SURVEY OF HEALTH INSURANCE AND PROGRAM PARTICIPATION
Draft #5
March 19, 2009
SECTION A: ROSTER and DEMOGRAPHICS
1. What are the names of all persons living or staying [here/at your home]? (Let’s start with you.)
PROBE: Is there a middle name (or suffix, like junior or senior)?
PROBE: Anyone else?
ENTER FIRST, LAST, THEN MIDDLE NAME AND SUFFIX, IF APPLICABLE.
First Name Last Name Middle Name Suffix
2. READ IF NECESSARY
For Person 2: How is NAME related to you?
For Persons 3+: And how about NAME? (How is NAME related to you?)
He/She is your...
(1) Husband/Wife
(2) Unmarried partner
(3) Child (biological/step/adopted)
(4) Grandchild
(5) Mother/Father
(6) Brother/Sister
(7) Other relative (Uncle, Cousin, In-law, etc.)
(8) Foster child
(9) Housemate/roommate
(10) Roomer/boarder
(11) Other nonrelative
3. READ IF NECESSARY:
For Persons 2+: Is NAME male or female?
For Persons 3+: And how about NAME? (Is NAME male or female)?
4. For Person 1: What is your age and date of birth?
For Persons 2+: And how about NAME? (What is NAME’S age and date of birth?)
5. For Person 1: Are you of Hispanic, Latino, or Spanish origin?
For Persons 2+: How about NAME? (Is NAME of Hispanic, Latino, or Spanish origin?)
6. For Person 1: I am going to read you a list of five race categories. Please choose one or more races that (NAME/you) (considers yourself/consider NAME/considers himself/considers herself) to be: White; Black or African American; American Indian or Alaska Native; Asian; OR Native Hawaiian or Other Pacific Islander.
Do not probe unless response is Hispanic or a Hispanic origin.
Enter all that apply.
(1) White
(2) Black or African American
(3) American Indian or Alaska Native
(4) Asian
(5) Native Hawaiian or Other Pacific Islander
(6) Other - DO NOT READ
7. ASK ONLY FOR PEOPLE AGE 15+
For Person 1: What is the highest degree or level of school you have COMPLETED?
For Persons 2+: How about NAME? (What is the highest degree or level of school NAME has COMPLETED?)
(1) No schooling
(2) Nursery school to 6th grade
(3) 7th or 8th grade
(4) 9th - 11th grade
(5) 12th grade, NO DIPLOMA
(6) High school graduate
(7) Some college, but no degree
(8) Associate's degree (AA, AS)
(9) Bachelor's degree (BA, BS)
(10) Some graduate school, but no degree
(11) Master's degree (MA, MS, MEng, MEd, MSW, MBA)
(12) Professional or Doctorate degree (MD, DDS, DVM, LLB, JD, PhD, EdD)
8. ASK ONLY FOR PEOPLE AGE 15+
Person 1: Did you ever serve on active duty in the U.S. Armed Forces?
Persons 2+: How about NAME? (Did NAME ever serve on active duty in the Armed Forces?)
9. ASK ONLY FOR PEOPLE AGE 15+
READ IF NECESSARY:
Person 1: Are you now married, widowed, divorced, separated, or never married?
Persons 2+: How about NAME? (Is NAME now married, widowed, divorced, separated, or never married?)
(1) Married
(2) Widowed
(3) Divorced
(4) Separated
(5) Never married
10. Is [your/the combined] total annual income [of all members of this household] above or below [$XX – amount is meant to approximate a poverty threshold, and should be calculated based on household size and number of children under 18]?
(1) Above
(2) Below
Specifications for dollar amount:
If there is no one under 18 living in the household then fill these amounts, based on the number of household members:
1 person: 20000
2 people: 25000
3 people: 30000
4 people: 40000
5 people: 45000
6 people: 50000
7 people: 60000
8 people: 65000
9 people: 75000
10+: 75000 + (# people - 9)*5000
If there is at least one child age 0-17 living in the household then fill these amounts, based on the number of household members :
1 person: 30000
2 people: 40000
3 people: 45000
4 people: 55000
5 people: 65000
6 people: 75000
7 people: 85000
8 people: 95000
9 people: 115000
10+: 115000 + (# people - 9)*10000
SECTION B: DISABILITY
DISINTRO
We want to learn about people who have physical, mental, or emotional conditions that cause serious difficulty with their daily activities. =>
HUHDSEAR
Person 1: Are you deaf or do you have serious difficulty hearing?
Persons 2+: How about [NAME]? (Is [NAME] deaf or does NAME have serious difficulty hearing?)
☐ Yes =>
☐ No =>
☐ DK/REF =>
HUHDSEYE
Person 1: Are you blind or do you have serious difficulty seeing even when wearing glasses?
Persons 2+: How about [NAME]? (Is [NAME] blind or does [NAME] have serious difficulty seeing even when wearing glasses?)
