Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Medicare Current Beneficiary Survey (MCBS)

Attachment 4 Questionnaire Comprehensive Format Section by Section HIS_05.01.0000

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

OMB: 0938-0568

Document [pdf]
Download: pdf | pdf
HISINTRO

HISINTRO

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

HISINT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

20

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:
Question Text:	

Now I'd like to review with you the information that we have about
health insurance plans that [you/(SP)] had at the time of the last
interview.

Int. Instr II:
INPUT FIELDS / ROUTING

10:36:13 AM Friday, February 13, 2009	

Page 1 of 190

HISINTRO
HISINT

Field1:

( HIS1020 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS1 - HISCORR ( HIS1030 )

English text: CONTINUE
Attribute
Empty

Route
HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:36:17 AM Friday, February 13, 2009

Page 2 of 190

HIS1

HIS1

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

HISCORR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

30

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If SP was covered by any other health insurance plan that was
"current" at the time of the previous round interview in addition to
Medicare, display "[You/(SP)] had Medicare coverage and (you
were/he was/she was) also covered by [READ PLAN NAMES
BELOW]."
Else display statement "The only health insurance coverage
[you/(SP)] had was Medicare."
If SP was covered by a Medicare Managed Care Plan that was
"current" at the time of the previous round interview, display,
"through a managed care plan."
Else do not display.
If HIS1 is displayed more than once, display "Let's see if there are
any other changes we need to make to the health insurance
coverage [you/(SP)] had as of (REFERENCE DATE)."
Else do not display.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

Display report below question text.
Display all health insurance plans that were "current" at the time of

10:36:20 AM Friday, February 13, 2009

Page 3 of 190

HIS1
the previous round interview. Display these plans in the following

order:

First line:

If SP was covered by a Medicare Managed care plan, display name

of this Medicare Managed care plan.

Else display "MEDICARE" for the Medicare plan.

Next list Medicaid, Tricare, all Public Plans, all Private Plans and all

Medicare Prescription Drug Plans. If there is more than one plan of

any type, display in order of entry.

Report header: PLANS AS OF (REFERENCE DATE)

Report layout:

Column 1, header="Plan Name", display PLAN.PLNAME.

Column 2, header="Plan Type", display PLAN.PLANTYPE.

If PLANTYPE=1/Medicare, display "(MCAR)".

If PLANTYPE=2/Medicaid, display "(MCAD)".

If PLANTYPE=3/PublicPlan, display "(PUBL)".

If PLANTYPE=4/PrivatePlan, display "(PRIV)".

If PLANTYPE=5/MHMO, display "(MHMO)".

If PLANTYPE=6/Tricare, display "(TRIC)".

If PLANTYPE=7/MPDP, display "(MPDP)".


TEXT:
Context Header:
Int. Instr I:
Question Text:

[Let’s see if there are any other changes we need to make to the
health insurance coverage [you/(SP)] had as of (REFERENCE
DATE).] [(You/(SP)] had Medicare coverage (through a managed
care plan) and (you were/he was/she was) also covered by [READ
PLAN NAMES BELOW]./The only health insurance coverage
[you/(SP)] had was Medicare (through a managed care plan)] on
(REFERENCE DATE). Is that correct?

Int. Instr II:
INPUT FIELDS / ROUTING

10:36:23 AM Friday, February 13, 2009

Page 4 of 190

HIS1
HISCORR

Field1:

( HIS1030 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
THISCorrect
1
No
No

Number Label
1 Yes

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISCLOSE - ENDHIS ( HIS3340 )

2

English text: YES, ALL CORRECT AS SHOWN
NoPlanMissing
HIS3 - ADDHITYPE ( HIS1110 )

3

English text: NO, PLAN MISSING
NoNameIncorrect

HIS2B - PLAN_CORRECT ( HIS1065 )

4

English text: NO, PLAN NAME INCORRECT
NoPlanDelete

HIS2 - PLAN_DELETION ( HIS1040 )

English text: NO, PLAN NEEDS DELETION
Attribute
Don't know

Route
HISCLOSE - ENDHIS ( HIS3340 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
Edit #1:

Note: This soft edit message should be displayed if

HISCORR=2/NoPlanMissing.

HISCORR = 1/Yes, 3/NoNameIncorrect, 4/NoPlanDelete, or DK.

If not true, display message "VERIFY THAT THE SP WAS

COVERED BY PLAN ON (REFERENCE DATE)."

