MEPS-HC Core Interview

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

Attachment 43 -- HC Health Insurance Section

MEPS-HC Core Interview

OMB: 0935-0118

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0935-0118 can be found here:

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MEPS FAMES P12R5/P13R3/P14R1 Health Insurance (HX) Section

December 8, 2008

Health Insurance (HX) Section

----------------------------------------------------

| THROUGHOUT THE SPECIFICATIONS FOR THIS CAPI |

| SECTION, FOR SCREENS THAT SPECIFY THE REFERENCE |

| PERIOD {END DATE} AS PART OF THE CONTEXT HEADER, |

| CAPI DISPLAYS THE {END DATE} ONLY FOR ROUND 5. IN |

| ANY OTHER ROUND, CAPI DOES NOT DISPLAY THE {END |

| DATE} IN THE CONTEXT HEADER. FOR MOST PERSONS, THE|

| END DATE FOR ROUND 5 WILL BE DECEMBER 31 OF THE |

| SECOND YEAR OF THE PANEL. |

----------------------------------------------------

BOX_00

======

----------------------------------------------------

| CONTEXT HEADER DISPLAY INSTRUCTIONS: |

| FOR MONTH DISPLAY 3 CHAR MONTH (EG. JAN, FEB) |

| |

| ROUNDS 1-4, DISPLAY ONLY THE BEGIN DATE RATHER |

| THAN BOTH THE BEGIN AND END DATE. IF ROUND 5 THEN |

| DISPLAY BOTH THE BEGIN AND END DATE. |

| |

| DISPLAY PERS.FULLNAME, ESTB.ESTBNAME, |

| PRND.BEGREFMM, PRND.BEGREFDD, PRND.BEGREFYY, |

| PRND.ENDREFMM, PRND.ENDREFDD, PRND.ENDREFYY |

----------------------------------------------------

HX01

====

{STR-DT}

{END-DT}

Now I’d like to talk with you about health insurance, an

important topic for most persons. We want to know about all

the health coverage that anyone in the family may have had to

help pay the costs of medical care at any time {since (START

DATE)/between (START DATE) and (END DATE)}.

{ASK RESPONDENT TO GET INSURANCE CARDS/IDENTIFYING INFORMATION

IF NOT ALREADY AVAILABLE.}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

----------------------------------------------------

| DISPLAY ‘ASK....AVAILABLE.’ IF ROUND 1. |

| OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

| IF ROUND 1, GO TO BOX_03 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_01 |

----------------------------------------------------

BOX_01

======

----------------------------------------------------

| ASK THE OLD EMPLOYMENT AND PRIVATE RELATED |

| INSURANCE (OE) SECTION. |

----------------------------------------------------

| AT COMPLETION OF OE SECTION, CONTINUE WITH BOX_02 |

----------------------------------------------------

BOX_02

======

----------------------------------------------------

| ASK THE OLD PUBLIC RELATED INSURANCE (PR) SECTION.|

----------------------------------------------------

| AT COMPLETION OF PR SECTION, CONTINUE WITH BOX_03 |

----------------------------------------------------

BOX_03

======

----------------------------------------------------

| IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS MEET THE|

| FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS |

| PROVIDING HEALTH INSURANCE |

| AND |

| - ESTABLISHMENT IS AN EMPLOYER |

| AND |

| - PERSON IS OR WAS A JOBHOLDER AT ESTABLISHMENT |

| AND |

| - ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’|

| OR IS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM- |

| SIZE-GREATER-THAN-1, |

| CONTINUE WITH LOOP_01 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_05 |

----------------------------------------------------

LOOP_01

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-PAIRS-|

| ROSTER, ASK HX02-END_LP01 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION |

| ABOUT PRIVATE HEALTH INSURANCE OBTAINED THROUGH |

| AN EMPLOYER. THIS LOOP CYCLES ON ESTABLISHMENT- |

| PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS |

| PROVIDING HEALTH INSURANCE |

| AND |

| - ESTABLISHMENT IS AN EMPLOYER |

| AND |

| - PERSON IS OR WAS A JOBHOLDER AT ESTABLISHMENT |

| AND |

| - ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’|

| OR IS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM- |

| SIZE-GREATER-THAN-1. |

----------------------------------------------------

HX02

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

You mentioned that (PERSON) (were/was) covered by health

insurance from (ESTABLISHMENT) {at some point after (START

DATE)/between (START DATE) and (END DATE)}.

SELECT ‘CONTINUE’ UNLESS RESPONDENT VOLUNTEERS INSURANCE

REPORTED IN ERROR.

CONTINUE ............................... 1 {BOX_04}

INSURANCE REPORTED IN ERROR ............ 2 {END_LP01}

[Code One]

----------------------------------------------------

| IF ROUND 1 THROUGH ROUND 4, DISPLAY ‘at some point|

| after (START DATE)’. IF ROUND 5, DISPLAY ‘between|

| (START DATE) and (END DATE)’. |

----------------------------------------------------

| ‘(ESTABLISHMENT)’ AND ‘(START DATE)’ IN RESPONSE |

| LABELS SHOULD BE PURPLE. |

----------------------------------------------------

| IF CODED ‘2’ (INSURANCE REPORTED IN ERROR) FLAG |

| THIS ESTABLISHMENT-PERSON-PAIR AS ‘NOT SEPARATE |

| SOURCE OF INSURANCE’ AND GO TO END_LP01 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_04 |

----------------------------------------------------

BOX_04

======

----------------------------------------------------

| ASK THE PRIVATE HEALTH INSURANCE DETAIL (HP) |

| SECTION FOR THIS ESTABLISHMENT-PERSON-PAIR. |

----------------------------------------------------

| AT COMPLETION OF HP SECTION, CONTINUE WITH |

| END_LP01 |

----------------------------------------------------

END_LP01

========

----------------------------------------------------

| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT-PERSON- |

| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |

| THE LOOP DEFINITION. |

----------------------------------------------------

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_01 AND CONTINUE WITH BOX_05 |

----------------------------------------------------

BOX_05

======

----------------------------------------------------

| IF ONE OR MORE ESTABLISHMENT-PERSON-PAIRS MEET |

| THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS |

| PROVIDING HEALTH INSURANCE |

| AND |

| - ESTABLISHMENT IS AN EMPLOYER |

| AND |

| - PERSON IS A JOBHOLDER AT ESTABLISHMENT |

| AND |

| - ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’ |

| AND |

| - FIRM SIZE OF ESTABLISHMENT = 1, |

| CONTINUE WITH LOOP_02 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_07 |

----------------------------------------------------

LOOP_02

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON-PAIRS-|

| ROSTER, ASK LOOP_03-END_LP02 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_02 COLLECTS INFORMATION |

| ABOUT THE SOURCES OF DIRECTLY PURCHASED HEALTH |

| INSURANCE ASSOCIATED WITH A SELF-EMPLOYED JOB |

| WHERE FIRM SIZE = 1. THIS LOOP CYCLES ON |

| ESTABLISHMENT-PERSON-PAIRS THAT MEET THE |

| FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS FLAGGED DURING THIS ROUND AS |

| PROVIDING HEALTH INSURANCE |

| AND |

| - ESTABLISHMENT IS AN EMPLOYER |

| AND |

| - PERSON IS A JOBHOLDER AT ESTABLISHMENT |

| AND |

| - ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’ |

| - FIRM SIZE OF ESTABLISHMENT = 1 |

----------------------------------------------------

LOOP_03

=======

----------------------------------------------------

| For each of the following: |

| |

| INSURANCE CATEGORY 1 |

| INSURANCE CATEGORY 2 |

| INSURANCE CATEGORY 3 |

| INSURANCE CATEGORY 4 |

| INSURANCE CATEGORY 5 |

| INSURANCE CATEGORY 6 |

| |

| ask HX03 - END_LP03 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_03 COLLECTS INFORMATION |

| ABOUT THE WAYS PERSON PURCHASED HEALTH INSURANCE |

| (INSURANCE CATEGORIES AT HX03) ASSOCIATED WITH A |

| SELF-EMPLOYED JOB WITH FIRM-SIZE = 1. THE FIRST |

| CYCLE OF THIS LOOP COLLECTS THE MAIN WAY PERSON |

| PURCHASES INSURANCE. SUBSEQUENT CYCLES COLLECT |

| ADDITIONAL WAYS PERSON PURCHASES INSURANCE. |

| |

| THE RESPONSE AT HX04 DETERMINES WHETHER THE LOOP |

| CYCLES AGAIN. IF HX04 IS CODED ‘1’ (YES), THE |

| LOOP CYCLES TO COLLECT THE NEXT INSURANCE |

| CATEGORY. IF HX04 IS CODED ‘2’ (NO), ‘-7’ |

| (REFUSED), OR ‘-8’ (DON’T KNOW), THE LOOP ENDS. |

----------------------------------------------------

HX03

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

SHOW CARD HX-1.

{You mentioned that (PERSON) {(are/is)/(were/was)} self-employed

and had health insurance through that business.} Which

category on this card comes closest to {the main/another} way

(PERSON) (purchase/purchases) this insurance?

FROM A PROFESSIONAL ASSOCIATION ........ 1 {BOX_06}

FROM A SMALL BUSINESS GROUP ............ 2 {BOX_06}

FROM A UNION ........................... 3 {BOX_06}

DIRECTLY FROM AN INSURANCE AGENT ....... 5 {BOX_06}

DIRECTLY FROM INSURANCE COMPANY ........ 6 {BOX_06}

DIRECTLY FROM AN HMO ................... 7 {BOX_06}

FROM A PREVIOUS EMPLOYER ............... 8 {BOX_06}

FROM A PREVIOUS EMPLOYER (COBRA) ....... 9 {BOX_06}

OTHER ................................. 91 {HX03OV}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

----------------------------------------------------

| STARTING IN PANEL 12 ROUND 2, CATEGORY ‘4’ (FROM |

| A HEALTH INSURANCE PURCHASING ALLIANCE) WAS |

| OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS. |

----------------------------------------------------

| DISPLAY ‘you mentioned that (PERSON) {(are/is)/ |

| (were/was)} self-employed and had health insurance|

| through that business.’ IF FIRST CYCLE THROUGH |

| LOOP_03. OTHERWISE USE A NULL DISPLAY. |

| |

| DISPLAY ‘(are/is)’ IF ESTABLISHMENT IS FLAGGED AS |

| A CURRENT EMPLOYER. DISPLAY ‘(were/was)’ IF |

| ESTABLISHMENT IS NOT FLAGGED AS A CURRENT |

| EMPLOYER, OR IF CURRENT ROUND IS ROUND 5. |

| |

| DISPLAY ‘the main’ IF FIRST CYCLE THROUGH LOOP_03.|

| OTHERWISE (I.E., NOT FIRST CYCLE), DISPLAY |

| ‘another’. |

----------------------------------------------------

HX03OV

======

OTHER:

[Enter Other Specify] .................. {BOX_06}

DK .................................... -8 {BOX_06}

BOX_06

======

----------------------------------------------------

| ASK PRIVATE HEALTH INSURANCE DETAIL (HP) SECTION |

| FOR THE RESPONSE CATEGORY SELECTED AT HX03. |

----------------------------------------------------

| AT COMPLETION OF HP SECTION, CONTINUE WITH HX04 |

----------------------------------------------------

HX04

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

SHOW CARD HX-1.

Aside from what you already told me about, is there another

category on this card which describes the way (PERSON)

(purchase/purchases) health insurance for (ESTABLISHMENT)?

YES .................................... 1 {END_LP03}

NO ..................................... 2 {END_LP03}

REF ................................... -7 {END_LP03}

DK .................................... -8 {END_LP03}

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

END_LP03

========

----------------------------------------------------

| IF HX04 IS CODED ‘1’ (YES), CYCLE TO COLLECT THE |

| NEXT WAY OF PURCHASING INSURANCE. |

----------------------------------------------------

| OTHERWISE, END LOOP_03 AND CONTINUE WITH END_LP02 |

----------------------------------------------------

END_LP02

========

----------------------------------------------------

| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT-PERSON- |

| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |

| THE LOOP DEFINITION. |

----------------------------------------------------

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_02 AND CONTINUE WITH BOX_07 |

----------------------------------------------------

BOX_07

======

----------------------------------------------------

| IF ROUND 1, GO TO HX06 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_08 |

----------------------------------------------------

BOX_08

======

----------------------------------------------------

| IF: |

| |

| ANY NEW RU MEMBERS ADDED TO RU THIS ROUND, |

| OR |

| ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING |

| MEDICARE TURNED 65 SINCE START DATE (USE REAL |

| DATE OF BIRTH ONLY), |

| OR |

| ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING |

| MEDICARE WERE = OR > 65 (OR IN AGE CATEGORY 9) IN |

| PREVIOUS ROUND, |

| CONTINUE WITH HX05 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_12 |

----------------------------------------------------

HX05

====

{STR-DT}

{END-DT}

My records indicate that (READ NAMES BELOW) {(are/is)}

{either} {65 years old or older} {or} {joined the household

since our last interview}.

[1. First Name,[Middle Name],Last Name-65]

[2. First Name,[Middle Name],Last Name-65]

[3. First Name,[Middle Name],Last Name-65]

(Has (READ NAME ABOVE)/Have any of these people) been covered

by Medicare {since (START DATE)/between (START DATE) and (END DATE)}?

YES .................................... 1

NO ..................................... 2 {LOOP_04}

REF ................................... -7 {LOOP_04}

DK .................................... -8 {LOOP_04}

HELP AVAILABLE FOR DEFINITION OF MEDICARE.

----------------------------------------------------

| DISPLAY ‘(are/is)’ AND ‘65 years old’ IF ANY RU |

| MEMBERS NOT ALREADY FLAGGED AS RECEIVING |

| MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU |

| MEMBERS NOT ALREADY FLAGGED AS RECEIVING |

| MEDICARE WERE = OR > 65 PREVIOUS ROUND. |

| |

| DISPLAY ‘joined the household since our last |

| interview’ IF ANY NEW RU MEMBERS ADDED TO THE RU |

| THIS ROUND. |

| |

| DISPLAY ‘either’ AND ‘or’ IF ANY NEW RU MEMBERS |

| ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS |

| NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED |

| 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY |

| FLAGGED AS RECEIVING MEDICARE WERE = OR > 65 |

| PREVIOUS ROUND. |

| |

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

| IF HX05 IS CODED ‘1’ (YES) AND ONLY ONE RU MEMBER |

| ELIGIBLE FOR HX05, SELECT THAT PERSON |

| AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04 |

----------------------------------------------------

| IF HX05 IS CODED ‘1’ (YES) AND MORE THAN ONE RU |

| MEMBER ELIGIBLE FOR HX05, GO TO HX07 |

----------------------------------------------------

| ROSTER DETAILS: |

| Title: RU_MEMBERS_1 |

| |

| COL #1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR DISPLAY |

| OF RU-MEMBERS. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. SELECT, ADD, DELETE, AND EDIT DISALLOWED. |

----------------------------------------------------

| ROSTER FILTER: |

| OTHERWISE, DISPLAY RU-MEMBERS WHO MEET ONE OF THE |

| FOLLOWING CONDITIONS: |

| 1. PERSON IS A NEW RU MEMBER THIS ROUND, |

| |

| 2. PERSON TURNED 65 YEARS OLD THIS ROUND AND IS |

| NOT FLAGGED AS COVERED BY MEDICARE DURING ANY |

| ROUND, |

| |

| 3. OR PERSON >= 65 (OR IN AGE CATEGORY 9) LAST |

| ROUND AND NOT FLAGGED AS COVERED BY MEDICARE |

| DURING ANY ROUND. |

----------------------------------------------------

HX06

====

{STR-DT}

There are several large public health insurance programs {with

similar names} that are easily confused.

Medicare is a health insurance program for persons 65 years or

over and for disabled persons. Other programs, such as

{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP NAME}, are

state programs which cover low income families and individuals

or children who do not have private health insurance.

SHOW CARD HX-2.

Let me first ask about Medicare. People covered by Medicare

usually have a card that looks like this.

At any time since (START DATE), has anyone in the family been

covered by Medicare?

YES .................................... 1

NO ..................................... 2

REF ................................... -7

DK .................................... -8

HELP AVAILABLE FOR DEFINITION OF MEDICARE.

----------------------------------------------------

| DISPLAY ‘or Denali KidCare’ FOR ‘STATE CHIP NAME’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| ALASKA. |

| |

| DISPLAY ‘or ALL Kids’ FOR ‘STATE CHIP NAME’ IF |

| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| ALABAMA. |

| |

| DISPLAY ‘or KidsCare’ FOR ‘STATE CHIP NAME’ IF |

| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| ARIZONA. |

| |

| DISPLAY ‘or ARKids First’ FOR ‘STATE CHIP NAME’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| ARKANSAS. |

| |

| DISPLAY ‘or Healthy Families’ FOR ‘STATE CHIP |

| NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS CALIFORNIA. |

| |

----------------------------------------------------

| DISPLAY ‘or Child Health Plan Plus (CHP+)’ FOR |

| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED IS COLORADO. |

| |

| DISPLAY ‘or HUSKY Healthcare’ FOR ‘STATE CHIP |

| NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS CONNECTICUT. |

| |

| DISPLAY ‘or DC Healthy Families’ FOR ‘STATE |

| CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS WASHINGTON, DC. |

| |

| DISPLAY ‘or DE Healthy Children Program’ FOR |

| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED IS DELAWARE. |

| |

| DISPLAY ‘or Florida KidCare’ FOR ‘STATE CHIP |

| NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS FLORIDA. |

| |

| DISPLAY ‘or PeachCare for Kids’ FOR ‘STATE CHIP |

| NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS GEORGIA. |

| |

| DISPLAY ‘or Healthy and Well Kids in IA’ |

| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |

| IS BEING CONDUCTED IS IOWA. |

| |

| DISPLAY ‘or children’s Health Insurance Program’ |

| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |

| IS BEING CONDUCTED IS IDAHO. |

| |

| DISPLAY ‘or All Kids’ FOR ‘STATE CHIP NAME’ IF |

| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| ILLINOIS. |

| |

| DISPLAY ‘or Hoosier Healthwise’ FOR ‘STATE CHIP |

| NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS INDIANA. |

| |

| DISPLAY ‘or Heathwave 21’ FOR ‘STATE CHIP NAME’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |

| IS KANSAS. |

| |

----------------------------------------------------

| DISPLAY ‘or KY Children’s Health Insurance |

| Program (KCHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN|

| WHICH INTERVIEW IS BEING CONDUCTED IS KENTUCKY. |

| |

| DISPLAY ‘or LA Children’s Health Insurance |

| Program’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED IS LOUISIANA. |

| |

| DISPLAY ‘or Maryland Children’s Health Program’ |

| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |

| IS BEING CONDUCTED IS MARYLAND. |

| |

| DISPLAY ‘or Children’s Medical Security Plan’ |

| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |

| IS BEING CONDUCTED IS MASSACHUSETTS. |

| |

| DISPLAY ‘or MIChild’ FOR ‘STATE CHIP NAME’ IF |

| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| MICHIGAN. |

| |

| DISPLAY ‘or MO HealthNet for Kids’ FOR ‘STATE |

| CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS MISSOURI. |

| |

| DISPLAY ‘or Children’s Health Insurance Program’ |

| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |

| IS BEING CONDUCTED IS MISSISSIPPI. |

| |

| DISPLAY ‘or MT Children’s Health Insurance Plan’ |

| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |

| IS BEING CONDUCTED IS MONTANA. |

| |

| DISPLAY ‘or Kids Connection’ FOR ‘STATE CHIP NAME’|

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| NEBRASKA. |

| |

| DISPLAY ‘or Nevada Check Up’ FOR ‘STATE CHIP NAME’|

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| NEVADA. |

| |

| DISPLAY ‘or Healthy Kids Gold’ FOR ‘STATE CHIP |

| NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS NEW HAMPSHIRE. |

| |

----------------------------------------------------

| DISPLAY ‘or NJ Family Care’ FOR ‘STATE CHIP NAME’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| NEW JERSEY. |

| |

| DISPLAY ‘or New MexiKids’ FOR ‘STATE CHIP NAME’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| NEW MEXICO. |

| |

| DISPLAY ‘or Child Health Plus (CHPlus)’ FOR |

| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED IS NEW YORK. |

| |

| DISPLAY ‘or NC Health Choice for Children’ FOR |

| ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED IS NORTH CAROLINA. |

| |

| DISPLAY ‘or Healthy Steps’ FOR ‘STATE CHIP NAME’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| NORTH DAKOTA. |

| |

| DISPLAY ‘or Healthy Start’ FOR ‘STATE CHIP NAME’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| OHIO. |

| |

| DISPLAY ‘or PA Children’s Health Insurance |

| Program’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED IS PENNSYLVANIA. |

| |

| DISPLAY ‘or RIte Care/RIte Share’ FOR ‘STATE CHIP |

| NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS RHODE ISLAND. |

| |

| DISPLAY ‘or Healthy Connections Kids’ FOR ‘STATE |

| CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS SOUTH CAROLINA. |

| |

| DISPLAY ‘or Children’s Health Insurance Program’ |

| FOR ‘STATE CHIP NAME’ IF STATE IN WHICH INTERVIEW |

| IS BEING CONDUCTED IS SOUTH DAKOTA. |

| |

| DISPLAY ‘or CoverKids’ FOR ‘STATE CHIP NAME’ IF |

| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| TENNESSEE. |

| |

| DISPLAY ‘or Children’s Health Insurance Program |

| (SCHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED IS TEXAS. |

| |

| DISPLAY ‘or Children’s Health Insurance Program |

| (SCHIP)’ FOR ‘STATE CHIP NAME’ IF STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED IS UTAH. |

