MEDICAL EXPENDITURE PANEL SURVEY
HOUSEHOLD COMPONENT
MAIN STUDY
CHESHIRE VERSION
SHOW CARDS
TO BE USED FOR PANELS 10 AND 11
Rounds 3 through 5
January 2007
TABLE OF CONTENTS
ROUNDS 3 THROUGH 5
| Card Number | Topic | Round(s) Used |
|---|---|---|
| RE-1B | Ethnic Background | 3, 4, 5 |
| RE-2B | Racial Background | 3, 4, 5 |
| RE-2C | Asian Ethnic Background | 3, 4, 5 |
| RE-3A-3K | Income Categories | 3 |
| PG-1 | Complications Experienced During Pregnancy | 3, 4, 5 |
| HE-1 | Level of Difficulty Categories | 3, 5 |
| HE-2 | Aspects of Children's Health | 4 |
| HE-3 | Children's General Health Status | 4 |
| CS-1 | Scale for Child Health Supplement | 4 |
| CS-2 | Scale for Child Health Supplement | 4 |
| CS-3 | Scale for Child Health Supplement | 4 |
| CS-3A | Number of Times Went to Doctor’s Office or Clinic | 4 |
| CS-4 | Scale for Child Health Supplement | 4 |
| CS-5 | Scale for Child Health Supplement | 4 |
| PP-1 | Types of Health Care Providers and Facilities | 3, 4, 5 |
| PP-2 | Types of Hospital Services/Long Term Care Facilities | 3, 4, 5 |
|
Types of Home Care Services |
3, 4, 5 |
|
|
Types of Medical Supplies/Expenses |
3, 4, 5 |
|
|
Types of Additional Medical Supplies/Expenses |
3, 5 | |
|
Types of Dental Care Providers |
3, 4, 5 |
|
|
Types of Medical Providers |
3, 4, 5 |
|
|
Types of Hospital Services |
3, 4, 5 |
|
|
Types of Other Medical Providers |
3, 4, 5 |
|
|
Types of Home Care Services |
3, 4, 5 |
|
|
Types of Long Term Care Facilities |
3, 4, 5 |
|
|
Types of Medical Supplies/Expenses |
3, 4, 5 |
|
|
Types of Additional Medical Supplies/Expenses |
3, 5 |
|
|
Reasons for Entering the Hospital |
3, 4, 5 |
|
|
Care Received During ER Visit |
3, 4, 5 |
|
|
Services Received During ER Visit |
3, 4, 5 |
|
|
Care Received During Outpatient Visit |
3, 4, 5 |
|
|
Treatments Received During Outpatient Visit |
3, 4, 5 |
|
|
Services Received During Outpatient Visit |
3, 4, 5 |
|
|
Care Received During Medical Provider Visit |
3, 4, 5 |
|
|
Treatments Received During Medical Provider Visit |
3, 4, 5 |
|
|
Services Received During Medical Provider Visit |
3, 4, 5 |
|
|
Care Received During Dental Visit |
3, 4, 5 |
|
|
Types of Home Health Care Workers |
3, 4, 5 |
|
|
Examples of Home Health Care Received |
3, 4, 5 |
|
|
Examples of Help With Daily Activities or Personal Care |
3, 4, 5 |
|
|
Reasons for Not Receiving Anything in Writing |
3, 4, 5 |
|
| Items Involved in the Accident/Injury |
3, 4, 5 |
|
|
Last Use of Peak Flow Meter |
3, 5 |
|
|
Weight Ranges |
3, 5 |
|
|
Difficulty Scale |
4 |
|
|
Provider’s Race |
4 |
|
|
Frequency Scale |
4 |
|
|
Reasons for Problems |
4 |
|
|
Problems Scale |
4 |
|
|
Types of Health Insurance Coverage |
3, 4, 5 |
|
|
Medicare Managed Care Plan Names for STATE |
3, 4, 5 |
|
|
Medicaid (and Gov’t-Hosp/Phys) HMO Plan Names for STATE |
3, 4, 5 |
|
|
Types of Other State Programs |
3, 4, 5 |
|
|
Ways in Which Health Insurance is Purchased |
3, 4, 5 |
|
|
Sample Medicare Card |
3, 4, 5 |
|
|
Sample Medicaid Card for STATE |
3, 4, 5 |
|
|
