HX33}} plan?
IF RESPONDENT IS NOT SURE, DO NOT PROBE. CODE ‘DON’T
KNOW’.
[Enter Amount in Dollars] .............. {HX35OV1}
REF ................................... -7 {HX35AA}
DK .................................... -8 {HX35AA}
----------------------------------------------------
DISPLAY ‘is (PERSON)’s Social Security deduction’
IF HX34A IS CODED ‘1’ (DEDUCTED FROM SOCIAL
SECURITY’. DISPLAY ‘(do/does) (PERSON) pay in
premiums’ IF HX34A IS CODED ‘2’ (PAY DIRECTLY) OR
‘3’ (BOTH).
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘{{PLAN NAME ENTERED AT HX31OV}/{NAME OF
PLAN FROM HX33}}’ IF A MEDICARE PLAN NAME WAS
SELECTED AT HX31OV OR ENTERED AT HX33. OTHERWISE
(I.E., IF HX33 WAS CODED ‘-7’ (REF) OR ‘-8’ (DK)),
USE A NULL DISPLAY.
DISPLAY ‘{PLAN NAME ENTERED AT HX31OV}’ IF A PLAN
LETTER WAS ENTERED AT HX31OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT HX31OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR
‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS
ENTERED.
----------------------------------------------------
HX35OV1
=======
Is that per year, per month, per week, or what?
ENTER UNIT OF COVERAGE:
PER YEAR ............................... 1 {END_LP11}
QUARTERLY/EVERY 3 MONTHS ............... 2 {END_LP11}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {END_LP11}
PER MONTH .............................. 4 {END_LP11}
PER WEEK ............................... 5 {END_LP11}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {END_LP11}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {END_LP11}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {END_LP11}
OTHER ................................. 91 {HX35OV2}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
[Code One]
HX35OV2
=======
OTHER:
[Enter Other Specify] .................. {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
HX35AA
======
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{PLAN NAME: {{PLAN NAME ENTERED AT HX31OV}/{NAME OF
PLAN FROM HX33}}}
SHOW CARD HX-5A.
Which category on the card best indicates the cost of
this
plan per month?
1 - 50 ................................. 1 {END_LP11}
51 - 100 ............................... 2 {END_LP11}
101 - 200 .............................. 3 {END_LP11}
201 - 300 .............................. 4 {END_LP11}
301 OR MORE ............................ 5 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
----------------------------------------------------
DISPLAY ‘PLAN NAME: {{PLAN NAME ENTERED AT
HX31OV}/{NAME OF PLAN FROM HX33}}’ IF A MEDICARE
PLAN NAME WAS SELECTED AT HX31OV OR ENTERED AT
HX33. OTHERWISE (I.E., IF HX33 WAS CODED ‘-7’
(REF) OR ‘-8’ (DK)), USE A NULL DISPLAY.
DISPLAY ‘{PLAN NAME ENTERED AT HX31OV}’ IF A PLAN
LETTER WAS ENTERED AT HX31OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT HX31OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR
‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS
ENTERED.
----------------------------------------------------
HX35A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{(Are/Is)/(Were/Was)} (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 1 OR ROUND 3,
CONTINUE WITH HX35B
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP11
----------------------------------------------------
HX35B
=====
{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)
(PERSON) (or
anyone in the family) pay anything else for (PERSON)’s
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 {HX35C}
NO ..................................... 2 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
[Code One]
HELP AVAILABLE FOR DEFINITION OF
PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
HX35C
=====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Many Medicare beneficiaries pay the premium for their
Medicare
drug coverage through their Social Security checks.
Some pay
directly to the provider? How (do/does) (PERSON) pay
for
(PERSON)’s Part D premium?
DEDUCTED FROM SOCIAL SECURITY .......... 1 {HX35D}
PAY DIRECTLY ........................... 2 {HX35D}
BOTH ................................... 3 {HX35D}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
HX35D
=====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
How much {is (PERSON)’s Social Security
deduction/(do/does)
(PERSON) pay in premiums} for (PERSON)’s Part D plan?
IF RESPONDENT IS NOT SURE, DO NOT PROBE. CODE ‘DON’T
KNOW’.
[Enter Amount in Dollars] .............. {HX35DOV1}
REF ................................... -7 {HX35E}
DK .................................... -8 {HX35E}
----------------------------------------------------
DISPLAY ‘is (PERSON)’s Social Security deduction’
IF HX35C IS CODED ‘1’ (DEDUCTED FROM SOCIAL
SECURITY’. DISPLAY ‘(do/does) (PERSON) pay in
premiums’ IF HX35C IS CODED ‘2’ (PAY DIRECTLY) OR
‘3’ (BOTH).
----------------------------------------------------
HX35DOV1
========
Is that per year, per month, per week, or what?
ENTER UNIT OF COVERAGE:
PER YEAR ............................... 1 {END_LP11}
QUARTERLY/EVERY 3 MONTHS ............... 2 {END_LP11}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {END_LP11}
PER MONTH .............................. 4 {END_LP11}
PER WEEK ............................... 5 {END_LP11}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {END_LP11}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {END_LP11}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {END_LP11}
OTHER ................................. 91 {HX35DOV2}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
[Code One]
HX35DOV2
========
OTHER:
[Enter Other Specify] .................. {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
HX35E
=====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
SHOW CARD HX-5B.
Which category on the card best indicates the cost of
this
plan per month?
1 - 30 ................................. 1 {END_LP11}
31 - 60 ................................ 2 {END_LP11}
61 - 90 ................................ 3 {END_LP11}
91 - 120 ............................... 4 {END_LP11}
121 OR MORE ............................ 5 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
END_LP11
========
----------------------------------------------------
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_11 AND CONTINUE WITH BOX_29
----------------------------------------------------
BOX_29
======
----------------------------------------------------
IF ANY RU MEMBER HAS MEDICAID/SCHIP OR GOVT-
HOSPITAL/PHYSICIAN AS A SOURCE OF INSURANCE
DURING THE CURRENT ROUND, CONTINUE WITH BOX_30
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_31C
----------------------------------------------------
BOX_30
======
----------------------------------------------------
IF NO ONE IN THE RU WAS COVERED BY MEDICAID/SCHIP
OR GOVT-HOSPITAL/PHYSICIAN DURING THE PREVIOUS
ROUND AND AT LEAST ONE RU MEMBER IS COVERED BY
MEDICAID/SCHIP DURING THE CURRENT ROUND
OR
IF NO ONE IN THE RU WAS COVERED BY MEDICAID/SCHIP
OR GOVT-HOSPITAL/PHYSICIAN DURING THE PREVIOUS
ROUND AND AT LEAST ONE RU MEMBER IS COVERED BY
GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND,
GO TO BOX_31AA
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_31C
----------------------------------------------------
----------------------------------------------------
NOTE: SINCE AN RU CANNOT HAVE BOTH MEDICAID/SCHIP
AND GOVT-HOSPITAL/PHYSICIAN, HX41-HX47OV WILL BE
ASKED ONLY ONCE; EITHER FOR A ‘YES’ TO HX10
(MEDICAID/SCHIP) OR A ‘YES’ TO HX14 (GOVT-
HOSPITAL/PHYSICIAN).
----------------------------------------------------
HX36
====
OMITTED.
BOX_31
======
OMITTED.
HX37
====
OMITTED.
HX38
====
OMITTED.
HX38OV1
=======
OMITTED.
HX38OV2
=======
OMITTED.
HX39
====
OMITTED.
HX40
====
OMITTED.
BOX_31AA
========
----------------------------------------------------
NOTE: STATES THAT DO NOT OFFER MEDICAID MANAGED
CARE PLANS INCLUDE THE FOLLOWING:
ALASKA MISSISSIPPI
WYOMING
ARKANSAS AND NEW HAMPSHIRE WERE REMOVED FROM THIS
LIST STARTING IN PANEL 12 ROUND 3.
----------------------------------------------------
----------------------------------------------------
IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED
DOES NOT OFFER A MEDICAID MANAGED CARE PLAN, CODE
HX41 ‘2’ (NO) AUTOMATICALLY BY CAPI AND GO TO HX42
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH HX41
----------------------------------------------------
HX41
====
{STR-DT}
{END-DT}
{Some people on {Medicaid/{STATE NAME FOR MEDICAID}}
or {STATE
CHIP NAME} can enroll in plans called HMOs. These
plans have
names like those listed on this card.}
SHOW CARD HX-6.
Is the name of the health insurance through
{{Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME}/the program
sponsored
by a state or local government agency which provides
hospital
and physician benefits}{, between (START DATE) and
(END DATE),}
listed on this card?
YES .................................... 1 {HX41OV}
NO ..................................... 2 {HX42}
REF ................................... -7 {HX42}
DK .................................... -8 {HX42}
----------------------------------------------------
DISPLAY ‘Some people on...on this card.’ IF
ASKING ABOUT MEDICAID/SCHIP. OTHERWISE, USE A
NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/
SCHIP. DISPLAY ‘the program....benefits’ IF
ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘, between (START DATE) and (END DATE),’
IF ROUND 5. 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 REAL
STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX
ON HX06.
