MEDICAL EXPENDITURE PANEL SURVEY
HOUSEHOLD COMPONENT MAIN STUDY

BLAISE/WVS SHOW CARDS

Panels 20, 21, and 22

January 2017

TABLE OF CONTENTS
ROUNDS 1-5
Card Number Topic Round(s) Used
RE-1 Ethnic Background 1, 2, 3, 4, 5
RE-2 Racial Background 1, 2, 3, 4, 5
PE-1 Types of Cancer 1, 2, 3, 4, 5
HE-1 Level of Difficulty Categories 1, 3, 5
CS-2 Scale for Child Health Supplement 2, 4
CS-3 Scale for Child Health Supplement 2, 4
CS-4 Number of Times Went to Doctor’s Office or Clinic 2, 4
CS-5 Scale for Child Health Supplement 2, 4
PP-1 Types of Health Care Providers and Facilities 1, 2, 3, 4, 5
PP-2 Types of Hospital Services/Long Term Care Facilities 1, 2, 3, 4, 5
PP-3 Types of Home Care Services 1, 2, 3, 4, 5
PP-3A Types of Long Term Care Facilities 1, 2, 3, 4, 5
PP-4 Types of Medical Supplies/Expenses 1, 2, 3, 4 ,5
PP-5 Types of Additional Medical Supplies/Expenses 3, 5
PP-6 Types of Dental Care Providers 1, 2, 3, 4, 5
PP-7 Types of Medical Providers 1, 2, 3, 4, 5
PP-8 Types of Hospital Services 1, 2, 3, 4, 5
PP-9 Types of Other Medical Providers 1, 2, 3, 4, 5
PP-10 Types of Home Care Services 1, 2, 3, 4, 5
PP-11 Types of Long Term Care Facilities 1, 2, 3, 4, 5
PP-12 Types of Medical Supplies/Expenses 1, 2, 3, 4, 5
PP-13 Types of Additional Medical Supplies/Expenses 3, 5
EV-1A Examples of Where Care Received (Event Typing) 1, 2, 4
EV-1B Examples of Where Care Received (Event Typing) 3, 5
HS-1 Reasons for Entering the Hospital 1, 2, 3, 4, 5
ER-1 Care Received During ER Visit 1, 2, 3, 4, 5
ER-2 Services Received During ER Visit 1, 2, 3, 4, 5
OP-1 Care Received During Outpatient Visit 1, 2, 3, 4, 5
OP-2 Services Received During Outpatient Visit 1, 2, 3, 4, 5
MV-1 Care Received During Medical Provider Visit 1, 2, 3, 4, 5
MV-2 Services Received During Medical Provider Visit 1, 2, 3, 4, 5
DN-1 Types of Dental Care Providers 1, 2, 3, 4, 5
DN-2 Care Received During Dental Visit 1, 2, 3, 4, 5
HH-1 Types of Home Health Care Workers 1, 2, 3, 4, 5
HH-2 Examples of Home Health Care Received 1, 2, 3, 4, 5
HH-3 Examples of Help With Daily Activities or Personal Care 1, 2, 3, 4, 5
CP-1 Reasons for Not Receiving Anything in Writing 1, 2, 3, 4, 5
PC-1 Last Use of Peak Flow Meter 3, 5
AP-1 Weight Ranges 3, 5
AC-1 Difficulty Scale 2, 4
AC-2 Provider’s Race 2, 4
AC-3 Frequency Scale 2, 4
AC-4 Reasons for Problems 2, 4
HX-1 Ways in Which Health Insurance is Purchased (for STATE) 1, 2, 3, 4, 5
HX-2 Sample Medicare Card 1, 2, 3, 4, 5
HX-3 Sample Medicaid Card for STATE 1, 2, 3, 4, 5
HX-4 Source of Health Insurance (for STATE) 1, 2, 3, 4, 5
HX-6 Medicare HMO Premium Ranges 1, 3
HX-7 Medicare Part D Premium Ranges 1, 3
HX-9 Types of Health Insurance Coverage 1, 2, 3, 4, 5
HX-11 Types of Other State Programs 2, 3, 4, 5
IN-1 Yearly Income Ranges 3, 5
IN-2 Yearly Income Ranges 3, 5
IN-3 Monthly Income Ranges 3, 5
IN-4 Other Sources of Income Categories 3, 5
AS-1 Asset Ranges 5
AS-2 Asset Ranges 5
AS-3 Asset Ranges 5
AS-4 Other Financial Assets 5
AS-5 Other Property and Assets 5

