CMS-P-0015A MCBS Facility Round 46 Health Ins Questionnaire

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

IN. HEALTH INSURANCE QUESTIONNAIRE
(BASELINE ONLY)

IN1PRE1 omitted.

IN1PRE2
The following questions are about {SP's} health insurance.
PRESS ENTER TO CONTINUE.

BOX IN3

If Baseline:
If HA47=-7,-8,-5, or -1 or if EX23A=-7,-8,-5, or -1, go to IN1.
Else, go to IN5A.
Else:
The last time IN was administered:
If IN1 or IN1A = 0, 2, or -8 and EX23A or HA47 = -8, -5, or -1; or
If IN1 = 1 and IN6 not = 1;
Go to IN1A.
If Round 20, go to IN5A.
Else, go to IN18.

IN1
Has {SP} ever been covered by {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR
MEDICAID)}?
YES................................................................................................
NO..................................................................................................
PENDING.......................................................................................
DK ..................................................................................................
RF ..................................................................................................

1
0
2
-8
-7

(IN2)
(BOX IN7)
(BOX IN7)
(BOX IN7)
(BOX IN7)

IN1A
{The last time we asked about {SP's} health insurance, {he/she} was not covered by {"PREFERRED" NAME FOR
MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)}}. Is {SP} now covered by {"PREFERRED" NAME FOR
MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)}?
YES................................................................................................
NO..................................................................................................
PENDING ......................................................................................
DK ..................................................................................................
RF ..................................................................................................

1

1
0
2
-8
-7

(BOX IN5)
(BOX IN5)
(BOX IN5)
(BOX IN5)

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

IN2
Do you have a document that shows {SP's} most current {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED
FOR" NAME FOR MEDICAID)} ID number?
YES ...............................................................................................
NO..................................................................................................
DK .................................................................................................
RF .................................................................................................

1
0
-8
-7

IN3
{Please read me {SP's} {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)}
ID number from the document/Please tell me {SP's} {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR"
NAME FOR MEDICAID)} ID number.}
_________________________________
MEDICAID ID NUMBER
DK............................................................. -8
RF ............................................................. -7

(IN5A)
(IN5A)

IN4
I'd like to verify the {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} ID
number that I have recorded. I have entered {MEDICAID ID NUMBER}. Is this correct?
YES........................................................... 1
NO ............................................................ 0

(IN5A)

IN5
Let me enter it again. (What {is/was} {SP's} {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME
FOR MEDICAID)} ID number?)
_________________________________
MEDICAID ID NUMBER

(IN4)

DK............................................................. -8
RF ............................................................. -7

IN5A
Some states now use HMOs (health maintenance organizations) to provide some or all health care for Medicaid
beneficiaries. {Is/Was} {SP} enrolled in a {"PREFERRED" NAME FOR MEDICAID} {or "ALLOWED FOR" NAME
FOR MEDICAID} HMO?
YES ..........................................................
NO ...........................................................
DK.............................................................
RF .............................................................

BOX IN3A

If baseline, continue.
If coming from IN1A, go to IN9.
Else, go to BOX IN5.

2

1
0
-8
-7

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

IN6
Was {SP} covered by {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} {on
September 1, {YEAR}/when {she/he} was admitted to {FACILITY/{FAD/RAD UNIT} on {FAD/RAD}}?
YES...........................................................
NO ............................................................
DK.............................................................
RF .............................................................

1
0
-8
-7

(BOX IN7)
(BOX IN7)
(BOX IN7)

IN7
In what year was {she/he} first covered by {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME
FOR MEDICAID)}?
YEAR (

BOX IN4

)

If IN7=-7 or -8, go to IN10.
If IN7YR>92, go to IN9.
Else, go to Box IN5.

IN9
In what month did {her/his} {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR
MEDICAID)} begin?
SELECT ONLY ONE.
USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

BOX IN5

If baseline:
If (IN7YR) FAD/RAD, go to BOX IN7; else, go to IN10.
Else:
If Round 20 and SP is CFR, go to INEND.
Else, go to IN18.

3

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

IN10
Please look at this card and tell me where {SP} was living {in {DATE FROM IN7/IN9.}/{when {her/his} {"PREFERRED"
NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} coverage first began.}
SHOW
CARD
IN1

BOX IN6

IN THIS FACILITY ......................................................................... 1
OTHER NURSING HOME/REHAB CENTER ................................ 2
PERSONAL CARE HOME/RESIDENTIAL CARE FACILITY ......... 3
CCRC/RETIREMENT HOME/CENTER ......................................... 4
HOSPITAL ..................................................................................... 5
PRIVATE HOME OR APARTMENT .............................................. 6
OTHER LTC FACILITY................................................................... 7
OTHER (SPECIFY)
91

(BOX IN7)
(BOX IN7)
(BOX IN7)
(BOX IN7)
(BOX IN7)
(BOX IN7)
(BOX IN7)

If FACILITY has more than one part, continue; else, go to BOX IN7.

IN11
In which part of {LARGER FACILITY} did {he/she} live {when {her/his} {"PREFERRED" NAME FOR MEDICAID} {(or
"ALLOWED FOR" NAME FOR MEDICAID)} coverage first began.}?
PROBE: Is it [READ NAMES FROM PLACE ROSTER]?
USE ARROW KEYS. TO SELECT, PRESS ENTER.
TO EXIT, PRESS ESC.

