COGNITIVE DRAFT
March 13, 2012
**** GET HOUSEHOLD ROSTER (** ASK Q1-9 of everyone in HH**)
1. What are the names of all people living or staying with you? Let’s start with you. (What is the name of the next person?) -- LIST ALL PEOPLE
2. How is (PERSON 2) related to you? (And how about (PERSON 3, etc))
[ ] SPOUSE/PARTNER
[ ] CHILD
[ ] GRANDCHILD
[ ] PARENT
[ ] BROTHER/SISTER
[ ] OTHER RELATIVE
[ ] FOSTER CHILD
[ ] ROOMMATE/HOUSEMATE
[ ] OTHER NON-RELATIVE
3. ASK IF NECESSARY: (Are you/is PERSON 2) male or female? (And how about PERSON 3, etc.)
[ ] MALE
[ ] FEMALE
4. What is your age? (And how about (PERSON 2, etc))
______ age
5. Are you of Hispanic, Latino, or Spanish origin? (And how about (PERSON 2, etc))
[ ] YES
[ ] NO
6. I’m going to read a list of 5 race categories. Please choose one or more races that you consider yourself to be: White; Black or African American; American Indian or Alaska Native; Asian; or Native Hawaiian or Other Pacific Islander. (And how about PERSON 2, etc. What does he/she consider himself/herself to be?)
[ ] White
[ ] Black or African American
[ ] American Indian or Alaska Native
[ ] Asian
[ ] Native Hawaiian or Other Pacific Islander.
7. ASK ONLY FOR PEOPLE AGE 15+: What is the highest degree or level of school you have completed? (And how about (PERSON 2, etc))
[ ] No schooling
[ ] Nursery school to 6th grade
[ ] 7th – 8th grade
[ ] 9th – 11th grade
[ ] 12th grade – NO DIPLOMA
[ ] High School graduate or the equivalent (for example: GED)
[ ] some college – NO DEGREE
[ ] Associates degree
[ ] Bachelor’s degree
[ ] Some graduate school – NO DEGREE
[ ] Master’s degree
[ ] Professional or Doctorate degree
8. ASK ONLY FOR PEOPLE AGE 15+: Did you ever serve on active duty in the US Armed Forces? (And how about (PERSON 2, etc))
[ ] Yes
[ ] No
9. READ ONLY IF NECESSARY/ASK ONLY FOR PEOPLE AGE 15+: Are you now married, widowed, divorced, separated, or never married?
[ ] Married
[ ] Widowed
[ ] Divorced
[ ] Separated
[ ] Never married
10.
Is (your/the combined) total annual income (of all of your family members living in this household) above or below [FILL NUMBER FROM CHART]
[ ] Above
[ ] Below
[ ] DK/REF
(UPDATED #s)
1 person |
$11,000 |
2 people |
$15,000 |
3 |
$18,000 |
4 |
$23, 000 |
5 |
$27,000 |
6+ |
$31,000 |
These next questions are about health coverage. I'll be asking you about coverage from January, 2011 up until now. First I’d like to ask you about yourself.
A2. Do you NOW have any type of health plan or health coverage?
[ ] YES (SKIP TO B1)
[ ] NO
A3. Are you NOW covered by Medicaid, Medical Assistance, CHIP, or any other kind of government assistance program that helps pay for health care?
READ IF NECESSARY: An example of a government program in Massachusetts is MassHealth
[ ] YES (SKIP TO B14)
[ ] NO
A4. Are you NOW covered by any kind of health plan, such as MassHealth?
[ ] YES (SKIP TO B14)
[ ] NO
A5. Are you NOW covered by any kind of health plan through the Health Connector, such as Commonwealth Care or Commonwealth Choice?
[ ] YES (SKIP TO B12)
[ ] NO
A6. OK, I have recorded that you are not covered by any kind of health plan or health coverage. Is that correct?