☐ Yes =>
☐ No =>
☐ DK/REF =>
HUHDSREM
Person 1: Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Persons 2+: How about [NAME]? (Because of a physical, mental, or emotional condition, does [NAME] have serious difficulty concentrating, remembering, or making decisions?)
☐ Yes =>
☐ No =>
☐ DK/REF =>
HUHDSPHY
Person 1: Do you have serious difficulty walking or climbing stairs?
Persons 2+: How about [NAME]? (Does [NAME] have serious difficulty walking or climbing stairs?)
☐ Yes =>
☐ No =>
☐ DK/REF =>
HUHDSDRS
Person 1: Do you have difficulty dressing or bathing?
Persons 2+: How about [NAME]? (Does [NAME] have difficulty dressing or bathing?)
☐ Yes =>
☐ No =>
☐ DK/REF =>
HUHDSOUT
Person 1: Because of a physical, mental, or emotional condition do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
Persons 2+: How about [NAME]? (Because of a physical, mental, or emotional condition does NAME have difficulty doing errands alone such as visiting a doctor's office or shopping?)
☐ Yes =>
☐ No =>
☐ DK/REF =>
Note: repeat series for all household members age 15+
SECTION C: LABOR FORCE
WORKYN
Did you work at a job or business at any time during 2008?
☐ Yes => WKSWORK
☐ No => WTEMP
☐ DK/Ref => WTEMP
WTEMP
Did you do any temporary, part-time, or seasonal work even for a few days during 2008?
☐ Yes => WKSWORK
☐ No => RSNNOTW
☐ DK/Ref => RSNNOTW
WKSWORK
During 2008 in how many weeks did you work even for a few hours? Include paid vacation and sick leave as work.
☐ 1-52 weeks
☐ DK/REF
=> HRSWK
HRSWK
In the [fill number of weeks from WKSWORK] weeks that you worked, how may hours did you usually work per week?
☐ [number of hours]
☐ DK/REF
=> CK-RSNNOTW
CK-RSNNOTW
if weeks worked (from WKSWORK) is less than 40 => RSNNOTW
else => WORKEARN
RSNNOTW
What was the main reason you did not work in 2008?
☐ Ill or disabled
☐ Retired
☐ Taking care of home or family
☐ Going to school
☐ Could not find work
☐ Other
=> CK-WORKEARN
CK-WORKEARN
if WTEMP = No/DK/REF => Section D (page 8)
else => WORKEARN
WORKEARN
How much did you earn from this work before taxes and other deductions during 2008?
PROBE: Your best estimate is fine.
☐ Amount: $
☐ DK/REF
=> EARNPD
EARNPD
READ IF NECESSARY: Is this a weekly, every other week, twice a month, monthly, or yearly amount?
☐ Weekly
☐ Every other week (bi-weekly)
☐ Twice a month
☐ Monthly
☐ Yearly
=> TIPS
TIPS
Does this amount include all tips, bonuses, overtime pay, or commissions you may have received from this work in 2008?
☐ Yes => Section D, page 8
☐ No => TIPSEARN
☐ DK/Ref => Section D, page 8
TIPSEARN
How much did you earn in tips, bonuses, overtime pay, or commissions from that work in 2008?
☐ Amount: $
☐ DK/REF
NOTE: repeat WORKYN thru TIPSEARN for all household members age 15+
SECTION D: PROGRAMS, PENSION AND INTEREST INCOME
A. PROGRAMS
1.Unemployment Compensation
UNEMP
At any time during 2008 did you receive any State or Federal unemployment compensation?
☐ Yes => UNEMPAMT
☐ No => SOCIAL SECURITY
☐ DK/Ref => SOCIAL SECURITY
UNEMPAMT
How many payments did you receive from State or Federal unemployment compensation during 2008?
☐ [number] =>
☐ DK/Ref =>
=> SOCIAL SECURITY
NOTE: repeat UNEMP and UNEMPAMT for all household members age 15+
2. Social Security
SSYN
During 2008 did (you/anyone in this household) receive any Social Security payments from the U.S. Government?
☐ Yes => SSWHO
☐ No => SSI
☐ DK/Ref => SSI
SSWHO
Read only if necessary
Who received Social Security payments either for themselves or as combined payments with other family members?
PROBE: Anyone else?
☐ [line numbers] => SSEASY
☐ DK/Ref => SSI
SSEASY
What is the easiest way for you to tell us (name's/your) Social Security payment; monthly, quarterly, or yearly?
☐ Monthly => SSMTHS
☐ Quarterly => SSMTHS
☐ Yearly => SSAMT
☐ DK/Ref => CK-SSR
SSMTHS
For how many (months/quarters) did (name/you) receive Social Security in 2008?
☐ [number] =>
☐ DK/Ref =>
=> CK-SSR
SSAMT
How much did (you/name) receive in Social Security payments in 2008?
☐ [number] =>
☐ DK/Ref =>
=> CK-SSR
CK-SSR
If NAME is 65+ => SSI
else => SSR
SSR
What were the reasons (name/you) (was/were) getting Social Security in 2008?
Enter all that apply, separate using the space bar or a comma.
