OMB Approval #: 0938-NEW
Introduction/consent (Adapted from the BRFSS which selects a household member at random based on intro in DHS Disparities project which drew from a list based sample. Some consent language was taken from MNHA 2007.)
HELLO, I am calling for the University of Minnesota. My name is (name) . We are working with the Centers for Medicare & Medicaid Services on a study to better understand access to health insurance.
May I please speak to (RESPONDENT NAME)? Go to INTRO
IF R NOT HOME:
Are you able to answer questions about health insurance coverage for (NAME)?
Is there a good time for me to try to reach (NAME)? CALLBACK – RECORD TIME
>INTRO<
You were (NAME WAS) selected at random from lists of people who are or have been enrolled in (STATE NAME) (HIFA program name) program.
This study takes about 7 to 15 minutes. Would this be a good time or would another time be better?
Before we start, let me tell you that everything you say will be kept private, except as required by law. Your phone number will not be linked to your answers. Your answers will be combined with those of other people in the study and will only be used by researchers on this project.
The study will not be used for marketing purposes and your decision whether or not to participate will not affect your insurance coverage, health care, eligibility for health care services. There are no risks to your participation in the study and there are no benefits. You may skip over questions or stop the interview at any time you wish.
If you have questions about the study and would like to contact the researcher doing the study, Kathleen Call at the University of Minnesota School of Public Health or someone at the University’s Research Subjects’ Advocates line, I can give you those phone numbers now or at the end of the survey. You may call collect.
Dr. Kathleen Call: 612-624-3922
Research Subjects’ Advocates Line: 612-625-1650
Do you have any questions before we continue?
IF NO, PROCEED WITH INTERVIEW
Health status
First, I have just a few questions about your (NAME’S) health.
>HSTAT< Health Status (from BRFSS)
Would you say that in general your (NAME’S) health is―
Please read:
Excellent
Very good
Good
Fair
Or
Poor
Do not read:
7 Don’t know / Not sure
9 Refused
>HD_1< Healthy Days ― Health-Related Quality of Life (From BRFSS)
Now thinking about your (NAME’S) physical health, which includes physical illness and injury, for how many days during the past 30 days was your (NAME’S) physical health not good?
_ _ Number of days
88 None
77 Don’t know / Not sure
99 Refused
>HD_2<
Now thinking about your (NAME’S) mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your (NAME’S) mental health not good?
_ _ Number of days
88 None [If hd1 and hd2 = 88 (None), go to next section]
Do not read:
77 Don’t know / Not sure
99 Refused
>HD_3<
During the past 30 days, for about how many days did poor physical or mental health keep you (NAME) from doing your (HIS/HER) usual activities, such as self-care, work, or recreation?
_ _ Number of days
88 None
Do not read:
77 Don’t know / Not sure
99 Refused
Health insurance coverage
These next questions are about health insurance coverage.
>HI< (HI is from BRFSS; all other health insurance questions are from the CPS)
Do you (does NAME) have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
1 Yes – GO TO EMPLOY
2 No – GO TO EMPLOY1
Do not read:
7 Don’t know / Not sure – GO TO EMPLOY
9 Refused – GO TO EMPLOY
>EMPLOY<
Are you (is NAME) covered by a health plan provided through [your/their] current or former employer or union? <MILITARY HEALTH INSURANCE WILL BE COVERED LATER IN ANOTHER QUESTION.>
1 Yes – GO TO DIRECT
2 No – GO TO DIRECT
Do not read:
7 Don’t know / Not sure – GO TO DIRECT
9 Refused – GO TO DIRECT
>EMPLOY1<
Just to make sure, are you (is NAME) covered by a health plan provided through [your/their] current or former employer or union? <MILITARY HEALTH INSURANCE WILL BE COVERED LATER IN ANOTHER QUESTION.>
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
>DIRECT<
Are you (is NAME) covered by a plan that [you/they] PURCHASED DIRECTLY FROM AN INSURANCE COMPANY, that is, not related to current or past employment?
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
>OUTSIDE<
Are you (is NAME) covered by the health plan of someone who does not live in this household?
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
>MEDCARE<
Are you (is NAME) covered by Medicare?
READ IF NECESSARY: Medicare is the health insurance for persons 65 years old and over or persons with disabilities
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
>MEDCAID<
Are you (is NAME) covered by Medicaid/fill MEDCAID name(s) per state]?