Edit #2:

Note: This soft edit should be displayed if

HISCORR=4/NoPlanDelete.

HISCORR = 1/Yes, 2/NoPlanMissing, 3/NoNameIncorrect, or DK.

If not true, display message "VERIFY THAT THE SP WAS NOT

10:36:31 AM Friday, February 13, 2009

Page 5 of 190

HIS1
COVERED BY PLAN ON (REFERENCE DATE)."
HARD EDIT CHECKS
Edit #1:

Note: The following edit disallows Medicare from being deleted.

If the SP was not covered by any other plans that were "current" at 

the time of the previous round interview, besides Medicare, 

HISCORR should ^= 4/NoPlanDelete.

If not true, display message "YOU CANNOT DELETE MEDICARE. 

PLEASE SELECT ANOTHER RESPONSE."

Edit #2:

Note: The following edits disallows a Medicare Managed Care plan

that was loaded by CMS to be edited or deleted.

If the SP was covered by a Medicare Managed Care plan that was

loaded from CMS, and was not covered by any other plans at the 

time of the previous round interview, besides Medicare and this

Medicare Managed Care plan that was loaded from CMS, HISCORR

should ^= 3/NoNameIncorrect and should ^= 4/NoPlanDelete.

If not true, display message "YOU CANNOT EDIT OR DELETE

(MEDICARE MANAGED CARE PLAN NAME). PLEASE SELECT

ANOTHER RESPONSE."

Edit #3:

Note: The following edit disallows Medicare, Medicaid or Tricare

from being edited.

If the SP was not covered by any other plans that were "current" at 

the time of the previous round interview, besides Medicare, Medicaid

and/or Tricare, HISCORR should ^= 3/NoNameIncorrect.

If not true, display message "YOU CANNOT EDIT MEDICARE, 

MEDICAID, OR TRICARE. PLEASE SELECT ANOTHER

RESPONSE."

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

51

MHMOCurrPrevRnd

Medicare Managed Care plan "current" at time of
previous round interview =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

10:36:31 AM Friday, February 13, 2009

Page 6 of 190

HIS1
67

MedicaidCurrentPrevRn
d

Medicaid "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid
and PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

72

TricareCurrentPrevRnd

Tricare "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round and
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

80

PublicCurrentPrevRnd

Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

81

PrivateCurrentPrevRnd

Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

343

MPDPCurrPrevRnd	

Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:36:31 AM Friday, February 13, 2009	

Page 7 of 190

HIS2

HIS2

Page Order # :

Design Screen Type:

Roster

Fields:	

Field 1:

PLAN_DELETION

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Plan Roster

Roster Type:

Single Item Select

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

40

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:	

Display all health insurance plans that were "current" at the time of
the previous round interview.
Display plans in the order of entry.

Display the following "current" plans as protected rows:

Medicare

Medicare Managed Care plan, if loaded by CMS.


Roster/Grid display:	

10:36:32 AM Friday, February 13, 2009	

COL #

HEADER

INSTRUCTIONS

1

Plan Name	

Display PLAN.PLNAME.

2

Plan Type	

Display PLAN.PLANTYPE:
1/Medicare, display "(MCAR)"
2/Medicaid, display "(MCAD)"
3/PublicPlan, display "(PUBL)"
4/PrivatePlan, display "(PRIV)"
5/MHMO, display "(MHMO)"
6/Tricare, display "(TRIC)"
7/MPDP, display "(MPDP)".

3

Plan Status	

Display PREVIOUS ROUND PLAN
STATUS.

Page 8 of 190

HIS2
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

What is the name of the plan that needs deletion?


Int. Instr II:

SELECT ONLY ONE PLAN FOR DELETION AT THIS ROSTER.


INPUT FIELDS / ROUTING

Field1:

PLAN_DELETION

( HIS1040 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:


String
TPlanPick8
1

No
No


Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:


8

Route
HIS2A - PLANDVB ( HIS1060 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Provider selected at HIS2.
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Provider selected at HIS2.
PLRO.PLRORND = previous round.
Set "PLAN DELETED" flag on PLAN selected at HIS2. See detailed instructions below:
PLANDFLG

Set PLAN.PLANDFLG=1/Yes.