Probe: Any Other Reason?
☐ Retired
☐ Disabled
☐ Widowed
☐ Spouse
☐ Surviving child
☐ Dependent child
☐ On behalf of surviving, dependent, or disabled children
☐ Other
=> SSI
NOTE: repeat SSEASY thru SSR for each name selected in SSWHO
3. SSI
SSIYN
During 2008 did (you/anyone in this household) receive any SSI payments, that is, Supplemental Security Income?
Note: SSI are assistance payments to low-income aged, blind and disabled persons,
and come from state or local welfare offices, the Federal government, or both.
☐ Yes => SSIWHO
☐ No => TANF
☐ DK/Ref => TANF
SSIWHO
Read only if necessary
Who received SSI?
PROBE: Anyone else?
☐ [line numbers] =>
☐ DK/Ref =>
=> TANF
4. TANF
Q59A88
At any time during 2008, even for one month, did (you/anyone in this household) receive any CASH assistance from a state or county welfare program such as (State Program Name)?
PROBE: Include cash payments from: welfare or welfare-to-work programs, Temporary Assistance for Needy Families program (TANF), Aid to Families with Dependent Children (AFDC), General Assistance/Emergency Assistance program, Diversion Payments, Refugee Cash and Medical Assistance program, General Assistance from Bureau of Indian Affairs, or
Tribal Administered General Assistance.
PROBE: Do not include food stamps, SSI, energy assistance, WIC, School meals, or
transportation, childcare, rental, or education assistance.
☐ Yes => TANFWHO
☐ No => FOOD STAMPS
☐ DK/Ref => FOOD STAMPS
TANFWHO
Read only if necessary
Who received this CASH assistance?
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> TANFEASY
TANFEASY
What is the easiest way for you to tell us (name's/your) CASH assistance payments;
weekly, every other week, twice a month, monthly, or yearly?
☐ Weekly => TANFPAY
☐ Every other week (bi-weekly) => TANFPAY
☐ Twice a month => TANFPAY
☐ Monthly => TANFPAY
☐ Yearly => TANFAMT
☐ DK/Ref => FOOD STAMPS
TANFPAY
How many (weekly/every other week/ twice a month/ monthly) cash assistance payments did (name/you) receive in 2008?
☐ [number] =>
☐ DK/Ref =>
=> FOOD STAMPS
TANFAMT
During 2008, how much CASH assistance did (name/you) receive?
☐ [number] =>
☐ DK/Ref =>
=> FOOD STAMPS
NOTE: repeat TANFEASY thru TANFAMT for each name selected in TANFWHO
5. Food Stamps
FSYN
Did (you/ anyone in this household) get food stamps or a food stamp benefit card at
any time during 2008?
☐ Yes => FSWHO
☐ No => CK-WIC
☐ DK/Ref => CK-WIC
FSWHO
Which of the people now living here were covered by food stamps during 2008?
PROBE: Anyone else?
☐ [line numbers] =>
☐ DK/Ref =>
=> FSAMT
FSAMT
How many months were food stamps received in 2008?
☐ [number] =>
☐ DK/Ref =>
=> CK-WIC
NOTE: repeat FSAMT for each name selected in FSWHO
CK-WIC
if there is at least one female age xx-xx in the household => WIC
else => RETIREMENT
6. WIC
WICYS
At any time during 2008, (was/were) (you/ anyone in this household) on WIC, the
Women, Infants, and Children Nutrition Program?
☐ Yes => WICWHO
☐ No => RETIREMENT
☐ DK/Ref => RETIREMENT
WICWHO
Read only if necessary
Who received WIC for themselves or on behalf of a child?
PROBE: Anyone else?
☐ [line numbers] =>
☐ DK/Ref =>
=> RETIREMENT
B. RETIREMENT AND PENSIONS
PNSNYN
During 2008 did (you/ anyone in this household) receive any pension or retirement
income from a previous employer or union, or any other type of retirement income
(other than Social Security)?
☐ Yes => PNSNWHO
☐ No => INTEREST
☐ DK/Ref => INTEREST
PNSNWHO
Read only if necessary
Who received pension or retirement income?
PROBE: Anyone else?
☐ [line numbers] =>
☐ DK/Ref =>
=> PNSNEASY
PNSNEASY
What is the easiest way for you to tell us (name's/your) pension or retirement income; weekly, every other week, twice a month, monthly, or yearly?
☐ Weekly => PNSNPAY
☐ Every other week (bi-weekly) => PNSNPAY
☐ Twice a month => PNSNPAY
☐ Monthly => PNSNPAY
☐ Yearly => PNSNAMT
☐ DK/Ref => INTEREST
PNSNPAY
How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in pension or retirement income in 2008?
☐ [number] =>
☐ DK/Ref =>
=> INTEREST
PNSNAMT
How much did (name/you) receive in pension or retirement income in 2008?