READ IF NECESSARY: Medicaid/fill MEDCAID name(s) is the government assistance program that pays for health care.
1 Yes [IF SINGLE-PERSON HH = > go to CICHIP; else = > go to MCAIDWH]
2 No – GO TO CICHIP
Do not read:
7 Don’t know / Not sure – GO TO CICHIP
9 Refused – GO TO CICHIP
>MILTARY<
Are you (is NAME) covered by TRICARE, CHAMPUS, CHAMPVA, VA, military health care, or Indian Health Service?
NOTE: "CHAMPVA" IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN'S AFFAIRS.
1 Yes – GO TO MILPLAN
2 No – GO TO OTHER
Do not read:
7 Don’t know / Not sure – GO TO OTHER
9 Refused – GO TO OTHER
>MILPLAN<
What plan are you (is NAME) covered by?
1 TRICARE, CHAMPUS or military health care
2 CHAMPVA
3 VA
4 Indian Health Service
5 Other
>OTHER<
Other than the plans I have already talked about, are you (is NAME) covered by [IF STATE HAS NO ENTRY IN LIST OF FILLS BELOW FILL: any other type of health plan?/ a health insurance plan such as the [fill OTHER name(s)] plan or any other type of plan?] ADD HIFA PLAN NAME HERE
1 Yes – GO TO OTHPLAN
2 No – GO TO CKVERIF
Do not read:
7 Don’t know / Not sure – GO TO CKVERIF
9 Refused – GO TO CKVERIF
>OTHPLAN<
What type of insurance do you (does NAME) have?
1 Medicare
2 Medicaid
3 HIFA PLAN HERE
4 TRICARE or CHAMPUS
5 CHAMPVA ("CHAMPVA" IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN'S AFFAIRS.)
6 VA health care
7 Military health care
8 Children's Health Insurance Program (CHIP)
9 Indian Health Service
10 Other government health care
11 Employer/union‑provided (policyholder)
12 Employer/union‑provided (as dependent)
13 Privately purchased (policyholder)
14 Privately purchased (as dependent)
15 Plan of someone outside the household
16 Other
Specify___________________________________________________________[store in VEROTH; allow 50 characters]
>CKVERIF<
If it's a single-person household and if NAME answered "yes" to any of the following items: EMPLOY, DIRECT, OUTSIDE, MEDCARE, MEDCAID, CHIP, MILTARY, OTHER, he/she should be classified as insured; set CKVERIF flag = 1
Else NAME should be classified as uninsured; set CKVERIF flag = 0 GO TO VERIFY
>VERIFY<
I have recorded that you are (NAME is) not covered by a health plan. Is that correct?
1 Yes (not covered) – GO TO ONHIFA
2 No – GO TO VERPLAN
Do not read:
7 Don’t know / Not sure – GO TO ONHIFA
9 Refused – GO TO ONHIFA
>VERPLAN<
What type of insurance are you (is NAME) covered by? Any other type of plan?
1 Medicare
2 Medicaid
3 HIFA PLAN HERE
4 TRICARE or CHAMPUS
5 CHAMPVA ("CHAMPVA" IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN'S AFFAIRS.)
6 VA health care
7 Military health care
8 Children's Health Insurance Program (CHIP)
9 Indian Health Service
10 Other government health care
11 Employer/union‑provided (policyholder)
12 Employer/union‑provided (as dependent)
13 Privately purchased (policyholder)
14 Privately purchased (as dependent)
15 Plan of someone outside the household
16 Other
Specify___________________________________________________________[store in VEROTH; allow 50 characters]
If OTHPLAN = 16 or VERPLAN = 16 go to H_PREHIFA
ELSE go to ONHIFA
HIFA QUESTIONS (created by U of M)
>ONHIFA<
Are you (is NAME) currently participating in the (insert state name) (insert HIFA PROGRAM NAME)?
1 Yes – GO TO PREHIFA
2 No – GO TO EXPLANATION
Do not read:
7 DK – GO TO EXPLANATION
9 Refused – GO TO EXPLANATION
>EXPLANATION<
Read short description of state programs tailored to the HIFA program the respondent is enrolled in. Be as specific as possible about program features to trigger recognition.
Repeat ONHIFA
>OFFHIFA<
When did you (NAME) stop participating in the (HIFA PROGRAM NAME)?