SOFT EDIT CHECKS

HARD EDIT CHECKS

10:36:34 AM Friday, February 13, 2009

Page 9 of 190

HIS2
TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

51

MHMOCurrPrevRnd

Medicare Managed Care plan "current" at time of
previous round interview =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

67

MedicaidCurrentPrevRn
d

Medicaid "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid
and PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

72

TricareCurrentPrevRnd

Tricare "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round and
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

80

PublicCurrentPrevRnd

Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

81

PrivateCurrentPrevRnd

Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

143

MHMOLoadedCMS

Medicare Managed Care plan loaded by CMS =
There is PLAN where PLAN.PLANTYPE=5/MHMO and
PLAN.MHMOLRND ^= empty.

10:36:34 AM Friday, February 13, 2009

Page 10 of 190

HIS2
343

MPDPCurrPrevRnd	

Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
HIS2 allows only 1 plan to be selected. It does not use the DELETE
function to delete plan. Instead, we set a "PLAN DELETED" flag on the
plan that has been selected.

10:36:34 AM Friday, February 13, 2009	

Page 11 of 190

HIS2A

HIS2A

Page Order # :

Design Screen Type:

Verbatim Text

Fields:

Field 1:

PLANDVB

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

60

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

Int. Instr II:

BRIEFLY EXPLAIN WHY PLAN NEEDS DELETION.


INPUT FIELDS / ROUTING


10:36:35 AM Friday, February 13, 2009

Page 12 of 190

HIS2A

Field1:

PLANDVB

( HIS1060 )

NONE

Cheshire Name:

REPLACES VB FIELDS IN CHESHIRE:
PLAN.PLANDVB1

PLAN.PLANDVB2

PLAN.PLANDVB3

PLAN.PLANDVB4

Item Text display:
Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Open
TOpen180
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

180

Route
HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:36:36 AM Friday, February 13, 2009

Page 13 of 190

HIS2B

HIS2B

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

PLAN_CORRECT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Plan Roster

Roster Type:

Multiple Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

Yes
No

No


Add Line
Delete Line

No
No

Grid Functions:

75

Display as ' Edit a Plan '


DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:	

Display all health insurance plans that were "current" at the time of
the previous round interview.
Display plans in the order of entry.
Display the following "current" plans as protected rows:
Medicare
Medicare Managed Care plan, if loaded by CMS
Medicaid
Tricare
SELECTION IS NOT REQUIRED ON THIS ROSTER.

Roster/Grid display:	

COL #
1

10:36:37 AM Friday, February 13, 2009	

HEADER
Plan Name

INSTRUCTIONS
Display PLAN.PLNAME.

Page 14 of 190

HIS2B
2

Plan Type	

Display PLAN.PLANTYPE:
1/Medicare, display "(MCAR)"
2/Medicaid, display "(MCAD)"
3/PublicPlan, display "(PUBL)"
4/PrivatePlan, display "(PRIV)"
5/MHMO, display "(MHMO)"
6/Tricare, display "(TRIC)"
7/MPDP, display "(MPDP)".

3

Plan Status	

Display PREVIOUS ROUND PLAN
STATUS.

Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

What is the name of the plan that is incorrect?


Int. Instr II:

EDIT ALL PLAN NAMES AT THIS ROSTER.


INPUT FIELDS / ROUTING

Field1:	
Cheshire Name:

PLAN_CORRECT

( HIS1065 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:


String
TPlanPick32
1

No
No


Number Label	
1 [Continuous answer.]	

FieldSize:
Min Value:

Max Value:

Mask:


32

Route
HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:

PLAN key = PLAN.PLANBASE + PLAN.PLANNUM

PLAN.PLANNUM = Number of Plan selected at HIS2B.

PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND

10:36:39 AM Friday, February 13, 2009	

Page 15 of 190

HIS2B
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS2B.
PLRO.PLRORND = previous round.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

51

MHMOCurrPrevRnd

Medicare Managed Care plan "current" at time of
previous round interview =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

67

MedicaidCurrentPrevRn
d

Medicaid "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid
and PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

72

TricareCurrentPrevRnd

Tricare "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round and
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

80

PublicCurrentPrevRnd

Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

10:36:39 AM Friday, February 13, 2009

Page 16 of 190

HIS2B
81

PrivateCurrentPrevRnd	

Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

143

MHMOLoadedCMS	

Medicare Managed Care plan loaded by CMS =
There is PLAN where PLAN.PLANTYPE=5/MHMO and
PLAN.MHMOLRND ^= empty.