----------------------------------------------------
HX41OV
======
Which plan is the health insurance through
{{Medicaid/{STATE NAME
FOR MEDICAID}} or {STATE CHIP NAME}/that program)}?
LETTER OF PLAN FROM SHOW CARD:
[Enter Plan Letter From Card] .........
----------------------------------------------------
DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}}’
IF ASKING ABOUT MEDICAID/SCHIP.
DISPLAY ‘that program’ IF ASKING ABOUT GOVT-
HOSPITAL/PHYSICIAN.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL
STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX
ON HX06.
----------------------------------------------------
----------------------------------------------------
WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY
THE FOLLOWING MESSAGE: "PLEASE VERIFY PLAN
SELECTED: {DISPLAY PLAN NAME SELECTED}." WHEN
INTERVIEWER PRESSES ENTER TO CLEAR THE MESSAGE,
PROCEED TO THE NEXT LOGICAL SCREEN.
FOR ‘DISPLAY PLAN NAME SELECTED’, DISPLAY THE
ACTUAL PLAN NAME THAT CORRESPONDS TO THE LETTER
ENTERED FOR THIS STATE.
----------------------------------------------------
----------------------------------------------------
FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S
INSURER FOR MEDICAID/SCHIP OR GOVT-HOSPITAL/
PHYSICIAN’.
----------------------------------------------------
----------------------------------------------------
IF ASKING ABOUT MEDICAID/SCHIP, CONTINUE WITH
BOX _31B
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO HX45
----------------------------------------------------
HX42
====
{STR-DT}
{END-DT}
Under {{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE
CHIP NAME}/
the program sponsored by a state or local government
agency which
provides hospital and physician benefits}
{(are/is)/(were/was)}
(READ NAME(S) FROM BELOW) signed up with 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 {HX44}
YES, SOME ARE .......................... 2 {HX44}
NO, NONE ARE ........................... 3 {HX43}
REF ................................... -7 {HX43}
DK .................................... -8 {HX43}
[Code One]
HELP AVAILABLE FOR DEFINITION OF HMO.
----------------------------------------------------
DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/
SCHIP. DISPLAY ‘the program....benefits’ IF
ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘(are/is)’ IF NOT ROUND 5. DISPLAY
‘(were/was)’ IF ROUND 5.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL
STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON
HX06.
----------------------------------------------------
----------------------------------------------------
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 SELECTION OF RU MEMBERS.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
1. ESTABLISHMENT IS MEDICAID/SCHIP OR GOVT-
HOSPITAL/PHYSICIAN,
AND
2. PERSON IS AN RU MBMBER FLAGGED AS COVERED BY
MEDICAID/SCHIP OR GOVT-HOSPITAL/PHYSICIAN DURING
THE CURRENT ROUND.
----------------------------------------------------
HX43
====
{STR-DT}
{END-DT}
{Does/Between (START DATE) and (END DATE), did}
{{Medicaid/{STATE
NAME FOR MEDICAID}} or {STATE CHIP NAME}/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 {HX44}
YES, SOME REQUIRED ..................... 2 {HX44}
NO, NONE REQUIRED ...................... 3
REF ................................... -7
DK .................................... -8
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.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/SCHIP.
DISPLAY ‘the program....benefits’ IF ASKING ABOUT
GOVT-HOSPITAL/PHYSICIAN.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL
STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX
ON HX06.
----------------------------------------------------
----------------------------------------------------
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 OR GOVT-HOSPITAL/PHYSICIAN.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED),
OR ‘-8’ (DON’T KNOW) AND IF ASKING ABOUT MEDICAID/
SCHIP, GO TO BOX_31B
----------------------------------------------------
----------------------------------------------------
IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED),
OR ‘-8’ (DON’T KNOW) AND ASKING ABOUT GOVT-
HOSPITAL/PHYSICIAN, GO TO HX45
----------------------------------------------------
----------------------------------------------------
OTHERWISE, (I.E., IF CODED ‘1’ (YES, ALL REQUIRED)
OR ‘2’ (YES, SOME REQUIRED)), CONTINUE WITH HX44
----------------------------------------------------
----------------------------------------------------
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. SELECT, ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
1. ESTABLISHMENT IS MEDICAID/SCHIP OR GOVT-
HOSPITAL/PHYSICIAN,
AND
2. PERSON IS AN RU MBMBER FLAGGED AS COVERED BY
MEDICAID/SCHIP OR GOVT-HOSPITAL/PHYSICIAN DURING
THE CURRENT ROUND.
----------------------------------------------------
HX44
====
{STR-DT}
{END-DT}
What is the name of the {{Medicaid/{STATE NAME FOR
MEDICAID}} or
{STATE CHIP NAME}} {HMO/health insurance} {from the
program
sponsored by a state or local government agency which
provides
hospital and physician benefits}?
[Enter Plan Name] .....................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/
SCHIP. IF ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN,
USE A NULL DISPLAY.
DISPLAY ‘from the....benefits’ IF ASKING ABOUT
GOVT-HOSPITAL/PHYSICIAN. IF ASKING ABOUT MEDICAID/
SCHIP, USE A NULL DISPLAY.
DISPLAY ‘HMO’ IF HX42 IS CODED ‘1’ (YES, ALL ARE)
OR ‘2’ (YES, SOME ARE).
DISPLAY ‘health insurance’ IF HX43 IS CODED ‘1’
(YES, ALL REQUIRED) OR ‘2’ (YES, SOME REQUIRED).
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL
STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX
ON HX06.
----------------------------------------------------
----------------------------------------------------
FLAG INSURER CODED ABOVE AS CURRENT ROUND’S
INSURER FOR MEDICAID/SCHIP OR GOVT-HOSPITAL/
PHYSICIAN.
----------------------------------------------------
----------------------------------------------------
IF ASKING ABOUT MEDICAID/SCHIP, CONTINUE WITH
BOX_31B
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO HX45
----------------------------------------------------
BOX_31B
=======
----------------------------------------------------
IF ROUND 1 OR ROUND 3 (AND ASKING ABOUT MEDICAID/
SCHIP), CONTINUE WITH HX45
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF ROUNDS 2, 4, OR 5 AND ASKING
ABOUT MEDICAID/SCHIP), GO TO BOX_31C
----------------------------------------------------
HX45
====
{STR-DT}
{END-DT}
{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF
PLAN FROM
HX44}}}
Does anyone in the family pay anything for the
coverage through
{(PLAN NAME)/{{Medicaid/{STATE NAME FOR MEDICAID}} or
{STATE
CHIP NAME}/the program sponsored by a state or local
government
agency which provides hospital and physician
benefits}?
[Do not include the cost of any copayments,
coinsurance or
deductibles anyone in the family may have had to pay.]
YES .................................... 1 {HX46}
NO ..................................... 2 {HX47}
REF ................................... -7 {BOX_31C}
DK .................................... -8 {BOX_31C}
HELP AVAILABLE FOR DEFINITION OF
PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
----------------------------------------------------
DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
OR GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE,
USE A NULL DISPLAY.
DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN
LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT HX41OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR
‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS
ENTERED.
DISPLAY ‘(PLAN NAME)’ IF THERE IS A CURRENT ROUND
INSURER ASSOCIATED WITH THE MEDICAID/SCHIP OR
GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE,
DISPLAY, {{Medicaid/... and physician benefits}’.
DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}}
or {STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/
SCHIP. DISPLAY ‘the program ... benefits’ IF
ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘Medicaid’ IF STATE IN WHCH INTERVIEW IS
BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY
‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL
STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME
‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS
(SUBSTITUTING THE REAL STATE NAME FOR PROGRAM).
FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX
ON HX06.
----------------------------------------------------
HX46
====
{STR-DT}
{END-DT}
{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF
PLAN FROM
HX44}}}
How much does anyone in the family pay for {the (PLAN
NAME)/
that} coverage?
[Enter Amount in Dollars] .............. {HX46OV1}
REF ................................... -7 {HX47}
DK .................................... -8 {HX47}
----------------------------------------------------
DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
OR GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE,
USE A NULL DISPLAY.
DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN
LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT HX41OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR
‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS
ENTERED.
DISPLAY ‘the (PLAN NAME)’ IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
OR GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE,
DISPLAY, ‘that’.
----------------------------------------------------
HX46OV1
=======
Is that per year, per month, per week, or what?
UNIT OF COVERAGE:
PER YEAR ............................... 1 {HX47}
QUARTERLY/EVERY 3 MONTHS ............... 2 {HX47}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {HX47}
PER MONTH .............................. 4 {HX47}
PER WEEK ............................... 5 {HX47}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {HX47}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {HX47}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {HX47}
OTHER ................................. 91 {HX46OV2}
REF ................................... -7 {HX47}
DK .................................... -8 {HX47}
[Code One]
HX46OV2
=======
OTHER:
[Enter Other Specify] .................. {HX47}
REF ................................... -7 {HX47}
DK .................................... -8 {HX47}
BOX_31A
=======
OMITTED.