----------------------------------------------------

| DISPLAY ‘or Dr. Dynasaur’ FOR ‘STATE CHIP NAME’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |

| IS VERMONT. |

| |

| DISPLAY ‘or FAMIS’ FOR ‘STATE CHIP NAME’ IF STATE |

| IN WHICH INTERVIEW IS BEING CONDUCTED IS VIRGINIA.|

| |

| DISPLAY ‘or West Virginia Children’s Health |

| Insurance Program’ FOR ‘STATE CHIP NAME’ IF |

| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| WEST VIRGINIA. |

| |

| DISPLAY ‘or BadgerCare’ FOR ‘STATE CHIP NAME’ IF |

| STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| WISCONSIN. |

| |

| DISPLAY ‘or Wyoming Kid Care (CHIP)’ FOR ‘STATE |

| CHIP NAME’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS WYOMING. |

| |

| OTHERWISE (I.E., STATE IS HI, ME, MN, OK, OR, WA) |

| DISPLAY ‘or State Children’s Health Insurance |

| Program’ FOR ‘STATE CHIP NAME.’ |

----------------------------------------------------

| DISPLAY ‘with similar names’ IF STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED USES ‘MEDICAID’ OR A |

| NAME SIMILAR TO MEDICARE (WHICH INCLUDES CA: |

| MEDI-CAL AND ME: MAINCARE). |

----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED IS ONE OF THE FOLLOWING: |

| ALASKA LOUISIANA OHIO |

| ALABAMA MICHIGAN SOUTH CAROLINA |

| ARKANSAS MISSISSIPPI TEXAS |

| COLORADO MONTANA UTAH |

| DELAWARE NEBRASKA VERMONT |

| FLORIDA NEVADA VIRGINIA |

| GEORGIA NEW HAMPSHIRE WASHINGTON |

| IDAHO NEW JERSEY WEST VIRGINIA |

| ILLINOIS NEW MEXICO WISCONSIN |

| INDIANA NEW YORK |

| IOWA NORTH CAROLINA |

| KANSAS NORTH DAKOTA |

----------------------------------------------------

| DISPLAY ‘Medical Assistance’ FOR ‘STATE NAME FOR |

| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS ONE OF THE FOLLOWING: |

| CONNECTICUT MARYLAND RHODE ISLAND |

| DISTRICT OF COLUMBIA MINNESOTA SOUTH DAKOTA |

| HAWAII PENNSYLVANIA |

| |

| DISPLAY ‘AZ Hlth Care Cost Containment System’ |

| FOR ‘STATE NAME FOR MEDICAID’ IF STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED IS ARIZONA. |

| |

| DISPLAY ‘Medi-Cal’ FOR ‘STATE NAME FOR MEDICAID’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| CALIFORNIA. |

| |

| DISPLAY ‘KYHealth Choices’ FOR ‘STATE NAME FOR |

| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS KENTUCKY. |

| |

| DISPLAY ‘MaineCare’ FOR ‘STATE NAME FOR MEDICAID’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| MAINE. |

| |

| DISPLAY ‘MassHealth’ FOR ‘STATE NAME FOR MEDICAID’|

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| MASSACHUSETTS. |

| |

| DISPLAY ‘MO HealthNet’ FOR ‘STATE NAME FOR |

| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS MISSOURI. |

| |

| DISPLAY ‘OR Health Plan’ FOR ‘STATE NAME FOR |

| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS OREGON. |

| |

| DISPLAY ‘SoonerCare’ FOR ‘STATE NAME FOR MEDICAID’|

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| OKLAHOMA. |

| |

| DISPLAY ‘TennCare’ FOR ‘STATE NAME FOR MEDICAID’ |

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS |

| TENNESSEE. |

| |

| DISPLAY ‘EqualityCare’ FOR ‘STATE NAME FOR |

| MEDICAID’ IF STATE IN WHICH INTERVIEW IS BEING |

| CONDUCTED IS WYOMING. |

----------------------------------------------------

| IF CODED ‘1’ (YES) AND SINGLE-PERSON RU, SELECT |

| PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO |

| LOOP_04 |

----------------------------------------------------

| IF CODED ‘1’ (YES) AND MULTI-PERSON RU, CONTINUE |

| WITH HX07 |

----------------------------------------------------

| IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T |

| KNOW) AND ONE OR MORE RU MEMBER = > 65 YEARS OLD, |

| GO TO LOOP_04 |

----------------------------------------------------

| IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T |

| KNOW) AND NO RU MEMBER = > 65 YEARS OLD, GO |

| TO BOX_12 |

----------------------------------------------------

HX07

====

{STR-DT}

{END-DT}

Who is covered by Medicare?

PROBE: Who else is covered by Medicare?

[1. First Name,[Middle Name],Last Name-65]

[2. First Name,[Middle Name],Last Name-65]

[3. First Name,[Middle Name],Last Name-65] {LOOP_04}

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_MEMBERS_SELECTONE |

| |

| COL # 1 HEADER: PERSON-TYPE-PROVIDER |

| INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER FOR |

| SELECTION OF RU MEMBERS. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT|

| ONE OR MORE FROM THE LISTED MEMBERS. |

| |

| 2. ADD, DELETE, AND EDIT DISALLOWED. |

----------------------------------------------------

| ROSTER FILTER: |

| IN ROUND 1, NONE. DISPLAY ALL. |

| IN ROUNDS 2-5, DISPLAY RU MEMBERS WHO MEET ONE OF |

| THE FOLLOWING CONDITIONS: |

| 1. PERSON IS A NEW RU MEMBER THIS ROUND, |

| |

| 2. PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT |

| FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND, |

| |

| 3. OR PERSON >= 65 YEARS OLD (OR IN AGE CATEGORY |

| 9) LAST ROUND AND NOT FLAGGED AS COVERED BY |

| MEDICARE DURING ANY ROUND. |

----------------------------------------------------

LOOP_04

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK |

| BOX_09-END_LP04 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_04 DETERMINES IF REASON FOR|

| MEDICARE IS CONDITION/DISABILITY FOR PERSONS < 65 |

| WHO RECEIVE MEDICARE AND COLLECTS SOCIAL SECURITY |

| STATUS FOR PERSONS = > 65 WHO ARE NOT COVERED BY |

| MEDICARE. THIS LOOP CYCLES ON PERSONS WHO MEET |

| ANY OF THE FOLLOWING CONDITIONS: |

| - IF ROUND 1: ALL CURRENT RU MEMBERS |

| - IF NOT ROUND 1: ALL CURRENT RU MEMBERS WHO |

| MEET ONE OF THE FOLLOWING CONDITIONS: |

| - PERSON IS A NEW RU MEMBER THIS ROUND, |

| OR |

| - PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT |

| FLAGGED AS COVERED BY MEDICARE DURING ANY |

| ROUND |

| OR |

| - PERSON => 65 YEARS OLD (OR IN AGE CATEGORY 9) |

| LAST ROUND AND NOT FLAGGED AS COVERED BY |

| MEDICARE DURING ANY ROUND. |

----------------------------------------------------

BOX_09

======

----------------------------------------------------

| IF ROUND 1, GO TO BOX_11 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_10 |

----------------------------------------------------

BOX_10

======

----------------------------------------------------

| IF PERSON ADDED THIS ROUND, CONTINUE WITH BOX_11 |

----------------------------------------------------

| IF HX05 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR |

| ‘-8’ (DON’T KNOW) AND RU MEMBER TURNED 65 THIS |

| ROUND, GO TO HX09 |

----------------------------------------------------

| OTHERWISE, GO TO END_LP04 |

----------------------------------------------------

| NOTE: HX09 IS NOT RE-ASKED OF PERSONS WHO WERE |

| OVER 65 DURING THE PREVIOUS ROUND AND DID NOT |

| RECEIVE MEDICARE AND WHO CONTINUE NOT RECEIVING |

| MEDICARE DURING THE CURRENT ROUND. |

----------------------------------------------------

BOX_11

======

----------------------------------------------------

| IF PERSON IS SELECTED AT HX07 AND IS < 65 YEARS |

| OLD (OR IN AGE CATEGORIES 1-8), CONTINUE WITH HX08|

----------------------------------------------------

| IF PERSON IS SELECTED AT HX07 AND IS = > 65 YEARS |

| OLD (OR IN AGE CATEGORY 9), GO TO END_LP04 |

----------------------------------------------------

| IF PERSON IS NOT SELECTED AT HX07 AND IS < 65 |

| YEARS OLD (OR IN AGE CATEGORIES 1-8), GO TO |

| END_LP04 |

----------------------------------------------------

| IF PERSON IS NOT SELECTED AT HX07 AND IS = > 65 |

| YEARS OLD (OR IN AGE CATEGORY 9), GO TO HX09 |

----------------------------------------------------

| IF HX07 IS NOT ASKED (I.E., HX05 OR HX06 IS CODED |

| ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW)) |

| AND PERSON IS < 65 YEARS OLD (OR IN AGE CATEGORIES|

| 1-8), GO TO END_LP04 |

----------------------------------------------------

| IF HX07 IS NOT ASKED (I.E., HX05 OR HX06 IS CODED |

| ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW)) |

| AND PERSON IS = > 65 YEARS OLD (OR IN AGE CATEGORY|

| 9), GO TO HX09 |

----------------------------------------------------

HX08

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

(Do/Does) (PERSON) receive Medicare because of a medical

condition or a disability?

YES .................................... 1 {END_LP04}

NO ..................................... 2 {END_LP04}

REF ................................... -7 {END_LP04}

DK .................................... -8 {END_LP04}

HELP AVAILABLE FOR DEFINITION OF CONDITION/DISABILITY.

HX09

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

People with Social Security usually get Medicare. (Do/Does)

(PERSON) receive Social Security?

YES .................................... 1 {END_LP04}

NO ..................................... 2 {END_LP04}

REF ................................... -7 {END_LP04}

DK .................................... -8 {END_LP04}

HELP AVAILABLE FOR DEFINITION OF SOCIAL SECURITY.

END_LP04

========

----------------------------------------------------

| CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER WHO |

| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|

----------------------------------------------------

| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |

| END LOOP_04 AND CONTINUE WITH BOX_12 |

----------------------------------------------------

BOX_12

======

----------------------------------------------------

| IF MEDICAID/SCHIP PROVIDED TO ANY RU MEMBER |

| DURING THE PREVIOUS ROUND, GO TO BOX_14 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_12A |

----------------------------------------------------

BOX_12A

=======

----------------------------------------------------

| IF GOVT-HOSPITAL/PHYSICIAN IS A SOURCE OF |

| INSURANCE FOR ANY RU MEMBER DURING THE CURRENT |

| ROUND, GO TO BOX_14 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH HX10 |

----------------------------------------------------

HX10

====

{STR-DT}

{END-DT}

{Some people are covered by programs called {Medicaid/{STATE

NAME FOR MEDICAID}} or {STATE CHIP NAME}. These are state

programs for low income families and individuals or children

who do not have private health insurance. They sometimes

cover persons with very large medical bills or those in

nursing homes.}

{SHOW CARD HX-3.}

{People covered by {Medicaid/{STATE NAME FOR MEDICAID}} or

{STATE CHIP NAME} usually have a (piece of paper/card) that

looks something like this.}

{During the last interview, we recorded that no one in the

family was covered by {Medicaid/{STATE NAME FOR MEDICAID}} or

{STATE CHIP NAME}.}

Has anyone in the family been covered by {Medicaid/{STATE NAME

FOR MEDICAID}} or {STATE CHIP NAME} at any time {since (START

DATE)/between (START DATE) and (END DATE)}?

YES .................................... 1

NO ..................................... 2 {BOX_14}

REF ................................... -7 {BOX_14}

DK .................................... -8 {BOX_14}

HELP AVAILABLE FOR DEFINITION OF MEDICAID/SCHIP.

----------------------------------------------------

| DISPLAY FIRST PARAGRAPH (‘Some .... homes.’) ONLY |

| IF ROUND 1. OTHERWISE, USE A NULL DISPLAY. |

----------------------------------------------------

| DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO |

| SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO|

| MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES |

| EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING |

| CONDUCTED IN TENNESSEE, USE A NULL DISPLAY. |

----------------------------------------------------

| DISPLAY THIRD PARAGRAPH (‘During... CHIP NAME}}.’)|

| ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL |

| DISPLAY. |

----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|

| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |

| STATE NAME FOR PROGRAM) IF THE STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|

| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |

| STATE, SEE BOX ON HX06. |

----------------------------------------------------

| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |

| SUBSTITUTING THE REAL NAME FOR PROGRAM. FOR THE |

| SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06. |

----------------------------------------------------

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

| IF CODED ‘1’ (YES) AND SINGLE-PERSON RU, SELECT |

| PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO |

| LOOP_05 |

----------------------------------------------------

| IF CODED ‘1’ (YES) AND MULTI-PERSON RU, CONTINUE |

| WITH HX11 |

----------------------------------------------------

HX11

====

{STR-DT}

{END-DT}

Who is covered by {Medicaid/{STATE NAME FOR MEDICAID}} or

{STATE CHIP NAME}?

PROBE: Who else is covered by {Medicaid/{STATE NAME FOR

MEDICAID}} or {STATE CHIP NAME}?

TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.

TO LEAVE, PRESS ESC.

[1. First Name,[Middle Name],Last Name-65]

[2. First Name,[Middle Name],Last Name-65]

[3. First Name,[Middle Name],Last Name-65]

-----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY |

| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |

| STATE NAME FOR PROGRAM) IF THE STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |

| STATE, SEE BOX ON HX06. |

-----------------------------------------------------

----------------------------------------------------

| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |

| SUBSTITUTING THE REAL NAME FOR PROGRAM. FOR THE |

| SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06. |

----------------------------------------------------

| GO TO LOOP_05 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_MEMBERS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR |

| SELECTION OF RU MEMBERS. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT|

| FROM THE LISTED MEMBERS. |

| |

| 2. ADD, DELETE, AND EDIT DISALLOLWED. |

----------------------------------------------------

| ROSTER FILTER: |

| NONE, DISPLAY ALL. |

----------------------------------------------------

LOOP_05

=======

-----------------------------------------------------

| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |

| PAIRS-ROSTER, ASK BOX_13 - END_LP05 |

-----------------------------------------------------

| LOOP DEFINITION: LOOP_05 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY MEDICAID/|

| SCHIP. THIS LOOP CYCLES ON ESTABLISHMENT-PERSON- |

| PAIRS THAT MEET THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS MEDICAID/SCHIP |

| AND |

| - PERSON IS FLAGGED AS COVERED BY MEDICAID/SCHIP |

| DURING THE CURRENT ROUND (I.E., SELECTED IN |

| HX11) |

-----------------------------------------------------

BOX_13

======

-----------------------------------------------------

| ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION |

| FOR THIS PERSON. |

-----------------------------------------------------

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP05 |

-----------------------------------------------------

END_LP05

========

----------------------------------------------------

| CYCLE ON NEXT PAIR ON THE RU-ESTABLISHMENT- |

| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |

| STATED IN THE LOOP DEFINITION. |

----------------------------------------------------

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_05 AND CONTINUE WITH BOX_14 |

----------------------------------------------------

BOX_14

======

----------------------------------------------------

| IF TRICARE/CHAMPVA PROVIDED TO ANY RU MEMBER |

| DURING THE PREVIOUS ROUND, GO TO BOX_16 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH HX12 |

----------------------------------------------------

HX12

====

{STR-DT}

{END-DT}

{During the last interview, we recorded that no one in the

family was covered by TRICARE or CHAMPVA.}

At any time {since (START DATE)/between (START DATE) and

(END DATE)}, has anyone in the family been covered by TRICARE

or CHAMPVA?

YES .................................... 1 {HX12A}

NO ..................................... 2 {BOX_16}

REF ................................... -7 {BOX_16}

DK .................................... -8 {BOX_16}

HELP AVAILABLE FOR DEFINITION OF TRICARE/CHAMPVA.

----------------------------------------------------

| DISPLAY FIRST PARAGRAPH (‘During .... TRICARE or |

| CHAMPVA.’) IF NOT ROUND 1. OTHERWISE, USE A |

| NULL DISPLAY. |

| |

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

HX12A

=====

{STR-DT}

{END-DT}

Which plan is it? Is it…

INTERVIEWER:

CODE MORE THAN ONE PLAN ONLY IF DIFFERENT RU MEMBERS

HAVE DIFFERENT PLANS.

CHECK ALL THAT APPLY.

TRICARE Standard; ...................... 1

TRICARE Prime; ......................... 2

TRICARE Extra; ......................... 3

TRICARE for Life; or ................... 4

CHAMPVA? ............................... 5

[Code All That Apply]

----------------------------------------------------

| IF HX12 IS CODED ‘1’ (YES) AND SINGLE-PERSON RU, |

| SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND |

| GO TO LOOP_06 |

----------------------------------------------------

| IF HX12 IS CODED ‘1’ (YES) AND MULTI-PERSON RU, |

| CONTINUE WITH HX13 |

----------------------------------------------------

HX13

====

{STR-DT}

{END-DT}

Who is covered by TRICARE or CHAMPVA?

PROBE: Who else is covered by TRICARE or CHAMPVA?