__ __ days ago
__ __ months ago
00 Never enrolled – GO TO HCA1
Do not read:
77 DK – GO TO HCA1
99 Refused – GO TO HCA1
>PREHIFA<
Just prior to participating in the (HIFA PROGRAM NAME) did you (NAME) have any health insurance coverage?
1 Yes – GO TO PRETYPE
2 No – GO TO H_REASONS
Do not read:
7 DK – GO TO H_REASONS
9 Refused – GO TO H_REASONS
>PRETYPE<
What type of insurance were you (was NAME) covered by prior to participating in the (HIFA PROGRAM NAME)?
1 Medicare
2 Medicaid
3 TRICARE or CHAMPUS
4 CHAMPVA ("CHAMPVA" IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN'S AFFAIRS.)
5 VA health care
6 Military health care
7 Children's Health Insurance Program (CHIP)
8 Indian Health Service
9 Other government health care
10 Employer/union‑provided (policyholder)
11 Employer/union‑provided (as dependent)
12 Privately purchased (policyholder)
13 Privately purchased (as dependent)
14 Plan of someone outside the household
15 Other
Specify____________________________________________________________[store in VEROTH; allow 50 characters]
>H_REASONS<
Why did you (NAME) decide to participate in the (HIFA PROGRAM NAME)?
DO NOT PROMPT -- MAP RESPONSE TO THOSE BELOW OR ENTER TEXT CLOSE TO VERBATIM
YOU (NAME) DID NOT HAVE HEALTH INSURANCE COVERAGE
YOUR (NAME’S) EMPLOYER DID NOT OFFER INSURANCE COVERAGE
YOU (NAME) COULD NOT AFFORD COVERAGE THROUGH EMPLOYER
YOU (NAME) COULD NOT AFFORD TO PURCHASE INSURANCE IN PRIVATE MARKET
YOU (NAME) LOST A JOB THAT PROVIDED HEALTH INSURANCE COVERAGE
INSURANCE THROUGH A FAMILY MEMBER WAS NO LONGER AVAILABLE
YOU WERE (NAME WAS) NO LONGER ELIGIBLE FOR THE PUBLIC HEALTH INSURANCE PROGRAM YOU WERE (NAME WAS) ENROLLED IN
OTHER SPECIFY _______________________________________________
_________________________________________________________________
>ABSENCE<
If your health insurance coverage through (HIFA PROGRAM NAME) was not (or “had not been”) available, what type of coverage would you be (or “have been) enrolled in?
0 None, would be uninsured
1 Medicare
2 Medicaid
3 TRICARE or CHAMPUS
4 CHAMPVA ("CHAMPVA" IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN'S AFFAIRS.)
5 VA health care
6 Military health care
7 Children's Health Insurance Program (CHIP)
8 Indian Health Service
9 Other government health care
10 Employer/union‑provided (policyholder)
11 Employer/union‑provided (as dependent)
12 Privately purchased (policyholder)
13 Privately purchased (as dependent)
14 Plan of someone outside the household
15 Other
Specify____________________________________________________________[store in VEROTH; allow 50 characters]
Health Care Access (from BRFSS)
We are close to the end of the survey. My next questions are about your (NAME’S) access to health care.
>HCA1<
Do you (does NAME) have one person you think (he/she thinks) of as your personal doctor or health care provider?
1 Yes, only one
2 More than one
3 No
Do not read:
7 Don’t know / Not sure
9 Refused
>HCA2<
Was there a time in the past 12 months when you (NAME) needed to see a doctor but could not because of cost?
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
>HCA3<
About how long has it been since you (NAME) last visited a doctor for a routine checkup? A routine checkup is general physical exam, not an exam for a specific injury, illness or condition.
1 Within past year (anytime less than 12 months ago)
2 Within past 2 years (2 year but less than 2 years ago)
3 Within past 5 years (2 years but less than 5 years ago)
4 5 or more years ago
7 Don’t know / Not sure
Do not read:
8 Never
9 Refused
Chronic Conditions and Health Risk Behavior
>DIAB< Diabetes (from BRFSS with SHAPE addition of “other health professional”)
Have you ever been told by a doctor or other health professional that you have diabetes?
If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”
If respondent says pre-diabetes or borderline diabetes, use response code 4.
(85)
1
Yes
2 Yes, but female told only during pregnancy
3 No
4 No,
pre-diabetes or borderline diabetes
Do not read:
7
Don't Know / Not sure
9 Refused
>HYPER< Hypertension (From BRFSS with SHAPE addition of “other health professional”)
Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?