343

MPDPCurrPrevRnd	

Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
HIS2B should only allowing editing of Plan Names. If a PLAN is selected
when the interviewer exits the roster, do not save.

10:36:39 AM Friday, February 13, 2009	

Page 17 of 190

HIS3

HIS3

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

ADDHITYPE

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

80

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

What type of insurance plan needs to be added?


Int. Instr II:

INPUT FIELDS / ROUTING


10:36:42 AM Friday, February 13, 2009

Page 18 of 190

HIS3
ADDHITYPE

Field1:

( HIS1110 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TADDHIType
1
No
No

Number Label
1 Medicaid

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS2AA - (HIS1575 )

2

English text: MEDICAID/MEDICAID MANAGED CARE PLAN
PublicPlan
HIS12 - PLAN_HISPUBLIC ( HIS2280 )

3

English text: PUBLIC PLAN OTHER THAN MEDICAID
PrivatePlan
HIS20 - PLAN_HISPRIVATE ( HIS2630 )

4

English text: PRIVATE HEALTH INSURANCE PLAN
MHMO
HISMC1 - PLAN_HISMHMO ( HIS1130 )

5

English text: MEDICARE ADVANTAGE PLAN
Tricare
BOX HIST1A - (HIS1935 )

6

English text: TRICARE
MPDP

HIS34 - PLAN_HISMPDP ( HIS3331 )

English text: MEDICARE PRESCRIPTION DRUG PLAN

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
Edit #1:

Note: SP can only have one Medicaid plan during a round:

If SP had Medicaid anytime during the previous round, ADDHITYPE

should = 2/PublicPlan, 3/PrivatePlan, 4/MHMO, 5/Tricare, or

6/MPDP.

If not true, display message: "MEDICAID ALREADY ON PLAN

ROSTER FOR PREVIOUS ROUND. SELECT ANOTHER PLAN 

TYPE."

10:36:49 AM Friday, February 13, 2009

Page 19 of 190

HIS3
Edit #2:

Note: SP can only have one Tricare plan during a round:

If SP had Tricare anytime during the previous round, ADDHITYPE

should = 1/Medicaid, 2/PublicPlan, 3/PrivatePlan, 4/MHMO, or

6/MPDP.

If not true, display message: "TRICARE ALREADY ON PLAN

ROSTER FOR PREVIOUS ROUND. SELECT ANOTHER PLAN 

TYPE."

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

150

MCaidAnyTimePrevRnd

SP covered by Medicaid anytime during previous round =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.

151

TricarAnyTimePrevRnd

SP covered by Tricare anytime during the previous round
=
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:36:49 AM Friday, February 13, 2009

Page 20 of 190

HISMC1

HISMC1

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

PLAN_HISMHMO

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Plan Roster

Roster Type:

Single Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:

Add Line
Delete Line

No
No

100

Display as ' Add a Plan '
Display as ' Edit a Plan '

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:

Display all health insurance plans from the Plan Roster.
Display plans in order of entry.
Display the following plans as protected rows:
Medicare plan
Medicare Managed Care plan if "current" at the time of the previous
round interview
Medicaid
Tricare
Public Plans
Private Plans
Medicare Prescription Drug Plans

Roster/Grid display:

COL #
1

10:36:50 AM Friday, February 13, 2009

HEADER
Plan Name

INSTRUCTIONS
Display PLAN.PLNAME.

Page 21 of 190

HISMC1
2

Plan Type

Display PLAN.PLANTYPE:
1/Medicare, display "(MCAR)"
2/Medicaid, display "(MCAD)"
3/PublicPlan, display "(PUBL)"
4/PrivatePlan, display "(PRIV)"
5/MHMO, display "(MHMO)"
6/Tricare, display "(TRIC)"
7/MPDP, display "(MPDP)".

3

Plan Status

Display PREVIOUS ROUND PLAN
STATUS.

Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

What is the name of the Medicare Advantage Plan that covered
[you/(SP)]?

Int. Instr II:

SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT
THIS ROSTER.

INPUT FIELDS / ROUTING

Field1:

PLAN_HISMHMO

( HIS1130 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TPlanPick32
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

32

Route
HISMC2 - HISMHMOCURR ( HIS1140 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:

PLAN key = PLAN.PLANBASE + PLAN.PLANNUM

PLAN.PLANNUM = Number of Plan selected at HIS2.