[1. First Name,[Middle Name],Last Name-65]

[2. First Name,[Middle Name],Last Name-65]

[3. First Name,[Middle Name],Last Name-65]

----------------------------------------------------

| GO TO LOOP_06 |

----------------------------------------------------

| ROSTER DETAILS: |

| Title: RU_MEMBERS_1 |

| |

| COL #1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR SELECTION|

| OF RU-MEMBERS. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT|

| FROM THE LISTED MEMBERS. |

| |

| 2. ADD, DELETE, AND EDIT DISALLOWED. |

----------------------------------------------------

| ROSTER FILTER: |

| NONE, DISPLAY ALL. |

----------------------------------------------------

LOOP_06

=======

----------------------------------------------------

| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |

| PAIRS-ROSTER, ASK BOX_15-END_LP06 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_06 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY TRICARE |

| OR CHAMPVA. THIS LOOP CYCLES ON ESTABLISHMENT- |

| PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS TRICARE/CHAMPVA |

| AND |

| - PERSON IS FLAGGED AS COVERED BY TRICARE/CHAMPVA|

| DURING THE CURRENT ROUND (I.E., SELECTED AT |

| HX13) |

----------------------------------------------------

BOX_15

======

----------------------------------------------------

| ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION |

| FOR THIS PERSON. |

----------------------------------------------------

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP06 |

----------------------------------------------------

END_LP06

========

----------------------------------------------------

| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT-PERSON- |

| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED |

| IN THE LOOP DEFINITION. |

----------------------------------------------------

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_06 AND CONTINUE WITH BOX_16 |

----------------------------------------------------

BOX_16

======

----------------------------------------------------

| IF MEDICAID/SCHIP IS A SOURCE OF INSURANCE FOR |

| ANY RU MEMBER DURING CURRENT ROUND, GO TO BOX_19 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_17 |

----------------------------------------------------

BOX_17

======

----------------------------------------------------

| IF GOVT-HOSPITAL/PHYSICIAN PROVIDED TO ANY RU |

| MEMBER DURING THE PREVIOUS ROUND, GO TO BOX_19 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH HX14 |

----------------------------------------------------

HX14

====

{STR-DT}

{END-DT}

{During the last interview, we recorded that no one in the

family was covered by any other state sponsored program which

provided hospital and physician benefits.}

At any time {since (START DATE)/between (START DATE) and

(END DATE)}, has anyone in the family had any other type of health

insurance obtained through any state or local government agency

which provided hospital and physician benefits?

YES .................................... 1 {HX14A}

NO ..................................... 2 {BOX_19}

REF ................................... -7 {BOX_19}

DK .................................... -8 {BOX_19}

HELP AVAILABLE FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.

----------------------------------------------------

| DISPLAY FIRST PARAGRAPH (‘During .... benefits.’) |

| IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

HX14A

=====

{STR-DT}

What is the name of the plan?

[Enter text] ...........................

----------------------------------------------------

| NOTE: ‘GOVT-HOSPITAL/PHYSICIAN’ SHOULD BE USED |

| FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER |

| (WHERE APPROPRIATE). |

----------------------------------------------------

| IF HX14 IS CODED ‘1’ (YES) AND SINGLE-PERSON RU, |

| SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND |

| GO TO LOOP_07 |

----------------------------------------------------

| IF HX14 IS CODED ‘1’ (YES) AND MULTI-PERSON RU, |

| CONTINUE WITH HX15 |

----------------------------------------------------

HX15

====

{STR-DT}

{END-DT}

Who is covered by a program sponsored by a state or local

government agency which provided hospital and physician

benefits?

PROBE: Who else is covered by a program sponsored by a state

or local government agency which provided hospital and

physician benefits?

[1. First Name,[Middle Name],Last Name-65]

[2. First Name,[Middle Name],Last Name-65]

[3. First Name,[Middle Name],Last Name-65]

----------------------------------------------------

| GO TO LOOP_07 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_MEMBERS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR |

| SELECTION OF RU MEMBERS. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT|

| FROM THE LISTED MEMBERS. |

| |

| 2. ADD, DELETE, AND EDIT DISALLOLWED. |

----------------------------------------------------

| ROSTER FILTER: |

| NONE, DISPLAY ALL. |

----------------------------------------------------

LOOP_07

=======

----------------------------------------------------

| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |

| PAIRS-ROSTER, ASK BOX_18-END_LP07 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_07 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY GOVT- |

| HOSPITAL/PHYSICIAN. THIS LOOP CYCLES ON |

| ESTABLISHMENT-PERSON-PAIRS THAT MEET THE |

| FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN |

| AND |

| - PERSON IS FLAGGED AS BEING COVERED BY GOVT- |

| HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND |

| (I.E., SELECTED AT HX15) |

----------------------------------------------------

BOX_18

======

----------------------------------------------------

| ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION |

| FOR THIS PERSON. |

----------------------------------------------------

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP07 |

----------------------------------------------------

END_LP07

========

----------------------------------------------------

| CYCLE ON NEXT PAIR ON THE RU-ESTABLISHMENT- |

| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |

| STATED IN THE LOOP DEFINITION. |

----------------------------------------------------

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_07 AND CONTINUE WITH BOX_19 |

----------------------------------------------------

BOX_19

======

----------------------------------------------------

| IF ANY TYPE OF OTHER PUBLIC INSURANCE PROVIDED TO |

| ANY RU MEMBER AT ANY TIME DURING THE PREVIOUS |

| ROUND, GO TO HX21 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH HX16 |

----------------------------------------------------

HX16

====

{STR-DT}

{END-DT}

{During the last interview, we recorded that no one in the

family/Some people} receive{d} health benefits from other state

programs such as (READ PROGRAM NAMES BELOW) or other public

programs that provide coverage for health care services.

{STATE NAME FOR PROGRAM #1..................}

{STATE NAME FOR PROGRAM #2..................}

{STATE NAME FOR PROGRAM #3..................}

{STATE NAME FOR PROGRAM #4..................}

At any time {since (START DATE)/between (START DATE) and (END

DATE)}, has anyone in the family been covered by any program like

this?

YES .................................... 1 {LOOP_08}

NO ..................................... 2 {HX21}

REF ................................... -7 {HX21}

DK .................................... -8 {HX21}

HELP AVAILABLE FOR A LIST OF OTHER STATE PROGRAMS.

----------------------------------------------------

| DISPLAY ‘During the last interview, we recorded |

| that no one in the family’ AND THE ‘d’ ON |

| ‘receive’ IF NOT ROUND 1. OTHERWISE, DISPLAY |

| ‘Some people’. |

| |

| DISPLAY THE LIST OF UP TO FOUR ACTUAL NAMES OF |

| STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR ‘STATE |

| NAME FOR PROGRAM #N’ IF STATE HAS OTHER STATE |

| PROGRAMS. OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

| STATE OTHER PUBLIC PROGRAM(S) |

| |

| ALASKA Chronic and Acute Medical |

| Assistance |

| AK AIDS Drug Assistance Program |

| AK Breast and Cervical Health Check|

| Senior Benefits Program |

| ALABAMA Senior Rx/Wellness |

| AL AIDS Drug Assistance Program |

| (ADAP) |

| Breast/Cervical Cancer Early Detect|

| Alabama Perinatal Hepatitis B Prog |

| ARIZONA CoppeRx Card |

| Non-Renal Transplant Medication |

| Prgm |

| AZ AIDS Drug Assistance Program |

| Well Woman HealthCheck Program |

| ARKANSAS Arkansas Kidney Disease Commission |

| AR AIDS Drug Assistance Program |

| Breast Care |

| AR Health Care Access Foundation |

| CALIFORNIA AIDS Drug Assistance Program |

| CA Discount Rx Drug Program |

| Breast/Cervical Cancer Early |

| Detect. |

| COLORADO Colorado Indigent Care Program |

| Women’s Wellness Connection |

| CO AIDS Drug Assistance Program |

| CONNECTICUT ConnPACE |

| CT AIDS Drug Assistance Program |

| Healthy Start |

| Breast/Cervical Cancer Early |

| Detect. |

| DELAWARE DE Prescription Assistance Program |

| DE AIDS Drug Assistance Program |

| Chronic Renal Disease Program |

| Breast and Cervical Cancer Program |

| DISTRICT OF |

| COLUMBIA DC AIDS Drug Assistance Program |

| Breast/Cervical Cancer Early |

| Detect. |

| FLORIDA AIDS Drug Assistance Program |

| Breast/Cervical Cancer Early |

| Detect. |

| Positive Healthcare |

| Florida Discount Drug Card Program |

| GEORGIA AIDS Drug Assistance Program |

| Breast/Cervical Cancer Early |

| Detect. |

----------------------------------------------------

| HAWAII AIDS Drug Assistance Program |

| Breast/Cervical Cancer Control Pgrm|

| Hawaii Rx Plus |

| IDAHO ID AIDS Drug Assistance Program |

| Family Support 360 Project |

| Women’s Health Check |

| Rx Idaho |

| ILLINOIS Chronic Renal Disease Program |

| Breast/Cervical Cancer Early |

| Detect. |

| IL AID Drug Assistance Program |

| Illinois Cares Rx |

| INDIANA Hoosier Rx |

| Children’s Special Hlth Care |

| Service |

| IN AIDS Drug Assistance Program |

| Breast/Cervical Cancer Early |

| Detect. |

| IOWA IA Priority Rx Savings Program |

| AIDS Drug Assistance Program |

| Care for Yourself BCCED Pgrm |

| KANSAS MediKan |

| KS AIDS Drug Assistance Program |

| Breast/Cervical Cancer Early |

| Detect. |

| KENTUCKY KY AIDS Drug Assistance Program |

| Health Kentucky |

| Kentucky Rx Drug Assistance Prgm |

| KY Women’s Cancer Screening |

| Program |

| LOUISIANA Breast/Cervical Cancer Early |

| Detect. |

| LA AIDS Drug Assistance Program |

| MAINE Maine AIDS Drug Assistance Program |

| Breast/Cervical Cancer Early |

| Detect. |

| Drugs for the Elderly |

| Medical Eye Care |

| MARYLAND Kidney Disease Program |

| MD AIDS Drug Assistance Program |

| Breast/Cervical Cancer Early |

| Detect. |

| Maryland Primary Adult Care Program|

| MASSACHUSETTS Prescription Advantage Plan |

| MA HIV Drug Assistance Program |

| Women’s Health Network |

| MICHIGAN MI AIDS Drug Assistance Program |

| Adult Medical Program |

| MI Rx Prescription Savings Program |

| Breast/Cervical Cancer Control |

| Prgm |

----------------------------------------------------

| MINNESOTA MN AIDS Drug Assistance Program |

| Sage Screening Program |

| MISSISSIPPI MS AIDS Drug Assistance Program |

| Breast/Cervical Cancer Early |

| Detect. |

| First Steps: Early Intervention |

| Program |

| MISSOURI MO AIDS Drug Assistance Program |

| Show Me Healthy Women |

| Extended Women’s Health |

| MoRx |

| MONTANA End-Stage Renal Disease Program |

| MT AIDS Drug Assistance Program |

| MT Breast and Cervical Health |

| Program |

| The Mental Health Services Plan |

| NEBRASKA Chronic Renal Disease Program |

| NE AIDS Drug Assistance Program |

| Every Woman Matters Program |

| NEW HAMPSHIRE Catastrophic Illness Program |

| Ryan White CARE Program |

| Breast/Cervical Cancer Early |

| Detect. |

| NEVADA Senior Rx Ins. Subsidy for Rx Drugs|

| NV AIDS Drug Assistance Program |

| Women’s Health Connection Program |

| Children w/Special Hlth Care Needs |

| NEW JERSEY Rx Assist. for the Aged and |

| Disabled |

| NJ AIDS Drug Distribution Program |

| End Stage Renal Disease Ptnt |

| Assist. |

| NJ Cancer Education/Early Detection|

| NEW MEXICO NM AIDS Drug Assistance Program |

| Family Infant Toddler Program |

| Breast/Cervical Cancer Early |

| Detect. |

| Discount Prescription Drug Program |

| NEW YORK Elderly Pharmaceutical Insure Prgm |

| APIC Primary Care |

| NY AIDS Drugs Assistance Program |

| Cancer Services Prgm Partnerships |

| NORTH |

| CAROLINA State Kidney Program |

| Breast/Cervical Cancer Control |

| Prgm |

| School Health Fund |

| Sickle Cell Syndrome Program |

----------------------------------------------------

| NORTH DAKOTA Women’s Way |

| ND AIDS Drug Assistance Program |

| Health Tracks |

| Children’s Special Health Services |

| OHIO OH Disability Assist Medical Prgm |

| Ohio HIV Drug Assistance Program |

| Ohio’s Best Rx Discount Card |

| Breast and Cervical Cancer Project |

| OKLAHOMA AIDS Drug Assistance Program |

| OK Prescription Drug Discount Prgm |

| Take Charge! |

| Oklahoma Family Planning Program |

| OREGON CAREAssit/AIDS Drug Assist Prgm |

| Senior Rx Drug Assist Prgm |

| OR Breast/Cervical Cancer Program |

| PENNSYLVANIA Special Pharmaceutical Benefits |

| Prgm |

| Pharma. Assist Contract for |

| Elderly |

| The Healthy Woman Program |

| Chronic Renal Disease Program |

| RHODE ISLAND General Public Assist Medical |

| Prgrm |

| RI Pharma. Assist to the Elderly |

| RI AIDS Drug Assistance Program |

| RI Women’s Cancer Screening Prgm |

| SOUTH |

| CAROLINA Best Chance Network |

| Gap Assist. Pharmacy Prog for |

| Seniors |

| Medically Indigent Assistance Prog.|

| Family Planning Program |

| SOUTH DAKOTA SD Chronic Renal Disease Program |

| All Women Count! Program |

| Rx Access |

| AIDS Drug Assistance Program |

| TENNESSEE Tennessee Renal Disease Program |

| Breast/Cervical Cancer Screen |

| Prgm |

| CoverRx |

| HIV Drug Assistance Program |

| TEXAS Division of Kidney HlthCare |

| Program |

| Texas HIV Medication Program |

| Breast and Cervical Cancer Services|

| Children w/Special Hlth Care Needs |

| UTAH Children w/Special Hlth Care Needs |

| Utah AIDS Drug Assistance Program |

| Utah Cancer Control Program |

| Primary Care Network of Utah |

----------------------------------------------------

| VIRGINIA VA AIDS Drug Assistance Program |

| Every Woman’s Life |

| Child Development Services Program |

| State/Local Hospitalization |

| Program |

| VERMONT Ladies First |

| VT End Stage Renal Disease Program |

| General Assistance Medical Services|

| Vpharm |

| WASHINGTON WA State Kidney Disease Program |

| WA HIV Drug Assistance Program |

| WA Breast/Cervical Cancer Hlth Prgm|

| General Assistance |

| WEST VIRGINIA WV AIDS Drug Assistance Program |

| Children w/Special Hlth Care Needs |

| WV Breast/Cervical Cancer Scrng |

| Pgrm |

| Right from the Start Project |

| WISCONSIN WI Sr. Care Rx Drug Assistance |

| Program |

| WI AIDS Drug Assistance Program |

| WI Chronic Renal Disease Program |

| Well-Woman Program |

| WYOMING Prescription Drug Assistance |

| Program |

| WY HIV/AIDS/Hepatitis Program |

| WY End Stage Renal Disease Program |

| Breast/Cervical Cancer Early |

| Detect. |

----------------------------------------------------

LOOP_08

=======

----------------------------------------------------

| For each of the following: |

| |

| GROUP 1 |

| GROUP 2 |

| |

| ask BOX_20-END_LP08 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_08 COLLECTS INFORMATION ON |

| OTHER STATE OR PUBLIC PROGRAMS. THE FIRST CYCLE |

| OF THIS LOOP COLLECTS GROUP 1 OTHER PUBLIC |

| INSURANCE PROGRAMS OR, IF NO GROUP 1, GROUP 2 |

| OTHER PUBLIC INSURANCE PROGRAMS. |

| |

| THIS LOOP CAN CYCLE A MAXIMUM OF TWICE. THE |

| SUBSEQUENT CYCLE OF THE LOOP IS DETERMINED BY THE |

| RESPONSE AT HX20. IF HX20 IS CODED ‘1’ (YES), |

| THE LOOP CYCLES AGAIN TO COLLECT GROUP 2 PUBLIC |

| INSURANCE INFORMATION. IF HX20 IS CODED ‘2’ (NO), |

| ‘-7’ (REFUSED), ‘-8’ (DON’T KNOW), OR IS NOT |

| ASKED, THE LOOP ENDS. |

----------------------------------------------------

BOX_20

======

----------------------------------------------------

| IF FIRST CYCLE OF LOOP_08, CONTINUE WITH HX17 |

----------------------------------------------------

| OTHERWISE (I.E., IF SECOND CYCLE OF LOOP_08), GO |

| TO HX18 |

----------------------------------------------------

HX17

====

{STR-DT}

{END-DT}

What is the name of the program?

PROBE: Any other state program?

NOTE: IF ONLY TANF, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA

IS MENTIONED, CODE 95.

{STATE SPECIFIC PLAN 1} ................ 1

{STATE SPECIFIC PLAN 2} ................ 2

{STATE SPECIFIC PLAN 3} ................ 3

{STATE SPECIFIC PLAN 4} ................ 4

OTHER ................................. 91 {HX17OV}

NONE OF THESE ......................... 95 {HX18}

REF ................................... -7 {BOX_21}

DK .................................... -8 {BOX_21}

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

[Code All That Apply]

----------------------------------------------------

| FOR ‘STATE SPECIFIC PLAN N’, DISPLAY AN ACTUAL |

| NAME OF A STATE PLAN WHEN INTERVIEW IS BEING |

| CONDUCTED IN A STATE THAT HAS OTHER STATE |

| PROGRAMS. FOR THE SPECIFIC NAMES OF PROGRAMS BY |

| STATE, SEE BOX ON HX16. |

----------------------------------------------------

| ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP|

| 1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED |

| ABOUT IN HX19. |

----------------------------------------------------

| CODES ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, AND ‘6’ ARE |

| RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE |

| HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER |

| CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC |

| PLANS, CODES WOULD START WITH ‘91’ AT HX17 OR ‘7’ |

| AT HX18.) |

----------------------------------------------------

| FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT |

| ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN |

| COMBINATION WITH ANY OTHER CODE. |

----------------------------------------------------

| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |

| WITH ANY OTHER CODE, CONTINUE WITH HX17OV |

----------------------------------------------------

| IF CODED ‘95’ (NONE OF THESE), GO TO HX18 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_21 |

----------------------------------------------------

| HARD CHECK: |

| EDIT: CODE ‘95’ (NONE OF THESE) CANNOT BE ENTERED|

| WITH ANY OTHER CODES. IF CODED ‘95’ (NONE OF |

| THESE) WITH ANY OTHER CODES, DISPLAY THE |

| FOLLOWING MESSAGE: “95 CANNOT BE CODED WITH ANY |

| OTHER RESPONSES. VERIFY AND RE-ENTER. CONTINUE.”|

----------------------------------------------------

HX17OV

======

OTHER:

[Enter Other Specify] .................. {BOX_21}

REF ................................... -7 {BOX_21}

DK .................................... -8 {BOX_21}

HX18

====

{STR-DT}

{END-DT}

What is the name of the program?

PROBE: Any other state program?

TANF (TEMPORARY ASSISTANCE FOR NEEDY

FAMILIES) .............................. 7

SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8

WIC (WOMEN, INFANTS AND CHILDREN) ...... 9

IHS (INDIAN HEALTH SERVICE) ........... 10

PUBLIC HEALTH CLINIC .................. 11

VA (VETERANS ADMINISTRATION) .......... 12

REF ................................... -7 {END_LP08}

DK .................................... -8 {END_LP08}

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

[Code All That Apply]

----------------------------------------------------

| ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A |

| GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN |

| ASKED ABOUT IN HX19 |

----------------------------------------------------

| IF: |

| NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- |

| HOSPITAL/PHYSICIAN DURING CURRENT ROUND |

| AND |

| HX18 IS CODED ‘7’ (TANF), ‘8’ (SSI), OR ‘9’ |

| (WIC), ALONE OR WITH ANY OTHER COMBINATION OF |

| CODES, CONTINUE WITH BOX_21 |

----------------------------------------------------

| OTHERWISE, GO TO END_LP08 |

----------------------------------------------------

BOX_21

======

----------------------------------------------------

| IF SINGLE-PERSON RU, SELECT PERSON AT HX19 |

| AUTOMATICALLY BY CAPI AND GO TO LOOP_09 |

----------------------------------------------------

| IF MULTI-PERSON RU, CONTINUE WITH HX19 |

----------------------------------------------------

HX19

====

{STR-DT}

{END-DT}

PROGRAM:

{STATE PROGRAM PROVIDING COVERAGE}

Who is covered by (READ PROGRAMS ABOVE)?