HX47
====
{STR-DT}
{END-DT}
{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF
PLAN FROM
HX44}}}
Who {else} pays {some of/for} the premium or cost
of this insurance?
FEDERAL GOVERNMENT .................... 1
STATE GOVERNMENT ...................... 2
LOCAL GOVERNMENT ...................... 3
SOME GOVERNMENT ....................... 4
OTHER ................................. 91 {HX47OV}
REF ................................... -7 {BOX_31C}
DK .................................... -8 {BOX_31C}
[Code All That Apply]
----------------------------------------------------
DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT
ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP
OR GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE,
USE A NULL DISPLAY.
DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN
LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL
PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED
AT HX41OV FOR THIS STATE.
DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR
‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS
ENTERED.
DISPLAY ‘else’ IF HX45 IS CODED ‘1’ (YES).
OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘some of’ IF HX45 IS CODED ‘1’ (YES).
DISPLAY ‘for’ IF HX45 IS CODED ‘2’ (NO).
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH HX47OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_31C
----------------------------------------------------
HX47OV
======
OTHER:
[Enter Other Specify] .................. {BOX_31C}
REF ................................... -7 {BOX_31C}
DK .................................... -8 {BOX_31C}
BOX_31C
=======
----------------------------------------------------
IF ROUND 1 OR ROUND 3, CONTINUE WITH BOX_31D
----------------------------------------------------
----------------------------------------------------
OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO
BOX_32
----------------------------------------------------
BOX_31D
=======
----------------------------------------------------
IF ANY RU MEMBER HAS TRICARE/CHAMPVA AS A SOURCE
OF INSURANCE DURING THE CURRENT ROUND, CONTINUE
WITH BOX_31E
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_32
----------------------------------------------------
BOX_31E
=======
----------------------------------------------------
IF NO ONE IN THE RU WAS COVERED BY TRICARE/CHAMPVA
DURING THE PREVIOUS ROUND AND AT LEAST ONE RU
MEMBER IS COVERED BY TRICARE/CHAMPVA DURING THE
CURRENT ROUND CONTINUE WITH HX47A
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_32
----------------------------------------------------
HX47A
=====
{STR-DT}
{END-DT}
[Now, let’s talk about the coverage someone in the
family has
through TRICARE or CHAMPVA.]
Does anyone in the family pay anything for the
coverage through
TRICARE or CHAMPVA?
[Do not include the cost of any copayments,
coinsurance or
deductibles anyone in the family may have had to pay.]
YES .................................... 1 {HX47B}
NO ..................................... 2 {BOX_32}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}
HELP AVAILABLE FOR DEFINITION OF
PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
HX47B
=====
{STR-DT}
{END-DT}
How much does anyone in the family pay for the
coverage through
TRICARE or CHAMPVA?
[Enter Amount in Dollars] .............. {HX47BOV1}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}
HX47BOV1
========
Is that per year, per month, per week, or what?
UNIT OF COVERAGE:
PER YEAR ............................... 1 {BOX_32}
QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_32}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_32}
PER MONTH .............................. 4 {BOX_32}
PER WEEK ............................... 5 {BOX_32}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_32}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_32}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_32}
OTHER ................................. 91 {HX47BOV2}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}
[Code One]
HX47BOV2
========
OTHER:
[Enter Other Specify] .................. {BOX_32}
REF ................................... -7 {BOX_32}
DK .................................... -8 {BOX_32}
BOX_32
======
-----------------------------------------------------
IF ANY ESTABLISHMENT RECORDED AS PROVIDING PRIVATE
INSURANCE (THAT WAS CREATED DURING THE CURRENT
ROUND) TO A CURRENT RU MEMBER, CONTINUE WITH
LOOP_12
-----------------------------------------------------
-----------------------------------------------------
OTHERWISE, GO TO BOX_45
-----------------------------------------------------
LOOP_12
=======
-----------------------------------------------------
for each element in the ru-establishment-person-
pairs-roster, ask hx48-end_lp12
-----------------------------------------------------
-----------------------------------------------------
LOOP DEFINITION: LOOP_12 COLLECTS PRIVATE HEALTH
INSURANCE INFORMATION. THIS LOOP CYCLES ON
ESTABLISHMENT-PERSON-PAIRS THAT MEET THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS PROVIDER OF PRIVATE HEALTH
INSURANCE TO A CURRENT RU MEMBER
AND
- THE INSURANCE COVERAGE PROVIDED BY THE
ESTABLISHMENT IS CREATED DURING THE CURRENT ROUND
-----------------------------------------------------
HX48
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
SHOW CARD HX-7.
Now I’d like to ask a few questions about
(POLICYHOLDER)’s health
insurance through (ESTABLISHMENT). What type of health
insurance
{(do/does)/did} (POLICYHOLDER) get through
(ESTABLISHMENT) {as of
(END DATE)}?
CHECK ALL THAT APPLY.
HOSPITAL AND PHYSICIAN BENEFITS,
INCLUDING COVERAGE THROUGH AN HMO ...... 1
DENTAL ................................. 2
PRESCRIPTION DRUGS ..................... 3
VISION ................................. 4
MEDICARE SUPPLEMENT/MEDIGAP ............ 5
LONG TERM CARE IN A NURSING HOME ....... 6
EXTRA CASH FOR HOSPITAL STAYS .......... 7
SERIOUS DISEASE OR DREAD DISEASE ....... 8
DISABILITY ............................. 9
WORKER’S COMPENSATION ................. 10
ACCIDENT .............................. 11
OTHER ................................. 91 {HX48OV}
REF ................................... -7 {BOX_33}
DK .................................... -8 {BOX_33}
[Code All That Apply]
HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.
----------------------------------------------------
DISPLAY ‘(do/does)’ IF INSURANCE BEING ASKED
ABOUT IS CURRENT (I.E., HQ02 IS CODED ‘1’ (YES,
COVERED NOW) FOR THE POLICYHOLDER, AND THE CURRENT
ROUND IS NOT ROUND 5. OTHERWISE, DISPLAY ‘did’.
DISPLAY ‘as of (END DATE)’ IF ROUND 5. OTHERWISE,
USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE
SHOW CARD.
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH HX48OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_33
----------------------------------------------------
HX48OV
======
OTHER:
[Enter Other Specify] ................. {BOX_33}
REF ................................... -7 {BOX_33}
DK .................................... -8 {BOX_33}
BOX_33
======
----------------------------------------------------
IF ESTABLISHMENT TYPE IS NOT INSURANCE CO. OR HMO
AND HX48 IS CODED ‘5’ (MEDICARE SUPPLEMENT OR
MEDIGAP) ONLY OR ‘5’ AND ANY OTHER CODES, CONTINUE
WITH HX49
----------------------------------------------------
----------------------------------------------------
IF ESTABLISHMENT TYPE IS INSURANCE CO. OR HMO AND
HX48 IS CODED ‘5’ (MEDICARE SUPPLEMENT OR MEDIGAP)
ONLY OR ‘5’ AND ANY OTHER CODES, AUTOMATICALLY
CODE HX49 WITH APPROPRIATE RESPONSES BY CAPI AND
THEN GO TO LOOP_13
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., HX48 IS NOT CODED ‘5’ (MEDICARE
SUPPLEMENT OR MEDIGAP)), GO TO BOX_35
----------------------------------------------------
HX49
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
What is the name of the insurance company or HMO from
which
(POLICYHOLDER) receives the Medicare Supplement or
Medigap
benefits?
IF MORE THAN ONE NAME, PROBE: What is the main
insurance company
or HMO from which (POLICYHOLDER) receives the
Medicare Supplement
or Medigap benefits?
IF RESPONDENT SAYS BOTH INSURANCE COMPANY AND HMO,
SELECT ‘HMO’.
NAME OF INSURER: [Enter Insurer] ..........
REF ...................... -7
DK ....................... -8
TYPE: 1 = INSURANCE COMPANY ...............
2 = HMO .............................
3 = SELF-INSURED COMPANY ............
REF ................................. -7
DK .................................. -8
HELP AVAILABLE FOR DEFINITION OF INSURANCE
CO/HMO/SELF-INSURED CO.
----------------------------------------------------
FLAG INSURANCE CO./HMO AS ‘SUPPLYING MEDICARE
SUPPLEMENT/MEDIGAP BENEFITS’. ALSO FLAG AS
CURRENT ROUND’S INSURER(S) FOR THIS ESTABLISHMENT-
PERSON-PAIR.
----------------------------------------------------
----------------------------------------------------
BOTH INSURER NAME AND INSURER TYPE MUST BE
ENTERED.