10:36:52 AM Friday, February 13, 2009

Page 22 of 190

HISMC1
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS2.
PLRO.PLRORND = previous round.
If Plan added, see PLAN ROSTER POP-UP specifications for pop-up window programming
instructions:
Variables populated in Plan Roster Pop-Up Window:
PLAN.PLANNUM
PLAN.PLANRNDC
PLAN.PLANTYPE
PLAN.PLNAME
For Plan selected, create previous round PLRO where PLRO.PLROPLAN =
PLAN.PLANNUM of plan selected at HISMC1 and PLRO.PLRORND = previous round.
HISMC2 and remaining PLAN details will be stored on this previous round PLRO.
Previous round PLRO may already exist.
See additional instructions below:
PLANTYPE	

If Plan is added at HISMC1, set
PLAN.PLANTYPE=5/MHMO.

PLANRNDC	

If Plan is added at HISMC1, set PLAN.PLANRNDC =
current round.

PLANSUMM	

If Plan is added at HISMC1, set
PLAN.PLANSUMM=1/Yes.

COVANYTM	

PLRO.COVANYTM=1/Yes for plan selected at
HISMC1.

PLROPLAN	

PLRO.PLROPLAN = PLAN.PLANNUM of plan
selected at HISMC1.

PLRORND	

PLRO.PLRORND = previous round.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

10:36:52 AM Friday, February 13, 2009	

Page 23 of 190

HISMC1
51

MHMOCurrPrevRnd	

Medicare Managed Care plan "current" at time of
previous round interview =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:36:52 AM Friday, February 13, 2009	

Page 24 of 190

HISMC2

HISMC2

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

HISMHMOCURR

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

110

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

[Were you/Was (SP)] covered by or enrolled in (MEDICARE

MANAGED CARE PLAN NAME) on (REFERENCE DATE)?

Int. Instr II:
INPUT FIELDS / ROUTING

10:36:55 AM Friday, February 13, 2009	

Page 25 of 190

HISMC2
HISMHMOCURR

Field1:

( HIS1140 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HISMC1 - (HIS1150 )

English text: YES
No

BOX HISMC2 - (HIS1175 )

English text: NO
Attribute
Don't know

Route
BOX HISMC2 - (HIS1175 )

Refusal

BOX HISMC2 - (HIS1175 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:36:59 AM Friday, February 13, 2009

Page 26 of 190

BOX HISMC1

BOX HISMC1

Page Order # :

120

BOX INSTRUCTIONS
( HIS1150 )	

OTHER THAN THE PLAN SELECTED AT HISMC1, IF ANOTHER MEDICARE
MANAGED CARE PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HISMC3 - HISMHMOCHNG (
HIS1160 ).
ELSE GO TO BOX HISMC2 - (HIS1175 ).

ASSIGNMENTS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

51

MHMOCurrPrevRnd

Medicare Managed Care plan "current" at time of
previous round interview =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
There is a rule that the SP can only have one "current" Medicare
Managed Care plan at the time of the interview.
BOX HISMC1 is called if the MHMO selected at HISMC2 is reported as
"current" at the time of the previous round interview at HISMC2 ­
HISMHMOCURR.
The purpose of BOX HISMC1 is determine if there is another MHMO
flagged as "current" at the time of the previous round interview. Should
only expect to find one "other" MHMO, if it exists.
If another MHMO is flagged as "current" at the time of the previous round
interview, BOX HISMC1 is routed to HISMC3 - HISMHMOCHNG to
determine if the "other" MHMO's status has changed.

10:36:59 AM Friday, February 13, 2009	

Page 27 of 190

HISMC3

HISMC3

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

HISMHMOCHNG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

130

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

HISMC3 is asking about the "other" MHMO that was current at the
time of the previous round interview, not the MHMO selected at
HISMC2.
Display the name of the "other" Medicare Managed Care Plan that
was "current" at the time of the previous round interview,
PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

10:37:01 AM Friday, February 13, 2009

I recorded previously that (PREVIOUS ROUND CURRENT
MEDICARE MANAGED CARE PLAN NAME) was [your/(SP’s)]
current Medicare Advantage Plan on (REFERENCE DATE). Has
this information changed?