[ ] YES – NOT COVERED (ASK A7)
[ ] NO
A7. And how about any plans during 2011? WERE you covered by any type of health plan or health coverage AT ANY TIME between January 2011 and now?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
[ ] Yes (ASK PAST LOOP SERIES FOR COGNITIVES)
[ ] No (SKIP TO PERSON 2)
[ ] DK/REF (SKIP TO PERSON 2)
Section B: Plan Type (Current Loop)
B1. In order to better understand peoples’ health care needs, we’d like to learn more about how you get that coverage. Is it provided through a job, the government, the state or some other way?
PROBE: "Job" includes coverage from someone’s own job as well as coverage from a spouse’s or parent’s job.
PROBE: Include coverage through former employers and unions, and COBRA plans.
PROBE: If this coverage is provided through a job with the government or the military, consider that coverage through a job.
[ ] JOB - current or former (SKIP TO B6)
[ ] GOVERNMENT (SKIP TO B5)
[ ] STATE (SKIP TO B5)
[ ] OTHER
B2. How is that coverage provided? Is it through a parent or spouse, do you buy it yourself, or do you get it some other way?
PROBE: If a parent/spouse buys the coverage, then code “Buy it”.
[ ] PARENT/SPOUSE (SKIP TO B9)
[ ] BUY IT (SKIP TO B9)
[ ] OTHER
B3. Is it provided through a former employer, a union or business association, or some other way?
[ ] FORMER EMPLOYER (SKIP TO B9)
[ ] UNION/BUSINESS ASSOC (SKIP TO B9)
[ ] OTHER (CONTINUE TO B4)
[ ] DK/REF (SKIP TO B11)
B4. Is it provided through the Indian Health Service, a school or some other way?
[ ] INDIAN HEALTH SERVICE (SKIP TO C1)
[ ] SCHOOL (SKIP TO B9)
[ ] OTHER (SKIP TO B11)
B5. Is or was that coverage related to a JOB with the (government/state)?
PROBE: Include coverage through FORMER employers and unions, and COBRA plans.
[ ] YES
[ ] NO (SKIP TO B7)
B6. Is that plan related to military service in any way?
[ ] YES (SKIP TO B8)
[ ] NO (SKIP TO B9)
[ ] DK/REF (SKIP TO B9)
B7. What type of government plan is it – Medicaid, Medical Assistance or CHIP, Medicare, military or VA care, or something else?
READ IF NECESSARY: An example of a government program in Massachusetts is MassHealth
[ ] Medicaid, Medical Assistance, CHIP (SKIP TO B11)
[ ] MEDICARE (SKIP TO C1)
[ ] MILITARY/VA care
[ ] OTHER (SKIP TO B11)
[ ] DK/REF (SKIP TO B11)
B8. Which plan are you covered by? Is it TRICARE, TRICARE for Life, CHAMPVA, VA care,
military health care, or something else?
[ ] TRICARE
[ ] TRICARE for Life
[ ] CHAMPVA
[ ] VA CARE
[ ] MILITARY HEALTH CARE
[ ] OTHER
B9. Who is the policyholder?
[ ] SELF
SOMEONE IN HOUSEHOLD
[ ] SPOUSE
[ ] PARENT
[ ] OTHER: WRITE IN RELATIONSHIP: _________________________ (SKIP TO B15CHK)
[ ] SOMEONE NOT IN HOUSEHOLD: WRITE IN RELATIONSHIP: _____(SKIP TO B15CHK)
B10CHK1: DOES B2=PARENT/SPOUSE?
[ ] YES (SKIP TO B10)
[ ] NO
B10CHK2: DOES B2=”BUY IT”
[ ] YES (SKIP TO B12)
[ ] NO (SKIP TO B15CHK)
B10. And is that coverage provided through their job, do they buy it themselves, or do they get it some other way?
[ ] JOB (SKIP TO B15)
[ ] BUY IT (SKIP TO B12)
[ ] OTHER
[ ] DK
B11. What do you call the program?
PROBE: IF R ANSWERS WITH PLAN NAME: OK, so that would be the plan name. What do you call the program? Some examples of programs in Massachusetts are MassHealth, Commonwealth Care, Commonwealth Choice and Commonwealth Bridge.”?