☐ [dollar amount] =>
☐ DK/Ref =>
NOTE: repeat PNSNEASY thru PNSNAMT for each name selected in PNSNWHO
C. INTEREST INCOME
INT1YN
At anytime during 2008 did (you/ anyone in this household): Have money in any kind of money market fund, interest earning checking account, or savings account?
☐ Yes =>
☐ No =>
☐ DK/Ref =>
=> INT2YN
INT2YN
At anytime during 2008 did (you/ anyone in this household): Have any savings bonds?
☐ Yes =>
☐ No =>
☐ DK/Ref =>
=> INT3YN
INT3YN
At anytime during 2008 did (you/ anyone in this household): Have any treasury notes, IRAs, certificates of deposit, or any other investments which pay interest?
☐ Yes =>
☐ No =>
☐ DK/Ref =>
=> CK-INTWHO
CK-INTWHO
if INT1YN, INT2YN or INT3YN = yes => INTWHO
else => CK-EXP
INTWHO
Read only if necessary
Which members of this household ages 15 and over had (interest earning accounts or
money market funds/savings bonds/treasury notes, IRAs, CDs, or any other
investments which pay interest)?
Probe: Anyone Else?
☐ [line numbers] => CK-INTAMT
☐ DK/Ref => CK-EXP
CK-INTAMT
if respondent’s name was selected in INTWHO => INTAMT
else => CK-EXP
INTAMT
How much did (name/you) receive in interest from these sources during 2008, including even small amounts reinvested or credited to accounts?
Only include interest received from U.S. Savings Bonds cashed during 2008.
☐ [dollar amount] =>
☐ DK/Ref =>
NOTE: repeat INTAMT for each name selected in INTWHO
CK-EXP
if case ID = X => Health Insurance Control (SHI1)
else if case ID = Y => Health Insurance ACS
else if case ID = Z => Health Insurance Test (1)
SECTION E: HEALTH INSURANCE CONTROL
SHI1
These next questions are about health insurance coverage during the calendar year 2008. The questions apply to ALL persons of ALL ages.
=> SHI2
SHI2
At any time in 2008, (was/were) (you/ anyone in this household) covered by a health
insurance plan provided through (their/your) current or former employer or union?
PROBE: Military health insurance will be covered later in another question.
☐ Yes => SHI3
☐ No => SHI7
☐ DK/REF => SHI7
SHI3
Who in this household were policyholders?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI4
SHI4
In addition to (name/you) who else in this household was covered by (name’s/your) plan?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI5
SHI5
Did (name’s/your) plan cover anyone living outside this household?
☐ Yes => Who? [?] PROBE: Anyone else?
☐ No =>
☐ DK/REF =>
=> SHI6
SHI6
Did (name’s/your) former or current employer or union pay for all, part, or none of
the health insurance premium?
NOTE: Report here employer's contribution to employee's health insurance premiums,
not the employee's medical bills.
☐ All
☐ Part
☐ None
=> SHI7
NOTE: Repeat SHI4 thru SHI6 for each policyholder selected in SHI3
SHI7
At any time during 2008, (was/were) (you/ anyone in this household) covered by a
health insurance plan that (you/they) PURCHASED DIRECTLY FROM AN
INSURANCE COMPANY, that is, not related to current or past employment?
☐ Yes => SHI8
☐ No => SHI11
☐ DK/REF => SHI11
SHI8
Who in this household were policyholders?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI9
SHI9
In addition to (name/you) who else in this household was covered by (name’s/your) plan?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI10
SHI10
Did (name’s/your) plan cover anyone living outside this household?
☐ Yes =>
☐ No =>
☐ DK/REF =>
=> SHI11
NOTE: Repeat SHI9 thru SHI10 for each policyholder selected in SHI8
SHI11
At any time in 2008, (was/were) (you/ anyone in this household) covered by the health insurance plan of someone who does not live in this household?
☐ Yes => SHI12
☐ No => SHI13
☐ DK/REF => SHI13
SHI12
Who was that?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI13
SHI13
At any time in 2008, (was/were) (you/ anyone in this household) covered by Medicare?
Read if necessary: Medicare is the health insurance for persons 65 years old and over OR persons with disabilities.
☐ Yes => SHI14
☐ No => SHI15
☐ DK/REF => SHI15
SHI14
Who was that?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI15
SHI15
At any time in 2008, (was/were) (you/ anyone in this household) covered by Medicaid / (fill state name)?
Read if necessary: Medicaid / (fill state name) is the Government Assistance Program that pays for health care.
☐ Yes => SHI16
☐ No => SHI21
☐ DK/REF => CK-SHI21
SHI16
Who was that?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI17
SHI17
How many months during 2008, (was/were) (name/you) covered by Medicaid/(fill State name)?
☐ Enter number of months (1-12)
=> CK-SHI21
NOTE: Repeat SHI7 for each person selected in SHI16
CK-SHI21
If anyone in the household is under 19 years old => SHI21
else => SHI18
SHI21
In (state), the (fill state CHIP program name) helps families get health insurance for
CHILDREN. (Just to be sure,) Were any of the children in this household covered
by that program?