PROBE: Who else is covered by (READ PROGRAMS ABOVE)?

[1. First Name,[Middle Name],Last Name-65]

[2. First Name,[Middle Name],Last Name-65]

[3. First Name,[Middle Name],Last Name-65]

----------------------------------------------------

| IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED|

| AT HX17. IF COMING FROM HX18, DISPLAY ALL |

| PROGRAMS SELECTED AT HX18. |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_MEMBERS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR |

| SELECTION OF RU MEMBERS. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. INTERVIEWER MAY SELECT|

| FROM THE LISTED MEMBERS. |

| |

| 2. ADD, DELETE, AND EDIT DISALLOLWED. |

----------------------------------------------------

| ROSTER FILTER: |

| NONE, DISPLAY ALL. |

----------------------------------------------------

LOOP_09

=======

----------------------------------------------------

| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |

| PAIRS ROSTER, ASK BOX_22-END_LP09 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_09 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY OTHER |

| PUBLIC PROGRAMS. THIS LOOP CYCLES ON ESTABLISHMENT|

| -PERSON-PAIRS THAT MEET THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS GROUP 1 OR GROUP 2 OTHER |

| PUBLIC PROGRAM |

| AND |

| - PERSON IS FLAGGED AS BEING COVERED BY GROUP 1 |

| OR GROUP 2 OTHER PUBLIC PROGRAM DURING THE |

| CURRENT ROUND (I.E., SELECTED IN HX19) |

----------------------------------------------------

| IF FIRST TIME THROUGH LOOP_08 AND HX17 IS NOT |

| CODED ‘95’ (NONE OF THESE), THIS LOOP CYCLES ON A |

| ESTABLISHMENT-PERSON-PAIR WHERE ESTABLISHMENT IS A|

| GROUP 1 OTHER PUBLIC PROGRAM. |

----------------------------------------------------

| IF HX17 IS CODED ‘95’ (NONE OF THESE) OR IF SECOND|

| CYCLE OF LOOP_08, THEN THE ESTABLISHMENT IS A |

| GROUP 2 OTHER PUBLIC PROGRAM. |

----------------------------------------------------

BOX_22

======

----------------------------------------------------

| ASK THE TIME PERIOD COVERED DETAIL (HQ) SECTION |

| FOR THIS PERSON. |

----------------------------------------------------

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP09 |

----------------------------------------------------

END_LP09

========

----------------------------------------------------

| CYCLE ON NEXT PAIR ON RU-ESTABLISHMENT- |

| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |

| STATED IN THE LOOP DEFINITION. |

----------------------------------------------------

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_09 AND CONTINUE WITH BOX_23 |

----------------------------------------------------

BOX_23

======

----------------------------------------------------

| IF HX17 IS CODED ‘95’ (NONE OF THESE) OR IF ON |

| SECOND CYCLE OF LOOP_08, GO TO END_LP08 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH HX20 |

----------------------------------------------------

HX20

====

{STR-DT}

{END-DT}

Are there any other state programs that provide coverage for

health care services to anyone else in the family?

YES .................................... 1 {END_LP08}

NO ..................................... 2 {END_LP08}

REF ................................... -7 {END_LP08}

DK .................................... -8 {END_LP08}

END_LP08

========

----------------------------------------------------

| IF HX20 IS CODED ‘1’ (YES), CYCLE TO COLLECT GROUP|

| 2 PUBLIC INSURANCE INFORMATION. |

----------------------------------------------------

| IF HX20 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), ‘-8’ |

| (DON’T KNOW), OR IS NOT ASKED, END LOOP_08 AND |

| CONTINUE WITH HX21 |

----------------------------------------------------

HX21

====

{STR-DT}

{END-DT}

Next, I have some questions about other sources of health

insurance anyone in the family may have had {since (START

DATE)/between (START DATE) and (END DATE)} to help pay hospital

and doctor bills and other health expenses such as nursing home

care or prescribed medicines. {This includes Medigap or

Medicare Supplements, plans through a private insurance carrier,

which some people who are eligible for Medicare have as

additional coverage.}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

----------------------------------------------------

| DISPLAY ‘This includes...coverage.’ IF ANYONE IN |

| RU HAS MEDICARE AS A SOURCE OF INSURANCE DURING |

| THE CURRENT ROUND. |

| |

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

HX22

====

{STR-DT}

{END-DT}

SHOW CARD HX-4.

Please look at this card. It lists various ways people can

obtain health insurance.

{Not counting insurance you already told me about, at/At} any

time {since (START DATE)/between (START DATE) and (END DATE)},

was anyone in the family covered by health insurance from any

{other} source, such as those listed on the card?

YES .................................... 1 {LOOP_10}

NO ..................................... 2 {BOX_25}

REF ................................... -7 {BOX_25}

DK .................................... -8 {BOX_25}

HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.

----------------------------------------------------

| DISPLAY ‘Not counting insurance you already told |

| me about, at’ AND ‘other’ IF ANY SOURCES OF |

| INSURANCE ARE RECORDED FOR THIS RU. |

| |

| IF NO SOURCES OF INSURANCE ARE RECORDED FOR THIS |

| RU, DISPLAY ‘At’. |

| |

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

LOOP_10

=======

----------------------------------------------------

| For each of the following: |

| |

| PRIVATELY PURCHASED INSURANCE CATEGORY 1 |

| PRIVATELY PURCHASED INSURANCE CATEGORY 2 |

| PRIVATELY PURCHASED INSURANCE CATEGORY 3 |

| PRIVATELY PURCHASED INSURANCE CATEGORY 4 |

| PRIVATELY PURCHASED INSURANCE CATEGORY 5 |

| PRIVATELY PURCHASED INSURANCE CATEGORY 6 |

| |

| ask HX23 - END_LP10 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_10 COLLECTS INFORMATION |

| ABOUT PRIVATELY PURCHASED HEALTH INSURANCE |

| OBTAINED FROM SOURCES OTHER THAN EMPLOYERS |

| MENTIONED IN THE EMPLOYMENT SECTION OF THE |

| INTERVIEW. THIS LOOP CYCLES ON SOURCES OF |

| PRIVATELY PURCHASED INSURANCE LISTED AT HX23. THE |

| first cycle of this loop collects the first source|

| OF privately purchased insurance. Subsequent |

| cycles of the loop are determined by tHE RESPONSE |

| at HX24. If HX24 is coded ‘1’ (YES), the loop |

| cycles again to collect the next source of |

| privately purchased insurance. if hx24 is coded |

| ‘2’ (no), ‘-7’ (refused), or ‘-8’ (don’t know), |

| the loop ends. |

----------------------------------------------------

HX23

====

{STR-DT}

{END-DT}

SHOW CARD HX-4.

From which of the sources on this card did anyone in the family

purchase health insurance?

FROM A GROUP OR ASSOCIATION .............. 1 {BOX_24}

DIRECTLY THROUGH A SCHOOL ................ 3 {BOX_24}

DIRECTLY FROM AN INSURANCE AGENT ......... 4 {BOX_24}

DIRECTLY FROM INSURANCE COMPANY .......... 5 {BOX_24}

DIRECTLY FROM AN HMO ..................... 6 {BOX_24}

FROM A UNION ............................. 7 {BOX_24}

FROM ANYONE’S PREVIOUS EMPLOYER (COBRA) .. 8 {BOX_24}

FROM ANYONE’S PREVIOUS EMPLOYER

(NOT COBRA) ............................ 9 {BOX_24}

FROM SPOUSE’S/DECEASED SPOUSE’S PREVIOUS

EMPLOYER .............................. 10 {BOX_24}

FROM SOME OTHER EMPLOYER ................ 11 {BOX_24}

UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 {BOX_24}

OTHER SOURCE ............................ 91 {HX23OV}

REF ..................................... -7 {BOX_24}

DK ...................................... -8 {BOX_24}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

----------------------------------------------------

| STARTING IN PANEL 12 ROUND 2, CATEGORY ‘2’ (FROM |

| A HEALTH INSURANCE PURCHASING ALLIANCE) WAS |

| OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS. |

----------------------------------------------------

| DISPLAY AN ‘ADD OTHER SOURCE’ BUTTON ON THIS |

| SCREEN. |

----------------------------------------------------

| IF ‘ADD OTHER SOURCE’ IS SELECTED, PRESENT ‘ADD |

| OTHER SOURCE’ POP-UP (HX23OV) AND THEN GO TO |

| BOX_24. |

----------------------------------------------------

HX23OV

======

ENTER OTHER:

[Enter Other Specify] ..................

REF .................................... -7

DK ..................................... -8

BOX_24

======

----------------------------------------------------

| ask private HEALTH INSURANCE detail (HP) SECTION |

| for the response category selected at hx23 AND |

| FLAGGED THIS ROUND AS PROVIDING HEALTH INSURANCE. |

----------------------------------------------------

| at COMPLETION of THE hp SECTION, continue with |

| hx24 |

----------------------------------------------------

HX24

====

{STR-DT}

{END-DT}

SHOW CARD HX-4.

Aside from what you already told me about, at any time {since

(START DATE)/between (START DATE) and (END DATE)}, was anyone in

the family covered by health insurance from any other source

listed on this card?

PROBE: Please include any type of health insurance anyone in

the family is covered by which has not been discussed yet. This

includes health insurance that was obtained from a source not

listed on this card.

YES .................................... 1 {END_LP10}

NO ..................................... 2 {END_LP10}

REF ................................... -7 {END_LP10}

DK .................................... -8 {END_LP10}

HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.

----------------------------------------------------

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

----------------------------------------------------

END_LP10

========

----------------------------------------------------

| If HX24 is coded ‘1’ (YES), cycle to collect the |

| next insurance category. |

----------------------------------------------------

| Otherwise end LOOP_10, and continue with BOX_25 |

----------------------------------------------------

BOX_25

======

----------------------------------------------------

| IF NO PUBLIC OR PRIVATE INSURANCE RECORDED FOR ANY|

| CURRENT RU MEMBER, GO TO BOX_45 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_26 |

----------------------------------------------------

BOX_26

======

----------------------------------------------------

| IF ANY RU MEMBER HAS MEDICARE AS A SOURCE OF |

| INSURANCE DURING THE CURRENT ROUND, CONTINUE WITH |

| BOX_27 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_29 |

----------------------------------------------------

BOX_27

======

----------------------------------------------------

| IF ROUND 1, GO TO LOOP_11 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_28 |

----------------------------------------------------

BOX_28

======

----------------------------------------------------

| IF NOT ROUND 1, CONTINUE WITH LOOP_11 ONLY FOR RU |

| MEMBERS WHERE MEDICARE WAS RECORDED AS BEING |

| RECEIVED THIS ROUND. THAT IS, CONTINUE WITH |

| LOOP_11 ONLY IF THERE IS AT LEAST ONE |

| ESTABLISHMENT-PERSON-PAIR WHERE THE ESTABLISHMENT |

| IS MEDICARE AND THE PAIR WAS CREATED THIS ROUND. |

----------------------------------------------------

| OTHERWISE, GO TO BOX_29 |

----------------------------------------------------

LOOP_11

=======

----------------------------------------------------

| FOR EACH ELEMENT IN THE RU-ESTABLISHMENT-PERSON- |

| PAIRS-ROSTER, ASK HX25-END_LP11 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_11 COLLECTS MEDICARE CARD |

| AND MANAGED CARE INFORMATION FOR RU MEMBERS |

| COVERED BY MEDICARE. THIS LOOP CYCLES ON |

| ESTABLISHMENT-PERSON-PAIRS THAT MEET THE FOLLOWING|

| CONDITIONS: |

| IF ROUND 1: |

| - ESTABLISHMENT IS MEDICARE |

| AND |

| - PERSON IS AN RU MEMBER FLAGGED AS COVERED BY |

| MEDICARE DURING THE ROUND |

| IF NOT ROUND 1: |

| - ESTABLISHMENT IS MEDICARE |

| AND |

| - PERSON IS AN RU MEMBER |

| AND |

| - ESTABLISHMENT-PERSON-PAIR WAS CREATED THIS ROUND|

----------------------------------------------------

HX25

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

CODE WITHOUT ASKING IF ANSWER IS KNOWN.

May I please see (PERSON)’s Medicare card?

IF NECESSARY, SAY: We do not need (PERSON)’s Medicare number, but

would like to record the exact date (PERSON)’s Medicare coverage

became effective and what type of coverage (PERSON) has through

Medicare.

CARD AVAILABLE ......................... 1 {HX26}

CARD NOT AVAILABLE ..................... 2 {HX29}

REF ................................... -7 {HX29}

DK .................................... -8 {HX29}

[Code One]

----------------------------------------------------

| STARTING IN PANEL 13 ROUND 1/PANEL 12 ROUND 3, |

| CAPI NO LONGER COLLECTS MEDICARE NUMBERS (SSN). |

----------------------------------------------------

HX26

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

INTERVIEWER:

CODE MEDICARE CARD(S) SHOWN/AVAILABLE.

MEDICARE CARD (RED, WHITE AND BLUE) .... 1 {HX27}

RAILROAD RETIREMENT BOARD CARD (RED,

WHITE AND BLUE) ........................ 2 {HX27}

SOME OTHER CARD ........................ 3 {HX28}

[Code All That Apply]

----------------------------------------------------

| NOTE: INTERVIEWERS WILL BE TRAINED TO CODE ANY |

| TYPE OF MANAGED CARE CARD COLLECTED HERE AS SOME |

| OTHER CARD. THE NAME OF THE MANAGED CARE |

| ORGANIZATION WILL BE COLLECTED AT HX28. |

----------------------------------------------------

| IF CODED ‘1’ (MEDICARE CARD) OR ‘2’ (RAILROAD |

| RETIREMENT BOARD CARD), CONTINUE WITH HX27 |

----------------------------------------------------

| IF CODED ‘3’ (SOME OTHER CARD) ONLY, GO TO HX28 |

----------------------------------------------------

HX27

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

INTERVIEWER:

RECORD THE FOLLOWING INFORMATION FROM THE CARD:

EFFECTIVE DATE:

[Enter Month,Day,Year-4]

TYPE OF COVERAGE (IS ENTITLED TO):

HOSPITAL ONLY .......................... 1

MEDICAL AND HOSPITAL ................... 2

MEDICAL ONLY ........................... 3

[Code One]

----------------------------------------------------

| STARTING IN PANEL 13, ROUND 1/PANEL 12, ROUND 3, |

| CAPI NO LONGER COLLECTS MEDICARE NUMBERS (SSN). |

----------------------------------------------------

| IF HX26 IS CODED ‘3’ (SOME OTHER CARD), CONTINUE |

| WITH HX28 |

----------------------------------------------------

| OTHERWISE, GO TO HX30A |

----------------------------------------------------

| HARD CHECK: |

| CHECK EFFECTIVE DATE. DATE MUST BE ON OR BEFORE |

| (I.E., < OR =) THE INTERVIEW DATE. IF EFFECTIVE |

| DATE IS ON OR BEFORE JANUARY 1, {YEAR}, WHERE |

| ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL, |

| FLAG RU MEMBER AS ‘WITH HEALTH INSURANCE COVERAGE |

| ON JAN 1, {YEAR}’. |

----------------------------------------------------

| SOFT RANGE CHECK: MEDICARE EFFECTIVE DATE MUST |

| BE = OR > BIRTH DATE OF PERSON. |

----------------------------------------------------

HX28

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

INTERVIEWER:

RECORD THE INFORMATION FROM THE {OTHER} CARD:

[Enter Text]

----------------------------------------------------

| DISPLAY ‘OTHER’ IF HX26 IS CODED ‘1’ (MEDICARE |

| CARD) OR ‘2’ (RAILROAD RETIREMENT BOARD CARD). |

----------------------------------------------------

| IF HX26 IS CODED ‘3’ (SOME OTHER CARD) ONLY, |

| CONTINUE WITH HX29 |

----------------------------------------------------

| IF HX26 IS CODED ‘1’ (MEDICARE CARD) OR ‘2’ |

| (RAILROAD RETIREMENT BOARD CARD) (IN ADDITION TO |

| ‘3’ (SOME OTHER CARD)), GO TO HX30A |

----------------------------------------------------

HX29

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

When did (PERSON)’s Medicare coverage start?

[Enter Month,Year-4] .................. {HX30}

REF ................................... -7 {HX29OV}

DK .................................... -8 {HX29OV}

----------------------------------------------------

| IF EFFECTIVE DATE IS: |

| - A VALID DATE (I.E., NOT ‘RF’ (REFUSED) OR ‘DK’ |

| (DON’T KNOW) IN THE MONTH OR YEAR FIELDS |

| AND |

| - ON OR BEFORE JANUARY 1, {YEAR}, WHERE ‘YEAR’ IS |

| THE FIRST CALENDAR YEAR OF THE PANEL, |

| THEN FLAG RU MEMBER AS ‘WITH HEALTH INSURANCE |

| COVERAGE ON JAN 1, {YEAR}. |

----------------------------------------------------

| HARD CHECK: |

| DATE MUST BE ON OR BEFORE (I.E., < OR =) INTERVIEW|

| DATE OR 12/31/{YEAR}, WHERE YEAR IS THE FIRST |

| CALENDAR YEAR OF THE PANEL, IF ROUND 5. ‘-7’ |

| (REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED ON THE|

| MONTH AND YEAR FIELDS. |

| |

| MEDICARE EFFECTIVE DATE MUST BE = OR > BIRTH DATE |

| OF PERSON. |

----------------------------------------------------

HX29OV

======

Did (PERSON) have Medicare coverage on January 1, {YEAR}?

YES ................................... 1 {HX30}

NO .................................... 2 {HX30}

REF ................................... -7 {HX30}

DK .................................... -8 {HX30}

----------------------------------------------------

| IF HX29OV CODED ‘1’ (YES), FLAG PERSON AS ‘WITH |

| HEALTH INSURANCE COVERAGE ON JAN 1, {YEAR}, WHERE |

| ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL. |

----------------------------------------------------

HX29OV2

=======

OMITTED.

HX30

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD HX-2.

(Do/Does) (PERSON) have a Medicare card that looks like this?

YES .................................... 1 {HX30A}

NO ..................................... 2 {HX30A}

REF ................................... -7 {HX30A}

DK .................................... -8 {HX30A}

HX30A

=====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

{At any time since (START DATE)/{Between (START DATE) and

(END DATE)}, {(have/has)/(were/was)} (PERSON) {been} covered

by the new Medicare prescribed drug coverage (also called

Part D)?

YES .................................... 1 {BOX_28A}

NO ..................................... 2 {BOX_28A}

REF ................................... -7 {BOX_28A}

DK .................................... -8 {BOX_28A}

HELP AVAILABLE FOR DEFINITION OF MEDICARE PART D.

----------------------------------------------------

| DISPLAY ‘At any time since (START DATE)’ AND |

| ‘(have/has)’ IF NOT ROUND 5. DISPLAY ‘Between |

| (START DATE) and (END DATE)’ AND ‘(were/was)’ |

| IF ROUND 5. |

| |

| DISPLAY ‘been’ IF NOT ROUND 5. OTHERWISE, USE A |

| NULL DISPLAY. |

----------------------------------------------------

BOX_28A

=======

----------------------------------------------------

| NOTE: CURRENTLY ALL STATES OFFER MEDICARE |

| MANAGED CARE PLANS. |

----------------------------------------------------

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |

| DOES NOT OFFER A MEDICARE MANAGED CARE PLAN, CODE |

| HX31 AND HX32 ‘2’ (NO) AUTOMATICALLY BY CAPI AND |

| GO TO END_LP11. |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH HX31 |

----------------------------------------------------

HX31

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

SHOW CARD HX-5.