< 1 > Medicaid
< 2 > Medical Assistance
< 3 > S-CHIP or CHIP (the State Children’s Health Insurance Program)
< 4 > MASS HEALTH
< 12 > COMMONWEALTH CARE (SKIP TO B17-2)
< 13 > COMMONWEALTH CHOICE (SKIP TO B17-1)
< 14 > COMMONWEALTH BRIDGE (SKIP TO B17-1)
< 18 > Other plan through the Health Connector (SKIP TO B17-1)
< 19 > other government plan
< 20 > OTHER: WRITE IN NAME: _________________________
<xx> FREECARE (SKIP TO E2)
B12. Is it a plan through the Health Connector, such as Commonwealth Care or Commonwealth Choice?
[ ] YES
[ ] NO (SKIP TO B14)
[ ] DK (SKIP TO B14)
B13. Which plan is it – Commonwealth Care, Commonwealth Choice, or Commonwealth Bridge?
[ ] COMMONWEALTH CARE WRITE IN PLANTYPE & SKIP TO B17-2
[ ] COMMONWEALTH CHOICE WRITE IN PLANTYPE & SKIP TO B17-1
[ ] COMMONWEALTH BRIDGE WRITE IN PLANTYPE & SKIP TO B17-1
[ ] DK/REF WRITE IN “Other plan through the Health Connector” & SKIP TO B17-1
B14. Did someone at a hospital, health clinic or social service agency help (you/POLICYHOLDER) get the coverage?
[ ] YES
[ ] NO
[ ] DK
B15CHK: Is Coverage Job or Union Based?
B1=JOB B3=Former employer OR UNION B5=YES B10 = JOB
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B15. Does (POLICYHOLDER’S) employer or union pay for all, part, or none of the health insurance premium?
NOTE: Report here employer's contribution to employee's health insurance premiums, not the employee's medical bills.
[ ] ALL
[ ] PART
[ ] NONE
[ ] DK
B16. Small businesses can offer health coverage to their employees through the Health Connector. Did [policyholder] get their coverage through the employee section of the Health Connector?
[ ] YES (SKIP TO C1)
[ ] NO (SKIP TO C1)
[ ] DK (SKIP TO C1)
B17-1. Do you pay a monthly premium – a fixed amount of money each month to have the health coverage?
[ ] YES
[ ] NO (SKIP TO C1)
[ ] DK (SKIP TO C1)
B18-1. Some people who get their coverage through the Health Connector pay a reduced or discounted monthly premium. Is your monthly premium reduced or discounted?
[ ] YES (SKIP TO C1)
[ ] NO (SKIP TO C1)
[ ] DK (SKIP TO C1)
B17-2. Do you pay a monthly premium – a fixed amount of money each month to have the health coverage?
[ ] YES
[ ] NO (SKIP TO C1)
[ ] DK (SKIP TO C1)
B18-2. Some people who get their coverage through [fill plan selected in GOVPLAN] pay a reduced or discounted monthly premium. Is your monthly premium reduced or discounted?
[ ] YES
[ ] NO
[ ] DK
Section C: Months of Coverage (Current Loop)
C1. Did that coverage start before or after January 1, 2011?
PROBE: Your best estimate is fine.
PROBE: When we say ‘that coverage’ we mean any coverage [you/policyholder] buys. So if [you/policyholder] switched plans but they were all bought, we still consider this all the same coverage.
PROBE: This question refers to PLANTYPE
[ ] Before January 1, 2011 (SKIP TO C4b)
[ ] On or after January 1, 2011
[ ] DK (SKIP TO C8)
C2. In what month did that coverage start?
PROBE: This question refers to PLANTYPE
______________ MONTH
[ ] DK (SKIP TO C8)
C3. And what year was that?
[ ] 2011
[ ] 2012
[ ] DK (SKIP TO C8)
C4a. And has it been continuous since [FILL C2/C3]?
PROBE: This question refers to PLANTYPE
[ ] YES (SKIP TO C9)
[ ] NO (SKIP TO C5)
[ ] DK (SKIP TO C5)
C4b. And has it been continuous since January, 2011?