Return To Table Of Contents



CARD RE-1

One or more categories may be selected.

  • -- Mexican

  • -- Mexican-American/Chicano

  • -- Puerto Rican

  • -- Cuban/Cuban American

  • -- Dominican

  • -- Central or South American

Return To Table Of Contents



CARD RE-2

One or more categories may be selected.

  • -- White

  • -- Black or African American

  • -- American Indian or Alaska Native

  • -- Asian Indian

  • -- Chinese

  • -- Filipino

  • -- Japanese

  • -- Korean

  • -- Vietnamese

  • -- Other Asian

  • -- Native Hawaiian

  • -- Guamanian or Chamorro

  • -- Samoan

  • -- Other Pacific Islander

Return To Table Of Contents



CARD PE-1

  • -- Bladder

  • -- Blood

  • -- Bone

  • -- Brain

  • -- Breast

  • -- Cervix

  • -- Colon

  • -- Esophagus

  • -- Gallbladder

  • -- Kidney

  • -- Larynx-Windpipe

  • -- Leukemia

  • -- Liver

  • -- Lung

  • -- Lymphoma

  • -- Melanoma

  • -- Mouth/Tongue/Lip

  • -- Ovary

  • -- Pancreas

  • -- Prostate

  • -- Rectum

  • -- Skin – Non-Melanoma

  • -- Skin (unknown type)

  • -- Soft tissue muscle or fat

  • -- Stomach

  • -- Testis

  • -- Throat-Pharynx

  • -- Thyroid

  • -- Uterus

  • -- Other

Return To Table Of Contents



CARD HE-1

  • -- No Difficulty

  • -- Some Difficulty

  • -- A Lot of Difficulty

  • -- Completely Unable To Do It

Return To Table Of Contents



CARD CS-2

  • 0  No Problem

  • 1

  • 2  Some Problem

  • 3

  • 4  A Very Big Problem

Return To Table Of Contents



CARD CS-3

  • -- Never

  • -- Sometimes

  • -- Usually

  • -- Always

Return To Table Of Contents



CARD CS-4

  • None

  • 1

  • 2

  • 3

  • 4

  • 5-9

  • 10 or more

Return To Table Of Contents



CARD CS-5

  • 0  Worst Health Care Possible

  • 1  

  • 2  

  • 3  

  • 4  

  • 5  

  • 6  

  • 7  

  • 8  

  • 9  

  • 10  Best Health Care Possible

Return To Table Of Contents



CARD PP-1

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
    • Retail Clinic (e.g., Pharmacy/Grocery Store Clinic)

  • Dental Care:
    • Dentist
    • Dental or Oral Surgeon
    • Orthodontist
    • Dental Hygienist
    • Dental Technician
    • Dental Assistant

Return To Table Of Contents



CARD PP-2

TYPES OF HOSPITAL SERVICES

  • Hospital Stay

  • Emergency Room Visit

  • Outpatient Department Visit

Return To Table Of Contents



CARD PP-3

TYPES OF HOME CARE SERVICES

  • Skilled Medical Care
    • Home care from a nurse, any type of therapist, a doctor, a social worker, or anyone else providing nursing or medical care.

  • Personal Care
    • Home care services including bathing, dressing, help getting around the house, or help with getting medication, either paid or unpaid.