Read if necessary: (fill state CHIP program name) is the name of your state's CHIP
program. It is the same as the Children's Health Insurance Program, which helps pay for
children's health care.
☐ Yes => SHI22
☐ No => SHI18
☐ DK/REF => SHI18
SHI22
Who was that?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI18
SHI18
At any time in, 2008 (was/were) (you/ anyone in this household) 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.
☐ Yes => SHI19
☐ No => SHICI
☐ DK/REF => SHICI
SHI19
Who was that?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHI20
SHI20
What plan (was/were) (name/you) covered by?
Enter all that apply, separate using the space bar or a comma.
Probe: Any Other Plan?
☐ TRICARE
☐ CHAMPVA
☐ VA
☐ Indian Health Service
☐ Other (specify)
=> SCHC1
NOTE: Repeat SHI20 for each person selected in SHI19
SHIC1
Other than the plans I have already talked about, during 2008, was anyone in this household covered by a health insurance plan [such as the (state-specific name plan) or any other type of plan/of any other type]?
☐ Yes => SHIC2
☐ No => CK-SHIC4
☐ DK/REF => CK-SHIC4
SHIC2
Who has insurance?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHIC3
SHIC3
What type of health insurance (was/were) (name/you) covered by in 2008?
Up to six entries allowed
Probe: Any Other Type Of Plan?
☐ Medicare
☐ Medicaid
☐ TRICARE or CHAMPUS
☐ CHAMPVA (CHAMPVA IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN\'S AFFAIRS)
☐ VA
☐ Military Health Care
☐ Children's Health Insurance Program (CHIP)
☐ Indian Health Service
☐ Other government health care
☐ Employer/union provided (policyholder)
☐ Employer/union provided (as dependent)
☐ Privately purchased (policyholder)
☐ Privately purchased (as dependent)
☐ Plan of someone outside the household
☐ Other (specify)
=> CK-SHIC4
NOTE: Repeat SHIC3 for each person selected in SHIC2
CK-SHIC4
if anyone in the household is uninsured => SHIC4
else => SHI24
SHIC4
I have recorded that (you/read list of names) (were/was) not covered by a health plan at any time during 2008. Is that correct?
☐ Yes => SHI24
☐ No => SHIC4A
☐ DK/REF => SHIC4A
SHIC4A
Who should be marked as covered?
Enter all that apply, separate using the space bar or a comma.
PROBE: Anyone Else?
☐ [line numbers] =>
☐ DK/Ref =>
=> SHIC6
SHIC6
What type of health insurance (was/were) (name/you) covered by in 2008?
Up to six entries allowed
Probe: Any other type of plan?
☐ Medicare
☐ Medicaid
☐ TRICARE or CHAMPUS
☐ CHAMPVA (CHAMPVA IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN\'S AFFAIRS)
☐ VA
☐ Military Health Care
☐ Children's Health Insurance Program (CHIP)
☐ Indian Health Service
☐ Other government health care
☐ Employer/union provided (policyholder)
☐ Employer/union provided (as dependent)
☐ Privately purchased (policyholder)
☐ Privately purchased (as dependent)
☐ Plan of someone outside the household
☐ Other (specify)
=> SHI24
NOTE: Repeat SHIC6 for each person selected in SHIC4A
=> WRAP-UP (SHI24)
SECTION E: HEALTH INSURANCE ACS
HICEMPLOYER
I am now going to ask you some questions about your health insurance and health coverage. [Are you/Is NAME] currently covered by health insurance through a current or former employer or union of yours or another family member?
☐ Yes
☐ No
☐ DK/Ref
HICDIRECT
[Are you/Is NAME] currently covered by health insurance purchased directly from an insurance company by you or another family member?
☐ Yes
☐ No
☐ DK/Ref
HICMEDICARE
[Are you/Is NAME] currently covered by Medicare, for people age 65 or older or people with certain disabilities?
☐ Yes
☐ No
☐ DK/Ref
HICMEDICAID
[Are you/Is NAME] currently covered by Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability?
☐ Yes
☐ No
☐ DK/Ref
HICMILITARY
[Are you/Is NAME] currently covered by TRICARE or other military health care?
☐ Yes
☐ No
☐ DK/Ref
HICVA
[Are you/Is NAME] currently covered through the Veterans’ Administration or have you ever used or enrolled [for? shouldn’t this be ‘in’?] Veterans’ Administration health care?
☐ Yes
☐ No
☐ DK/Ref
HICINDIAN
[Are you/Is NAME] currently covered through the Indian Health Service?
☐ Yes
☐ No
☐ DK/Ref
HICOTHER
[Are you/Is NAME] currently covered by any other health insurance or health coverage plan?
☐ Yes
☐ No
☐ DK/Ref
NOTE: repeat HICEMPLOYER thru HICOTHER for all household members
=> WRAP-UP (SHI24)
SECTION E: HEALTH INSURANCE TEST
1. PERSON 1: These next questions are about health insurance coverage. [IF MULTI-PERSON HOUSEHOLD: First I’d like to ask you about yourself.]
