MEDICAL EXPENDITURE PANEL SURVEY
HOUSEHOLD COMPONENT MAIN STUDY
BLAISE/WVS SHOW CARDS
Panels 16, 17, and 18
January 2013
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 |
RE-3 |
Highest Level of School Completed |
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-1 |
Scale for Child Health Supplement |
2, 4 |
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-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 |
Treatments Received During Outpatient Visit |
1, 2, 3, 4, 5 |
OP-3 |
Services Received During Outpatient Visit |
1, 2, 3, 4, 5 |
MV-1 |
Types of Places for Medical Provider Visit |
1, 2, 3, 4, 5 |
MV-2 |
Care Received During Medical Provider Visit |
1, 2, 3, 4, 5 |
MV-3 |
Treatments Received During Medical Provider Visit |
1, 2, 3, 4, 5 |
MV-4 |
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 |
AC-5 |
Problems Scale |
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-5 |
Medicare Managed Care Plan Names 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-8 |
Medicaid (and Gov’t-Hosp/Phys) HMO Plan Names for STATE |
1, 2, 3, 4, 5 |
HX-9 |
Types of Health Insurance Coverage |
1, 2, 3, 4, 5 |
HX-10 |
Plan Names (For Federal Civilian Employees For STATE) |
1 |
HX-11 |
Types of Other State Programs |
2, 3, 4, 5 |
SP-1 |
Problem Scale |
2, 4 |
SP-2 |
Health Plan Scale |
2, 4 |
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
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
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
- -- Less than 1st Grade
- -- 1st Grade
- -- 2nd Grade
- -- 3rd Grade
- -- 4th Grade
- -- 5th Grade
- -- 6th Grade
- -- 7th Grade
- -- 8th Grade
- -- 9th Grade
- -- 10th Grade
- -- 11th Grade
- -- 12th Grade, No Diploma
- -- GED or Equivalent
- -- High School Diploma
- -- Some College, No Degree
- -- Associate Degree: Occupational, Technical, or Vocational Program
- -- Associate Degree: Academic Program
- -- Bachelor’s Degree (Example: BA, AB, BS, BBA)
- -- Master’s Degree (Example: MA, MS, MEng, MEd, MBA)
- -- Professional School (Example: MD, DDS, DVM, JD)
- -- Doctorate Degree (Example: PhD, EdD)
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- -- 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
- -- No Difficulty
- -- Some Difficulty
- -- A Lot of Difficulty
- -- Completely Unable To Do It
Return To Table Of Contents
- -- Definitely True
- -- Mostly True
- -- Don't Know
- -- Mostly False
- -- Definitely False
Return To Table Of Contents
- 0 No Problem
- 1
- 2 Some Problem
- 3
- 4 A Very Big Problem
Return To Table Of Contents
- -- Never
- -- Sometimes
- -- Usually
- -- Always
Return To Table Of Contents
- None
- 1
- 2
- 3
- 4
- 5-9
- 10 or more
Return To Table Of Contents
- 0 Worst Health Care Possible
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Best Health Care Possible
Return To Table Of Contents
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
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
Return To Table Of Contents
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
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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
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- 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
- 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
TYPES OF DENTAL CARE PROVIDERS
- Dentist
- Dental or Oral Surgeon
- Orthodontist
- Dental Hygienist
- Dental Technician
- Dental Assistant
Return To Table Of Contents
TYPES OF MEDICAL PROVIDERS
- Medical Professionals:
- Medical Doctor Physician’s Assistant
- Nurse Optometrist/Ophthalmologist Nurse Practitioner
- Podiatrist (Foot Doctor)
- Midwife/Nurse Midwife Chiropractor
- Physiatrist Acupuncturist
- Paramedic Audiologist
- Health Aide
- Physical Therapy or Rehabilitation Services
- Therapist-Physical, Speech, Occupational
- Mental Health Professionals:
- Psychiatrist
- Psychologist
- Psychiatric Social Worker
- Mental Health Therapist
Return To Table Of Contents
TYPES OF HOSPITAL SERVICES
- Hospital Stay
- Emergency Room Visit
- Outpatient Department Visit
Return To Table Of Contents
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
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
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
Return To Table Of Contents
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
- 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
- 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
- -- 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
- -- 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
- -- 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
Return To Table Of Contents
- -- 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)
Return To Table Of Contents
- -- 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
- -- 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
- -- 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
Return To Table Of Contents
- -- 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
- -- Doctor’s Office or Group Practice
- -- Managed Care Plan Center/HMO
- -- Medical Clinic
- -- Rural Health Clinic
- -- Company Clinic
- -- School Clinic
- -- Other Clinic
- -- Neighborhood Family Health Center
- -- Community Health Center
- -- Birthing Center
- -- Walk-in Urgent Care
- -- Laboratory/X-ray Facility
- -- Laser Eye Surgery Center
- -- Other Freestanding Surgical Center
- -- VA Facility
- -- Indian Health Service (IHS) Facility
- -- Some Other Place
Return To Table Of Contents
- -- 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
- -- 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
Return To Table Of Contents
- -- 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
- -- General Dentist
- -- Hygienist (Dental)
- -- Technician (Dental)
- -- Dental Surgeon
- -- Orthodontist
- -- Endodontist
- -- Periodontist
- -- Other
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- 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
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- -- 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
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- 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
- 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
- -- 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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- -- 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
- -- 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
- -- Very Difficult
- -- Somewhat Difficult
- -- Not Too Difficult
- -- Not At All Difficult
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- -- White
- -- Black/African American
- -- Asian
- -- Indian/Native American Alaska Native
- -- Other Pacific Islander
- -- Some Other Race
Return To Table Of Contents
- -- Never
- -- Sometimes
- -- Usually
- -- Always
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- -- 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
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- -- A Big Problem
- -- A Small Problem
- -- Not A Problem
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- -- 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)
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Sample Medicare Card
Return To Table Of Contents
Sample Medicaid Card
[State Name Here]
(One for Each State)
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- -- 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
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Medicare Managed Care Plans
[State Name Here]
(One for Each State)
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- -- 1 - 50
- -- 51 - 100
- -- 101 - 200
- -- 201 - 300
- -- 301 or more
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- -- 1 - 30
- -- 31 - 60
- -- 61 - 90
- -- 91 - 120
- -- 121 or more
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State-Specific Plan Names
[State Name Here]
(One for Each State)
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- -- 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
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Plan Name (for Federal Civilian Employees)
[State Name Here]
(One for Each State)
Return To Table Of Contents
- -- 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
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- -- A Big Problem
- -- A Small Problem
- -- Not a Problem
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- 0 Worst Health Plan Possible
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Best Health Plan Possible
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- -- 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
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- -- 1 - 100
- -- 101 - 500
- -- 501 - 1,000
- -- 1,001 - 5,000
- -- 5,001 - 15,000
- -- 15,001 or more
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- -- 1 - 250
- -- 251 - 500
- -- 501 - 750
- -- 751 - 1,000
- -- 1,001 or more
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- -- 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
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- -- 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
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- -- 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
Return To Table Of Contents
- -- 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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- -- 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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- -- 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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