If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”
1
Yes
2 Yes, but female told only during pregnancy
3 No
Do not read:
7
Don't Know / Not sure
9 Refused
>DEPRES1< (From BRFSS with SHAPE addition of “other health professional”)
Have you ever been told by a doctor or other health professional that you have depression?
1
Yes
2 No – GO TO SMOKE1
Do not read:
7
Don't Know / Not sure
9 Refused
>DEPRES2< (From SHAPE)
Are you currently under the care of a doctor or other health professional such as a psychiatrist, a psychologist, a therapist, or a counselor for your depression?
1
Yes
2 No
Do not read:
7
Don't Know / Not sure
9 Refused
>DEPRES3< (From SHAPE)
Are you currently taking any medication that was prescribed to you for you to treat depression?
1
Yes
2 No
Do not read:
7
Don't Know / Not sure
9 Refused
>DEPRES4< (From SHAPE)
Do you still have depression?
1
Yes
2 No
Do not read:
7
Don't Know / Not sure
9 Refused
>SMOKE1< (from BRFSS)
Have you smoked at least 100 cigarettes in your entire life?
NOTE: 5 packs = 100 cigarettes
1 Yes
2 No– GO TO AGE
Do not read:
7 Don’t know / Not sure– GO TO AGE
9 Refused– GO TO AGE
>SMOKE2< (from BRFSS)
Do you now smoke cigarettes every day, some days, or not at all?
1 Every day
2 Some days
3 Not at all – GO TO AGE
Do not read:
7 Don’t know/Not sure – GO TO AGE
9 Refused – GO TO AGE
>SMOKE3< (from BRFSS)
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
Demographics (from BRFSS unless otherwise indicated)
>AGE<
What is your (NAME’S) age?
_ _ Code age in years
Do not read:
07 Don’t know / Not sure
09 Refused
>ETHNICITY<
Are you (is NAME) Hispanic or Latino?
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
>RACE<
Which one or more of the following would you say is your (NAME’S) race?
(Check all that apply)
Please read:
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or Alaska Native
Or
6 Other [specify]
DO NOT READ:
8 No additional choices
7 Don’t know / Not sure
9 Refused
>MARSTAT<
Are you (is NAME) …?
Please read:
1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married
Or
6 A member of an unmarried couple
Do not read:
Refused
>KIDSHH<
How many children less than 18 years of age live in your household?
_ _ Number of children
88 None
Do not read:
99 Refused
>EDUC<
What is the highest grade or year of school you (NAME) completed?
Read only if necessary:
1 Never attended school or only attended kindergarten
2 Grades 1 through 8 (Elementary)
3 Grades 9 through 11 (Some high school)
4 Grade 12 or GED (High school graduate)
5 College 1 year to 3 years (Some college or technical school
6 College 4 years or more (College graduate)
Do not read:
Refused
>EMPLOY<
Are you (is NAME) currently…?
Please read:
1 Employed for wages – GO TO EMPSTAT2
2 Self-employed– GO TO EMPSTAT2
3 Out of work for more than 1 year – GO TO INCOME
4 Out of work for less than 1 year – GO TO INCOME
5 Homemaker – GO TO INCOME
6 Student – GO TO INCOME
7 Retired – GO TO INCOME
Or
8 Unable to Work
Do not read:
Refused
>EMPSTAT2< (from MNHA)
Do you (does NAME) have more than one paying job?
1 Yes – GO TO HOURS
2 No – GO TO EMPERM
7 Don’t know / Not sure
9 Refused – GO TO EMPERM
>HOURS< from MNHA
Thinking about all of your (NAME’S) jobs, what is the total number of hours usually worked per week?
________ (1-100) hours
Do not read:
777 Don’t Know / Not sure
999 Refused
>HRS
How many hours per week do you (does NAME) usually work at your (their) primary place of employment?
________ (1-100) hours
Do not read:
777 Don’t Know / Not sure
999 Refused
>EMPERM< from MNHA
Thinking about your (NAME’S) primary job, is this a permanent, temporary, or seasonal job?
1 Permanent
2 Temporary
3 Seasonal
Do not read:
7 Don’t Know / Not sure
9 Refused
IF EMPLOY = 1 GO TO SIZE1
IF EMPLOY = 2 GO TO SIZE 2
>SIZE1< from MNHA
Counting all locations where this employer operates, are there more than 50 people working for your (NAME’S) employer?