----------------------------------------------------
----------------------------------------------------
IF INSURER NAME IS ENTERED, CONTINUE WITH LOOP_13
----------------------------------------------------
----------------------------------------------------
IF INSURER NAME IS CODED ‘-7’ (REF) OR ‘-8’ (DK),
GO TO BOX_35
----------------------------------------------------
BOX_34
======
OMITTED.
LOOP_13
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER, ASK HX50-END_LP13
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_13 COLLECTS OTHER POLICY
NAMES FOR THE HEALTH INSURANCE COMPANIES OR HMOs
PROVIDING MEDICARE SUPPLEMENT/MEDIGAP BENEFITS
(THAT IS, INSURERS ENUMERATED AT HX49).
THIS LOOP CYCLES ON TRIPLES THAT MEET THE
FOLLOWING CONDITIONS:
- ESTABLISHMENT IS PROVIDER OF PRIVATE INSURANCE
WHICH PROVIDES MEDICARE SUPPLEMENT/MEDIGAP
BENEFITS
AND
- PERSON IS THE POLICYHOLDER FOR THE INSURANCE
PROVIDED THROUGH THIS ESTABLISHMENT
AND
- INSURER IS THE SOURCE OF THE BENEFITS PROVIDED
TO PERSON THROUGH THE ESTABLISHMENT (I.E., THE
INSURANCE COMPANY, HMO, OR SELF-INSURED COMPANY)
----------------------------------------------------
HX50
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
Is there any other name for the {INSURANCE COMPANY OR
HMO
NAME.} policy, such as Option A, $100 Deductible Plan,
90/80
Plan, Gold Plan, or High Option Plan?
YES, ANOTHER NAME ...................... 1 {HX50OV}
NO OTHER NAME .......................... 2 {END_LP13}
REF ................................... -7 {END_LP13}
DK .................................... -8 {END_LP13}
HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH
OPTION.
[Code One]
----------------------------------------------------
DISPLAY THE NAME OF THE INSURANCE CO/HMO
RECORDED IN HX49_01 WHICH IS BEING LOOPED ON FOR
‘INSURANCE...NAME.’
----------------------------------------------------
HX50OV
======
OTHER NAME:
[Enter Insurance Company or HMO] ....... {END_LP13}
REF ................................... -7 {END_LP13}
DK .................................... -8 {END_LP13}
END_LP13
========
----------------------------------------------------
CYCLE ON NEXT TRIPLE ON THE RU-ESTABLISHMENT-
PERSON-INSURER-TRIPLES-ROSTER THAT MEETS THE
CONDITIONS STATED IN THE LOOP DEFINITION
----------------------------------------------------
----------------------------------------------------
IF NO MORE TRIPLES MEET THE STATED CONDITIONS,
END LOOP_13 AND CONTINUE WITH BOX_35
----------------------------------------------------
BOX_35
======
----------------------------------------------------
IF ESTABLISHMENT TYPE IS INSURANCE COMPANY,
INSURANCE COMPANY - FROM AGENT, OR HMO,
AND HX48 IS CODED ‘1’ (HOSPITAL AND
PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN
HMO) (BUT NOT ‘5’ (MEDIGAP)), FLAG INSURANCE
COMPANY/HMO AS ‘SUPPLYING HOSPITAL AND PHYSICIAN
BENEFITS’ AND AUTOMATICALLY CODE HX51 WITH
APPROPRIATE RESPONSES BY CAPI AND GO TO LOOP_14
----------------------------------------------------
----------------------------------------------------
IF ESTABLISHMENT TYPE IS NOT INSURANCE COMPANY,
INSURANCE COMPANY - FROM AGENT, OR HMO,
AND HX48 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN
BENEFITS, INCLUDING COVERAGE THROUGH AN HMO) AND
NOT ALSO CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP),
CONTINUE WITH HX51
----------------------------------------------------
----------------------------------------------------
IF ROUND 1 AND HX48 IS CODED ‘1’ (HOSPITAL AND
PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN
HMO) AND ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP) (IN
COMBINATION WITH ANY OTHER CODES), GO TO BOX_38
----------------------------------------------------
----------------------------------------------------
IF HX48 IS NOT CODED ‘1’ (HOSPITAL AND PHYSICIAN
BENEFITS, INCLUDING COVERAGE THROUGH AN HMO) BUT
IS CODED ‘2’ (DENTAL), ‘3’ (PRESCRIPTION DRUGS),
‘4’ (VISION), ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP),
‘6’ (LONG TERM CARE IN A NURSING HOME), ‘7’ (EXTRA
CASH FOR HOSPITAL STAYS), ‘8’ (SERIOUS DISEASE OR
DREAD DISEASE), OR ‘91’ (OTHER), GO TO BOX_38
----------------------------------------------------
----------------------------------------------------
IF HX48 IS CODED ANY COMBINATION OF ONLY CODES ‘9’
(DISABILITY), ‘10’ (WORKER’S COMPENSATION) OR ‘11’
(ACCIDENT), GO TO END_LP12
----------------------------------------------------
----------------------------------------------------
IF ROUND 1 AND HX48 IS CODED ‘-7’ (REFUSED) OR
‘-8’ (DON’T KNOW), GO TO BOX_39
----------------------------------------------------
----------------------------------------------------
IF ROUND 2, 3, 4, OR 5 AND HX48 IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), GO TO BOX_38
----------------------------------------------------
HX51
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
What is the name of the insurance company or HMO from
which
(POLICYHOLDER) receives hospital and physician
benefits?
IF MORE THAN ONE NAME, PROBE: What is the main
insurance company
or HMO from which (POLICYHOLDER) receives hospital
and physician
benefits?
IF RESPONDENT SAYS BOTH INSURANCE COMPANY AND HMO,
SELECT ‘HMO’.
NAME OF INSURER: [Enter Insurer] ..........
REF ...................... -7
DK ....................... -8
TYPE: 1 = INSURANCE COMPANY ...............
2 = HMO .............................
3 = SELF-INSURED COMPANY ............
REF ................................. -7
DK .................................. -8
HELP AVAILABLE FOR DEFINITION OF INSURANCE
CO/HMO/SELF-INSURED CO.
----------------------------------------------------
FLAG INSURANCE CO./HMO AS ‘SUPPLYING HOSPITAL AND
PHYSICIAN BENEFITS’. ALSO FLAG AS CURRENT ROUND’S
INSURER(S) FOR THIS ESTABLISHMENT-PERSON-PAIR.
----------------------------------------------------
----------------------------------------------------
BOTH INSURER NAME AND INSURER TYPE MYST BE
ENTERED.
----------------------------------------------------
----------------------------------------------------
IF INSURER NAME IS ENTERED, CONTINUE WITH LOOP_14
----------------------------------------------------
----------------------------------------------------
IF INSURER NAME IS CODED ‘-7’ (REF) OR ‘-8’ (DK),
GO TO BOX_38
----------------------------------------------------
BOX_36
======
OMITTED.
LOOP_14
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER, ASK HX52-END_LP14
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_14 COLLECTS OTHER POLICY
NAMES FOR THE HEALTH INSURANCE COMPANIES OR HMOS
PROVIDING HOSPITAL/PHYSICIAN BENEFITS BUT NOT
MEDICARE SUPPLEMENT OR MEDIGAP. THIS LOOP CYCLES
ON TRIPLES THAT MEET THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS PROVIDER OF PRIVATE INSURANCE
WHICH PROVIDES HOSPITAL/PHYSICIAN BENEFITS BUT
NOT MEDICARE SUPPLEMENT OR MEDIGAP
AND
- PERSON IS THE POLICYHOLDER FOR THE INSURANCE
PROVIDED THROUGH THIS ESTABLISHMENT
AND
- INSURER IS THE SOURCE OF THE BENEFITS PROVIDED
TO PERSON THROUGH THE ESTABLISHMENT (I.E., THE
INSURANCE COMPANY, HMO OR SELF-INSURED COMPANY)
----------------------------------------------------
HX52
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
Is there any other name for the {INSURANCE COMPANY OR
HMO
NAME.} policy, such as Option A, $100 Deductible Plan,
90/80
Plan, Gold Plan, or High Option Plan?
YES, ANOTHER NAME ...................... 1 {HX52OV}
NO OTHER NAME .......................... 2 {END_LP14}
REF ................................... -7 {END_LP14}
DK .................................... -8 {END_LP14}
HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH
OPTION.
[Code One]
----------------------------------------------------
DISPLAY THE NAME OF THE INSURANCE CO/HMO
RECORDED IN HX51_01 WHICH IS BEING LOOPED ON FOR
‘INSURANCE...NAME.’
----------------------------------------------------
HX52OV
======
OTHER NAME:
[Enter Insurance Company or HMO] ....... {END_LP14}
REF ................................... -7 {END_LP14}
DK .................................... -8 {END_LP14}
END_LP14
========
----------------------------------------------------
CYCLE ON NEXT TRIPLE ON RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION
----------------------------------------------------
----------------------------------------------------
IF NO MORE TRIPLES MEET THE STATED CONDITIONS,
END LOOP_14 AND CONTINUE WITH BOX_38
----------------------------------------------------
BOX_37
======
----------------------------------------------------
Omitted.