PERSONS 2+: Next I’d like to ask you about NAME.
=> CK2
CK2:
if NAME is 65+ => 2
else go to 3
2. [Are you/Is NAME] covered by Medicare?
☐ Yes => 16
☐ No => 3
☐ DK/REF => 3
Author Note: Create grid with household members (rows), months of coverage (columns) and plan types (within grid).
3. [Do you/Does NAME] have any type of health plan or health coverage?
☐ Yes => 8
☐ No => 4
☐ DK/REF => 4
4. [Are you/Is NAME] covered by Medicaid, Medical Assistance, S-CHIP, or any other kind of government assistance program that helps pay for health care?
☐ Yes => 16
☐ No => CK5
☐ DK/REF => CK5
CK5:
If Medicare already asked go to Q6
else go to Q5
5. [Are you/Is NAME] covered by Medicare?
☐ Yes => 16
☐ No => 6
☐ DK/REF => 6
6. [Are you/Is NAME] covered by [fill state-specific program names for Medicaid, SCHIP and other government programs in respondent’s state].
☐ Yes => 16
☐ No => 7
☐ DK/REF => 7
7. OK, I have recorded that [you are/NAME is] not covered by any kind of health plan or health coverage. Is that correct?
☐ Yes (not covered) => 28
☐ No (covered) => 8
☐ DK/REF => 28
AUTHOR NOTE ON FILLS:
if the plan is currently held, fill Q8 thru Q15, Q23, Q24, QN2 and QN3 with “is” and fill N1 with “provides.”
else if the plan was held at some point in 2008 but is not currently held, or if Q26=yes, fill Q8 thru Q15, Q23, Q24, QN2 and QN3 with “was” and fill N1 with “provided.”
8. (ASK OR VERIFY)
In order to better understand the health care needs of Americans, we’d like to learn more about how [you/NAME] [get/got] that coverage. [Is/Was] it provided through a job, the government, or some other way?
PROBE: “Employer/union” coverage includes coverage from someone’s own employer or union as well as coverage from a spouse’s or parent’s employer or union.
PROBE: Include coverage through former employers and unions, and COBRA plans.
PROBE: If this coverage is provided through employment with the government or the military, consider that coverage through an employer.
PROBE: If this is a military plan (not related to employment) consider it government coverage.
☐ Job (current or former) => 11
☐ Government => 9
☐ Other => 14
☐ DK/REF => 13
9. (ASK OR VERIFY)
[Note the ‘or was’ is to avoid confusion for respondents with currently-held retiree plans].
[Is (or was)/Was] that coverage related to a JOB with the government?
PROBE: Include coverage through former employers and unions, and COBRA plans.
☐ Yes => 11
☐ No => 10
☐ DK/REF => 10
10. (ASK OR VERIFY)
What type of government plan [is/was] it – Medicare, Medicaid, Medical Assistance or S-CHIP, military or Veterans’ Administration coverage, or something else?
READ IF NECESSARY: Some of the government programs in [STATE] are: [fill state-specific program names for Medicaid, SCHIP and other government programs in respondent’s state].
READ IF NECESSARY: Medicare is for people 65 years old and older or people with certain disabilities; Medicaid is for low-income families, disabled and elderly people who require nursing home care; and S-CHIP is for low-income families and children.
☐ Medicare => CK16
☐ Medicaid, Medical Assistance or S-CHIP => circle program name(s) above that were selected by respondent then => CK16
☐ Military or Veterans’ Administration care => 12
☐ Other => 13
☐ DK/REF => 13
11. (ASK OR VERIFY, IF NECESSARY)
[Is/Was] that plan related to military service in any way?
☐ Yes => Q12
☐ No => Q15
☐ DK/REF => Q15
12. (ASK OR VERIFY)
Which plan [are you/is NAME/were you/was NAME] covered by? [Is/Was] it TRICARE, CHAMPVA, Veterans’ Administration care, military health care, or something else?
☐ TRICARE
☐ TRICARE for Life
☐ CHAMPVA
☐ Veterans’ Administration
☐ Military health care
☐ Other (specify)
☐ DK/REF
=> CK15
13. [Is/Was] it a government assistance-type plan?
☐ Yes => CK16
☐ No => N3
☐ DK/REF => N3
14. (ASK OR VERIFY)
How [is/was] that coverage provided? [Is/Was] it through...
☐ a parent or spouse => QN1
☐ direct purchase from the insurance company => QN1
☐ a union or business association => QN1
☐ a school => CK16
☐ or some other way? => QN3
☐ DK/REF => QN3
N1. (ASK OR VERIFY)
Who [provides/provided] the coverage?
☐ [display household roster] => CKN2
☐ someone outside the household => CK16
☐ DK/REF => N3
CKN2
if Q14=direct => CK16
else => N2
N2. And [is/was] that coverage provided through their job, direct purchase from the insurance company, or some other way?
