Flat Fee (FF) Section

BOX_00 (FF1000)

BOX_10 (FF1001)

BOX_20 (FF1005)

FF10 (FF1015)

BLAISE NAME: FFeeGrp

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER.} {EV} {EVN-DT}

Question Text:

Let me review the groups of health care events I have recorded for {you/{PERSON}}. Please tell me if any of these groups include the charge that covered {this hospital stay/this visit}/the services received at home}.

REVIEW FLAT FEE GROUPS WITH RESPONDENT. SELECT FLAT FEE GROUP COVERED BY SAME CHARGE AS EVENT BEING ASKED ABOUT.

Responses: ADD GROUP 0 FF20 (FF1020)

{FLAT FEE GROUP} 1 1 BOX_60 (FF1160)

{FLAT FEE GROUP} 2 2 BOX_60 (FF1160)

{FLAT FEE GROUP} 3 3 BOX_60 (FF1160)

{FLAT FEE GROUP} 4 4 BOX_60 (FF1160)

{FLAT FEE GROUP} N 5 BOX_60 (FF1160)

Programmer Instructions: Since this roster will include all flat fee groups, current round single events can be added to any flat fee group created during the current round or a previous round (FlatFeeGroup[I].FFeeName).

Roster Behavior: 1.Only single select allowed.

Display Instructions: Roster 2- No Add/Edit/Delete

Roster Definition: Display the person's-flat-fee-groups-roster (FFEE, FFEENAME) for selection.

Roster Filter: No filter; display all.

Display 'this hospital stay' if event type is HS.

Display 'this visit' if event type is ER, OP, MV, or DN.

Display 'the services received at home' if event type is HH.

FF20 (FF1020)

BLAISE NAME: FFeeRoster

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER.} {EV} {EVN-DT}

Question Text:

Let me review the list of health care events I have recorded for {you/{PERSON}}. Please tell me which of these were included in the same charge that covered {this hospital stay/this visit/the services received at home}.

REVIEW EVENTS WITH RESPONDENT.

SELECT EVENTS COVERED BY SAME CHARGE AS EVENT BEING ASKED ABOUT.

ENTER ALL THAT APPLY.

MEDICAL PROVIDER DOCTOR OR EVENT TYPE ADMIT DATE DISCHARGE DATE DEPARTMENT NAME

EVENT OUTSIDE REFERENCE PERIOD 0

{MEDICAL PROVIDER} {DOC OR DEPT} {EVENT TYPE}{ADMIT DATE} {DISCHARGE DATE}1

{MEDICAL PROVIDER} {DOC OR DEPT} {EVENT TYPE}{ADMIT DATE} {DISCHARGE DATE}2

{MEDICAL PROVIDER} {DOC OR DEPT} {EVENT TYPE}{ADMIT DATE} {DISCHARGE DATE}3

{MEDICAL PROVIDER} {DOC OR DEPT} {EVENT TYPE}{ADMIT DATE} {DISCHARGE DATE}4

{MEDICAL PROVIDER} {DOC OR DEPT} {EVENT TYPE}{ADMIT DATE} {DISCHARGE DATE}N

Responses:

Programmer Instructions: RF/DK not allowed.

Display Instructions: Display the roster in nonproportional text.

Roster 1 - Report

Roster Definition:

This item displays all medical events on person's-medical-events- roster for selection in the info pane. The 5 columns to be displayed are: MEDICAL PROVIDER, DOCTOR OR DEPARTMENT NAME, EVENT TYPE, ADMIT DATE, DISCHARGE DATE. For MEDICAL PROVIDER, display the name of provider associated with this event (EVNT.LORPNAME), if PV70 has a value, display the doctor or department associated with this event, display the two- letter event abbreviation (EVNT.EVNTTPYE) for EVENT TYPE, for Admit date display the month, day, and year of medical events (EVNT.EVNTBEGM,EVNT,EVNTBEGD,EVNT,EVNTBEGY), and the discharge date for HS events (EVNT.EVNTENDM,EVNT.EVNTENDD,EVNT.EVNTENDY). For MV, ER, OP, or DN, events display the visit date for {ADMIT DATE} and use a null display for {DISCHARGE DATE}.