NOTE: ALL ROUNDS, CONTINUE WITH BOX_38
----------------------------------------------------
HX53
====
OMITTED.
HX54
====
OMITTED.
LOOP_15
=======
OMITTED.
HX55
====
OMITTED.
HX55OV
======
OMITTED.
END_LP15
========
OMITTED.
BOX_38
======
----------------------------------------------------
IF ROUND 1, CONTINUE WITH BOX_39
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_40
----------------------------------------------------
HX56
====
OMITTED.
LOOP_16
=======
OMITTED.
HX57
====
OMITTED.
HX57OV
======
OMITTED.
HX58
====
OMITTED.
END_LP16
========
OMITTED.
BOX_39
======
----------------------------------------------------
IF ESTABLISHMENT-PERSON-PAIR BEING ASKED ABOUT
IS FLAGGED AS THROUGH THE FEDERAL GOVERNMENT
(EM96 IS CODED ‘2’ (THE FEDERAL GOVERNMENT) OR
HP13 IS CODED ‘1’ (YES)),
CONTINUE WITH HX59
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_40
----------------------------------------------------
HX59
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
SHOW CARD HX-8.
Is the name of (POLICYHOLDER)’s insurance plan through
(ESTABLISHMENT) listed on this card?
YES .................................... 1 {HX59OV}
NO ..................................... 2 {BOX_40}
REF ................................... -7 {BOX_40}
DK .................................... -8 {BOX_40}
HX59OV
======
Which insurance plan is (POLICYHOLDER)’s
(ESTABLISHMENT)
insurance?
CODE LETTER OF PLAN FROM SHOW CARD:
[Enter Plan Letter From Card] ......... {BOX_40}
----------------------------------------------------
WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY
THE FOLLOWING MESSAGE: "PLEASE VERIFY PLAN
ENTERED." WHEN INTERVIEWER PRESSES CLEARS THE
MESSAGE, PROCEED TO THE NEXT LOGICAL SCREEN.
----------------------------------------------------
BOX_40
======
----------------------------------------------------
IF THIS ESTABLISHMENT-PERSON-PAIR HAS AT LEAST ONE
INSURER THAT PROVIDES HOSPITAL AND PHYSICIAN
BENEFITS OR THAT PROVIDES MEDICARE SUPPLEMENT/
MEDIGAP COVERAGE AND THE POLICYHOLDER IS NOT
LISTED AS A COVERED PERSON WITH MEDICAID OR GOVT-
HOSPITAL/PHYSICIAN FOR THE CURRENT ROUND,
CONTINUE WITH LOOP_17
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_42
----------------------------------------------------
LOOP_17
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER, ASK BOX_4OA - END_LP17
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_17 COLLECTS INFORMATION ON
PLANS THAT PROVIDE HOSPITAL/PHYSICIAN BENEFITS OR
MEDICARE SUPPLEMENT/MEDIGAP COVERAGE TO EACH
POLICYHOLDER NOT ALSO COVERED BY MEDICAID OR GOVT-
HOSPITAL/PHYSICIAN TO DETERMINE IF THAT PLAN IS AN
HMO/MANAGED CARE PLAN. THIS LOOP CYCLES ON
TRIPLES THAT MEET THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS PROVIDER OF HOSPITAL/PHYSICIAN
BENEFITS OR MEDICARE SUPPLEMENT/MEDIGAP COVERAGE
AND
- PERSON IS NOT LISTED AS A COVERED PERSON WITH
MEDICAID OR GOVT-HOSPITAL/PHYSICIAN
AND
- INSURER IS THE SOURCE OF THE HOSPITAL AND
PHYSICIAN BENEFITS PROVIDED TO PERSON THROUGH
THE ESTABLISHMENT (I.E., THE INSURANCE COMPANY
OR SELF-INSURED COMPANY)
----------------------------------------------------
BOX_40A
=======
----------------------------------------------------
IF INSURER IS AN HMO (EPIN.INSTYPE = 2), CONTINUE
WITH HX60A
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF INSURER IS NOT AN HMO), GO
TO BOX_41
----------------------------------------------------
HX60A
=====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
INSURER NAME: {NAME OF INSURER BEING LOOPED ON}
Will (POLICYHOLDER)’s plan pay for any of the costs of
visits to doctors who are not part of
(POLICYHOLDER)’s
HMO, even if (POLICYHOLDER) (do/does) not have
a referral?
YES .................................... 1 {END_LP17}
NO ..................................... 2 {END_LP17}
REF ................................... -7 {END_LP17}
DK .................................... -8 {END_LP17}
BOX_41
======
----------------------------------------------------
PRESENT MANAGED CARE (MC) SECTION FOR THIS INSURER
----------------------------------------------------
----------------------------------------------------
AT COMPLETION OF THE MC SECTION, CONTINUE WITH
END_LP17
----------------------------------------------------
END_LP17
========
----------------------------------------------------
CYCLE ON NEXT TRIPLE ON RU-ESTABLISHMENT-PERSON-
INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION.
----------------------------------------------------
----------------------------------------------------
IF NO MORE TRIPLES MEET THE STATED CONDITIONS,
END LOOP_17 AND CONTINUE WITH BOX_42
----------------------------------------------------
BOX_42
======
----------------------------------------------------
IF ROUND 1 OR ROUND 3 AND IF HX48 IS CODED ‘5’
(MEDICARE SUPPLEMENT/MEDIGAP), CONTINUE WITH HX60
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_43
----------------------------------------------------
HX60
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
CODE WITHOUT ASKING IF ANSWER IS KNOWN.
Many Medicare Supplemental or Medigap
Plans are referred to by
a Plan Letter. Do you know the Plan Letter for
(PERSON)’s
plan?
PROBE: What is it?
[Enter Plan Letter] .................... {BOX_43}
REF ................................... -7 {BOX_43}
DK .................................... -8 {BOX_43}
HELP AVAILABLE FOR DEFINITION OF PLAN LETTER.
----------------------------------------------------
HARD CHECK: MEDICARE SUPPLEMENTAL OR MEDIGAP
PLANS: MEDICARE SUPPLEMENTAL OR MEDIGAP PLAN
LETTER MUST BE 1 CHARACTER LONG, A-L, UPPER OR
LOWER CASE. IF CODED OTHER THAN A-L DISPLAY THE
FOLLOWING MESSAGE: "Medicare Supplemental or
Medigap Plan letter must be A through L. Verify
and re-enter plan letter."
----------------------------------------------------
BOX_43
======
----------------------------------------------------
IF ROUND 1 OR ROUND 3, CONTINUE WITH HX61
----------------------------------------------------
----------------------------------------------------
OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO
END_LP12
----------------------------------------------------
BOX_44
======
OMITTED.
HX61
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
For the coverage through (ESTABLISHMENT), does anyone
in the
family pay all of the premium or cost, some of the
premium or
cost, or none of the premium or cost?
[Do not include the cost of any copayments,
coinsurance or
deductibles anyone in the family may have had to pay.]
[Do include any contribution made to the plan
as part of a
paycheck.]
YES, PAY ALL OF PREMIUM/COST ........... 1 {HX62}
YES, PAY SOME OF PREMIUM/COST .......... 2 {HX62}
YES, BUT DON’T KNOW IF PAY ALL OR SOME
OF PREMIUM/COST ........................ 3 {HX62}
NO, DO NOT PAY ......................... 4 {HX63}
REF ................................... -7 {END_LP12}
DK .................................... -8 {END_LP12}
[Code One]
HELP AVAILABLE FOR DEFINITION OF
PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.
----------------------------------------------------
NOTE: THE ESTABLISHMENT NAME WHICH SHOULD BE
DISPLAYED HERE FOR THE INSURANCE FROM A
SELF-EMPLOYED-FIRM-SIZE-1 AND INSURANCE FROM
DIRECTLY PURCHASED SOURCES, SHOULD BE THE NAME OF
THE SOURCE, NOT THE NAME OF THE EMPLOYER OR
DIRECTLY PURCHASED CATEGORY.
----------------------------------------------------
HX62
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
How much {(do/does)/did} (POLICYHOLDER) pay for the
(ESTABLISHMENT) coverage?
[Enter Amount in Dollars] .............. {HX62OV1}
REF ................................... -7 {BOX_44A}
DK .................................... -8 {BOX_44A}
----------------------------------------------------
DISPLAY ‘(do/does)’ IF INSURANCE BEING ASKED
ABOUT IS CURRENT (I.E., HQ02 IS CODED ‘1’ (YES,
COVERED NOW)) FOR THE POLICYHOLDER. OTHERWISE,
DISPLAY ‘did’.