PROBE: This question refers to PLANTYPE
[ ] YES (SKIP TO C9)
[ ] NO
[ ] DK
C5. In what month did this most recent spell of coverage start?
PROBE: This question refers to PLANTYPE
PROBE: Your best estimate is fine.
______________ MONTH
[ ] DK (SKIP TO C8)
C6. And what year was that?
[ ] 2011
[ ] 2012
[ ] DK (SKIP TO C8)
C7CHK: HOW DID R ANSWER C1?
[ ] Before January 2011
[ ] After January 2011 (SKIP TO C7b)
NOTE: PLANTYPE = PLANTYPE in original and PLANTYPE2=PLANOR
C7a. A little earlier you mentioned you were covered by [PLANTYPE] at some point before January 2011
and I’ve just recorded that you were also covered from [fill C5/C6] until now.
Were there any other months between January 2011 and [fill C5/C6] that you were also covered [PLANTYPE2]?
[ ] YES (SKIP TO C8b)
[ ] NO (SKIP TO C9)
[ ] DK/REF (SKIP TO C9)
C7b. A little earlier you mentioned you were covered by [PLANTYPE] in [fill C2/C3]
and I’ve just recorded that you were also covered from [fill C5/C6] until now.
Were there any other months between January 2011 and [fill C5/C6] that you were also covered [PLANTYPE2]?
[ ] YES (SKIPT TO C8b)
[ ] NO (SKIP TO C9)
[ ] DK/REF (SKIP TO C9)
C8. What months in 2012 were you covered by [PLANTYPE2]? How about any (other) months in 2011?
C8b. What other months in 2012 were you also covered [PLANTYPE2]? How about any (other) months in 2011?
[ ] January 2011 [ ] Feb 2011 [ ] March 2011 [ ] April 2011 [ ] May 2011 [ ] June 2011 [ ] July 2011 [ ] August 2011 [ ] Sept 2011 [ ] Oct 2011 [ ] Nov 2011 [ ] Dec 2011 |
[ ] January 2012 [ ] Feb 2012 [ ] March 2012 [ ] April 2012 [ ] May 2012 [ ] June 2012 [ ] July 2012 [ ] August 2012
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C9. INT CHECK: DOES THIS HOUSEHOLD HAVE 2 OR MORE MEMBERS?
[ ] YES
[ ] NO (SKIP TO E1CHK)
Section D: Additional Household Members Covered by Plan/Plan type (Current Loop)
D1. And is anyone else in this household also covered by [PLANTYPE2]?
[ ] YES
[ ] NO (SKIP TO E1CHK)
[ ] DK/REF (SKIP TO E1CHK)
D2. Who? (Who else is covered by [PLANTYPE2])? (Anyone else?)
___________________________________
___________________________________
___________________________________
D3CHK: ANSWER TO C4 (CONTINUOUS COVERAGE)
[ ] YES
[ ] NO (SKIP TO D4)
D3.
And was {NAME from D2} also covered from January 2011 until now?
And was {NAME FROM D2} also covered from [fill C2/C3] until now
And were [NAMEs from D2] all also covered from January, 2011 until now?
And were [NAMEs from D2] all also covered from [fill C2/C3] until now?
[ ] Yes (
[ ] NO
[ ] DK/REF
Section E: Additional Current and Past Plans
E1CHK: Are there any gaps in coverage (based on cheat sheet grid)
[ ] Yes
[ ] NO (SKIP TO E2)
E1. Ok so far I have recorded that you were covered by [PLANTYPE] in [fill months from cheat sheet grid]. What about [months not covered]? Were you covered by any type of health plan or health coverage in [that/those] month(s)?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
[ ] Yes (WILL NOT ASK PAST LOOP SERIES FOR COGNITIVES)
[ ] No
[ ] DK/REF
E2. Ok other than PLANTYPE do you NOW have any other type of health plan or health coverage?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
[ ] Yes (WILL NOT ASK CONCURRENT SERIES FOR COGNITIVES)
[ ] No
[ ] DK/REF
E3CHK HOW DID R ANSWER E1?