For HS events display the hospital stay admit date for {ADMIT DATE} and the hospital stay discharge date for the {DISCHARGE DATE}.

Roster Filter:

Display events that meet the following conditions:

Event is not the event currently looping on.

Event has CP status of 'PROCESSED' or 'UNPROCESSED' (display event regardless of CP status).

Event is not already included in a flat fee group or a repeat visit group.

Event is not already coded (VERIFIED) as a copayment.

Event type is not IC.

Event is not an HS event with a discharge date coded '95' (STILL IN HOSPITAL).

Event is not an HH event with event date = interview month.

Event is not an HH event type 'INFORMAL' or 'VOLUNTEERED: MEAL DELIVERY SERVICE.'

Event is not an OM event.

FF30 (FF1035)

BLAISE NAME: FFeeName

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

INTERVIEWER: RECORD 'NAME OF FLAT FEE GROUP' FOR EVENTS SELECTED IN PREVIOUS QUESTION:

Responses: 1

Programmer Instructions: If Round 1, continue with FF40.

If Round 5, go to FF60.

Otherwise, go toFF80.

Write flat fee group to person’s-flat-fee-groups-roster.

Display Instructions:

FF40 (FF1045)

BLAISE NAME: FFeeVstBefStart

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP..}

Question Text:

Did the charge which included the services for {FLAT FEE GROUP} cover any visits before {START DATE}?

Responses: YES 1 FF50 (FF1050)

NO 2 FF80 (FF1080)

REFUSED RF FF80 (FF1080)

DON'T KNOW DK FF80 (FF1080)

Display Instructions: For {FLAT FEE GROUP}, display the name of the flat fee group selected at FF10 or entered at FF30.

FF50 (FF1050)

BLAISE NAME: FFeeVisBef

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP..}

Question Text:

How many visits did {you/{PERSON}} have before {START DATE}?

ENTER NUMBER OF VISITS:

Responses: 1 FF80 (FF1080)

REFUSED RF FF80 (FF1080)

DON'T KNOW DK FF80 (FF1080)

Display Instructions:

FF60 (FF1070)

BLAISE NAME: FFeeVisAft

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}

Question Text:

Will the charge which includes the services for {FLAT FEE GROUP} cover any visits after December 31, {YEAR}?

Responses: YES 1 FF70 (FF1075)

NO 2 FF80 (FF1080)

REFUSED RF FF80 (FF1080)

DON'T KNOW DK FF80 (FF1080)

Display Instructions: For {FLAT FEE GROUP}, display the name of the flat fee group selected at FF10 or entered at FF30.

(For specifications purposes only; CAPI handles automatically): for 'YEAR' in question text, display the second year of the panel.

FF70 (FF1075)

BLAISE NAME: FFeeNumVisAft

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP..}

Question Text:

Approximately, how many visits will {you/ {PERSON}} have after December 31, {YEAR}?

NUMBER OF VISITS:

Responses: 1 FF80 (FF1080)

REFUSED RF FF80 (FF1080)

DON'T KNOW DK FF80 (FF1080)

Programmer Instructions: Hard Range: TBD

Display Instructions: (For specifications purposes only; CAPI handles automatically): for 'YEAR' in question text, display the second year of the panel.

FF80 (FF1080)

BLAISE NAME: FFeeIntro

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

Now I'd like to ask you about the charges for the services for {FLAT FEE GROUP} for {you/{PERSON}}.

PRESS 1 AND ENTER TO CONTINUE.

HELP:F1

Responses: CONTINUE 1 FF90 (FF1085)

Display Instructions: For '{FLAT FEE GROUP}' display the name of the flat fee group selected at FF10 or entered at FF30.

FF90 (FF1085)

BLAISE NAME: FFeeRcvBill

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

{Have/Has} {you/{PERSON}} (or anyone in the family) received anything in writing, such as a bill, receipt, or statement, for the services for {FLAT FEE GROUP}?