☐ job (current or former)[store name selected in N1 in Q15 as policyholder] => CK16
☐ direct purchase from the insurance company )[store name selected in N1 in Q15 as policyholder] => CK16
☐ some other way => N3
☐ DK/REF => N3
N3. What type of plan is/was this?
=> CK16
CK15
if this is a job-based military plan => Q15
else => CK16
15. And who [is/was] the policyholder? [include “Someone outside household”]
Name of policyholder ____________________________________________________
PROBE: What is the name of the person who has the policy?
=> CK16
Author note:
if NAME is different from the policyholder named selected in Q15, flag the policyholder as having coverage [now/in 2008] for purposes of routing in CK29b
include an open-text field (25 characters) to capture a respondent-defined name or label for the plan (such as employer name or insurance carrier) in case there was extensive turnover (e.g.: multiple jobs and/or multiple plans from the same employer within the year) and/or complexity (e.g.: different members transitioned on and off the plans).
CK16:
if this is a currently-held plan => Q16
else if this is a plan not currently held but held at some point in 2008, or if Q26=yes
=> Q22
16. Did that coverage start before or after January 1, 2008?
PROBE: Your best estimate is fine.
[If this is a job-based plan fill: PROBE: When we say “that coverage” we mean any coverage through [policyholder’s] employer. So if [policyholder] switched plans offered by the employer, or even switched employers, we still consider this all the same coverage.]
[If this is a directly-purchased plan fill: PROBE: When we say “that coverage” we mean any coverage directly purchased by you or another policyholder. So if you/NAME switched plans but they were all directly-purchased, we still consider this all the same coverage.]
☐ Before January 1, 2008 => CK20
☐ On or after January 1, 2008 => Q18
☐ DK/REF => Q17
17. Did [you/NAME] have the coverage at any time during 2008?
☐ Yes => Q22
☐ No => CK23
☐ DK/REF => CK23
18. In what month did that coverage start?
☐ Month [1-12] => pop-up: (READ IF NECESSARY) And what year was that?
☐ 2008 => CK20
☐ 2009 => CK23
☐ DK/REF => Q19
19. Do you know if it was before or after January 1, 2009?
[If this is a job-based plan fill: PROBE: When we say “that coverage” we mean any coverage through [policyholder’s] employer. So if [policyholder] switched plans offered by the employer, or even switched employers, we still consider this all the same coverage.]
[If this is a directly-purchased plan fill: PROBE: When we say “that coverage” we mean any coverage directly purchased by you or another policyholder. So if you/NAME switched plans but they were all directly-purchased, we still consider this all the same coverage.]
☐ Before January 1, 2009 => Q22
☐ On or after January 1, 2009 => CK23
☐ DK/REF => Q22
CK20:
If this is a Medicare plan => Q23
else => Q20
20. And has it been continuous since then?
[If this is a job-based plan fill: PROBE: When we say “that coverage” we mean any coverage through [policyholder’s] employer. So if [policyholder] switched plans offered by the employer, or even switched employers, we still consider this all the same coverage.]
[If this is a directly-purchased plan fill: PROBE: When we say “that coverage” we mean any coverage directly purchased by you or another policyholder. So if you/NAME switched plans but they were all directly-purchased, we still consider this all the same coverage.]
☐ Yes => CK23
☐ No => 21
☐ DK/REF => 21
21. In what month did this most recent spell of coverage start?
☐ Month [1-12] =>
☐ Month [1-4] in 2009
☐ DK/REF
=> CK23
22. What months in 2008 were you covered by that plan?
☐ Month [1-12] => CK23
☐ None => Q27
☐ DK/REF => CK23
CK23:
if single-person household => CK26
else if 2-person household and NAME is a dependent (Q15, the policyholder, is the name of the other household member)
and if the plan began sometime in 2009 => Q27
if the plan began prior to January 1, 2009 => CK25
else => Q23
23. [If 2-person household fill] And [is/was] NAME also covered by [policyholder’s/ Medicaid/Medicare/Veterans’ Administration care/that] plan?
[Else fill]: [Is/Was] anyone else within this household also covered by [policyholder’s/ Medicaid/Medicare/Veterans’ Administration care/that] plan?
☐ Yes => CK24
☐ No => CK26
☐ DK/REF => CK26
Author note: ensure fill correctly displays plan name
CK24
If 2-person household
and the plan began sometime in 2009 flag all names selected in Q23 as having coverage now for purposes of routing in CK29b and then => Q27
and the plan began prior to January 1, 2009 => CK25
else => Q24
24. Who? (Who else [is/was] covered by that plan)? => CK25
CK25
If the initial enrollee was covered the entire 12 months of 2008 => Q25
else if the plan began sometime in 2009 => flag all names selected in Q24 as having coverage now for purposes of routing in CK29b and then => Q27
else => QN4
25. And [was NAME/were NAMES] also covered all 12 months of 2008?
☐ Yes => CK26
☐ No => QN4
☐ DK/REF => QN4
N4. [For first person selected in Q24 and for the policyholder in 2-person household where the first person reporting was the dependent (see CK23, 2nd bullet)]: What months during 2008 [was NAME] covered?