  • Household Chore Services
    • Help in the home with services like cooking or cleaning either paid or unpaid.

  • Companionship
    • Services such as reading, talking, or going for a walk, a drive, or to a restaurant either paid or unpaid.

  • Any Other Type of Home Care

Return To Table Of Contents



CARD PP-3A

TYPES OF LONG TERM CARE FACILITIES

  • Inpatient Rehabilitation Facility or Convalescent Home

  • Nursing Home

  • Residential Mental Health Treatment Center

  • Residential Eating Disorder Treatment Center

  • Residential Drug and Alcohol Treatment Center

  • Residential Addiction Treatment Center

  • Residential Hospice Care

  • Residential Respite Care

Return To Table Of Contents



CARD PP-4

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

Return To Table Of Contents



CARD PP-5

  • 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
    • -- Adult disposable diapers
    • -- Catheters
    • -- Syringes not prescribed by a physician
    • -- IV supplies

  • Alterations/Modifications
    • -- Ramps
    • -- Handrails
    • -- Elevators
    • -- Automobile modifications

  • Other

Return To Table Of Contents



CARD PP-6

TYPES OF DENTAL CARE PROVIDERS

  • Dentist

  • Dental or Oral Surgeon

  • Orthodontist

  • Dental Hygienist

  • Dental Technician

  • Dental Assistant

Return To Table Of Contents



CARD PP-7

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

Return To Table Of Contents



CARD PP-8

TYPES OF HOSPITAL SERVICES

  • Hospital Stay

  • Emergency Room Visit

  • Outpatient Department Visit

Return To Table Of Contents



CARD PP-9

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
    • Retail Clinic (e.g., Pharmacy/Grocery Store Clinic)

  • Mental Health Professionals:
    • Psychiatric Social Worker
    • Mental Health Therapist

Return To Table Of Contents



CARD PP-10

TYPES OF HOME CARE SERVICES

  • Skilled Medical Care
    • Home care from a nurse, any type of therapist, a doctor, a social worker, or anyone else providing nursing or medical care.

  • Personal Care
    • Home care services including bathing, dressing, help getting around the house, or help with getting medication, either paid or unpaid.

  • Household Chore Services
    • Help in the home with services like cooking or cleaning either paid or unpaid.

  • Companionship
    • Services such as reading, talking, or going for a walk, a drive, or to a restaurant either paid or unpaid.

  • Any Other Type of Home Care

Return To Table Of Contents



CARD PP-11

TYPES OF LONG TERM CARE FACILITIES

  • Inpatient Rehabilitation Facility or Convalescent Home

  • Nursing Home

  • Residential Mental Health Treatment Center

  • Residential Eating Disorder Treatment Center

  • Residential Drug and Alcohol Treatment Center

  • Residential Addiction Treatment Center

  • Residential Hospice Care

  • Residential Respite Care

Return To Table Of Contents



CARD PP-12

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

Return To Table Of Contents



CARD PP-13

  • 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
    • -- Adult disposable diapers
    • -- Catheters
    • -- Syringes not prescribed by a physician
    • -- IV supplies

  • Alterations/Modifications
    • -- Ramps
    • -- Handrails
    • -- Elevators
    • -- Automobile modifications

  • Other

Return To Table Of Contents



CARD EV-1A (Rounds 1, 2 and 4)

  • -- Hospital Stay

  • -- Hospital Emergency Room

  • -- Hospital Outpatient Department

  • -- Medical Provider
    • e.g., Doctor’s Office, Group Practice, Clinic, HMO, Lab, Mental Health Care, Alternative Care

  • -- Dental Office/Dental Clinic

  • -- At Home

  • -- Other Medical Expenses
    • Eyeglasses or Contact Lenses
    • Insulin, Other Diabetic Equipment/Supplies

  • -- Institutional/Long Term Care Stay
    • e.g., Nursing Home, Rehabilitation Facility, Drug Treatment, Psychiatric Facility