ELP:F1

Responses: YES, AND DOCUMENTATION AVAILABLE 1 BOX_30 (FF1105)

YES, BUT DOCUMENTATION NOT AVAILABLE 2 BOX_30 (FF1105)

NO 3 FF100 (FF1090)

REFUSED RF FF100 (FF1090)

DON'T KNOW DK FF100 (FF1090)

Display Instructions: For '{FLAT FEE GROUP}' display the name of the flat fee group selected at FF10 or entered at FF30.

FF100 (FF1090)

BLAISE NAME: FFeeYNoBill

Context Header:

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

& CP-1.

Please look at card CP-1. Why {have/has} {you/{PERSON}} (or anyone in the family) not received anything in writing?

HELP:F1

Responses: PAID AT TIME OF VISIT 1 BOX_30 (FF1105)

MADE A COPAYMENT 2 BOX_30 (FF1105)

BILL SENT DIRECTLY TO OTHER SOURCE 3 FF110 (FF1095)

BILL HAS NOT ARRIVED 4 BOX_30 (FF1105)

NO BILL SENT: HMO PLAN 5 BOX_30 (FF1105)

NO BILL SENT: VA (VETERANS ADMINISTRATION)/CHAMPVA 6 BOX_30 (FF1105)

NO BILL SENT: MILITARY FACILITY 7 BOX_30 (FF1105)

NO BILL SENT: PUBLIC ASSISTANCE/MEDICAID/SCHIP 8 BOX_30 (FF1105)

NO BILL SENT: INDIAN HEALTH SERVICE (IHS) 9 BOX_30 (FF1105)

NO BILL SENT: WORKER'S COMPENSATION 10 BOX_30 (FF1105)

NO BILL SENT: PRIVATE HEALTH CENTER/CLINIC 11 BOX_30 (FF1105)

NO BILL SENT: PUBLIC CLINIC/HEALTH CENTER OR PRIVATE CHARITY 12 BOX_30 (FF1105)

NO CHARGE: TELEPHONE CALL 13 BOX_60 (FF1160)

FREE FROM PROVIDER 14 BOX_60 (FF1160)

GOVERNMENT-FINANCED RESEARCH AND CLINICAL TRIALS 15 BOX_60 (FF1160)

REFUSED RF BOX_30 (FF1105)

DON'T KNOW DK BOX_30 (FF1105)

Display Instructions:

FF110 (FF1095)

BLAISE NAME: FFeeWhereBill

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

To whom was the bill sent?

RECORD VERBATIM.

Responses: 1 FF120 (FF1100)

REFUSED RF FF120 (FF1100)

DON'T KNOW DK FF120 (FF1100)

Display Instructions:

FF120 (FF1100)

BLAISE NAME: FfeeWhereBillTp

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

Responses: HMO 1 BOX_30 (FF1105)

VA (VETERANS ADMINISTRATION)/CHAMPVA 2 BOX_30 (FF1105)

TRICARE 3 BOX_30 (FF1105)

OTHER MILITARY 4 BOX_30 (FF1105)

PUBLIC ASSISTANCE/MEDICAID/SCHIP 5 BOX_30 (FF1105)

WORKER'S COMPENSATION 6 BOX_30 (FF1105)

PRIVATE INSURANCE COMPANY 7 BOX_30 (FF1105)

INDIAN HEALTH SERVICE (IHS) 8 BOX_30 (FF1105)

OTHER 91 BOX_30 (FF1105)

REFUSED RF BOX_30 (FF1105)

DON'T KNOW DK BOX_30 (FF1105)

Display Instructions:

BOX_30 (FF1105)

FF130 (FF1110)

BLAISE NAME: FFeeKnowTotal

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

Do you know the total charge for the services for {FLAT FEE GROUP}?