As you may know, Medicare allows beneficiaries in certain parts

of the country to enroll in managed care plans, such as HMOs

(Health Maintenance Organizations) or PPOs (Preferred Provider

Organizations) to receive their Medicare-funded health care.

These plans have names like those listed on this card.

Is the name of (PERSON)’s insurance through Medicare{, between

(START DATE) and (END DATE),} listed on this card?

YES .................................... 1 {HX31OV}

NO ..................................... 2 {HX32}

REF ................................... -7 {HX32}

DK .................................... -8 {HX32}

HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED CARE.

----------------------------------------------------

| DISPLAY ‘, between (START DATE) and (END DATE),’ |

| IF ROUND 5. OTHERWISE, USE A NULL DISPLAY. |

----------------------------------------------------

HX31OV

======

Which insurance plan is (PERSON)’s Medicare managed care plan?

CODE LETTER OF PLAN FROM SHOW CARD:

[Enter Plan Letter From Card] .........

----------------------------------------------------

| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |

| THE FOLLOWING MESSAGE: “PLEASE VERIFY PLAN |

| SELECTED: {DISPLAY PLAN NAME SELECTED}.” WHEN |

| INTERVIEWER PRESSES ENTER TO CLEAR THE MESSAGE, |

| PROCEED TO THE NEXT LOGICAL SCREEN. |

| |

| FOR ‘DISPLAY PLAN NAME SELECTED’, DISPLAY THE |

| ACTUAL PLAN NAME THAT CORRESPONDS TO THE LETTER |

| ENTERED FOR THIS STATE. |

----------------------------------------------------

| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |

| MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON- |

| PAIR. |

----------------------------------------------------

| IF ROUND 1, GO TO HX34 |

----------------------------------------------------

| OTHERWISE, GO TO END_LP11 |

----------------------------------------------------

HX32

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

Even though (PERSON)’s Medicare plan was not listed on the card,

{(is/are) (PERSON) currently/between (START DATE) and (END DATE),

(were/was) (PERSON)} enrolled in a Medicare managed care plan such

as an HMO (Health Maintenance Organization) or PPO (Preferred

Provider Organization)? When answering this question, please

include only insurance from Medicare, not any privately purchased

insurance.

YES .................................... 1 {HX33}

NO ..................................... 2 {END_LP11}

REF ................................... -7 {END_LP11}

DK .................................... -8 {END_LP11}

HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED CARE.

----------------------------------------------------

| DISPLAY ‘(is/are) (PERSON) currently’ IF NOT ROUND|

| 5. DISPLAY ‘between (START DATE) and (END DATE), |

| (were/was) (PERSON)’ IF ROUND 5. |

----------------------------------------------------

HX32A

=====

OMITTED.

HX33

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

What is the name of the (PERSON)’s Medicare managed care plan?

[Enter Plan Name] .....................

REF ................................... -7

DK .................................... -8

----------------------------------------------------

| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |

| MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON- |

| PAIR. |

----------------------------------------------------

| IF ROUND 1, CONTINUE WITH HX34 |

----------------------------------------------------

| OTHERWISE, GO TO END_LP11 |

----------------------------------------------------

HX34

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

PLAN NAME: {{PLAN NAME ENTERED AT HX31OV}/{NAME OF PLAN FROM HX33}}

Medicare beneficiaries pay their Part B premiums through their

Social Security checks. In addition, (do/does) (PERSON) (or

anyone in the family) pay anything directly to (PLAN NAME) for

this coverage?

[Do not include the cost of any copayments, coinsurance or

deductibles anyone in the family may have had to pay.]

YES .................................... 1 {HX35}

NO ..................................... 2 {END_LP11}

REF ................................... -7 {END_LP11}

DK .................................... -8 {END_LP11}

[Code One]

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

----------------------------------------------------

| DISPLAY ‘{PLAN NAME ENTERED AT HX31OV}’ IF A PLAN |

| LETTER WAS ENTERED AT HX31OV. DISPLAY THE ACTUAL |

| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |

| AT HX31OV FOR THIS STATE. |

| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR |

| ‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS |

| ENTERED. |

----------------------------------------------------

HX35

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

PLAN NAME: {{PLAN NAME ENTERED AT HX31OV}/{NAME OF PLAN FROM HX33}}

How much (do/does) (PERSON) pay for the (PLAN NAME) coverage?

[Enter Amount in Dollars] .............. {HX35OV1}

REF ................................... -7 {END_LP11}

DK .................................... -8 {END_LP11}

----------------------------------------------------

| DISPLAY ‘{PLAN NAME ENTERED AT HX31OV}’ IF A PLAN |

| LETTER WAS ENTERED AT HX31OV. DISPLAY THE ACTUAL |

| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |

| AT HX31OV FOR THIS STATE. |

| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX33 FOR |

| ‘NAME OF PLAN FROM HX33’ IF A PLAN NAME WAS |

| ENTERED. |

----------------------------------------------------

HX35OV1

=======

Is that per year, per month, per week, or what?

ENTER UNIT OF COVERAGE:

PER YEAR ............................... 1 {END_LP11}

QUARTERLY/EVERY 3 MONTHS ............... 2 {END_LP11}

BIMONTHLY/EVERY 2 MONTHS ............... 3 {END_LP11}

PER MONTH .............................. 4 {END_LP11}

PER WEEK ............................... 5 {END_LP11}

BIWEEKLY/EVERY 2 WEEKS ................. 6 {END_LP11}

SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {END_LP11}

SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {END_LP11}

OTHER ................................. 91 {HX35OV2}

REF ................................... -7 {END_LP11}

DK .................................... -8 {END_LP11}

[Code One]

HX35OV2

=======

OTHER:

[Enter Other Specify] .................. {END_LP11}

REF ................................... -7 {END_LP11}

DK .................................... -8 {END_LP11}

END_LP11

========

----------------------------------------------------

| CYCLE ON NEXT PAIR ON ru-establishment-person- |

| pairs-roster that meets the conditions stated in |

| the loop definition. |

----------------------------------------------------

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_11 AND CONTINUE WITH BOX_29 |

----------------------------------------------------

BOX_29

======

----------------------------------------------------

| IF ANY RU MEMBER HAS MEDICAID/SCHIP OR GOVT- |

| HOSPITAL/PHYSICIAN AS A SOURCE OF INSURANCE |

| DURING THE CURRENT ROUND, CONTINUE WITH BOX_30 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_31C |

----------------------------------------------------

BOX_30

======

----------------------------------------------------

| IF NO ONE IN THE RU WAS COVERED BY MEDICAID/SCHIP |

| OR GOVT-HOSPITAL/PHYSICIAN DURING THE PREVIOUS |

| ROUND AND AT LEAST ONE RU MEMBER IS COVERED BY |

| MEDICAID/SCHIP DURING THE CURRENT ROUND |

| OR |

| IF NO ONE IN THE RU WAS COVERED BY MEDICAID/SCHIP |

| OR GOVT-HOSPITAL/PHYSICIAN DURING THE PREVIOUS |

| ROUND AND AT LEAST ONE RU MEMBER IS COVERED BY |

| GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND, |

| GO TO BOX_31AA |

----------------------------------------------------

| OTHERWISE, GO TO BOX_31C |

----------------------------------------------------

| NOTE: SINCE AN RU CANNOT HAVE BOTH MEDICAID/SCHIP|

| AND GOVT-HOSPITAL/PHYSICIAN, HX41-HX47OV WILL BE |

| ASKED ONLY ONCE; EITHER FOR A ‘YES’ TO HX10 |

| (MEDICAID/SCHIP) OR A ‘YES’ TO HX14 (GOVT- |

| HOSPITAL/PHYSICIAN). |

----------------------------------------------------

HX36

====

OMITTED.

BOX_31

======

OMITTED.

HX37

====

OMITTED.

HX38

====

OMITTED.

HX38OV1

=======

OMITTED.

HX38OV2

=======

OMITTED.

HX39

====

OMITTED.

HX40

====

OMITTED.

BOX_31AA

========

----------------------------------------------------

| NOTE: STATES THAT DO NOT OFFER MEDICAID MANAGED |

| CARE PLANS INCLUDE THE FOLLOWING: |

| ALASKA MISSISSIPPI |

| WYOMING |

| |

| ARKANSAS AND NEW HAMPSHIRE WERE REMOVED FROM THIS |

| LIST STARTING IN PANEL 12 ROUND 3. |

----------------------------------------------------

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |

| DOES NOT OFFER A MEDICAID MANAGED CARE PLAN, CODE |

| HX41 ‘2’ (NO) AUTOMATICALLY BY CAPI AND GO TO HX42|

----------------------------------------------------

| OTHERWISE, CONTINUE WITH HX41 |

----------------------------------------------------

HX41

====

{STR-DT}

{END-DT}

{Some people on {Medicaid/{STATE NAME FOR MEDICAID}} or {STATE

CHIP NAME} can enroll in plans called HMOs. These plans have

names like those listed on this card.}

SHOW CARD HX-6.

Is the name of the health insurance through {{Medicaid/{STATE

NAME FOR MEDICAID}} or {STATE CHIP NAME}/the program sponsored

by a state or local government agency which provides hospital

and physician benefits}{, between (START DATE) and (END DATE),}

listed on this card?

YES .................................... 1 {HX41OV}

NO ..................................... 2 {HX42}

REF ................................... -7 {HX42}

DK .................................... -8 {HX42}

----------------------------------------------------

| DISPLAY ‘Some people on...on this card.’ IF |

| ASKING ABOUT MEDICAID/SCHIP. OTHERWISE, USE A |

| NULL DISPLAY. |

----------------------------------------------------

| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or |

| {STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/ |

| SCHIP. DISPLAY ‘the program....benefits’ IF |

| ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN. |

----------------------------------------------------

| DISPLAY ‘, between (START DATE) and (END DATE),’ |

| IF ROUND 5. OTHERWISE, USE A NULL DISPLAY. |

----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|

| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |

| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|

| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |

| STATE, SEE BOX ON HX06. |

----------------------------------------------------

| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |

| (SUSTITUTING THE REAL STATE NAME FOR PROGRAM). |

| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |

| ON HX06. |

----------------------------------------------------

HX41OV

======

Which plan is the health insurance through {{Medicaid/{STATE NAME

FOR MEDICAID}} or {STATE CHIP NAME}/that program)}?

LETTER OF PLAN FROM SHOW CARD:

[Enter Plan Letter From Card] .........

----------------------------------------------------

| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}}’ |

| IF ASKING ABOUT MEDICAID/SCHIP. |

| DISPLAY ‘that program’ IF ASKING ABOUT GOVT- |

| HOSPITAL/PHYSICIAN. |

----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|

| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |

| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|

| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |

| STATE, SEE BOX ON HX06. |

----------------------------------------------------

| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |

| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |

| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |

| ON HX06. |

----------------------------------------------------

| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |

| THE FOLLOWING MESSAGE: “PLEASE VERIFY PLAN |

| SELECTED: {DISPLAY PLAN NAME SELECTED}.” WHEN |

| INTERVIEWER PRESSES ENTER TO CLEAR THE MESSAGE, |

| PROCEED TO THE NEXT LOGICAL SCREEN. |

| |

| FOR ‘DISPLAY PLAN NAME SELECTED’, DISPLAY THE |

| ACTUAL PLAN NAME THAT CORRESPONDS TO THE LETTER |

| ENTERED FOR THIS STATE. |

----------------------------------------------------

| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |

| INSURER FOR MEDICAID/SCHIP OR GOVT-HOSPITAL/ |

| PHYSICIAN’. |

----------------------------------------------------

| IF ASKING ABOUT MEDICAID/SCHIP, CONTINUE WITH |

| BOX _31B |

----------------------------------------------------

| OTHERWISE, GO TO HX45 |

----------------------------------------------------

HX42

====

{STR-DT}

{END-DT}

Under {{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP NAME}/

the program sponsored by a state or local government agency which

provides hospital and physician benefits} {(are/is)/(were/was)}

(READ NAME(S) FROM BELOW) signed up with an HMO, that is a Health

Maintenance Organization {between (START DATE) and (END DATE)}?

[With an HMO, you must generally receive care from HMO

physicians. If another doctor is seen, the expense is not

covered unless you were referred by the HMO, or there was a

medical emergency.]

[1. First Name,[Middle Name],Last Name-65]

[2. First Name,[Middle Name],Last Name-65]

[3. First Name,[Middle Name],Last Name-65]

YES, ALL ARE ........................... 1 {HX44}

YES, SOME ARE .......................... 2 {HX44}

NO, NONE ARE ........................... 3 {HX43}

REF ................................... -7 {HX43}

DK .................................... -8 {HX43}

[Code One]

HELP AVAILABLE FOR DEFINITION OF HMO.

----------------------------------------------------

| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or |

| {STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/ |

| SCHIP. DISPLAY ‘the program....benefits’ IF |

| ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN. |

----------------------------------------------------

| DISPLAY ‘(are/is)’ IF NOT ROUND 5. DISPLAY |

| ‘(were/was)’ IF ROUND 5. |

----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|

| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |

| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|

| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |

| STATE, SEE BOX ON HX06. |

----------------------------------------------------

| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |

| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |

| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON |

| HX06. |

----------------------------------------------------

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. OTHERWISE, USE A NULL DISPLAY. |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR SELECTION OF RU MEMBERS. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. SELECT, ADD, DELETE, AND EDIT DISALLOWED. |

----------------------------------------------------

| ROSTER FILTER: |

| 1. ESTABLISHMENT IS MEDICAID/SCHIP OR GOVT- |

| HOSPITAL/PHYSICIAN, |

| AND |

| 2. PERSON IS AN RU MBMBER FLAGGED AS COVERED BY |

| MEDICAID/SCHIP OR GOVT-HOSPITAL/PHYSICIAN DURING |

| THE CURRENT ROUND. |

----------------------------------------------------

HX43

====

{STR-DT}

{END-DT}

{Does/Between (START DATE) and (END DATE), did} {{Medicaid/{STATE

NAME FOR MEDICAID}} or {STATE CHIP NAME}/the program sponsored by

a state or local government agency which provides hospital and

physician benefits} require (READ NAME(S) BELOW) to sign up with

a certain primary care doctor, group of doctors, or with a certain

clinic which they must go to for all of their routine care?

PROBE: Do not include emergency care or care from a specialist

they were referred to.

[1. First Name,[Middle Name],Last Name-65]

[2. First Name,[Middle Name],Last Name-65]

[3. First Name,[Middle Name],Last Name-65]

YES, ALL REQUIRED ...................... 1 {HX44}

YES, SOME REQUIRED ..................... 2 {HX44}

NO, NONE REQUIRED ...................... 3

REF ................................... -7

DK .................................... -8

HELP AVAILABLE FOR DEFINITION OF PRIMARY CARE DOCTOR AND ROUTINE CARE.

----------------------------------------------------

| DISPLAY ‘Does’ IF NOT ROUND 5. DISPLAY ‘Between |

| (START DATE) and (END DATE), did’ IF ROUND 5. |

----------------------------------------------------

| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or |

| {STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/SCHIP.|

| DISPLAY ‘the program....benefits’ IF ASKING ABOUT |

| GOVT-HOSPITAL/PHYSICIAN. |

----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|

| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |

| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|

| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |

| STATE, SEE BOX ON HX06. |

----------------------------------------------------

| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |

| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |

| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |

| ON HX06. |

----------------------------------------------------

| IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED), |

| OR ‘-8’ (DON’T KNOW), THERE IS NO INSURER |

| ASSOCIATED WITH THE CURRENT ROUND FOR MEDICAID/ |

| SCHIP OR GOVT-HOSPITAL/PHYSICIAN. |

----------------------------------------------------

| IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED), |

| OR ‘-8’ (DON’T KNOW) AND IF ASKING ABOUT MEDICAID/|

| SCHIP, GO TO BOX_31B |

----------------------------------------------------

| IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED), |

| OR ‘-8’ (DON’T KNOW) AND ASKING ABOUT GOVT- |

| HOSPITAL/PHYSICIAN, GO TO HX45 |

----------------------------------------------------

| OTHERWISE, (I.E., IF CODED ‘1’ (YES, ALL REQUIRED)|

| OR ‘2’ (YES, SOME REQUIRED)), CONTINUE WITH HX44 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR SELECTION OF RU-MEMBERS. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. SELECT, ADD, DELETE, AND EDIT DISALLOWED. |

----------------------------------------------------

| ROSTER FILTER: |

| 1. ESTABLISHMENT IS MEDICAID/SCHIP OR GOVT- |

| HOSPITAL/PHYSICIAN, |

| AND |

| 2. PERSON IS AN RU MBMBER FLAGGED AS COVERED BY |

| MEDICAID/SCHIP OR GOVT-HOSPITAL/PHYSICIAN DURING |

| THE CURRENT ROUND. |

----------------------------------------------------

HX44

====

{STR-DT}

{END-DT}

What is the name of the {{Medicaid/{STATE NAME FOR MEDICAID}} or

{STATE CHIP NAME}} {HMO/health insurance} {from the program

sponsored by a state or local government agency which provides

hospital and physician benefits}?

[Enter Plan Name] .....................

REF ................................... -7

DK .................................... -8

----------------------------------------------------

| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} or |

| {STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/ |

| SCHIP. IF ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN, |

| USE A NULL DISPLAY. |

| DISPLAY ‘from the....benefits’ IF ASKING ABOUT |

| GOVT-HOSPITAL/PHYSICIAN. IF ASKING ABOUT MEDICAID/|

| SCHIP, USE A NULL DISPLAY. |

| |

| DISPLAY ‘HMO’ IF HX42 IS CODED ‘1’ (YES, ALL ARE) |

| OR ‘2’ (YES, SOME ARE). |

| DISPLAY ‘health insurance’ IF HX43 IS CODED ‘1’ |

| (YES, ALL REQUIRED) OR ‘2’ (YES, SOME REQUIRED). |

----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHICH INTERVIEW IS |

| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|

| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |

| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|

| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |

| STATE, SEE BOX ON HX06. |

----------------------------------------------------

| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |

| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |

| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |

| ON HX06. |

----------------------------------------------------

| FLAG INSURER CODED ABOVE AS CURRENT ROUND’S |

| INSURER FOR MEDICAID/SCHIP OR GOVT-HOSPITAL/ |

| PHYSICIAN. |

----------------------------------------------------

| IF ASKING ABOUT MEDICAID/SCHIP, CONTINUE WITH |

| BOX_31B |

----------------------------------------------------

| OTHERWISE, GO TO HX45 |

----------------------------------------------------

BOX_31B

=======

----------------------------------------------------

| IF ROUND 1 OR ROUND 3 (AND ASKING ABOUT MEDICAID/ |

| SCHIP), CONTINUE WITH HX45 |

----------------------------------------------------

| OTHERWISE (I.E., IF ROUNDS 2, 4, OR 5 AND ASKING |

| ABOUT MEDICAID/SCHIP), GO TO BOX_31C |

----------------------------------------------------

HX45

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF PLAN FROM

HX44}}}

Does anyone in the family pay anything for the coverage through

{(PLAN NAME)/{{Medicaid/{STATE NAME FOR MEDICAID}} or {STATE

CHIP NAME}/the program sponsored by a state or local government

agency which provides hospital and physician benefits}?

[Do not include the cost of any copayments, coinsurance or

deductibles anyone in the family may have had to pay.]

YES .................................... 1 {HX46}

NO ..................................... 2 {HX47}

REF ................................... -7 {BOX_31C}

DK .................................... -8 {BOX_31C}

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

----------------------------------------------------

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| OR GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE, |

| USE A NULL DISPLAY. |

| |

| DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN |

| LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL |

| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |

| AT HX41OV FOR THIS STATE. |

| |

| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR |

| ‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS |

| ENTERED. |

| |

| DISPLAY ‘(PLAN NAME)’ IF THERE IS A CURRENT ROUND |

| INSURER ASSOCIATED WITH THE MEDICAID/SCHIP OR |

| GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE, |

| DISPLAY, {{Medicaid/... and physician benefits}’. |

| DISPLAY ‘{Medicaid/{STATE NAME FOR MEDICAID}} |

| or {STATE CHIP NAME}’ IF ASKING ABOUT MEDICAID/ |

| SCHIP. DISPLAY ‘the program ... benefits’ IF |

| ASKING ABOUT GOVT-HOSPITAL/PHYSICIAN. |

----------------------------------------------------

| DISPLAY ‘Medicaid’ IF STATE IN WHCH INTERVIEW IS |

| BEING CONDUCTED USES THE NAME ‘MEDICAID’. DISPLAY|

| ‘STATE NAME FOR MEDICAID’ (SUBSTITUTING THE REAL |

| STATE NAME FOR THE PROGRAM) IF THE STATE IN WHICH |

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME|

| ‘MEDICAID.’ FOR THE SPECIFIC NAME TO USE BY |

| STATE, SEE BOX ON HX06. |

----------------------------------------------------

| DISPLAY ‘or STATE CHIP NAME’ UNDER ALL CONDITIONS |

| (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM). |

| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |

| ON HX06. |

----------------------------------------------------

HX46

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF PLAN FROM

HX44}}}

How much does anyone in the family pay for {the (PLAN NAME)/

that} coverage?

[Enter Amount in Dollars] .............. {HX46OV1}

REF ................................... -7 {HX47}

DK .................................... -8 {HX47}

----------------------------------------------------

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| OR GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE, |

| USE A NULL DISPLAY. |

| |

| DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN |

| LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL |

| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |

| AT HX41OV FOR THIS STATE. |

| |

| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR |

| ‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS |

| ENTERED. |

| |

| DISPLAY ‘the (PLAN NAME)’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| OR GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE, |

| DISPLAY, ‘that’. |

----------------------------------------------------

HX46OV1

=======

Is that per year, per month, per week, or what?

UNIT OF COVERAGE:

PER YEAR ............................... 1 {HX47}

QUARTERLY/EVERY 3 MONTHS ............... 2 {HX47}

BIMONTHLY/EVERY 2 MONTHS ............... 3 {HX47}

PER MONTH .............................. 4 {HX47}

PER WEEK ............................... 5 {HX47}

BIWEEKLY/EVERY 2 WEEKS ................. 6 {HX47}

SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {HX47}

SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {HX47}

OTHER ................................. 91 {HX46OV2}

REF ................................... -7 {HX47}

DK .................................... -8 {HX47}

[Code One]

HX46OV2

=======

OTHER:

[Enter Other Specify] .................. {HX47}

REF ................................... -7 {HX47}

DK .................................... -8 {HX47}

BOX_31A

=======

OMITTED.

HX47

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT HX41OV}/{NAME OF PLAN FROM

HX44}}}

Who {else} pays {some of/for} the premium or cost

of this insurance?

FEDERAL GOVERNMENT .................... 1

STATE GOVERNMENT ...................... 2

LOCAL GOVERNMENT ...................... 3

SOME GOVERNMENT ....................... 4

OTHER ................................. 91 {HX47OV}

REF ................................... -7 {BOX_31C}

DK .................................... -8 {BOX_31C}

[Code All That Apply]

----------------------------------------------------

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| OR GOVT-HOSPITAL/PHYSICIAN INSURANCE. OTHERWISE, |

| USE A NULL DISPLAY. |

| |

| DISPLAY ‘{PLAN NAME ENTERED IN HX41OV}’ IF A PLAN |

| LETTER WAS ENTERED AT HX41OV. DISPLAY THE ACTUAL |

| PLAN NAME THAT CORRESPONDS TO THE LETTER ENTERED |

| AT HX41OV FOR THIS STATE. |

| |

| DISPLAY THE ACTUAL PLAN NAME ENTERED AT HX44 FOR |

| ‘NAME OF PLAN FROM HX44’ IF A PLAN NAME WAS |

| ENTERED. |

| |

| DISPLAY ‘else’ IF HX45 IS CODED ‘1’ (YES). |

| OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘some of’ IF HX45 IS CODED ‘1’ (YES). |

| DISPLAY ‘for’ IF HX45 IS CODED ‘2’ (NO). |

----------------------------------------------------

| FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT |

| ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN |

| COMBINATION WITH ANY OTHER CODE. |

----------------------------------------------------

| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |

| WITH ANY OTHER CODE, CONTINUE WITH HX47OV |

----------------------------------------------------

| OTHERWISE, GO TO BOX_31C |

----------------------------------------------------

HX47OV

======

OTHER:

[Enter Other Specify] .................. {BOX_31C}

REF ................................... -7 {BOX_31C}

DK .................................... -8 {BOX_31C}

BOX_31C

=======

----------------------------------------------------

| IF ROUND 1 OR ROUND 3, CONTINUE WITH BOX_31D |

----------------------------------------------------

| OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO |

| BOX_32 |

----------------------------------------------------

BOX_31D

=======

----------------------------------------------------

| IF ANY RU MEMBER HAS TRICARE/CHAMPVA AS A SOURCE |

| OF INSURANCE DURING THE CURRENT ROUND, CONTINUE |

| WITH BOX_31E |

----------------------------------------------------

| OTHERWISE, GO TO BOX_32 |

----------------------------------------------------

BOX_31E

=======

----------------------------------------------------

| IF NO ONE IN THE RU WAS COVERED BY TRICARE/CHAMPVA|

| DURING THE PREVIOUS ROUND AND AT LEAST ONE RU |

| MEMBER IS COVERED BY TRICARE/CHAMPVA DURING THE |

| CURRENT ROUND CONTINUE WITH HX47A |

----------------------------------------------------

| OTHERWISE, GO TO BOX_32 |

----------------------------------------------------

HX47A

=====

{STR-DT}

{END-DT}

[Now, let’s talk about the coverage someone in the family has

through TRICARE or CHAMPVA.]

Does anyone in the family pay anything for the coverage through

TRICARE or CHAMPVA?

[Do not include the cost of any copayments, coinsurance or

deductibles anyone in the family may have had to pay.]

YES .................................... 1 {HX47B}

NO ..................................... 2 {BOX_32}

REF ................................... -7 {BOX_32}

DK .................................... -8 {BOX_32}

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

HX47B

=====

{STR-DT}

{END-DT}

How much does anyone in the family pay for the coverage through

TRICARE or CHAMPVA?

[Enter Amount in Dollars] .............. {HX47BOV1}

REF ................................... -7 {BOX_32}

DK .................................... -8 {BOX_32}

HX47BOV1

========

Is that per year, per month, per week, or what?

UNIT OF COVERAGE:

PER YEAR ............................... 1 {BOX_32}

QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_32}

BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_32}

PER MONTH .............................. 4 {BOX_32}

PER WEEK ............................... 5 {BOX_32}

BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_32}

SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_32}

SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_32}

OTHER ................................. 91 {HX47BOV2}

REF ................................... -7 {BOX_32}

DK .................................... -8 {BOX_32}

[Code One]

HX47BOV2

========

OTHER:

[Enter Other Specify] .................. {BOX_32}

REF ................................... -7 {BOX_32}

DK .................................... -8 {BOX_32}

BOX_32

======

-----------------------------------------------------

| IF ANY ESTABLISHMENT RECORDED AS PROVIDING PRIVATE |

| INSURANCE (THAT WAS CREATED DURING THE CURRENT |

| ROUND) TO A CURRENT RU MEMBER, CONTINUE WITH |

| LOOP_12 |

-----------------------------------------------------

| OTHERWISE, GO TO BOX_45 |

-----------------------------------------------------

LOOP_12

=======

-----------------------------------------------------

| for each element in the ru-establishment-person- |

| pairs-roster, ask hx48-end_lp12 |

-----------------------------------------------------

| LOOP DEFINITION: LOOP_12 COLLECTS PRIVATE HEALTH |

| INSURANCE INFORMATION. THIS LOOP CYCLES ON |

| ESTABLISHMENT-PERSON-PAIRS THAT MEET THE |

| FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS PROVIDER OF PRIVATE HEALTH |

| INSURANCE TO A CURRENT RU MEMBER |

| AND |

| - THE INSURANCE COVERAGE PROVIDED BY THE |

| ESTABLISHMENT IS CREATED DURING THE CURRENT ROUND|

-----------------------------------------------------

HX48

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

SHOW CARD HX-7.

Now I’d like to ask a few questions about (POLICYHOLDER)’s health

insurance through (ESTABLISHMENT). What type of health insurance

{(do/does)/did} (POLICYHOLDER) get through (ESTABLISHMENT) {as of

(END DATE)}?

CHECK ALL THAT APPLY.

HOSPITAL AND PHYSICIAN BENEFITS,

INCLUDING COVERAGE THROUGH AN HMO ...... 1

DENTAL ................................. 2

PRESCRIPTION DRUGS ..................... 3

VISION ................................. 4

MEDICARE SUPPLEMENT/MEDIGAP ............ 5

LONG TERM CARE IN A NURSING HOME ....... 6

EXTRA CASH FOR HOSPITAL STAYS .......... 7

SERIOUS DISEASE OR DREAD DISEASE ....... 8

DISABILITY ............................. 9

WORKER’S COMPENSATION ................. 10

ACCIDENT .............................. 11

OTHER ................................. 91 {HX48OV}

REF ................................... -7 {BOX_33}

DK .................................... -8 {BOX_33}

[Code All That Apply]

HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.

----------------------------------------------------

| DISPLAY ‘(do/does)’ IF INSURANCE BEING ASKED |

| ABOUT IS CURRENT (I.E., HQ02 IS CODED ‘1’ (YES, |

| COVERED NOW) FOR THE POLICYHOLDER, AND THE CURRENT|

| ROUND IS NOT ROUND 5. OTHERWISE, DISPLAY ‘did’. |

| |

| DISPLAY ‘as of (END DATE)’ IF ROUND 5. OTHERWISE,|

| USE A NULL DISPLAY. |

----------------------------------------------------

| NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE |

| SHOW CARD. |

----------------------------------------------------

| FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT |

| ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN |

| COMBINATION WITH ANY OTHER CODE. |

----------------------------------------------------

| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |

| WITH ANY OTHER CODE, CONTINUE WITH HX48OV |

----------------------------------------------------

| OTHERWISE, GO TO BOX_33 |

----------------------------------------------------

HX48OV

======

OTHER:

[Enter Other Specify] ................. {BOX_33}

REF ................................... -7 {BOX_33}

DK .................................... -8 {BOX_33}

BOX_33

======

----------------------------------------------------

| IF ESTABLISHMENT TYPE IS NOT INSURANCE CO. OR HMO |

| AND HX48 IS CODED ‘5’ (MEDICARE SUPPLEMENT OR |

| MEDIGAP) ONLY OR ‘5’ AND ANY OTHER CODES, CONTINUE|

| WITH HX49 |

----------------------------------------------------

| IF ESTABLISHMENT TYPE IS INSURANCE CO. OR HMO AND |

| HX48 IS CODED ‘5’ (MEDICARE SUPPLEMENT OR MEDIGAP)|

| ONLY OR ‘5’ AND ANY OTHER CODES, AUTOMATICALLY |

| CODE HX49 WITH APPROPRIATE RESPONSES BY CAPI AND |

| THEN GO TO LOOP_13 |

----------------------------------------------------

| OTHERWISE (I.E., HX48 IS NOT CODED ‘5’ (MEDICARE |

| SUPPLEMENT OR MEDIGAP)), GO TO BOX_35 |

----------------------------------------------------

HX49

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

What is the name of the insurance company or HMO from which

(POLICYHOLDER) receives the Medicare Supplement or Medigap

benefits?

IF MORE THAN ONE NAME, PROBE: What is the main insurance company

or HMO from which (POLICYHOLDER) receives the Medicare Supplement

or Medigap benefits?

IF RESPONDENT SAYS BOTH INSURANCE COMPANY AND HMO, SELECT ‘HMO’.

NAME OF INSURER: [Enter Insurer]

TYPE: 1 = INSURANCE COMPANY ...............

2 = HMO .............................

3 = SELF-INSURED COMPANY ............

REF ................................. -7

DK .................................. -8

HELP AVAILABLE FOR DEFINITION OF INSURANCE CO/HMO/SELF-INSURED CO.

----------------------------------------------------

| FLAG INSURANCE CO./HMO AS ‘SUPPLYING MEDICARE |

| SUPPLEMENT/MEDIGAP BENEFITS’. ALSO FLAG AS |

| CURRENT ROUND’S INSURER(S) FOR THIS ESTABLISHMENT-|

| PERSON-PAIR. |

----------------------------------------------------

| BOTH INSURER NAME AND INSURER TYPE MYST BE |

| ENTERED. |

----------------------------------------------------

| CONTINUE WITH LOOP_13 |

----------------------------------------------------

BOX_34

======

OMITTED.

LOOP_13

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON- |

| INSURER-TRIPLES-ROSTER, ASK HX50-END_LP13 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_13 COLLECTS OTHER POLICY |

| NAMES FOR THE HEALTH INSURANCE COMPANIES OR HMOs |

| PROVIDING MEDICARE SUPPLEMENT/MEDIGAP BENEFITS |

| (THAT IS, INSURERS ENUMERATED AT HX49). |

| THIS LOOP CYCLES ON TRIPLES THAT MEET THE |

| FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS PROVIDER OF PRIVATE INSURANCE |

| WHICH PROVIDES MEDICARE SUPPLEMENT/MEDIGAP |

| BENEFITS |

| AND |

| - PERSON IS THE POLICYHOLDER FOR THE INSURANCE |

| PROVIDED THROUGH THIS ESTABLISHMENT |

| AND |

| - INSURER IS THE SOURCE OF THE BENEFITS PROVIDED |

| TO PERSON THROUGH THE ESTABLISHMENT (I.E., THE |

| INSURANCE COMPANY, HMO, OR SELF-INSURED COMPANY)|

----------------------------------------------------

HX50

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

Is there any other name for the {INSURANCE COMPANY OR HMO

NAME.} policy, such as Option A, $100 Deductible Plan, 90/80

Plan, Gold Plan, or High Option Plan?

YES, ANOTHER NAME ...................... 1 {HX50OV}

NO OTHER NAME .......................... 2 {END_LP13}

REF ................................... -7 {END_LP13}

DK .................................... -8 {END_LP13}

HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH OPTION.

[Code One]

----------------------------------------------------

| DISPLAY THE NAME OF THE INSURANCE CO/HMO |

| RECORDED IN HX49_01 WHICH IS BEING LOOPED ON FOR |

| ‘INSURANCE...NAME.’ |

----------------------------------------------------

HX50OV

======

OTHER NAME:

[Enter Insurance Company or HMO] ....... {END_LP13}

REF ................................... -7 {END_LP13}

DK .................................... -8 {END_LP13}

END_LP13

========

----------------------------------------------------

| CYCLE ON NEXT TRIPLE ON THE RU-ESTABLISHMENT- |

| PERSON-INSURER-TRIPLES-ROSTER THAT MEETS THE |

| CONDITIONS STATED IN THE LOOP DEFINITION |

----------------------------------------------------

| IF NO MORE TRIPLES MEET THE STATED CONDITIONS, |

| END LOOP_13 AND CONTINUE WITH BOX_35 |

----------------------------------------------------

BOX_35

======

----------------------------------------------------

| IF ESTABLISHMENT TYPE IS INSURANCE COMPANY, |

| INSURANCE COMPANY - FROM AGENT, OR HMO, |

| AND HX48 IS CODED ‘1’ (HOSPITAL AND |

| PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN |

| HMO) (BUT NOT ‘5’ (MEDIGAP)), FLAG INSURANCE |

| COMPANY/HMO AS ‘SUPPLYING HOSPITAL AND PHYSICIAN |

| BENEFITS’ AND AUTOMATICALLY CODE HX51 WITH |

| APPROPRIATE RESPONSES BY CAPI AND GO TO LOOP_14 |

----------------------------------------------------

| IF ESTABLISHMENT TYPE IS NOT INSURANCE COMPANY, |

| INSURANCE COMPANY - FROM AGENT, OR HMO, |

| AND HX48 IS CODED ‘1’ (HOSPITAL AND PHYSICIAN |

| BENEFITS, INCLUDING COVERAGE THROUGH AN HMO) AND |

| NOT ALSO CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP), |

| CONTINUE WITH HX51 |

----------------------------------------------------

| IF ROUND 1 AND HX48 IS CODED ‘1’ (HOSPITAL AND |

| PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN |

| HMO) AND ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP) (IN |

| COMBINATION WITH ANY OTHER CODES), GO TO BOX_38 |

----------------------------------------------------

| IF HX48 IS NOT CODED ‘1’ (HOSPITAL AND PHYSICIAN |

| BENEFITS, INCLUDING COVERAGE THROUGH AN HMO) BUT |

| IS CODED ‘2’ (DENTAL), ‘3’ (PRESCRIPTION DRUGS), |

| ‘4’ (VISION), ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP), |

| ‘6’ (LONG TERM CARE IN A NURSING HOME), ‘7’ (EXTRA|

| CASH FOR HOSPITAL STAYS), ‘8’ (SERIOUS DISEASE OR |

| DREAD DISEASE), OR ‘91’ (OTHER), GO TO BOX_38 |

----------------------------------------------------

| IF HX48 IS CODED ANY COMBINATION OF ONLY CODES ‘9’|

| (DISABILITY), ‘10’ (WORKER’S COMPENSATION) OR ‘11’|

| (ACCIDENT), GO TO END_LP12 |

----------------------------------------------------

| IF ROUND 1 AND HX48 IS CODED ‘-7’ (REFUSED) OR |

| ‘-8’ (DON’T KNOW), GO TO BOX_39 |

----------------------------------------------------

| IF ROUND 2, 3, 4, OR 5 AND HX48 IS CODED ‘-7’ |

| (REFUSED) OR ‘-8’ (DON’T KNOW), GO TO BOX_38 |

----------------------------------------------------

HX51

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

What is the name of the insurance company or HMO from which

(POLICYHOLDER) receives hospital and physician benefits?

IF MORE THAN ONE NAME, PROBE: What is the main insurance company

or HMO from which (POLICYHOLDER) receives hospital and physician

benefits?

IF RESPONDENT SAYS BOTH INSURANCE COMPANY AND HMO, SELECT ‘HMO’.

NAME OF INSURER: [Enter Insurer]

TYPE: 1 = INSURANCE COMPANY ...............

2 = HMO .............................

3 = SELF-INSURED COMPANY ............

REF ................................. -7

DK .................................. -8

HELP AVAILABLE FOR DEFINITION OF INSURANCE CO/HMO/SELF-INSURED CO.

----------------------------------------------------

| FLAG INSURANCE CO./HMO AS ‘SUPPLYING HOSPITAL AND |

| PHYSICIAN BENEFITS’. ALSO FLAG AS CURRENT ROUND’S|

| INSURER(S) FOR THIS ESTABLISHMENT-PERSON-PAIR. |

----------------------------------------------------

| BOTH INSURER NAME AND INSURER TYPE MYST BE |

| ENTERED. |

----------------------------------------------------

| CONTINUE WITH LOOP_14 |

----------------------------------------------------

BOX_36

======

OMITTED.

LOOP_14

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON- |

| INSURER-TRIPLES-ROSTER, ASK HX52-END_LP14 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_14 COLLECTS OTHER POLICY |

| NAMES FOR THE HEALTH INSURANCE COMPANIES OR HMOS |

| PROVIDING HOSPITAL/PHYSICIAN BENEFITS BUT NOT |

| MEDICARE SUPPLEMENT OR MEDIGAP. THIS LOOP CYCLES |

| ON TRIPLES THAT MEET THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS PROVIDER OF PRIVATE INSURANCE |

| WHICH PROVIDES HOSPITAL/PHYSICIAN BENEFITS BUT |

| NOT MEDICARE SUPPLEMENT OR MEDIGAP |

| AND |

| - PERSON IS THE POLICYHOLDER FOR THE INSURANCE |

| PROVIDED THROUGH THIS ESTABLISHMENT |

| AND |

| - INSURER IS THE SOURCE OF THE BENEFITS PROVIDED |

| TO PERSON THROUGH THE ESTABLISHMENT (I.E., THE |

| INSURANCE COMPANY, HMO OR SELF-INSURED COMPANY) |

----------------------------------------------------

HX52

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

Is there any other name for the {INSURANCE COMPANY OR HMO

NAME.} policy, such as Option A, $100 Deductible Plan, 90/80

Plan, Gold Plan, or High Option Plan?

YES, ANOTHER NAME ...................... 1 {HX52OV}

NO OTHER NAME .......................... 2 {END_LP14}

REF ................................... -7 {END_LP14}

DK .................................... -8 {END_LP14}

HELP AVAILABLE FOR DEFINITION OF LOW OPTION/HIGH OPTION.

[Code One]

----------------------------------------------------

| DISPLAY THE NAME OF THE INSURANCE CO/HMO |

| RECORDED IN HX51_01 WHICH IS BEING LOOPED ON FOR |

| ‘INSURANCE...NAME.’ |

----------------------------------------------------

HX52OV

======

OTHER NAME:

[Enter Insurance Company or HMO] ....... {END_LP14}

REF ................................... -7 {END_LP14}

DK .................................... -8 {END_LP14}

END_LP14

========

----------------------------------------------------

| CYCLE ON NEXT TRIPLE ON RU-ESTABLISHMENT-PERSON- |

| INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS |

| STATED IN THE LOOP DEFINITION |

----------------------------------------------------

| IF NO MORE TRIPLES MEET THE STATED CONDITIONS, |

| END LOOP_14 AND CONTINUE WITH BOX_38 |

----------------------------------------------------

BOX_37

======

----------------------------------------------------

| Omitted. |

| |

| NOTE: ALL ROUNDS, CONTINUE WITH BOX_38 |

----------------------------------------------------

HX53

====

OMITTED.

HX54

====

OMITTED.

LOOP_15

=======

OMITTED.

HX55

====

OMITTED.

HX55OV

======

OMITTED.

END_LP15

========

OMITTED.

BOX_38

======

----------------------------------------------------

| IF ROUND 1, CONTINUE WITH BOX_39 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_40 |

----------------------------------------------------

HX56

====

OMITTED.

LOOP_16

=======

OMITTED.

HX57

====

OMITTED.

HX57OV

======

OMITTED.

HX58

====

OMITTED.

END_LP16

========

OMITTED.

BOX_39

======

----------------------------------------------------

| IF ESTABLISHMENT-PERSON-PAIR BEING ASKED ABOUT |

| IS FLAGGED AS THROUGH THE FEDERAL GOVERNMENT |

| (EM96 IS CODED ‘2’ (THE FEDERAL GOVERNMENT) OR |

| HP13 IS CODED ‘1’ (YES)), |

| CONTINUE WITH HX59 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_40 |

----------------------------------------------------

HX59

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

SHOW CARD HX-8.

Is the name of (POLICYHOLDER)’s insurance plan through

(ESTABLISHMENT) listed on this card?

YES .................................... 1 {HX59OV}

NO ..................................... 2 {BOX_40}

REF ................................... -7 {BOX_40}

DK .................................... -8 {BOX_40}

HX59OV

======

Which insurance plan is (POLICYHOLDER)’s (ESTABLISHMENT)

insurance?

CODE LETTER OF PLAN FROM SHOW CARD:

[Enter Plan Letter From Card] ......... {BOX_40}

----------------------------------------------------

| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |

| THE FOLLOWING MESSAGE: “PLEASE VERIFY PLAN |

| ENTERED.” WHEN INTERVIEWER PRESSES CLEARS THE |

| MESSAGE, PROCEED TO THE NEXT LOGICAL SCREEN. |

----------------------------------------------------

BOX_40

======

----------------------------------------------------

| IF THIS ESTABLISHMENT-PERSON-PAIR HAS AT LEAST ONE|

| INSURER THAT PROVIDES HOSPITAL AND PHYSICIAN |

| BENEFITS OR THAT PROVIDES MEDICARE SUPPLEMENT/ |

| MEDIGAP COVERAGE AND THE POLICYHOLDER IS NOT |

| LISTED AS A COVERED PERSON WITH MEDICAID OR GOVT- |

| HOSPITAL/PHYSICIAN FOR THE CURRENT ROUND, |

| CONTINUE WITH LOOP_17 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_42 |

----------------------------------------------------

LOOP_17

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-ESTABLISHMENT-PERSON- |

| INSURER-TRIPLES-ROSTER, ASK BOX_4OA - END_LP17 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_17 COLLECTS INFORMATION ON |

| PLANS THAT PROVIDE HOSPITAL/PHYSICIAN BENEFITS OR |

| MEDICARE SUPPLEMENT/MEDIGAP COVERAGE TO EACH |

| POLICYHOLDER NOT ALSO COVERED BY MEDICAID OR GOVT-|

| HOSPITAL/PHYSICIAN TO DETERMINE IF THAT PLAN IS AN|

| HMO/MANAGED CARE PLAN. THIS LOOP CYCLES ON |

| TRIPLES THAT MEET THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS PROVIDER OF HOSPITAL/PHYSICIAN |

| BENEFITS OR MEDICARE SUPPLEMENT/MEDIGAP COVERAGE|

| AND |

| - PERSON IS NOT LISTED AS A COVERED PERSON WITH |
| MEDICAID OR GOVT-HOSPITAL/PHYSICIAN |

| AND |

| - INSURER IS THE SOURCE OF THE HOSPITAL AND |

| PHYSICIAN BENEFITS PROVIDED TO PERSON THROUGH |

| THE ESTABLISHMENT (I.E., THE INSURANCE COMPANY |

| OR SELF-INSURED COMPANY) |

----------------------------------------------------

BOX_40A

=======

----------------------------------------------------

| IF INSURER IS AN HMO (EPIN.INSTYPE = 2), CONTINUE |

| WITH HX60A |

----------------------------------------------------

| OTHERWISE (I.E., IF INSURER IS NOT AN HMO), GO |

| TO BOX_41 |

----------------------------------------------------

HX60A

=====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

INSURER NAME: {NAME OF INSURER BEING LOOPED ON}

Will (POLICYHOLDER)’s plan pay for any of the costs of

visits to doctors who are not part of (POLICYHOLDER)’s

HMO, even if (POLICYHOLDER) (do/does) not have a referral?

YES .................................... 1 {END_LP17}

NO ..................................... 2 {END_LP17}

REF ................................... -7 {END_LP17}

DK .................................... -8 {END_LP17}

BOX_41

======

----------------------------------------------------

| PRESENT MANAGED CARE (MC) SECTION FOR THIS INSURER|

----------------------------------------------------

| AT COMPLETION OF THE MC SECTION, CONTINUE WITH |

| END_LP17 |

----------------------------------------------------

END_LP17

========

----------------------------------------------------

| CYCLE ON NEXT TRIPLE ON RU-ESTABLISHMENT-PERSON- |

| INSURER-TRIPLES-ROSTER THAT MEETS THE CONDITIONS |

| STATED IN THE LOOP DEFINITION. |

----------------------------------------------------

| IF NO MORE TRIPLES MEET THE STATED CONDITIONS, |

| END LOOP_17 AND CONTINUE WITH BOX_42 |

----------------------------------------------------

BOX_42

======

----------------------------------------------------

| IF ROUND 1 OR ROUND 3 AND IF HX48 IS CODED ‘5’ |

| (MEDICARE SUPPLEMENT/MEDIGAP), CONTINUE WITH HX60 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_43 |

----------------------------------------------------

HX60

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

CODE WITHOUT ASKING IF ANSWER IS KNOWN.

Many Medicare Supplemental or Medigap Plans are referred to by

a Plan Letter. Do you know the Plan Letter for (PERSON)’s

plan?

PROBE: What is it?

[Enter Plan Letter] .................... {BOX_43}

REF ................................... -7 {BOX_43}

DK .................................... -8 {BOX_43}

HELP AVAILABLE FOR DEFINITION OF PLAN LETTER.

BOX_43

======

----------------------------------------------------

| IF ROUND 1 OR ROUND 3, CONTINUE WITH HX61 |

----------------------------------------------------

| OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO |

| END_LP12 |

----------------------------------------------------

BOX_44

======

OMITTED.

HX61

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

For the coverage through (ESTABLISHMENT), does anyone in the

family pay all of the premium or cost, some of the premium or

cost, or none of the premium or cost?

[Do not include the cost of any copayments, coinsurance or

deductibles anyone in the family may have had to pay.]

[Do include any contribution made to the plan as part of a

paycheck.]

YES, PAY ALL OF PREMIUM/COST ........... 1 {HX62}

YES, PAY SOME OF PREMIUM/COST .......... 2 {HX62}

YES, BUT DON’T KNOW IF PAY ALL OR SOME

OF PREMIUM/COST ........................ 3 {HX62}

NO, DO NOT PAY ......................... 4 {HX63}

REF ................................... -7 {END_LP12}

DK .................................... -8 {END_LP12}

[Code One]

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

----------------------------------------------------

| NOTE: THE ESTABLISHMENT NAME WHICH SHOULD BE |

| DISPLAYED HERE FOR THE INSURANCE FROM A |

| SELF-EMPLOYED-FIRM-SIZE-1 AND INSURANCE FROM |

| DIRECTLY PURCHASED SOURCES, SHOULD BE THE NAME OF |

| THE SOURCE, NOT THE NAME OF THE EMPLOYER OR |

| DIRECTLY PURCHASED CATEGORY. |

----------------------------------------------------

HX62

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

How much {(do/does)/did} (POLICYHOLDER) pay for the

(ESTABLISHMENT) coverage?

[Enter Amount in Dollars] .............. {HX62OV1}

REF ................................... -7 {BOX_44A}

DK .................................... -8 {BOX_44A}

----------------------------------------------------

| DISPLAY ‘(do/does)’ IF INSURANCE BEING ASKED |

| ABOUT IS CURRENT (I.E., HQ02 IS CODED ‘1’ (YES, |

| COVERED NOW)) FOR THE POLICYHOLDER. OTHERWISE, |

| DISPLAY ‘did’. |

----------------------------------------------------

| NOTE: THE ESTABLISHMENT NAME WHICH SHOULD BE |

| DISPLAYED HERE FOR THE INSURANCE FROM A |

| SELF-EMPLOYED-FIRM-SIZE-1 AND INSURANCE FROM |

| DIRECTLY PURCHASED SOURCES, SHOULD BE THE NAME OF |

| THE SOURCE, NOT THE NAME OF THE EMPLOYER OR |

| DIRECTLY PURCHASED CATEGORY. |

----------------------------------------------------

HX62OV1

=======

{Is/Was} that per year, per month, per week, or what?

UNIT OF COVERAGE:

PER YEAR ............................... 1 {BOX_44A}

QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_44A}

BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_44A}

PER MONTH .............................. 4 {BOX_44A}

PER WEEK ............................... 5 {BOX_44A}

BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_44A}

SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_44A}

SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_44A}

OTHER ................................. 91 {HX62OV2}

REF ................................... -7 {BOX_44A}

DK .................................... -8 {BOX_44A}

[Code One]

----------------------------------------------------

| DISPLAY ‘Is’ IF INSURANCE BEING ASKED ABOUT IS |

| CURRENT (I.E., HQ02 IS CODED ‘1’ (YES, COVERED |

| NOW)) FOR THE POLICYHOLDER. OTHERWISE, DISPLAY |

| ‘Was’. |

----------------------------------------------------

HX62OV2

=======

OTHER:

[Enter Other Specify] .................. {BOX_44A}

REF ................................... -7 {BOX_44A}

DK .................................... -8 {BOX_44A}

BOX_44A

=======

-----------------------------------------------------

| IF HX61 IS CODED ‘1’ (YES, PAY ALL OF PREMIUM/ |

| COST), GO TO END_LP12 |

-----------------------------------------------------

| OTHERWISE, CONTINUE WITH HX63 |

-----------------------------------------------------

HX63

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {NAME OF

ESTABLISHMENT} {STR-DT}

{END-DT}

Who {else} pays {some of/for} the premium or cost

of this insurance?

CHECK ALL THAT APPLY.

FEDERAL GOVERNMENT .................... 1

STATE GOVERNMENT ...................... 2

LOCAL GOVERNMENT ...................... 3

SOME GOVERNMENT ....................... 4

EMPLOYER .............................. 5

UNION ................................. 6

OTHER ................................. 91 {HX63OV}

REF ................................... -7 {END_LP12}

DK .................................... -8 {END_LP12}

[Code All That Apply]

----------------------------------------------------

| DISPLAY ‘else’ IF HX61 IS CODED ‘2’ (YES, PAY SOME|

| OF PREMIUM/COST) OR ‘3’ (YES, BUT DON’T KNOW IF |

| PAY ALL OR SOME OF PREMIUM/COST). OTHERWISE, USE |

| A NULL DISPLAY |

| |

| DISPLAY ‘some of’ IF HX61 IS CODED ‘2’ (YES, PAY |

| SOME OF PREMIUM/COST) OR ‘3’ (YES, BUT DON’T KNOW |

| IF PAY ALL OR SOME OF PREMIUM/COST). DISPLAY ‘for’|

| IF HX61 IS CODED ‘4’ (NO, DO NOT PAY). |

----------------------------------------------------

| FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT |

| ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN |

| COMBINATION WITH ANY OTHER CODE. |

----------------------------------------------------

| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |

| WITH ANY OTHER CODE, CONTINUE WITH HX63OV |

----------------------------------------------------

| OTHERWISE, GO TO END_LP12 |

----------------------------------------------------

HX63OV

======

OTHER:

[Enter Other Specify] .................. {END_LP12}

REF ................................... -7 {END_LP12}

DK .................................... -8 {END_LP12}

END_LP12

========

------------------------------------------------------

| CYCLE ON NEXT PAIR IN RU-ESTABLISHMENT-PERSON- |

| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |

| THE LOOP DEFINITION. |

------------------------------------------------------

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_12 AND CONTINUE WITH BOX_45 |

------------------------------------------------------

BOX_45

======

------------------------------------------------------

| IF ROUND 1, CONTINUE WITH BOX_46 |

------------------------------------------------------

| OTHERWISE, GO TO BOX_50 |

------------------------------------------------------

BOX_46

======

------------------------------------------------------

| IF ALL PERSONS IN RU HAVE HEALTH INSURANCE (I.E., |

| FLAGGED AS HAVING MEDICARE, MEDICAID/SCHIP, |

| GOVT-HOSPITAL/PHYSICIAN, TRICARE/CHAMPVA, OTHER |

| PUBLIC OR PRIVATE INSURANCE) COVERAGE ON JANUARY 1, |

| {YEAR}, WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF |

| THE PANEL, GO TO BOX_48 |

------------------------------------------------------

| OTHERWISE, (AT LEAST ONE RU MEMBER BORN BEFORE |

| 12/31/{YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE |

| FIRST CALENDAR YEAR OF THE PANEL, IS WITHOUT HEALTH |

| INSURANCE ON JANUARY 1, {YEAR}, WHERE ‘YEAR’ IS THE |

| FIRST CALENDAR YEAR OF THE PANEL), CONTINUE WITH |

| LOOP_18 |

------------------------------------------------------

LOOP_18

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK |

| HX64-END_LP18 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_18 COLLECTS INFORMATION |

| ABOUT RU MEMBERS WITH NO HEALTH INSURANCE ON |

| JANUARY 1, {YEAR}, WHERE YEAR IS THE FIRST |

| CALENDAR YEAR OF THE PANEL. THIS LOOP CYCLES ON RU|

| MEMBERS WHO ARE NOT A COVERED PERSON IN ANY |

| ESTABLISHMENT-POLICYHOLDER-COVERED-PERSON-TRIPLE |

| THAT MEETS THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS MEDICARE, MEDICAID/SCHIP, GOVT-|

| HOSPITAL/PHYSICIAN, OTHER PUBLIC, |

| TRICARE/CHAMPVA, OR PRIVATE INSURANCE |

| AND |

| - PERSON IS A CURRENT RU MEMBER WITH A BIRTH DATE |

| PRIOR TO DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS |

| THE YEAR PRIOR TO THE FIRST CALENDAR YEAR OF THE|

| PANEL (OR AGE CATEGORY > 1) |

| AND |

| - PERIOD OF COVERAGE INCLUDES JANUARY 1, {YEAR}, |

| WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE |

| PANEL. |

----------------------------------------------------

HX64

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

I have recorded that (PERSON) (were/was) without insurance on

January 1, {YEAR}. (Were/Was) (PERSON) covered by a health

insurance plan or program at any time in the years {YEAR} or

{YEAR}?

YES .................................... 1 {HX65}

NO ..................................... 2 {END_LP18}

REF ................................... -7 {END_LP18}

DK .................................... -8 {END_LP18}

----------------------------------------------------

| (FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES |

| AUTOMATICALLY): IN THE QUESTION TEXT, “... on |

| JANUARY 1, {YEAR},” ‘YEAR’ IS THE FIRST CALENDAR |

| YEAR OF THE PANEL. IN THE QUESTION TEXT, “... at |

| any time in the years {YEAR} or {YEAR}?” CAPI |

| DISPLAYS THE TWO YEARS PRIOR TO THE FIRST CALENDAR|

| YEAR OF THE PANEL. (FOR PANEL 12 FOR EXAMPLE, THIS|

| WOULD BE ‘2005 or 2006?’). |

----------------------------------------------------

HX65

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

When (were/was) (PERSON) most recently covered by health

insurance? That is, in what month and year did that health

insurance end for the last time in {YEAR} or {YEAR}?

[Enter Month,Year-4] ................... {HX66}

REF ................................... -7 {HX66}

DK .................................... -8 {HX66}

----------------------------------------------------

| (FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES |

| AUTOMATICALLY): CAPI DISPLAYS THE TWO YEARS PRIOR |

| TO THE FIRST CALENDAR YEAR OF THE PANEL FOR |

| “‘YEAR’ OR ‘YEAR’?”. (FOR PANEL 12 FOR EXAMPLE, |

| THIS WOULD BE ‘2005 or 2006?’). |

----------------------------------------------------

| ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED |

| ON THE MONTH AND YEAR FIELDS. |

----------------------------------------------------

HX66

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

Was (PERSON)’s health insurance that ended in {MONTH AND YEAR

FROM HX65/{YEAR} or {YEAR}} obtained through an employer or a

union, was it a government program such as Medicaid, or what?

CHECK ALL THAT APPLY.

OBTAINED THROUGH UNION, PRIVATE

EMPLOYER OR PUBLIC EMPLOYER (FEDERAL,

STATE, OR LOCAL GOVT.) ................. 1

MEDICARE ............................... 2

MEDICAID ............................... 3

TRICARE/CHAMPVA ........................ 4

VA OR MILITARY HEALTH CARE ............. 5

PURCHASED DIRECTLY FROM GROUP, ASSOC.,

OR INS. AGENT, INS. CO. OR HMO ......... 6

OTHER TYPE OF GOVERNMENT SPONSORED

PROGRAM ................................ 7

OTHER PUBLIC PROGRAM:

TANF ................................ 8

SSI ................................. 9

{STATE PROGRAM 1} .................. 10

{STATE PROGRAM 2} .................. 11

{STATE PROGRAM 3} .................. 12

{STATE PROGRAM 4} .................. 13

OTHER ................................. 91 {HX66OV}

REF ................................... -7 {END_LP18}

DK .................................... -8 {END_LP18}

[Code All That Apply]

HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.