Return To Table Of Contents



CARD EV-1B (Rounds 3 and 5)

  • -- Hospital Stay

  • -- Hospital Emergency Room

  • -- Hospital Outpatient Department

  • -- Medical Provider
    • e.g., Doctor’s Office, Group Practice, Clinic, HMO, Lab, Mental Health Care, Alternative Care

  • -- Dental Office/Dental Clinic

  • -- At Home

  • -- Other Medical Expenses
    • Eyeglasses or Contact Lenses
    • Insulin, Other Diabetic Equipment/Supplies
    • Ambulance, Orthopedic Items, Hearing Devices, Prostheses, Bathroom Aids, Medical Equipment, Disposable Supplies, Alterations/Modifications

  • -- Institutional/Long Term Care Stay
    • e.g., Nursing Home, Rehabilitation Facility, Drug Treatment, Psychiatric Facility

Return To Table Of Contents



CARD HS-1

  • -- 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)

  • -- Pregnancy-Related Complications

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CARD ER-1

  • -- Diagnosis or Treatment

  • -- Emergency (e.g., Accident or Injury)

  • -- Psychotherapy or Mental Health Counseling

  • -- Follow-up or Post-Operative Visit

  • -- Immunization or Shots

  • -- Pregnancy-Related (Including Prenatal Care and Delivery)

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CARD ER-2

  • -- Laboratory Tests

  • -- Throat Swab

  • -- Sonogram or Ultrasound

  • -- X-Rays

  • -- Mammogram

  • -- MRI or CAT Scan

  • -- EKG or ECG

  • -- EEG

  • -- Vaccination

  • -- Anesthesia

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CARD OP-1

  • -- 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

  • -- Pregnancy-Related (Including Prenatal Care and Delivery)

  • -- Well Child Exam

  • -- Laser Eye Surgery

Return To Table Of Contents



CARD OP-2

  • -- Laboratory Tests

  • -- Throat Swab

  • -- Sonogram or Ultrasound

  • -- X-Rays

  • -- Mammogram

  • -- MRI or CAT Scan

  • -- EKG or ECG

  • -- EEG

  • -- Vaccination

  • -- Anesthesia

Return To Table Of Contents



CARD MV-1

  • -- 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

  • -- Pregnancy-Related (Including Prenatal Care and Delivery)

  • -- Well Child Exam

  • -- Laser Eye Surgery

Return To Table Of Contents



CARD MV-2

  • -- Laboratory Tests

  • -- Throat Swab

  • -- Sonogram or Ultrasound

  • -- X-Rays

  • -- Mammogram

  • -- MRI or CAT Scan

  • -- EKG or ECG

  • -- EEG

  • -- Vaccination

  • -- Anesthesia

Return To Table Of Contents



CARD DN-1

  • -- General Dentist

  • -- Hygienist (Dental)

  • -- Technician (Dental)

  • -- Dental Surgeon

  • -- Orthodontist

  • -- Endodontist

  • -- Periodontist

  • -- Other

Return To Table Of Contents



CARD DN-2

  • 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

Return To Table Of Contents



CARD HH-1

  • -- 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

Return To Table Of Contents



CARD HH-2

  • 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

Return To Table Of Contents



CARD HH-3

  • 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

Return To Table Of Contents



CARD CP-1

  • -- 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 (Veterans Administration)/CHAMPVA

    • -- Military Facility

    • -- Public Assistance/Medicaid/SCHIP

    • -- Indian Health Service (IHS)

    • -- 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)

  • -- No Charge: Telephone Call

  • -- Free From Provider (Professional Courtesy/Free Sample)