1 Yes – GO TO SIZEB
2 No – GO TO SIZEA
Do not read:
7 Don’t Know / Not sure
9 Refused
>SIZE2< from MNHA
Including yourself (NAME) are there more than 50 people working for this business?
1 Yes -- GO TO SIZEB
2 No – GO TO SIZEA
Do not read:
7 Don’t Know / Not sure
9 Refused
NOTE FOR SIZEA AND SIZEB: If EMPLOY=2, use “business” instead of “employer.”
Which category best represents the total number of persons who work for your (NAME’S) employer/business?
>SIZEA< from MNHA
1 Just one
2 Between 2 and 10
3 Between 11 and 50
Do not read:
7 Don’t Know
9 Refused
>SIZEB< from MNHA
Which category best represents the total number of persons who work for your (NAME’S) employer/business?
1 Between 51 and 100
2 Between 101 and 500
3 Between 501 and 1000
4 Over 1000
Do not read:
7 Don’t Know / Not sure
9 Refused
1 Government
2 Health/Education/Social/Child Care Services
3 Agriculture/Farming
4 Construction/Mining
5 Manufacturing *
6 Computer Technology
7 Public Utilities/Transportation/Communications **
8 Retail and Wholesale Trade/Sales ***
9 Banking/Finance/Insurance/Real Estate
10 Other (specify) _______________________
Do not read:
77 Don’t know / Not sure
99 Refused
* Manufacturing examples: factory, textile mill, steel mill, automobile manufacturer, electronic equipment manufacturer, chemical/drug manufacturer, food processing, printing, publishing
** Public Utilities examples: electric company, air transportation, trucking, busing, television and radio services/broadcasting, telecommunications)
*** Retail/Wholesale examples: department stores, restaurants, grocery stores, distributor
>INCOME<
Is your (NAME’S) annual household income from all sources―
If respondent refuses at ANY income level, code ‘99’ (Refused)
Read only if necessary:
04 Less than $25,000 If “no,” ask 05; if “yes,” ask 03
($20,000 to less than $25,000)
03 Less than $20,000 If “no,” code 04; if “yes,” ask 02
($15,000 to less than $20,000)
02 Less than $15,000 If “no,” code 03; if “yes,” ask 01
($10,000 to less than $15,000)
01 Less than $10,000 If “no,” code 02
($20,000 to less than $25,000)
05 Less than $35,000 If “no,” ask 06
($25,000 to less than $35,000)
06 Less than $50,000 If “no,” ask 07
($35,000 to less than $50,000)
07 Less than $75,000 If “no,” ask 08
($50,000 to less than $75,000)
08 $75,000 or more
Do not read:
77 Don’t know / Not sure
99 Refused
>TOTCNT< From MNHA
How many people live on this income?
____ ____ people (1-20)
Do not read:
77. Don’t Know
99. Refused
>WEIGHT< (From BRFSS)
About how much do you weigh without shoes?
Note: If respondent answers in metrics, put “9” in column .
Round fractions up
_ _ _ _ Weight
(pounds/kilograms)
Do not read:
7777 Don’t know / Not sure
9999 Refused
>HEIGHT< (From BRFSS)
About how tall are you without shoes?
Note: If respondent answers in metrics, put “9” in column .
Round fractions down
_ _ _ _ Height
(ft/inches/meters/centimeters)
Do not read:
7777 Don’t know / Not sure
9999 Refused
>COUNTY<
What county do you (does NAME) live in?
_ _ _ FIPS county code
Do not read:
777 Don’t know / Not sure
999 Refused
>ZIP<
What is the ZIP Code where you live (NAME lives)?
_ _ _ _ _ ZIP Code
Do not read:
77777 Don’t know / Not sure
99999 Refused
>SEX<
Indicate sex of respondent. Ask only if necessary.
Are you (is NAME) male or female?
1 Male
2 Female
Closing statement
Please read:
That is my last question. Do you have any questions for me?
Thank you very much for your time.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
HIFA Enrollee Survey
CMS-10262
(mm/yyyy) Page
| File Type | application/msword |
| File Title | HELLO, I am calling for the |
| Author | jraasch |
| Last Modified By | Robert Coulam |
| File Modified | 2009-01-16 |
| File Created | 2009-01-16 |