[ ] YES/SKIPPED (SKIP TO COGNITIVE PROBES)
[ ] NO/DK/REF
E3. And how about any other plans during 2011? Other than PLANTYPE WERE you covered by any other type of health plan or health coverage AT ANY TIME between January 2011 and now?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
[ ] Yes (WILL NOT ASK PAST LOOP SERIES FOR COGNITIVES)
[ ] No
[ ] DK/REF
ASK COGNITIVE PROBES – SET 1 HERE……
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EXTRA QUESTIONS (to be asked after probing Sections A-E)
ENGLISH PROFICIENCY
X1. Do you speak a language other than English at home?
[ ] Yes
[ ] No (SKIP TO X6)
X2. What is this language? _________
X3. How well do you speak English?
[ ] Very well
[ ] Well
[ ] Not well
[ ] Not at all
GETTING INFORMATION ABOUT HEALTH COVERAGE
X4. Where did you apply for your current health insurance – was it at work, online, at a hospital or clinic, or somewhere else?
[ ] Work (SKIP TO X6)
[ ] Online
[ ] Hospital/Clinic
[ ] Somewhere else Where? _______________________________
X5. Did someone help you with the application?
[ ] Yes Who helped you?
[ ] No
X6. Think about where you got information about your health coverage or health plan. In the past year, how much information did you get about your health coverage or health plan from {READ A} - did you get a lot, some, a little, or none?
a. The Health Connector website?
(if Spanish: Was the information mainly in Spanish, mainly in English or about the same amount in both languages?)
b. The Health Connector phone helpline?
(if Spanish: Was the information mainly in Spanish, mainly in English or about the same amount in both languages?)
c. Financial counselors at a hospital or clinic?
(if Spanish: Was the information mainly in Spanish, mainly in English or about the same amount in both languages?)
d. A community organization – like Healthcare for All?
(if Spanish: Was the information mainly in Spanish, mainly in English or about the same amount in both languages?)
e. Somewhere else Where?
X7. (for Spanish only) How much difficulty did you have finding information in Spanish about…
Your health insurance coverage? Little or none / Some / A lot
How to apply for insurance?
How to renew or reapply for your health coverage?
USE OF MEDICAL SERVICES
X8. In the last fifteen months, that is since January 1, 2011, have you seen a doctor or any other health care provider for care for yourself (or any of your children)?
[ ] Yes
[ ] No --> Have you (or any of your children) received any kind of medical care or services since January 1, 2011?
[ ] Yes
[ ] No
ASK COGNITIVE PROBES – SET 2 HERE……
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IF THERE IS TIME: QUESTIONS ABOUT INSURANCE OF OTHER HOUSEHOLD MEMBERS
F1. INTERVIEWER CHECK: LOOK AT CHEAT SHEET FOR PERSON 2 – DO YOU ALREADY KNOW SOMETHING ABOUT INSURANCE FOR PERSON 2 (SHARED PLANS) ?
[ ] YES
[ ] NO ASK ENTIRE SERIES OF SECTIONS A-E
F2. Now I’d like to ask about {NAME OF PERSON 2}. Other than PLANTYPE does (he/she) NOW have any other type of health plan or health coverage?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
[ ] Yes (WILL NOT ASK CONCURRENT SERIES FOR COGNITIVES)
[ ] No
[ ] DK/REF
F3. And how about any other plans during 2011? Other than PLANTYPE was (he/she) covered by any other type of health plan or health coverage AT ANY TIME between January 2011 and now?
PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.
[ ] Yes (WILL NOT ASK PAST LOOP SERIES FOR COGNTIVIES)
[ ] No
[ ] DK/REF
**********REPEAT F1, F2, & F3 FOR EACH OTHER HOUSEHOLD MEMBER ************
**** THERE ARE NO PROBES FOR THESE QUESTIONS ****
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jo Pascale |
| File Modified | 0000-00-00 |
| File Created | 2021-02-02 |