  • -- Government-Financed Research And Clinical Trials

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CARD PC-1

  • -- Within the last 7 days

  • -- More than 7 days ago, but within last 30 days

  • -- More than 30 days ago

Return To Table Of Contents



CARD AP-1

  • -- 99 pounds or less

  • -- 100 to 149 pounds

  • -- 150 to 199 pounds

  • -- 200 to 249 pounds

  • -- 250 to 299 pounds

  • -- 300 pounds or more

Return To Table Of Contents



CARD AC-1

  • -- Very Difficult

  • -- Somewhat Difficult

  • -- Not Too Difficult

  • -- Not At All Difficult

Return To Table Of Contents



CARD AC-2

  • -- White

  • -- Black/African American

  • -- Asian

  • -- Indian/Native American Alaska Native

  • -- Other Pacific Islander

  • -- Some Other Race

Return To Table Of Contents



CARD AC-3

  • -- Never

  • -- Sometimes

  • -- Usually

  • -- Always

Return To Table Of Contents



CARD AC-4

  • -- 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

Return To Table Of Contents



CARD HX-1

  • -- From a Professional Association

  • -- From a Small Business Group

  • -- From a Union

  • -- Directly From an Insurance Agent

  • -- Directly From Insurance Company

  • -- Directly From an HMO

  • -- Directly From a High Risk Pool

  • -- From a Previous Employer

  • -- From a Previous Employer (COBRA)

  • -- Directly From the Health Insurance Marketplace

Return To Table Of Contents



CARD HX-2

Sample Medicare Card

Sample Medicare Card

Return To Table Of Contents



CARD HX-3

Sample Medicaid Card
[State Name Here]

(One for Each State)

Return To Table Of Contents



CARD HX-4

  • -- From a Group or Association

  • -- Directly Through a School

  • -- Directly From an Insurance Agent

  • -- Directly From Insurance Company

  • -- Directly From an HMO

  • -- Directly From an High Risk Pool

  • -- 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

  • -- Directly From the Health Insurance Marketplace

Return To Table Of Contents



CARD HX-6

  • -- 1 - 50

  • -- 51 - 100

  • -- 101 - 200

  • -- 201 - 300

  • -- 301 or more

Return To Table Of Contents



CARD HX-7

  • -- 1 - 30

  • -- 31 - 60

  • -- 61 - 90

  • -- 91 - 120

  • -- 121 or more

Return To Table Of Contents



CARD HX-9

  • -- 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

Return To Table Of Contents



CARD HX-11

  • -- 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)/CHAMPVA

Return To Table Of Contents



CARD IN-1

  • -- 1 - 5,000

  • -- 5,001 - 10,000

  • -- 10,001 - 15,000

  • -- 15,001 - 25,000

  • -- 25,001 - 50,000

  • -- 50,001 - 100,000

  • -- 100,001 or more

Return To Table Of Contents



CARD IN-2

  • -- 1 - 100

  • -- 101 - 500

  • -- 501 - 1,000

  • -- 1,001 - 5,000

  • -- 5,001 - 15,000

  • -- 15,001 or more

Return To Table Of Contents



CARD IN-3

  • -- 1 - 250

  • -- 251 - 500

  • -- 501 - 750

  • -- 751 - 1,000

  • -- 1,001 or more

Return To Table Of Contents



CARD IN-4

  • -- 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

Return To Table Of Contents



CARD AS-1

  • -- 0 - 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

Return To Table Of Contents



CARD AS-2

  • -- 0 - 100

  • -- 101 - 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 or more

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CARD AS-3

  • -- 0 - 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 or more

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CARD AS-4

  • -- Certificates of Deposit (CDs)

  • -- Government savings bonds

  • -- Individual development accounts

  • -- Treasury bills

  • -- Bonds

  • -- Bond mutual funds

  • -- Shares of stock

  • -- Stock mutual funds

  • -- Education savings accounts

  • -- Annuities

  • -- Trusts

  • -- Other financial assets

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CARD AS-5

  • -- Second homes

  • -- Rental real estate

  • -- Business or Farm

  • -- Money owed to you by persons outside of the family

  • -- Boats or other recreational vehicles

  • -- Other significant assets such as jewelry, art work or antiques

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