[For all others selected in Q24]: How about NAME? (What months during 2008 was NAME covered?) [repeat for each additional name selected in Q24]
☐ Same months as initial enrollee [display months]
☐ [Months 1-12]
☐ DK/REF
=> CK26
CK26:
If this is a job-based plan and NAME was covered less than 12 months of 2008 by this plan => Q26
else => Q27
26. And before that plan, [were you/was NAME] covered by any other job-sponsored health plan at any time in 2008?
☐ Yes => Q15
☐ No, DK, REF => Q27
27. Other than [plan(s)], [are you/is NAME] also covered by any other type of health plan or health coverage? Do not include plans that cover only one type of care, such as dental or vision plans.
☐ Yes => Q8
☐ No, DK, REF => Q28
28. How about during 2008? (Other than [plan(s)] [were you/was NAME] covered by any (other) type of health plan or health coverage at any time during 2008?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
☐ Yes => Q8
☐ No, DK, REF => CK29a
CK29a:
If there are more household members on the roster who have not been asked about yet => CK29b
else => => WRAP-UP (SHI24)
CK29b:
If the next person on the roster was reported as having coverage (now or during 2008) during the course of any previous person’s interview => Q29 for that person
else => Q1 for that person
29. Now I’d like to ask you about [PERSON 2+]. Other than the [plan(s)] you reported earlier, does [PERSON 2+] have any other type of health plan or health coverage?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
☐ Yes => Q8
☐ No => Q30
☐ DK/REF => Q30
30. How about during 2008? Other than the [plan(s)] you reported earlier, did [PERSON 2+] have any other type of health plan or health coverage at any time during 2008?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
☐ Yes => Q8
☐ No => go back to CK29a
☐ DK/REF => go back to CK29a
=> WRAP-UP (SHI24)
SECTION F: WRAP-UP
SHI24
An important factor in evaluating a person's or family's health insurance situation is their current health status and/or the current health status of other family members.
=> SHI25
SHI25
Would you say (name's/your) health in general is excellent, very good, good, fair, or poor?
☐ Excellent
☐ Very good
☐ Good
☐ Fair
☐ Poor
NOTE: Repeat SHI25 for each household member then => CK-END
CK-END
if this case ID was linked to an address and an advance letter was sent => VZIP
else => LINK
LINK
The Census Bureau would like to conduct additional research without taking up your time with more questions. We would like your permission to obtain the information that you have given to other government agencies on topics such as Social Security and Medicare benefits. Do you have any objections?
☐ Yes =>
☐ No =>
☐ DK/REF =>
=> ZIP
LINK HELP SCREEN
WHY DOES THE CENSUS BUREAU WANT CONSENT TO GET ADDITIONAL INFORMATION?
Providing your consent allows the Census Bureau to get some additional data from other government agencies. This helps make sure the data are complete. The same confidentiality laws that protect your survey answers also protect any additional information we collect (Title 13, US Code, Section 9). Providing your consent is voluntary.
ZIP
What is your zip code?
☐ [5 digit boxes]
☐ DK/REF
H_ZIP (Help screen for ZIP)
WHY DO YOU WANT MY ZIP CODE?
Because this survey is a random sample of telephone numbers, we need zip codes and addresses to establish your geographic location. Your location within the U.S. is an important part of analyzing this survey. It helps us understand differences across urban, rural and suburban areas. You will NOT be placed on any type of mailing list.
=> ADDRESS
ADDRESS
And your address?
STREET NUMBER AND NAME
ADDITIONAL NUMBER/NAME
CITY
STATE
H_ADDRESS (Help screen for ADDRESS)
WHY DO YOU WANT MY ADDRESS?
Because this survey is a random sample of telephone numbers, we need zip codes and addresses to establish your geographic location. Your location within the U.S. is an important part of analyzing this survey. It helps us understand differences across urban, rural and suburban areas. You will NOT be placed on any type of mailing list.
=> END
VZIP
I just need to verify this. Is your zip code [fill zip code]?
☐ Yes
☐ No => What is your zip code? [5 digit boxes]
☐ DK/REF
H_ZIP (Help screen for ZIP)
WHY DO YOU WANT MY ZIP CODE?
Because this survey is a random sample of telephone numbers, we need zip codes and addresses to establish your geographic location. Your location within the U.S. is an important part of analyzing this survey. It helps us understand differences across urban, rural and suburban areas. You will NOT be placed on any type of mailing list.
=> VADDRESS
VADDRESS
And is your address [fill address]?
☐ Yes
☐ No => What is your address? [street number, name, city, state]
☐ DK/REF
H_ADDRESS (Help screen for ADDRESS)
WHY DO YOU WANT MY ADDRESS?
Because this survey is a random sample of telephone numbers, we need zip codes and addresses to establish your geographic location. Your location within the U.S. is an important part of analyzing this survey. It helps us understand differences across urban, rural and suburban areas. You will NOT be placed on any type of mailing list.
THANK YOU!!
| File Type | application/octet-stream |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |