HEALTH COVERAGE QUESTIONNAIRE
Do you NOW have any type of health plan or health coverage?
Yes Go to #2
No STOP HERE
In order to better understand the health care needs of Americans, we’d like to learn more about how you get that coverage. Is it provided through a job, the government, or some other way?
Job Go to #8 (on back)
Government Go to #6
Other way Go to #3
How is that coverage provided? Is it through a parent or spouse, do you buy it yourself, or is it through
some other source?
Parent or spouse Go to #5
Buy it myself How do you get your coverage? _________________________ STOP HERE
Some other way Go to #4
Is it provided through a former employer, a union or business association, or some other way?
Former employer Go to #8
Union or business association Go to #8
Some other way How do you get your coverage? _______________________ STOP HERE
And is that coverage provided through their job, do they buy it themselves, or do they get it some other
way?
Job STOP HERE
Buy it themselves How do they get the coverage? ______________________ STOP HERE
Some other way How do they get that coverage? _______________________ STOP HERE
Is that coverage related to a JOB with the government?
Yes Go to #8
No Go to #7
What type of government plan is it – Medicaid, Medical Assistance or S-CHIP, Medicare, military or Veterans Administration coverage, or something else?
Medicaid, Medical Assistance, SCHIP STOP HERE
Medicare STOP HERE
Military or Veterans Administration care STOP HERE
Other What type of coverage is it? __________________________________ STOP HERE
Who is the policyholder? _____________________________ STOP HERE
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | pasca001 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-02 |