Source of Health Insurance |
3, 4, 5 |
|
|
Medicare Managed Care Plan Names for STATE |
3, 4, 5 |
|
|
Medicaid (and Gov’t-Hosp/Phys) HMO Plan Names for STATE |
3, 4, 5 |
|
|
Types of Health Insurance Coverage |
3, 4, 5 |
|
|
Problem Scale |
4 |
|
|
Health Plan Scale |
4 |
|
|
Yearly Income Ranges |
3, 5 |
|
|
Monthly Income Ranges |
3, 5 |
|
|
TANF Program Names for STATE |
3, 5 |
|
|
Other Sources of Income Categories |
3, 5 |
|
|
Asset Ranges |
5 |
Puerto Rican
Cuban/Cuban American
Dominican
Mexican
Mexican-American
Central or South America
White
Black/African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $10,600 | less than $883 |
| B. | $10,600 – $15,900 | $883 – $1,325 |
| C. | $15,901 – $21,200 | $1,326 – $1,767 |
| D. | $21,201 – $31,800 | $1,768 – $2,650 |
| E. | more than $31,800 |
more than $2,650 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $13,700 | less than $1,142 |
| B. | $13,700 – $20,600 | $1,142 – $1,717 |
| C. | $20,601 – $27,400 | $1,718 – $2,283 |
| D. | $27,401 – $41,100 | $2,284 – $3,425 |
| E. | more than $41,100 |
more than $3,425 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $9,800 | less than $817 |
| B. | $9,800 – $14,700 | $817 – $1,225 |
| C. | $14,701 – $19,500 | $1,226 – $1,625 |
| D. | $19,501 – $29,300 | $1,626 – $2,442 |
| E. | more than $29,300 |
more than $2,442 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $12,300 | less than $1,025 |
| B. | $12,300 – $18,500 | $1,025 – $1,542 |
| C. | $18,501 – $24,700 | $1,543 – $2,058 |
| D. | $24,701 – $37,000 | $2,059 – $3,083 |
| E. | more than $37,000 |
more than $3,083 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $16,200 | less than $1,350 |
| B. | $16,200 – $24,400 | $1,350 – $2,033 |
| C. | $24,401 – $32,500 | $2,034 – $2,708 |
| D. | $32,501 – $48,700 | $2,709 – $4,058 |
| E. | more than $48,700 |
more than $4,058 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $20,800 | less than $1,733 |
| B. | $20,800 – $31,300 | $1,733 – $2,608 |
| C. | $31,301 – $41,700 | $2,609 – $3,475 |
| D. | $41,701 – $62,500 | $3,476 – $5,208 |
| E. | more than $62,500 |
more than $5,208 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $24,600 | less than $2,050 |
| B. | $24,600 – $36,900 | $2,050 – $3,075 |
| C. | $36,901 – $49,300 | $3,076 – $4,108 |
| D. | $49,301 – $73,900 | $4,109 – $6,158 |
| E. | more than $73,900 |
more than $6,158 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $27,800 | less than $2,317 |
| B. | $27,800 – $41,800 | $2,317 – $3,483 |
| C. | $41,801 – $55,700 | $3,484 – $4,642 |
| D. | $55,701 – $83,500 | $4,643 – $6,958 |
| E. | more than $83,500 |
more than $6,958 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $31,600 | less than $2,633 |
| B. | $31,600 – $47,300 | $2,633 – $3,942 |
| C. | $47,301 – $63,100 | $3,943 – $5,258 |
| D. | $63,101 – $94,700 | $5,259 – $7,892 |
| E. | more than $94,700 |
more than $7,892 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $35,100 | less than $2,925 |
| B. | $35,100 – $52,600 | $2,925 – $4,383 |
| C. | $52,601 – $70,100 | $4,384 – $5,842 |
| D. | $70,101 – $105,200 | $5,843 – $8,767 |
| E. | more than $105,200 |
more than $8,767 |
| Wages and Salaries | Social Security or Railroad Retirement |
| Interest or Dividends | Private, Military, or Government Pensions |
| Retirement Income or Annuities | Survivor Benefits |
| Public Assistance/TANF | Supplemental Security Income (SSI) |
| Disability Benefits | Child Support or Alimony |
| Farm or Business Income | Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
Yearly |
Monthly | |
|---|---|---|
| A. | less than $42,000 | less than $3,500 |
| B. | $42,000 – $63,000 | $3,500 – $5,250 |
| C. | $63,001 – $84,100 | $5,251 – $7,008 |
| D. | $84,101 – $126,100 | $7,009 – $10,508 |
| E. | more than $126,100 |
more than $10,508 |
-- High Blood Pressure, Toxemia, Pre-Eclampsia, or Eclampsia
-- Anemia
-- Diabetes, Gestational Diabetes, or High Blood Sugar
-- Low Lying Placenta (Placenta Previa)
-- Vaginal Bleeding
-- Premature Labor
-- No Difficulty
-- Some Difficulty
-- A Lot of Difficulty
-- Completely Unable To Do It
0____________________________________________________________4
NO PROBLEM A VERY BIG PROBLEM
-- Definately False
-- Mostly False
-- Mostly True
-- Definately True
-- Definitely True
-- Mostly True
-- Don't Know
-- Mostly False
-- Definitely False
0 No Problem
1
2 Some Problem
3
4 A Very Big Problem
-- Never
-- Sometimes
-- Usually
-- Always
None
1
2
3
4
5-9
10 or more
-- A Big Problem
-- A Small Problem
-- Not A Problem
0 Worst Health Care Possible
1
2
3
4
5
6
7
8
9
10 Best Health Care Possible
TYPES OF HEALTH CARE PROVIDERS AND FACILITIES
Medical Professionals and Practitioners:
Medical Doctor
Nurse or Nurse Practitioner
Paramedic
Health Aide
Physician’s Assistant
Midwife/Nurse Midwife
Optometrist/Ophthalmologist
Podiatrist (Foot Doctor)
Chiropractor
Acupuncturist
Therapist - Physical, Speech, Occupational
Audiologist
Physiatrist
Physical Therapy or Rehabilitation Services
Mental Health Professionals:
Psychiatrist
Psychologist
Psychiatric Social Worker
Mental Health Therapist
Medical Facility or Clinic:
Health Clinic
Walk-in Surgi-Clinic
Company or School Clinic
Infirmary
Neighborhood Health Clinic
Family Planning Center
Mental Health Facility
Dental Care:
Dentist
Dental or Oral Surgeon
Orthodontist
Dental Hygienist
Dental Technician
Dental Assistant
TYPES OF HOSPITAL SERVICES
Hospital Stay
Emergency Room Visit
Outpatient Department Visit
TYPES OF LONG TERM CARE FACILITIES
Convalescent Home
Nursing Home
Nursing Home Unit of a Hospital
Intermediate Care Facilities
Board and Care Homes
Residential Psychiatric Institution
Facility for the Intellectually Disabled
Group Homes
Long Term Place that Provides Hospice Care
Long Term Place that Provides Respite Care
Assisted Living Facilities
TYPES OF
HOME CARE SERVICESSkilled Medical Care
Personal Care
Household Chore Services
Companionship
Any Other Type of Home Care
TYPES OF OTHER MEDICAL SUPPLIES/EXPENSES
Eyeglasses or Contact Lenses ......
Bought
Replaced
Paid for Repairing
Diabetic Equipment or Supplies ...
Insulin
Syringes
Test Paper
Other Diabetic Equipment or Supplies
Ambulance Services
Orthopedic Items
-- Corrective shoes or inserts
-- Braces
-- Crutches
-- Canes
-- Walkers
-- Wheelchairs
-- Scooters
Hearing Devices
-- Hearing aids
-- Amplifiers for a telephone
-- Adaptive speech equipment
-- Speech synthesizer
Prostheses
-- Artificial limbs
Bathroom Aids
-- Portable commodes
-- Raised toilet seats
-- Portable tub seats
-- Handrails
-- Other bathing equipment
Medical Equipment
-- Hospital beds
-- Lifts
-- Monitors
-- Special chairs
-- Oxygen
-- Bed pans
-- Adaptive feeding equipment
-- Vaporizer or nebulizer
-- Blood pressure monitor
Disposable Supplies
-- Ostomy supplies
-- Bandages
-- Dressings
-- Tape
-- Diapers
-- Catheters
-- Syringes not prescribed by a physician
-- IV supplies
Alterations/Modifications
-- Ramps
-- Handrails
-- Elevators
-- Automobile modifications
Other
TYPES OF DENTAL CARE PROVIDERS
Dentist
Dental or Oral Surgeon
Orthodontist
Dental Hygienist
Dental Technician
Dental Assistant
TYPES OF MEDICAL PROVIDERS
Medical Professionals:
Medical Doctor
Nurse
Nurse Practitioner
Midwife/Nurse Midwife
Physiatrist
Paramedic
Health Aide
Physical Therapy or Rehabilitation Services
Therapist-Physical, Speech, Occupational
Physician’s Assistant
Optometrist/Ophthalmologist
Podiatrist (Foot Doctor)
Chiropractor
Acupuncturist
Audiologist
Mental Health Professionals:
Psychiatrist
Psychologist
Psychiatric Social Worker
Mental Health Therapist
TYPES OF HOSPITAL SERVICES
Hospital Stay
Emergency Room Visit
Outpatient Department Visit
TYPES OF OTHER MEDICAL PROVIDERS
Medical Professionals and Practitioners:
Paramedic
Health Aide
Physician’s Assistant
Midwife
Optometrist/Ophthalmologist
Podiatrist (Foot Doctor)
Chiropractor
Acupuncturist
Therapist - Physical, Speech, Occupational
Audiologist
Physical Therapy or Rehabilitation Services
Medical Facility or Clinic:
Health Clinic
Walk-in Surgi-Clinic
Company or School Clinic
Infirmary
Neighborhood Health Clinic
Family Planning Center
Mental Health Facility
Mental Health Professionals:
Psychiatric Social Worker
Mental Health Therapist
TYPES OF HOME CARE SERVICES
Skilled Medical Care
Personal Care
Household Chore Services
Companionship
Any Other Type of Home Care
TYPES OF LONG TERM CARE FACILITIES
Convalescent Home
Nursing Home
Nursing Home Unit of a Hospital
Intermediate Care Facilities
Board and Care Homes
Residential Psychiatric Institution
Facility for the Intellectually Disabled
Group Homes
Long Term Place that Provides Hospice Care
Long Term Place that Provides Respite Care
Assisted Living Facilities
TYPES OF OTHER MEDICAL SUPPLIES/EXPENSES
Eyeglasses or Contact Lenses .....
Bought
Replaced
Paid for Repairing
Diabetic Equipment or Supplies
...Insulin
Syringes
Test Paper
Other Diabetic Equipment or Supplies
Ambulance Services
Orthopedic Items
-- Corrective shoes or inserts
-- Braces
-- Crutches
-- Canes
-- Walkers
-- Wheelchairs
-- Scooters
Hearing Devices
-- Hearing aids
-- Amplifiers for a telephone
-- Adaptive speech equipment
-- Speech synthesizer
Prostheses
-- Artificial limbs
Bathroom Aids
-- Portable commodes
-- Raised toilet seats
-- Portable tub seats
-- Handrails
-- Other bathing equipment
Medical Equipment
-- Hospital beds
-- Lifts
-- Monitors
-- Special chairs
-- Oxygen
-- Bed pans
-- Adaptive feeding equipment
-- Vaporizer or nebulizer
-- Blood pressure monitor
Disposable Supplies
-- Ostomy supplies
-- Bandages
-- Dressings
-- Tape
-- Diapers
-- Catheters
-- Syringes not prescribed by a physician
-- IV supplies
Alterations/Modifications
-- Ramps
-- Handrails
-- Elevators
-- Automobile modifications
Other
-- Operation or Surgical Procedure
-- Treatment or Therapy, Not Including Surgery
-- Diagnostic Tests Only
-- Give Birth To a Baby - Normal or Caesarean Section (Mother)
-- To Be Born (Baby)
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health Counseling
-- Follow-up or Post-Operative Visit
-- Immunization or Shots
-- Maternity Care (Pre/Postnatal)
-- Laboratory Tests
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
-- General Checkup
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health Counseling
-- Follow-up or Post-Operative Visit
-- Immunizations or Shots
-- Vision Exam
-- Maternity Care (Pre/Postnatal)
-- Well Child Exam
-- Laser Eye Surgery
-- Physical Therapy
-- Occupational Therapy
-- Speech Therapy
-- Chemotherapy
-- Radiation Therapy
-- Kidney Dialysis
-- IV Therapy
-- Drug or Alcohol Treatment
-- Allergy Shot
-- Psychotherapy/Counseling
-- Shots, Other Than Allergy
-- Laboratory Tests
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
-- General Checkup
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health Counseling
-- Follow-up or Post-Operative Visit
-- Immunizations or Shots
-- Vision Exam
-- Maternity Care (Pre/Postnatal)
-- Well Child Exam
-- Laser Eye Surgery
-- Physical Therapy
-- Occupational Therapy
-- Speech Therapy
-- Chemotherapy
-- Radiation Therapy
-- Kidney Dialysis
-- IV Therapy
-- Drug or Alcohol Treatment
-- Allergy Shot
-- Psychotherapy/Counseling
-- Shots, Other Than Allergy
-- Laboratory Tests
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
-- Other Diagnostic Test
* DIAGNOSTIC OR PREVENTATIVE
-- General Exam, Checkup or Consultation
-- Cleaning, Prophylaxis, or Polishing
-- X-Rays, Radiographs, or Bitewings
-- Fluoride Treatment
-- Sealant (Plastic Coatings on Back Teeth)
* RESTORATIVE OR ENDODONTIC
-- Fillings
-- Inlays
-- Crowns or Caps
-- Root Canal
* PERIODONTIC (GUM TREATMENT)
-- Periodontal Scaling, Root Planing, or Gum Surgery
-- Periodontal Recall Visit (Periodic or Regular)
* ORAL SURGERY
-- Extraction, Tooth Pulled
-- Implants
-- Abscess or Infection Treatment
-- Other Oral Surgery
* PROSTHETICS
-- Fixed Bridges
-- Dentures or Removable Partial Dentures
-- Relining or Repair of Bridges or Dentures
* ORTHODONTICS
-- Orthodontia, Braces, or Retainers
* ADDITIONAL PROCEDURES
-- Bonding, Whitening, or Bleaching
-- Treatment for TMD or TMJ
-- Certified Nursing Assistant (CNA)
-- Companion
-- Dietitian/Nutritionist
-- Home Health/Home Care Aide
-- Hospice Worker
-- Homemaker
-- I.V. or Infusion Therapist
-- Medical Doctor
-- Nurse/Nurse Practitioner
-- Nurse’s Aide
-- Occupational Therapist
-- Personal Care Attendant
-- Physical Therapist
-- Respiratory Therapist
-- Social Worker
-- Speech Therapist
Medical Treatments
Changing bandages, wound care, giving medication, taking blood pressure, giving shots or injections, any type of therapy, other medical treatments
| Help Using Medical Equipment or Assistive Device (Examples)
Oxygen tank, wheelchair, walker, hospital bed, tub seat, special railing, special commode, other medical equipment or assistive device |
Help With Daily Activities or Personal Care (Examples)
Using the telephone, paying bills, shopping, driving, housework, preparing meals, bathing, dressing, using the toilet, getting in or out of a bed or chair, walking, eating, other daily activities or personal care
Help With Daily
Activities or Personal Care
(Examples
Using the telephone, paying bills, shopping, driving, housework, preparing meals, bathing, dressing, using the toilet, getting in or out of a bed or chair, walking, eating, other daily activities or personal care
-- Paid At Time Of Visit
-- Made A Co-payment
-- Bill Sent Directly To Other Source
-- Bill Has Not Arrived
-- No Bill Sent:
-- HMO Plan
-- VA
-- Military Facility
-- Public Assistance/Medicaid/SCHIP
-- Worker’s Compensation
-- School, Employer, or Other Private Health Center/Clinic
-- Public Clinic/Health Center or Private Charity (Include Community and Migrant Health Center, Federally
Qualified Health Center, Indian Health Services)
-- No Charge: Telephone Call
-- Free From Provider (Professional Courtesy/Free Sample)
-- Government-Financed Research And Clinical Trials
-- A Motor Vehicle
-- A Gun
-- Weapon Other Than a Gun
-- A Poison or Something That Can Poison (Like Gasoline or a Cleaning Fluid or Chemical)
-- A Fire or Something Hot That Would Cause a Burn
-- A Drowning or Near-Drowning
-- A Sports Injury
-- A Fall (Exclude Falls Related to Sports)
-- Within the last 7 days
-- More than 7 days ago, but within last 30 days
-- More than 30 days ago
-- 79 pounds or less
-- 80 to 99 pounds
-- 100 to 119 pounds
-- 120 to 139 pounds
-- 140 to 159 pounds
-- 160 to 179 pounds
-- 180 to 199 pounds
-- 200 to 219 pounds
-- 220 to 239 pounds
-- 240 to 259 pounds
-- 260 to 279 pounds
-- 280 to 299 pounds
-- 300 to 319 pounds
-- 320 to 339 pounds
-- 340 to 359 pounds
-- 360 to 379 pounds
-- 380 to 399 pounds
-- 400 pounds or more
-- Very Difficult
-- Somewhat Difficult
-- Not Too Difficult
-- Not At All Difficult
-- White
-- Black/African American
-- Asian
-- Indian/Native American Alaska Native
-- Other Pacific Islander
-- Some Other Race
-- Never
-- Sometimes
-- Usually
-- Always
-- Couldn’t Afford Care
-- Insurance Company Wouldn’t Approve, Cover Or Pay For Care
-- Doctor Refused To Accept Family’s Insurance Plan
-- Problems Getting to Doctor’s Office
-- Different Language
-- Couldn’t Get Time Off Work
-- Didn’t Know Where To Go To Get Care
-- Was Refused Services
-- Couldn’t Get Child Care
-- Didn’t Have Time Or Took Too Long
-- A Big Problem
-- A Small Problem
-- Not A Problem
-- Hospital and Physician Benefits, Including Coverage Through an HMO
-- Dental
-- Prescription Drugs
-- Vision
-- Medicare Supplement or Medigap
-- Long-Term Care in a Nursing Home
-- Extra Cash for Hospital Stays
-- Serious Disease or Dread Disease
Medicare Managed Care Plans
[State Name Here]
(One for Each State)
Plan Names
[State Name Here]
(One for Each State)
-- TANF (Temporary Aid for Needy Families)
-- SSI (Supplemental Security Income)
-- WIC (Women, Infants and Children)
-- IHS (Indian Health Service)
-- Public Health Clinic
-- VA (Veterans Administration)
-- From a Professional Association
-- From a Small Business Group
-- From a Union
-- From a Health Insurance Purchasing Alliance
-- Directly From an Insurance Agent
-- Directly From Insurance Company
-- Directly From an HMO
-- From a Previous Employer
-- From a Previous Employer (COBRA)
Sample Medicare Card
Sample Medicaid Card
[State Name Here]
(One for Each State)
-- From a Group or Association
-- From a Health Insurance Purchasing Alliance
-- Directly Through a School
-- Directly From an Insurance Agent
-- Directly From Insurance Company
-- Directly From an HMO
-- From a Union
-- From Anyone’s Previous Employer (COBRA)
-- From Anyone’s Previous Employer (Not COBRA)
-- From Spouse’s/Deceased Spouse’s Previous Employer
-- From Some Other Employer
-- Under Plan of Someone Not Living Here
Medicare Managed Care Plans
[State Name Here]
(One for Each State)
State-Specific Plan Names
[State Name Here]
(One for Each State)
-- Hospital and Physician Benefits, Including Coverage Through an HMO
-- Dental
-- Prescription Drugs
-- Vision
-- Medicare Supplement or Medigap
-- Long-Term Care in a Nursing Home
-- Extra Cash for Hospital Stays
-- Serious Disease or Dread Disease
-- A Big Problem
-- A Small Problem
-- Not a Problem
0 Worst Health Plan Possible
1
2
3
4
5
6
7
8
9
10 Best Health Plan Possible
-- 1 - 2,500
-- 2,501 - 5,000
-- 5,001 - 10,000
-- 10,001 - 20,000
-- 20,001 - 30,000
-- 30,001 - 40,000
-- 40,001 - 50,000
-- 50,001 - 75,000
-- 75,001 - 100,000
-- 100,001 or more
-- 1 - 250
-- 251 - 500
-- 501 - 750
-- 751 - 1,000
-- 1,001 or more
State-Specific TANF Program
[State Name Here]
(One for Each State)
-- Wages and salary
-- Farm income (or loss)
-- Business income (or loss)
-- Social Security/Railroad Retirement
-- Private, military, or government pensions
-- Interest
-- Dividends
-- Rental income (or loss)
-- Other source
-- 0 - 500
-- 501 - 1,000
-- 1,001 - 5,000
-- 5,001 - 10,000
-- 10,001 - 25,000
-- 25,001 - 50,000
-- 50,001 - 100,000
-- 100,001 - 250,000
-- 250,001 - 500,000
-- 500,001 - 1,000,000
-- 1,000,001 or more