BOX IN7

If HA44A = 0 and HA44B (Medicare number) -7 or -8, or HA44A = 1, go to IN13;
Else, continue.

IN12A
Our records show that {SP} is covered by Medicare. I'd like to ask some questions about {his/her} Medicare coverage.

4

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

IN12-13
Was {SP} covered by {VARIABLE TEXT} of Medicare on {September 1, {YEAR}/{FAD/RAD}}?
IN12

YES = 1, NO = 0
(
)

Part A?
IN13
Part B?

(

)

Part D?

(

)

IN13A

PRESS F1 FOR PART A, PART B, AND PART D DEFINITIONS.

BOX IN8

If coming from IN12A, continue.
Else, go to IN18.

IN14
I'd like to verify the Medicare ID number we have in our records.
Do you have a document that shows {SP's} Medicare ID number?
YES ................................................................................................ 1
NO ................................................................................................. 0
DK................................................................................................... -8
RF ................................................................................................... -7

(IN18)
(IN18)
(IN18)

IN14A
The Medicare ID number for {SP} that we show in our records is {MEDICARE #/RRB#}. Is this the same ID number that
you have in your records?
YES................................................................................................. 1
NO .................................................................................................. 0
DK................................................................................................... -8
RF ................................................................................................... -7

IN14B
Does {SP}'s Medicare ID number begin with a letter or number?
NUMBER ...................................................................................... 1
LETTER ........................................................................................ 2

5

(IN18)
(IN18)
(IN18)

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

IN15
{Please read me {SP's} Medicare ID number from your records/Please tell me {SP's} Medicare ID number.}
MEDICARE: (
)-(
)-(
)-(
)
AREA GROUP END
BIC
RRB: (

)
RRB#

DK .................................................................................................. -8
RF .................................................................................................. -7

(IN18)
(IN18)

IN16
I'd like to verify the Medicare ID number that I have recorded. I have entered {MEDICARE#/RRB#}. Is this correct?
YES................................................................................................
NO..................................................................................................
DK ..................................................................................................
RF ..................................................................................................

1
0
-8
-7

(IN18)
(IN18)
(IN18)

IN17
Let me enter it again. (What {is/was} {SP's} Medicare ID number?)
{MEDICARE: (

)-(
)-(
)-(
)} (IN16)
AREA GROUP END
BIC

{RRB: (

)}

(IN16)

RRB#
DK .................................................................................................. -8
RF .................................................................................................. -7

IN18
On {September 1, {YEAR}/{FAD/RAD}}, was {SP} covered by private health insurance that pays for some or all charges
for inpatient and outpatient hospital and physician services {and/or supplements Medicare (Medigap policy)}?
YES .........................
NO ...........................
DK ..........................
RF ...........................

1
0
-8
-7

(IN19)
(IN20)
(IN20)
(IN20)

IN19
What is the name of the insurance company?
PROBE: Any others?

IN20
On {September 1, {YEAR}/{FAD/RAD}}, was {SP} covered by private health insurance that pays for some or all charges
for more than 100 days of nursing home care, that is, a long-term care policy?
YES................................................................................................. 1
NO .................................................................................................. 0
DK .................................................................................................. -8
RF .................................................................................................. -7

6

(IN21)
(IN22)
(IN22)
(IN22)

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

IN21
What is the name of the insurance company?
PROBE: Any others?

IN22
Was {SP} covered by either TRICARE or CHAMPVA for hospital or physician care on {September 1,
{YEAR}/{FAD/RAD}}?
YES ................................................................................................ 1
NO ................................................................................................. 0
PRESS F1 FOR EXPLANATION OF TRICARE AND CHAMPVA.

7

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

IN23
Was {SP} covered by any other Department of Veterans Affairs (VA) program or contract on {September 1,
{YEAR}/{FAD/RAD}}?
YES ............................................................................................... 1
NO ................................................................................................. 0

IN24
{Besides {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)}, was/Was} {SP}
covered by any other public assistance health insurance program on {September 1, {YEAR}/{FAD/RAD}}?
YES ...............................................................................................
NO .................................................................................................
DK ..................................................................................................
RF .................................................................................................

1
0
-8
-7

IN25
What {is/was} the name of the public assistance health insurance program?

NAME OF PUBLIC ASSISTANCE HEALTH INSURANCE PROGRAM

Box IN8 omitted.
IN26 omitted.

BOX IN9

If SP alive, and a CFR, FFC, or FCF, and round = any fall round, continue.
Else, go to INEND.

BQ13A
Is {SP} currently married, widowed, divorced, separated, or never married?
MARRIED .................................................
WIDOWED................................................
DIVORCED ...............................................
SEPARATED ............................................
NEVER MARRIED ....................................

INEND
YOU HAVE COMPLETED THE HEALTH INSURANCE SECTION FOR THIS SP.
PRESS ENTER TO RETURN TO NAVIGATION SCREEN.

8

1
2
3
4
5

(BOX IN9)
(BOX IN9)
(BOX IN9)

IN. HEALTH INSURANCE

2006 Facility Interview
(Baseline Only)

Medicare beneficiaries who are entitled to Medicare Part A or enrolled in Part B are
eligible to enroll in subsidized prescription drug coverages offered in their areas
through Medicare Part D.

9