----------------------------------------------------
----------------------------------------------------
NOTE: THE ESTABLISHMENT NAME WHICH SHOULD BE
DISPLAYED HERE FOR THE INSURANCE FROM A
SELF-EMPLOYED-FIRM-SIZE-1 AND INSURANCE FROM
DIRECTLY PURCHASED SOURCES, SHOULD BE THE NAME OF
THE SOURCE, NOT THE NAME OF THE EMPLOYER OR
DIRECTLY PURCHASED CATEGORY.
----------------------------------------------------
HX62OV1
=======
{Is/Was} that per year, per month, per week, or what?
UNIT OF COVERAGE:
PER YEAR ............................... 1 {BOX_44A}
QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_44A}
BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_44A}
PER MONTH .............................. 4 {BOX_44A}
PER WEEK ............................... 5 {BOX_44A}
BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_44A}
SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_44A}
SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_44A}
OTHER ................................. 91 {HX62OV2}
REF ................................... -7 {BOX_44A}
DK .................................... -8 {BOX_44A}
[Code One]
----------------------------------------------------
DISPLAY ‘Is’ IF INSURANCE BEING ASKED ABOUT IS
CURRENT (I.E., HQ02 IS CODED ‘1’ (YES, COVERED
NOW)) FOR THE POLICYHOLDER. OTHERWISE, DISPLAY
‘Was’.
----------------------------------------------------
HX62OV2
=======
OTHER:
[Enter Other Specify] .................. {BOX_44A}
REF ................................... -7 {BOX_44A}
DK .................................... -8 {BOX_44A}
BOX_44A
=======
-----------------------------------------------------
IF HX61 IS CODED ‘1’ (YES, PAY ALL OF PREMIUM/
COST), GO TO END_LP12
-----------------------------------------------------
-----------------------------------------------------
OTHERWISE, CONTINUE WITH HX63
-----------------------------------------------------
HX63
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF
ESTABLISHMENT} {STR-DT}
{END-DT}
Who {else} pays {some of/for} the premium or cost
of this insurance?
CHECK ALL THAT APPLY.
FEDERAL GOVERNMENT .................... 1
STATE GOVERNMENT ...................... 2
LOCAL GOVERNMENT ...................... 3
SOME GOVERNMENT ....................... 4
EMPLOYER .............................. 5
UNION ................................. 6
OTHER ................................. 91 {HX63OV}
REF ................................... -7 {END_LP12}
DK .................................... -8 {END_LP12}
[Code All That Apply]
----------------------------------------------------
DISPLAY ‘else’ IF HX61 IS CODED ‘2’ (YES, PAY SOME
OF PREMIUM/COST) OR ‘3’ (YES, BUT DON’T KNOW IF
PAY ALL OR SOME OF PREMIUM/COST). OTHERWISE, USE
A NULL DISPLAY
DISPLAY ‘some of’ IF HX61 IS CODED ‘2’ (YES, PAY
SOME OF PREMIUM/COST) OR ‘3’ (YES, BUT DON’T KNOW
IF PAY ALL OR SOME OF PREMIUM/COST). DISPLAY ‘for’
IF HX61 IS CODED ‘4’ (NO, DO NOT PAY).
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH ANY OTHER CODE, CONTINUE WITH HX63OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP12
----------------------------------------------------
HX63OV
======
OTHER:
[Enter Other Specify] .................. {END_LP12}
REF ................................... -7 {END_LP12}
DK .................................... -8 {END_LP12}
END_LP12
========
------------------------------------------------------
CYCLE ON NEXT PAIR IN RU-ESTABLISHMENT-PERSON-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.
------------------------------------------------------
------------------------------------------------------
IF NO MORE PAIRS MEET THE STATED CONDITIONS,
END LOOP_12 AND CONTINUE WITH BOX_45
------------------------------------------------------
BOX_45
======
------------------------------------------------------
IF ROUND 1, CONTINUE WITH BOX_46
------------------------------------------------------
------------------------------------------------------
OTHERWISE, GO TO BOX_51
------------------------------------------------------
BOX_46
======
------------------------------------------------------
IF ALL PERSONS IN RU HAVE HEALTH INSURANCE (I.E.,
FLAGGED AS HAVING MEDICARE, MEDICAID/SCHIP,
GOVT-HOSPITAL/PHYSICIAN, TRICARE/CHAMPVA, OTHER
PUBLIC OR PRIVATE INSURANCE) COVERAGE ON JANUARY 1,
{YEAR}, WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF
THE PANEL, GO TO BOX_48
------------------------------------------------------
------------------------------------------------------
OTHERWISE, (AT LEAST ONE RU MEMBER BORN BEFORE
12/31/{YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE
FIRST CALENDAR YEAR OF THE PANEL, IS WITHOUT HEALTH
INSURANCE ON JANUARY 1, {YEAR}, WHERE ‘YEAR’ IS THE
FIRST CALENDAR YEAR OF THE PANEL), CONTINUE WITH
LOOP_18
------------------------------------------------------
LOOP_18
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK
HX64-END_LP18
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_18 COLLECTS INFORMATION
ABOUT RU MEMBERS WITH NO HEALTH INSURANCE ON
JANUARY 1, {YEAR}, WHERE YEAR IS THE FIRST
CALENDAR YEAR OF THE PANEL. THIS LOOP CYCLES ON RU
MEMBERS WHO ARE NOT A COVERED PERSON IN ANY
ESTABLISHMENT-POLICYHOLDER-COVERED-PERSON-TRIPLE
THAT MEETS THE FOLLOWING CONDITIONS:
- ESTABLISHMENT IS MEDICARE, MEDICAID/SCHIP, GOVT-
HOSPITAL/PHYSICIAN, OTHER PUBLIC,
TRICARE/CHAMPVA, OR PRIVATE INSURANCE
AND
- PERSON IS A CURRENT RU MEMBER WITH A BIRTH DATE
PRIOR TO DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS
THE YEAR PRIOR TO THE FIRST CALENDAR YEAR OF THE
PANEL (OR AGE CATEGORY > 1)
AND
- PERIOD OF COVERAGE INCLUDES JANUARY 1, {YEAR},
WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE
PANEL.
----------------------------------------------------
HX64
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
I have recorded that (PERSON) (were/was) without
insurance on
January 1, {YEAR}. (Were/Was) (PERSON) covered by a
health
insurance plan or program at any time in the years
{YEAR} or
{YEAR}?
YES .................................... 1 {HX65}
NO ..................................... 2 {END_LP18}
REF ................................... -7 {END_LP18}
DK .................................... -8 {END_LP18}
----------------------------------------------------
(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): IN THE QUESTION TEXT, "... on
JANUARY 1, {YEAR}," ‘YEAR’ IS THE FIRST CALENDAR
YEAR OF THE PANEL. IN THE QUESTION TEXT, "... at
any time in the years {YEAR} or {YEAR}?" CAPI
DISPLAYS THE TWO YEARS PRIOR TO THE FIRST CALENDAR
YEAR OF THE PANEL. (FOR PANEL 12 FOR EXAMPLE, THIS
WOULD BE ‘2005 or 2006?’).
----------------------------------------------------
HX65
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
When (were/was) (PERSON) most recently covered by
health
insurance? That is, in what month and year did that
health
insurance end for the last time in {YEAR} or
{YEAR}?
[Enter Month,Year-4] ................... {HX66}
REF ................................... -7 {HX66}
DK .................................... -8 {HX66}
----------------------------------------------------
(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): CAPI DISPLAYS THE TWO YEARS PRIOR
TO THE FIRST CALENDAR YEAR OF THE PANEL FOR
"‘YEAR’ OR ‘YEAR’?". (FOR PANEL 12 FOR EXAMPLE,
THIS WOULD BE ‘2005 or 2006?’).
----------------------------------------------------
----------------------------------------------------
‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED
ON THE MONTH AND YEAR FIELDS.
----------------------------------------------------
HX66
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Was (PERSON)’s health insurance that ended in {MONTH
AND YEAR
FROM HX65/{YEAR} or {YEAR}} obtained through an
employer or a
union, was it a government program such as Medicaid,
or what?
CHECK ALL THAT APPLY.
OBTAINED THROUGH UNION, PRIVATE
EMPLOYER OR PUBLIC EMPLOYER (FEDERAL,
STATE, OR LOCAL GOVT.) ................. 1
MEDICARE ............................... 2
MEDICAID ............................... 3
TRICARE/CHAMPVA ........................ 4
VA OR MILITARY HEALTH CARE ............. 5
PURCHASED DIRECTLY FROM GROUP, ASSOC.,
OR INS. AGENT, INS. CO. OR HMO ......... 6
OTHER TYPE OF GOVERNMENT SPONSORED
PROGRAM ................................ 7
OTHER PUBLIC PROGRAM:
TANF ................................ 8
SSI ................................. 9
{STATE PROGRAM 1} .................. 10
{STATE PROGRAM 2} .................. 11
{STATE PROGRAM 3} .................. 12
{STATE PROGRAM 4} .................. 13
OTHER ................................. 91 {HX66OV}
REF ................................... -7 {END_LP18}
DK .................................... -8 {END_LP18}
[Code All That Apply]
HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.
----------------------------------------------------
IF HX65 IS NOT CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW), DISPLAY THE DATE ENTERED AT HX65 FOR ‘MONTH
AND YEAR FROM HX65’. DISPLAY ‘{YEAR} or
{YEAR}’ IF HX65 IS CODED ‘-7’ (REFUSED) OR ‘-8’
(DON’T KNOW), WHERE ‘YEAR’ AND ‘YEAR’ DISPLAYS
THE TWO YEARS PRIOR TO THE FIRST CALENDAR YEAR OF
THE PANEL. FOR PANEL 12 FOR EXAMPLE, THIS WOULD BE
‘2005’ or ‘2006’.
----------------------------------------------------
----------------------------------------------------
FOR ‘STATE PROGRAM N’, DISPLAY AN ACTUAL NAME OF
A STATE PLAN. FOR THE SPECIFIC NAMES OF PLANS
BY STATE, SEE BOX ON HX16.
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH OTHER CODES, CONTINUE WITH HX66OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP18
----------------------------------------------------
HX66OV
======
OTHER:
[Enter Other Specify] .................. {END_LP18}
REF ................................... -7 {END_LP18}
DK .................................... -8 {END_LP18}
HX67
====
OMITTED.
HX68
====
OMITTED.
HX68OV
======
OMITTED.
BOX_47
======
OMITTED.
HX69
====
OMITTED.
END_LP18
========
----------------------------------------------------
CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER THAT
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION
----------------------------------------------------
----------------------------------------------------
IF NO MORE PERSONS MEET THE STATED CONDITIONS,
END LOOP_18 AND CONTINUE WITH BOX_48
----------------------------------------------------
BOX_48
======
----------------------------------------------------
IF NO CURRENT RU MEMBERS WHO WERE BORN BEFORE
DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS THE YEAR
PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL,
HAVE ANY TYPE OF COMPREHENSIVE PUBLIC INSURANCE
(I.E., MEDICARE, MEDICAID/SCHIP, GOVT-
HOSPITAL/PHYSICIAN, OR TRICARE/CHAMPVA)
AND
NO CURRENT RU MEMBERS WHO WERE BORN BEFORE
DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS THE YEAR
PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL,
HAVE ANY PRIVATE INSURANCE THAT INCLUDED HOSPITAL
AND PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT/
MEDIGAP BENEFITS ON 1/1/{YEAR}, WHERE ‘YEAR’ IS
THE FIRST CALENDAR YEAR OF THE PANEL, GO TO
BOX_49
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH LOOP_19
----------------------------------------------------
LOOP_19
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK
HX70-END_LP19
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_19 COLLECTS INFORMATION ON
ALL RU MEMBERS WITH PUBLIC AND PRIVATE HEALTH
INSURANCE PROVIDING HOSPITAL/PHYSICIAN BENEFITS OR
MEDICARE SUPPLEMENT/MEDIGAP BENEFITS ON JANUARY 1,
{YEAR}, WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF
THE PANEL, TO DETERMINE PERIODS OF COVERAGE IN
{YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE
FIRST CALENDAR YEAR OF THE PANEL. THIS LOOP CYCLES
ON PERSONS THAT MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER
AND
- PERSON’S DATE OF BIRTH IS BEFORE 12/31/{YEAR},
WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE FIRST
CALENDAR YEAR OF THE PANEL, OR PERSON’S AGE IS
AGE CATEGORIES 2-9
AND
- PERSON HAD COMPREHENSIVE HEALTH INSURANCE
COVERAGE ON 1/1/{YEAR}, WHERE ‘YEAR’ IS THE
FIRST CALENDAR YEAR OF THE PANEL. COMPREHENSIVE
HEALTH INSURANCE REFERS TO THE PERSON BEING A
COVERED PERSON ON AT LEAST ONE OF THE FOLLOWING
ESTABLISHMENT-POLICYHOLDER-COVERED-PERSON-
TRIPLES ON 1/1/{YEAR}, WHERE ‘YEAR’ IS THE FIRST
CALENDAR YEAR OF THE PANEL:
- ESTABLISHMENT IS MEDICARE
- ESTABLISHMENT IS MEDICAID/SCHIP
- ESTABLISHMENT IS TRICARE
- ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN
- ESTABLISHMENT IS PRIVATE WITH HOSPITAL AND
PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR
MEDIGAP (I.E., HX48 = 1 OR 5)
----------------------------------------------------
HX70
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {STR-DT}
{END-DT}
I have recorded that (PERSON) had health insurance
coverage on
January 1, {YEAR}. (Were/Was) (PERSON) ever without
health
insurance coverage at any time in {YEAR}?
YES .................................... 1 {HX71}
NO ..................................... 2 {END_LP19}
REF ................................... -7 {END_LP19}
DK .................................... -8 {END_LP19}
----------------------------------------------------
(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): FOR ‘YEAR’ IN, "... on JANUARY 1,
{YEAR}," DISPLAY THE FIRST CALENDAR YEAR OF THE
PANEL. FOR ‘YEAR’ IN "... at any time in {YEAR},"
DISPLAY THE YEAR PRIOR TO THE FIRST CALENDAR YEAR
OF THE PANEL.
----------------------------------------------------
HX71
====
{POLICYHOLDER FIRST MIDDLE LAST NAME} {STR-DT}
{END-DT}
Altogether, how many weeks or months (were/was)
(PERSON)
without health insurance coverage in the year {YEAR}?
[Enter Small Number] ................... {HX71OV}
REF ................................... -7 {END_LP19}
DK .................................... -8 {END_LP19}
----------------------------------------------------
(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): FOR ‘YEAR’ IN THE QUESTION TEXT,
DISPLAY THE YEAR PRIOR TO THE FIRST CALENDAR YEAR
OF THE PANEL.
----------------------------------------------------
HX71OV
======
ENTER UNIT:
WEEKS .................................. 1 {END_LP19}
MONTHS ................................. 2 {END_LP19}
REF ................................... -7 {END_LP19}
DK .................................... -8 {END_LP19}
[Code One]
HX72
====
OMITTED.
HX73
====
OMITTED.
HX73OV
======
OMITTED.
HX74
====
OMITTED.
HX75
====
OMITTED.
HX75OV
======
OMITTED.
END_LP19
========
----------------------------------------------------
CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER THAT
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION
----------------------------------------------------
----------------------------------------------------
IF NO MORE PERSONS MEET THE STATED CONDITIONS,
END LOOP_19 AND CONTINUE WITH BOX_49
----------------------------------------------------
BOX_49
======
----------------------------------------------------
IF ALL CURRENT RU MEMBERS WHO WERE BORN BEFORE
DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS THE YEAR
PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL,
HAVE ONLY PRIVATE INSURANCE THAT INCLUDES HOSPITAL
AND PHYSICIAN BENEFITS
AND/OR
ALL CURRENT RU MEMBERS HAVE ONLY COMPREHENSIVE
PUBLIC INSURANCE ON JANUARY 1, {YEAR}, WHERE
‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL,
GO TO BOX_51
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH LOOP_20
----------------------------------------------------
LOOP_20
=======
----------------------------------------------------
FOR EACH ELEMENT IN RU-MEMBERS-ROSTER,
ASK HX76-END_LP20
----------------------------------------------------
----------------------------------------------------
LOOP DEFINITION: LOOP_20 COLLECTS INFORMATION FOR
EACH RU MEMBER WHOSE DATE OF BIRTH IS PRIOR TO
12/31/{YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO
THE FIRST CALENDAR YEAR OF THE PANEL, (OR AGE
CATEGORY > 1), AND WHO IS COVERED BY PRIVATE
INSURANCE THAT DOES NOT INCLUDE EITHER HOSPITAL/
PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT/MEDIGAP
BENEFITS ON JANUARY 1, {YEAR}, WHERE ‘YEAR’ IS THE
FIRST CALENDAR YEAR OF THE PANEL. THE LOOP CYCLES
ON PERSONS WERE EVER COVERED BY A MORE
COMPREHENSIVE PLAN THAT PROVIDED HOSPITAL/
PHYSICIAN COVERAGE DURING {YEAR}, WHERE ‘YEAR’ IS
THE YEAR PRIOR TO THE FIRST CALENDAR YEAR OF THE
PANEL, OR {YEAR}, WHERE ‘YEAR’ IS TWO YEARS PRIOR
TO THE FIRST CALENDAR YEAR OF THE PANEL. THE LOOP
CYCLES ON PERSONS THAT MEET THE FOLLOWING
CONDITIONS:
- PERSON IS A CURRENT RU MEMBER
AND
- PERSON’S DATE OF BIRTH IS BEFORE 12/31/{YEAR},
WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE FIRST
CALENDAR YEAR OF THE PANEL, OR IN AGE CATEGORIES
2-9
AND
- PERSON DID NOT HAVE COMPREHENSIVE HEALTH
INSURANCE COVERAGE ON 1/1/{YEAR}, WHERE ‘YEAR’
IS THE FIRST CALENDAR YEAR OF THE PANEL.
COMPREHENSIVE HEALTH INSURANCE REFERS TO THE
PERSON BEING A COVERED PERSON ON AT LEAST ONE OF
THE FOLLOWING ESTABLISHMENT-POLICYHOLDER-
COVERED-PERSON-TRIPLES ON 1/1/{YEAR}, WHERE
‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL:
- ESTABLISHMENT IS MEDICARE
- ESTABLISHMENT IS MEDICAID
- ESTABLISHMENT IS TRICARE
- ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN
- ESTABLISHMENT IS PRIVATE WITH HOSPITAL AND
PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR
MEDIGAP (I.E., HX48 = 1 OR 5)
AND
- PERSON IS COVERED PERSON ON AT LEAST ONE OF THE
FOLLOWING ESTABLISHMENT-POLICYHOLDER-COVERED-
PERSON-TRIPLES ON 1/1/{YEAR}, WHERE ‘YEAR’ IS
THE FIRST CALENDAR YEAR OF THE PANEL:
----------------------------------------------------
----------------------------------------------------
- ESTABLISHMENT IS GROUP 1 OR GROUP 2 OTHER
PUBLIC
- ESTABLISHMENT IS PRIVATE WITHOUT HOSPITAL AND
PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR
MEDIGAP (I.E., HX48 IS NOT CODED 1 OR 5)
----------------------------------------------------
HX76
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
I have recorded that (PERSON) {had health insurance
coverage for
(READ TYPES OF INSURANCE BELOW) coverage} {and} {was
covered by a
public program} on January 1, {YEAR}. (Were/Was)
(PERSON) ever
covered by a more comprehensive health insurance plan
or program
that paid for medical and doctor’s bills at any time
in the years
{YEAR} or {YEAR}?
{TYPE OF INSURANCE IN HX48} {TYPE OF INSURANCE IN
HX48}
{TYPE OF INSURANCE IN HX48} {TYPE OF INSURANCE IN
HX48}
{TYPE OF INSURANCE IN HX48} {TYPE OF INSURANCE IN
HX48}
YES .................................... 1 {HX77}
NO ..................................... 2 {END_LP20}
REF ................................... -7 {END_LP20}
DK .................................... -8 {END_LP20}
----------------------------------------------------
DISPLAY ‘had health...(BELOW)’ IF PERSON
CONFIRMED AS POLICYHOLDER (HP09 IS CODED ‘1’
(YES)) OR SELECTED AS POLICYHOLDER (SELECTED AT
HP11) OR SELECTED AS A DEPENDENT (SELECTED AT
HP16) FOR ANY PRIVATE ESTABLISHMENT-POLICYHOLDER
PAIR WHERE HX48 IS NOT CODED ‘1’ (HOSPITAL AND
PHYSICIAN BENEFITS) AND NOT CODED ‘5’ (MEDICARE
SUPPLEMENT/MEDIGAP) EITHER ALONE OR WITH ANY
COMBINATION OF CODES FOR ALL OF THOSE PRIVATE
ESTABLISHMENT-POLICYHOLDER PARIS. OTHERWISE, USE
A NULL DISPLAY.
DISPLAY ‘was....program’ IF PERSON SELECTED AT
HX19 (FOR EITHER GROUP 1 OR GROUP 2 PROGRAM).
OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘and’ IF PERSON CONFIRMED AS POLICYHOLDER
(HP09 IS CODED ‘1’ (YES)) OR SELECTED AS
POLICYHOLDER (SELECTED AT HP11) OR SELECTED AS A
DEPENDENT (SELECTED AT HP16) FOR ANY PRIVATE
ESTABLISHMENT-POLICYHOLDER PAIR WHERE HX48 IS NOT
CODED ‘1’ (HOSPITAL AND PHYSICIAN BENEFITS) AND
NOT CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP) EITHER
ALONE OR WITH ANY COMBINATION OF CODES FOR ALL OF
THOSE PRIVATE ESTABLISHMENT-POLICYHOLDER PAIRS
AND PERSON SELECTED AT HX19 (FOR EITHER GROUP 1
OR GROUP 2 PROGRAM).
----------------------------------------------------
----------------------------------------------------
(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): IN THE QUESTION TEXT, "... on
JANUARY 1, {YEAR}," ‘YEAR’ IS THE FIRST CALENDAR
YEAR OF THE PANEL. IN THE QUESTION TEXT, "... at
any time in the years {YEAR} or {YEAR}?" CAPI
DISPLAYS THE TWO YEARS PRIOR TO THE FIRST CALENDAR
YEAR OF THE PANEL. (FOR PANEL 12 FOR EXAMPLE, THIS
WOULD BE ‘2005 or 2006?’).
----------------------------------------------------
HX77
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
When (were/was) (PERSON) most recently covered by this
kind of
health insurance? That is, in what month and year did
the
health insurance that paid for medical and doctor’s
bills end
for the last time in {YEAR} or {YEAR}?
[Enter Month,Year-4] ................... {HX78}
REF ................................... -7 {HX78}
DK .................................... -8 {HX78}
----------------------------------------------------
(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): CAPI DISPLAYS THE TWO YEARS PRIOR
TO THE FIRST CALENDAR YEAR OF THE PANEL FOR
"‘YEAR’ OR ‘YEAR’?". (FOR PANEL 12 FOR EXAMPLE,
THIS WOULD BE ‘2005 or 2006?’).
----------------------------------------------------
----------------------------------------------------
‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED
ON THE MONTH AND YEAR FIELDS.
----------------------------------------------------
HX78
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Was (PERSON)’s health insurance that ended in {DATE
FROM
HX77/{YEAR} or {YEAR}} obtained through an employer or
union, was
it a government program such as Medicare or Medicaid,
or what?
CHECK ALL THAT APPLY.
OBTAINED THROUGH UNION, PRIVATE
EMPLOYER OR PUBLIC EMPLOYER (FEDERAL,
STATE, OR LOCAL GOVERNMENT) ............ 1
MEDICARE ............................... 2
MEDICAID ............................... 3
TRICARE/CHAMPVA ........................ 4
VA OR MILITARY HEALTH CARE ............. 5
PURCHASED DIRECTLY FROM GROUP,
ASSOCIATION, OR INSURANCE AGENT,
INSURANCE COMPANY OR HMO ............... 6
OTHER TYPE OF GOVERNMENT SPONSORED
PROGRAM ................................ 7
OTHER PUBLIC PROGRAM:
TANF ................................ 8
SSI ................................. 9
{STATE PROGRAM 1}................... 10
{STATE PROGRAM 2} .................. 11
{STATE PROGRAM 3} .................. 12
{STATE PROGRAM 4} .................. 13
OTHER ................................. 91 {HX78OV}
REF ................................... -7 {END_LP20}
DK .................................... -8 {END_LP20}
[Code All That Apply]
HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.
----------------------------------------------------
IF HX77 IS NOT CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T
KNOW), DISPLAY THE DATE ENTERED AT HX77 FOR ‘MONTH
AND YEAR FROM HX77’. DISPLAY ‘in {YEAR} or
{YEAR}’ IF HX77 IS CODED ‘-7’ (REFUSED) OR ‘-8’
(DON’T KNOW), WHERE "‘YEAR’ or ‘YEAR’" DISPLAYS
THE TWO YEARS PRIOR TO THE FIRST CALENDAR YEAR OF
THE PANEL. FOR PANEL 12 FOR EXAMPLE, THIS WOULD BE
‘2005’ or ‘2006’.
----------------------------------------------------
----------------------------------------------------
FOR ‘STATE PROGRAM N’, DISPLAY AN ACTUAL NAME OF
STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A
STATE THAT HAS OTHER STATE PROGRAMS. FOR THE
SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON
HX16.
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT
ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN
COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH OTHER CODES, CONTINUE WITH HX78OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP20
----------------------------------------------------
HX78OV
======
OTHER:
[Enter Other Specify] .................. {END_LP20}
REF ................................... -7 {END_LP20}
DK .................................... -8 {END_LP20}
HX79
====
OMITTED.
HX80
====
OMITTED.
HX80OV
======
OMITTED.
END_LP20
========
----------------------------------------------------
CYCLE ON NEXT PERSON ON ru-members-roster that
meetS the conditions stated in the loop definition
----------------------------------------------------
----------------------------------------------------
IF NO MORE PERSONS MEET THE STATED CONDITIONS,
END LOOP_20 AND CONTINUE WITH BOX_51
----------------------------------------------------
BOX_50
======
OMITTED.
LOOP_21
=======
OMITTED.
HX81
====
OMITTED.
END_LP21
========
OMITTED.
BOX_51
======
----------------------------------------------------
GO TO NEXT QUESTIONNAIRE SECTION
----------------------------------------------------
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