----------------------------------------------------

| IF HX65 IS NOT CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T|

| KNOW), DISPLAY THE DATE ENTERED AT HX65 FOR ‘MONTH|

| AND YEAR FROM HX65’. DISPLAY ‘{YEAR} or |

| {YEAR}’ IF HX65 IS CODED ‘-7’ (REFUSED) OR ‘-8’ |

| (DON’T KNOW), WHERE ‘YEAR’ AND ‘YEAR’ DISPLAYS |

| THE TWO YEARS PRIOR TO THE FIRST CALENDAR YEAR OF |

| THE PANEL. FOR PANEL 12 FOR EXAMPLE, THIS WOULD BE|

| ‘2005’ or ‘2006’. |

----------------------------------------------------

| FOR ‘STATE PROGRAM N’, DISPLAY AN ACTUAL NAME OF |

| A STATE PLAN. FOR THE SPECIFIC NAMES OF PLANS |

| BY STATE, SEE BOX ON HX16. |

----------------------------------------------------

| FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT |

| ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN |

| COMBINATION WITH ANY OTHER CODE. |

----------------------------------------------------

| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |

| WITH OTHER CODES, CONTINUE WITH HX66OV |

----------------------------------------------------

| OTHERWISE, GO TO END_LP18 |

----------------------------------------------------

HX66OV

======

OTHER:

[Enter Other Specify] .................. {END_LP18}

REF ................................... -7 {END_LP18}

DK .................................... -8 {END_LP18}

HX67

====

OMITTED.

HX68

====

OMITTED.

HX68OV

======

OMITTED.

BOX_47

======

OMITTED.

HX69

====

OMITTED.

END_LP18

========

----------------------------------------------------

| CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER THAT |

| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|

----------------------------------------------------

| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |

| END LOOP_18 AND CONTINUE WITH BOX_48 |

----------------------------------------------------

BOX_48

======

----------------------------------------------------

| IF NO CURRENT RU MEMBERS WHO WERE BORN BEFORE |

| DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS THE YEAR |

| PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL, |

| HAVE ANY TYPE OF COMPREHENSIVE PUBLIC INSURANCE |

| (I.E., MEDICARE, MEDICAID/SCHIP, GOVT- |

| HOSPITAL/PHYSICIAN, OR TRICARE/CHAMPVA) |

| AND |

| NO CURRENT RU MEMBERS WHO WERE BORN BEFORE |

| DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS THE YEAR |

| PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL, |

| HAVE ANY PRIVATE INSURANCE THAT INCLUDED HOSPITAL |

| AND PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT/ |

| MEDIGAP BENEFITS ON 1/1/{YEAR}, WHERE ‘YEAR’ IS |

| THE FIRST CALENDAR YEAR OF THE PANEL, GO TO |

| BOX_49 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH LOOP_19 |

----------------------------------------------------

LOOP_19

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, ASK |

| HX70-END_LP19 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_19 COLLECTS INFORMATION ON |

| ALL RU MEMBERS WITH PUBLIC AND PRIVATE HEALTH |

| INSURANCE PROVIDING HOSPITAL/PHYSICIAN BENEFITS OR|

| MEDICARE SUPPLEMENT/MEDIGAP BENEFITS ON JANUARY 1,|

| {YEAR}, WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF|

| THE PANEL, TO DETERMINE PERIODS OF COVERAGE IN |

| {YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE |

| FIRST CALENDAR YEAR OF THE PANEL. THIS LOOP CYCLES|

| ON PERSONS THAT MEET THE FOLLOWING CONDITIONS: |

| - PERSON IS A CURRENT RU MEMBER |

| AND |

| - PERSON’S DATE OF BIRTH IS BEFORE 12/31/{YEAR}, |

| WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE FIRST |

| CALENDAR YEAR OF THE PANEL, OR PERSON’S AGE IS |

| AGE CATEGORIES 2-9 |

| AND |

| - PERSON HAD COMPREHENSIVE HEALTH INSURANCE |

| COVERAGE ON 1/1/{YEAR}, WHERE ‘YEAR’ IS THE |

| FIRST CALENDAR YEAR OF THE PANEL. COMPREHENSIVE |

| HEALTH INSURANCE REFERS TO THE PERSON BEING A |

| COVERED PERSON ON AT LEAST ONE OF THE FOLLOWING |

| ESTABLISHMENT-POLICYHOLDER-COVERED-PERSON- |

| TRIPLES ON 1/1/{YEAR}, WHERE ‘YEAR’ IS THE FIRST|

| CALENDAR YEAR OF THE PANEL: |

| - ESTABLISHMENT IS MEDICARE |

| - ESTABLISHMENT IS MEDICAID/SCHIP |

| - ESTABLISHMENT IS TRICARE |

| - ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN |

| - ESTABLISHMENT IS PRIVATE WITH HOSPITAL AND |

| PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR |

| MEDIGAP (I.E., HX48 = 1 OR 5) |

----------------------------------------------------

HX70

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {STR-DT}

{END-DT}

I have recorded that (PERSON) had health insurance coverage on

January 1, {YEAR}. (Were/Was) (PERSON) ever without health

insurance coverage at any time in {YEAR}?

YES .................................... 1 {HX71}

NO ..................................... 2 {END_LP19}

REF ................................... -7 {END_LP19}

DK .................................... -8 {END_LP19}

----------------------------------------------------

| (FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES |

| AUTOMATICALLY): FOR ‘YEAR’ IN, “... on JANUARY 1, |

| {YEAR},” DISPLAY THE FIRST CALENDAR YEAR OF THE |

| PANEL. FOR ‘YEAR’ IN “... at any time in {YEAR},” |

| DISPLAY THE YEAR PRIOR TO THE FIRST CALENDAR YEAR |

| OF THE PANEL. |

----------------------------------------------------

HX71

====

{POLICYHOLDER FIRST MIDDLE LAST NAME} {STR-DT}

{END-DT}

Altogether, how many weeks or months (were/was) (PERSON)

without health insurance coverage in the year {YEAR}?

[Enter Small Number] ................... {HX71OV}

REF ................................... -7 {END_LP19}

DK .................................... -8 {END_LP19}

----------------------------------------------------

| (FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES |

| AUTOMATICALLY): FOR ‘YEAR’ IN THE QUESTION TEXT, |

| DISPLAY THE YEAR PRIOR TO THE FIRST CALENDAR YEAR |

| OF THE PANEL. |

----------------------------------------------------

HX71OV

======

ENTER UNIT:

WEEKS .................................. 1 {END_LP19}

MONTHS ................................. 2 {END_LP19}

REF ................................... -7 {END_LP19}

DK .................................... -8 {END_LP19}

[Code One]

HX72

====

OMITTED.

HX73

====

OMITTED.

HX73OV

======

OMITTED.

HX74

====

OMITTED.

HX75

====

OMITTED.

HX75OV

======

OMITTED.

END_LP19

========

----------------------------------------------------

| CYCLE ON NEXT PERSON ON RU-MEMBERS-ROSTER THAT |

| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|

----------------------------------------------------

| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |

| END LOOP_19 AND CONTINUE WITH BOX_49 |

----------------------------------------------------

BOX_49

======

----------------------------------------------------

| IF ALL CURRENT RU MEMBERS WHO WERE BORN BEFORE |

| DECEMBER 31, {YEAR}, WHERE ‘YEAR’ IS THE YEAR |

| PRIOR TO THE FIRST CALENDAR YEAR OF THE PANEL, |

| HAVE ONLY PRIVATE INSURANCE THAT INCLUDES HOSPITAL|

| AND PHYSICIAN BENEFITS |

| AND/OR |

| ALL CURRENT RU MEMBERS HAVE ONLY COMPREHENSIVE |

| PUBLIC INSURANCE ON JANUARY 1, {YEAR}, WHERE |

| ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL, |

| GO TO BOX_50 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH LOOP_20 |

----------------------------------------------------

LOOP_20

=======

----------------------------------------------------

| FOR EACH ELEMENT IN RU-MEMBERS-ROSTER, |

| ASK HX76-END_LP20 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_20 COLLECTS INFORMATION FOR|

| EACH RU MEMBER WHOSE DATE OF BIRTH IS PRIOR TO |

| 12/31/{YEAR}, WHERE ‘YEAR’ IS THE YEAR PRIOR TO |

| THE FIRST CALENDAR YEAR OF THE PANEL, (OR AGE |

| CATEGORY > 1), AND WHO IS COVERED BY PRIVATE |

| INSURANCE THAT DOES NOT INCLUDE EITHER HOSPITAL/ |

| PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT/MEDIGAP |

| BENEFITS ON JANUARY 1, {YEAR}, WHERE ‘YEAR’ IS THE|

| FIRST CALENDAR YEAR OF THE PANEL. THE LOOP CYCLES |

| ON PERSONS WERE EVER COVERED BY A MORE |

| COMPREHENSIVE PLAN THAT PROVIDED HOSPITAL/ |

| PHYSICIAN COVERAGE DURING {YEAR}, WHERE ‘YEAR’ IS |

| THE YEAR PRIOR TO THE FIRST CALENDAR YEAR OF THE |

| PANEL, OR {YEAR}, WHERE ‘YEAR’ IS TWO YEARS PRIOR |

| TO THE FIRST CALENDAR YEAR OF THE PANEL. THE LOOP |

| CYCLES ON PERSONS THAT MEET THE FOLLOWING |

| CONDITIONS: |

| - PERSON IS A CURRENT RU MEMBER |

| AND |

| - PERSON’S DATE OF BIRTH IS BEFORE 12/31/{YEAR}, |

| WHERE ‘YEAR’ IS THE YEAR PRIOR TO THE FIRST |

| CALENDAR YEAR OF THE PANEL, OR IN AGE CATEGORIES|

| 2-9 |

| AND |

| - PERSON DID NOT HAVE COMPREHENSIVE HEALTH |

| INSURANCE COVERAGE ON 1/1/{YEAR}, WHERE ‘YEAR’ |

| IS THE FIRST CALENDAR YEAR OF THE PANEL. |

| COMPREHENSIVE HEALTH INSURANCE REFERS TO THE |

| PERSON BEING A COVERED PERSON ON AT LEAST ONE OF|

| THE FOLLOWING ESTABLISHMENT-POLICYHOLDER- |

| COVERED-PERSON-TRIPLES ON 1/1/{YEAR}, WHERE |

| ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE PANEL: |

| - ESTABLISHMENT IS MEDICARE |

| - ESTABLISHMENT IS MEDICAID |

| - ESTABLISHMENT IS TRICARE |

| - ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN |

| - ESTABLISHMENT IS PRIVATE WITH HOSPITAL AND |

| PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR |

| MEDIGAP (I.E., HX48 = 1 OR 5) |

| AND |

| - PERSON IS COVERED PERSON ON AT LEAST ONE OF THE |

| FOLLOWING ESTABLISHMENT-POLICYHOLDER-COVERED- |

| PERSON-TRIPLES ON 1/1/{YEAR}, WHERE ‘YEAR’ IS |

| THE FIRST CALENDAR YEAR OF THE PANEL: |

----------------------------------------------------

| - ESTABLISHMENT IS GROUP 1 OR GROUP 2 OTHER |

| PUBLIC |

| - ESTABLISHMENT IS PRIVATE WITHOUT HOSPITAL AND |

| PHYSICIAN BENEFITS OR MEDICARE SUPPLEMENT OR |

| MEDIGAP (I.E., HX48 IS NOT CODED 1 OR 5) |

----------------------------------------------------

HX76

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

I have recorded that (PERSON) {had health insurance coverage for

(READ TYPES OF INSURANCE BELOW) coverage} {and} {was covered by a

public program} on January 1, {YEAR}. (Were/Was) (PERSON) ever

covered by a more comprehensive health insurance plan or program

that paid for medical and doctor’s bills at any time in the years

{YEAR} or {YEAR}?

{TYPE OF INSURANCE IN HX48} {TYPE OF INSURANCE IN HX48}

YES .................................... 1 {HX77}

NO ..................................... 2 {END_LP20}

REF ................................... -7 {END_LP20}

DK .................................... -8 {END_LP20}

----------------------------------------------------

| DISPLAY ‘had health...(BELOW)’ IF PERSON |

| CONFIRMED AS POLICYHOLDER (HP09 IS CODED ‘1’ |

| (YES)) OR SELECTED AS POLICYHOLDER (SELECTED AT |

| HP11) OR SELECTED AS A DEPENDENT (SELECTED AT |

| HP16) FOR ANY PRIVATE ESTABLISHMENT-POLICYHOLDER |

| PAIR WHERE HX48 IS NOT CODED ‘1’ (HOSPITAL AND |

| PHYSICIAN BENEFITS) AND NOT CODED ‘5’ (MEDICARE |

| SUPPLEMENT/MEDIGAP) EITHER ALONE OR WITH ANY |

| COMBINATION OF CODES FOR ALL OF THOSE PRIVATE |

| ESTABLISHMENT-POLICYHOLDER PARIS. OTHERWISE, USE |

| A NULL DISPLAY. |

| |

| DISPLAY ‘was....program’ IF PERSON SELECTED AT |

| HX19 (FOR EITHER GROUP 1 OR GROUP 2 PROGRAM). |

| OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘and’ IF PERSON CONFIRMED AS POLICYHOLDER |

| (HP09 IS CODED ‘1’ (YES)) OR SELECTED AS |

| POLICYHOLDER (SELECTED AT HP11) OR SELECTED AS A |

| DEPENDENT (SELECTED AT HP16) FOR ANY PRIVATE |

| ESTABLISHMENT-POLICYHOLDER PAIR WHERE HX48 IS NOT |

| CODED ‘1’ (HOSPITAL AND PHYSICIAN BENEFITS) AND |

| NOT CODED ‘5’ (MEDICARE SUPPLEMENT/MEDIGAP) EITHER|

| ALONE OR WITH ANY COMBINATION OF CODES FOR ALL OF |

| THOSE PRIVATE ESTABLISHMENT-POLICYHOLDER PAIRS |

| AND PERSON SELECTED AT HX19 (FOR EITHER GROUP 1 |

| OR GROUP 2 PROGRAM). |

----------------------------------------------------

| (FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES |

| AUTOMATICALLY): IN THE QUESTION TEXT, “... on |

| JANUARY 1, {YEAR},” ‘YEAR’ IS THE FIRST CALENDAR |

| YEAR OF THE PANEL. IN THE QUESTION TEXT, “... at |

| any time in the years {YEAR} or {YEAR}?” CAPI |

| DISPLAYS THE TWO YEARS PRIOR TO THE FIRST CALENDAR|

| YEAR OF THE PANEL. (FOR PANEL 12 FOR EXAMPLE, THIS|

| WOULD BE ‘2005 or 2006?’). |

----------------------------------------------------

HX77

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

When (were/was) (PERSON) most recently covered by this kind of

health insurance? That is, in what month and year did the

health insurance that paid for medical and doctor’s bills end

for the last time in {YEAR} or {YEAR}?

[Enter Month,Year-4] ................... {HX78}

REF ................................... -7 {HX78}

DK .................................... -8 {HX78}

----------------------------------------------------

| (FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES |

| AUTOMATICALLY): CAPI DISPLAYS THE TWO YEARS PRIOR |

| TO THE FIRST CALENDAR YEAR OF THE PANEL FOR |

| “‘YEAR’ OR ‘YEAR’?”. (FOR PANEL 12 FOR EXAMPLE, |

| THIS WOULD BE ‘2005 or 2006?’). |

----------------------------------------------------

| ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ARE ALLOWED |

| ON THE MONTH AND YEAR FIELDS. |

----------------------------------------------------

HX78

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

Was (PERSON)’s health insurance that ended in {DATE FROM

HX77/{YEAR} or {YEAR}} obtained through an employer or union, was

it a government program such as Medicare or Medicaid, or what?

CHECK ALL THAT APPLY.

OBTAINED THROUGH UNION, PRIVATE

EMPLOYER OR PUBLIC EMPLOYER (FEDERAL,

STATE, OR LOCAL GOVERNMENT) ............ 1

MEDICARE ............................... 2

MEDICAID ............................... 3

TRICARE/CHAMPVA ........................ 4

VA OR MILITARY HEALTH CARE ............. 5

PURCHASED DIRECTLY FROM GROUP,

ASSOCIATION, OR INSURANCE AGENT,

INSURANCE COMPANY OR HMO ............... 6

OTHER TYPE OF GOVERNMENT SPONSORED

PROGRAM ................................ 7

OTHER PUBLIC PROGRAM:

TANF ................................ 8

SSI ................................. 9

{STATE PROGRAM 1}................... 10

{STATE PROGRAM 2} .................. 11

{STATE PROGRAM 3} .................. 12

{STATE PROGRAM 4} .................. 13

OTHER ................................. 91 {HX78OV}

REF ................................... -7 {END_LP20}

DK .................................... -8 {END_LP20}

[Code All That Apply]

HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.

----------------------------------------------------

| IF HX77 IS NOT CODED ‘-7’ (REFUSED) OR ‘-8’ (DON’T|

| KNOW), DISPLAY THE DATE ENTERED AT HX77 FOR ‘MONTH|

| AND YEAR FROM HX77’. DISPLAY ‘in {YEAR} or |

| {YEAR}’ IF HX77 IS CODED ‘-7’ (REFUSED) OR ‘-8’ |

| (DON’T KNOW), WHERE “‘YEAR’ or ‘YEAR’” DISPLAYS |

| THE TWO YEARS PRIOR TO THE FIRST CALENDAR YEAR OF |

| THE PANEL. FOR PANEL 12 FOR EXAMPLE, THIS WOULD BE|

| ‘2005’ or ‘2006’. |

----------------------------------------------------

| FOR ‘STATE PROGRAM N’, DISPLAY AN ACTUAL NAME OF |

| STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A |

| STATE THAT HAS OTHER STATE PROGRAMS. FOR THE |

| SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON |

| HX16. |

----------------------------------------------------

| FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT |

| ALLOW ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IN |

| COMBINATION WITH ANY OTHER CODE. |

----------------------------------------------------

| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |

| WITH OTHER CODES, CONTINUE WITH HX78OV |

----------------------------------------------------

| OTHERWISE, GO TO END_LP20 |

----------------------------------------------------

HX78OV

======

OTHER:

[Enter Other Specify] .................. {END_LP20}

REF ................................... -7 {END_LP20}

DK .................................... -8 {END_LP20}

HX79

====

OMITTED.

HX80

====

OMITTED.

HX80OV

======

OMITTED.

END_LP20

========

----------------------------------------------------

| CYCLE ON NEXT PERSON ON ru-members-roster that |

| meetS the conditions stated in the loop definition|

----------------------------------------------------

| IF NO MORE PERSONS MEET THE STATED CONDITIONS, |

| END LOOP_20 AND CONTINUE WITH BOX_51 |

----------------------------------------------------

BOX_50

======

OMITTED.

LOOP_21

=======

OMITTED.

HX81

====

OMITTED.

END_LP21

========

OMITTED.

BOX_51

======

----------------------------------------------------

| GO TO NEXT QUESTIONNAIRE SECTION |

----------------------------------------------------

28-125

File Type	application/msword
File Title	MEPS Health Insurance - P12R5/P13R3/P14R1
Subject	HX Section Item Specifications
Author	Agency for Healthcare Research and Quality
Last Modified By	wcarroll
File Modified	2009-07-09
File Created	2009-07-09