HELP: F1

Responses: YES 1 FF140 (FF1115)

NO 2 FF150 (FF1120)

REFUSED RF FF150 (FF1120)

DON'T KNOW DK FF150 (FF1120)

Display Instructions: For '{FLAT FEE GROUP}' display the name of the flat fee group selected at FF10 or entered at FF30.

FF140 (FF1115)

BLAISE NAME: FFeeTotChrg

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

How much was the total charge, including any amounts that may be paid by health insurance or other sources?

{Include charges for procedures such as x-rays, lab tests, or diagnostic procedures that are listed separately on the bill or statement.}

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.

HELP: F1

Responses: 1

REFUSED RF

DON'T KNOW DK

Programmer Instructions: If the amount is $0, go to BOX_60. Otherwise, go to FF150.

Soft check: If amount is > $100,000, display the following message: "VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED."

Hard check: Amount cannot be < 0.

Display Instructions: Display 'Include charges for procedures such as x-rays, lab tests, or diagnostic procedures that are listed separately on the bill or statement.” if FF90 is coded '1' (YES, AND DOCUMENTATION AVAILABLE). Otherwise, use a null display.

FF150 (FF1120)

BLAISE NAME: FFeeAmtUPay

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

How much of the {{AMT TOT CH}/total charge} did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?

IF AMOUNT PAID IS NOTHING, ENTER 0. ENTER AMOUNT.

HELP: F1

Responses: 1 FF160 (FF1125)

REFUSED RF FF160 (FF1125)

DON'T KNOW DK FF160 (FF1125)

Programmer Instructions: Soft check: if amount is > $10,000, display the following message: ‘VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED.’

Display Instructions: Display ‘{AMT TOT CH}’ if an amount is given for the total charge at FF140. Display ‘total charge’ if FF130 is coded ‘2’ (NO), ‘RF’ (REFUSED), ‘DK’ (DON’T KNOW), or is not asked.

For {AMT TOT CH} display the dollar amount entered at FF140.

FF160 (FF1125)

BLAISE NAME: FFeeAnySrcPay

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

Has any private insurance company, HMO, Medicare, Medicaid, or any other source made any payments for the services for {FLAT FEE GROUP}?

HELP: F1

Responses: YES 1 FF170 (FF1130)

NO 2 BOX_40 (FF1145)

REFUSED RF BOX_40 (FF1145)

DON'T KNOW DK BOX_40 (FF1145)

Display Instructions: For '{FLAT FEE GROUP}' display the name of the flat fee group selected at FF10 or entered at FF30.

FF170 (FF1130)

BLAISE NAME: FFeeSOPRoster

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

Who else paid?

PROBE: Anyone else?

ENTER ALL THAT APPLY.

CTRL-A: ADD

CTRL-E: EDIT

CTRL-D: DELETE

Responses: {Name of Source of Payment}1 1 FF180 (FF1135)

{Name of Source of Payment} 2 2 FF180 (FF1135)

{Name of Source of Payment} 3 3 FF180 (FF1135)

{Name of Source of Payment} 4 4 FF180 (FF1135)

{Name of Source of Payment} N 5 FF180 (FF1135)

EMPTY Empty

Programmer Instructions: Roster behavior:

1. Multiple select allowed.
   
   
2. Multiple add allowed.
   
   
3. Pressing CTRL-A displays a pop-up with a blank text entry field and a selectable pick list of 15 common sources of payment. (See below for a detailed list). The interviewer can type a new source or select one from the list. Upon return to FF170, the added source will appear on the roster as selected.

GOVERNMENT SOURCES:

- 'Medicare'

- 'Medicaid{/STATE NAME FOR MEDICAID}'

- 'SCHIP/{STATE NAME FOR CHIP}'

- 'VA (VETERAN'S ADMINISTRATION)/CHAMPVA'

- 'Tricare'

- 'Military Facility'

- 'Indian Health Service'

- 'Worker's Compensation'

PRIVATE SOURCES:

- 'AARP'

- 'Aetna'

- 'Blue Cross/Blue Shield'

- 'Cigna'

- 'Delta Dental'

- 'Kaiser/Kaiser Permanente'

- 'United Healthcare'

- Other Source not listed

4. Limited delete allowed. If interviewer adds a source of payment, delete is possible for that source only, as long as the interviewer has not left the screen. If delete is attempted when it is not allowed, CAPI displays the following error message: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'

If 'Other Source not listed' is selected, CAPI should display a text box for entry.

Write sources selected to the Event’s-Sources-of- Payment-roster

If at least one source is added or selected during the current round, the flag SOPFlag should be set to YES.

Display Instructions: Roster 3- add/edit/delete allowed.

Roster definition:

Display the RU-Sources-Of-Payment-roster for selection. Display payment source name (SRCS.SRCNAME)

Display all sources of payment except PERSON/FAMILY

Display '/STATE NAME FOR MEDICAID' (substituting the real state name for program) if the state in which interview being conducted does not use the name 'Medicaid'. Otherwise, use a null display. For the specific name to use by state, see the plan fill file.

Display 'STATE NAME FOR CHIP' under all conditions (substituting the real state name for program). For the specific name to use by state, see the plan fill file.

FF180 (FF1135)

BLAISE NAME: PayFAmtPaid

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

How much did {SOURCE} pay?

ENTER AMOUNT.

TOTAL CHARGE: ${TOTAL CHARGE}

Responses: 1

REFUSED RF

DON'T KNOW DK

Programmer Instructions: Preloaded Grid Type 2- including FF180

Soft check: If amount entered is > $10,000, display the following message: "VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED."

Flag all sources and associated amounts as ‘payment’.

Interviewer enters a dollar amount for each source displayed. Amounts can be changed as many times as necessary before the interviewer leaves the screen.

2. The PERSON/FAMILY amount paid cell is protected and prefilled with the family out-of- pocket payment amount entered at FF150; no changes are allowed to this amount.

Soft Check:

If any source coded '$0', display the following message: "IF {SOURCE} DID NOT PAY ANY PART OF THE TOTAL CHARGE, CORRECT THE SOURCES THAT MADE DIRECT PAYMENTS TO THIS PROVIDER AT FF160 (FFeeAnySrcPay) OR FF170 (FFeeSOPRoster). IF {SOURCE} IS THE ONLY SOURCE OF DIRECT PAYMENT, GO TO FF160 (FFeeAnySrcPay) AND CODE ‘2’ (NO). IF THERE ARE OTHER SOURCES OF PAYMENT, GO TO FF170 (FFeeSOPRoster) AND DELETE {SOURCE} FROM THE LIST OF SOURCES OF DIRECT PAYMENT. IF RESPONDENT DOES NOT KNOW HOW MUCH{SOURCE} PAID, CODE “DK” AT FF180 (PayFAmtPaid).” CAPI displays F160 (FFeeAnySrcPay), FF170 (FFeeSOPRoster), and FF180 (PayFAmtPaid) as options to return to.

Display Instructions: Roster 1- Report

Roster definition:

Display the Event’s-Sources-of-Payment-roster for entry of payment amount in the form pane.

Display payment source name.

Roster Filter:

Display all sources selected at FF170 for this event-provider pair and the ‘PERSON/FAMILY’ record.

For TOTAL CHARGE, display amount entered at FF140, otherwise, display "N/A" if FF140=empty, DK, RF.

BOX_40 (FF1145)

BOX_50 (FF1150)

FF190 (FF1155)

BLAISE NAME: FFeeElsePay

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT} FLAT FEE GROUP:

{NAME OF FLAT FEE EVENT GROUP}

Question Text:

Does anyone in the family or any other source expect to make additional payments for the services for {FLAT FEE iGROUP}?

Responses: YES 1 BOX_60 (FF1160)

NO 2 BOX_60 (FF1160)

REFUSED RF BOX_60 (FF1160)

DON'T KNOW DK BOX_60 (FF1160)

Display Instructions: For '{FLAT FEE GROUP}' display the name of the flat fee group selected at FF10 or entered at FF30.

BOX_60 (FF1160)

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