Page 28 of 190

HISMC3
Int. Instr II:
INPUT FIELDS / ROUTING
HISMHMOCHNG

Field1:
Cheshire Name:

( HIS1160 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HISMC2 - (HIS1175 )

English text: YES
No

BOX HISMC2 - (HIS1175 )

English text: NO
Attribute
Don't know

Route
BOX HISMC2 - (HIS1175 )

Refusal

BOX HISMC2 - (HIS1175 )

BACKGROUND VARIABLE ASSIGNMENTS
If HISMC3 - HISMHMOCHNG = 1/Yes, we need to correct the status of the (other)
Medicare Managed Care plan that was current at the time of the previous round to "NOT
CURRENT". Set on PLRO where PLRO.PLRORND=previous round and
PLRO.PLROPLAN = this PLAN.PLANNUM.
Set variables as instructed below.
FUTURE SPEC: Log change to previous round plan on TRNS.
COVCURNT	

If MHISMHMOCHNG = 1/Yes, set
PLRO.COVCURNT=2/No on previous round PLRO
for Medicare Managed Care plan that was current at
the time of the previous round interview.

SOFT EDIT CHECKS

10:37:07 AM Friday, February 13, 2009	

Page 29 of 190

HISMC3
HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

51

MHMOCurrPrevRnd

Medicare Managed Care plan "current" at time of
previous round interview =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:37:07 AM Friday, February 13, 2009

Page 30 of 190

BOX HISMC2

BOX HISMC2

Page Order # :

140

BOX INSTRUCTIONS
( HIS1175 )	

IF THE PLAN SELECTED AT HIMC1 HAS BEEN IDENTIFIED AS THE SP'S
CURRENT MEDICARE MANAGED CARE PLAN AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, SET THE PREVIOUS ROUND STATUS
OF THIS PLAN TO "CURRENT". OTHERWISE, SET THE PREVIOUS
ROUND STATUS OF THIS PLAN TO "NOT CURRENT" .
GO TO BOX HISMC2A - (HIS1177 ).

ASSIGNMENTS
Set status of Medicare Managed Care plan selected at HISMC1.
Set status variable, PLRO.COVCURNT, on PLRO where PLRO.PLRORND=previous
round and PLRO.PLROPLAN = PLAN.PLANNUM selected at HISMC1. Set as instructed
below.
COVCURNT	

If (HISMHMOCURR=1/Yes and
HISMHMOCHNG=2/No,DK,RF) or
(HISMHMOCURR=2/No, DK or RF>), set
PLRO.COVCURNT=2/No.
Else if HISMHMOCURR=1/Yes and
(HISMHMOCHNG=1/Yes or EMPTY), set
PLRO.COVCURNT=1/Yes.

TECHNICAL NOTES

DESIGN NOTES
The purpose of BOX HISMC2 is to set the status of the MHMO selected at
HISMC1. Once status is set, all routes go to BOX HISMC2A.

10:37:07 AM Friday, February 13, 2009	

Page 31 of 190

BOX HISMC2A

BOX HISMC2A

Page Order # :

145

BOX INSTRUCTIONS
( HIS1177 )	

IF THIS MEDICARE MANAGED CARE PLAN WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HISMC4 ­
MHMORX ( HIS1180 ).
ELSE GO TO HIS1 - HISCORR ( HIS1030 ).

ASSIGNMENTS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

75

ThisMHMOCurrentPrev
Rnd

This MHMO Plan was "current" at the time of the previous
round interview =
For this PLAN, there is a PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
When a plan is added in HIS, it is added to the previous round data.
When asking if Plan was "current" at the time of the previous round
interview, we are asking whether or not the Plan just added in HIS was
reported as "current" on the reference date in the current round HIS
section.

10:37:07 AM Friday, February 13, 2009	

Page 32 of 190

HISMC4

HISMC4

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

MHMORX

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

150

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Display "[you/(SP)]" in BOLD in last sentence.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [you/(SP)] have prescribed medicine coverage through
(MEDICARE MANAGED CARE PLAN NAME)?
[PROBE: I am asking about the type of insurance coverage that
[you/(SP)] personally had, not what the plan offers everyone.]

Int. Instr II:
10:37:10 AM Friday, February 13, 2009

Page 33 of 190

HISMC4
INPUT FIELDS / ROUTING
MHMORX

Field1:

( HIS1180 )

PLRO.MHMORX

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISMC5 - MHMODENT ( HIS1420 )

English text: YES
No
English text: NO

Attribute
Don't know

Route
HISMC5 - MHMODENT ( HIS1420 )

Refusal

HISMC5 - MHMODENT ( HIS1420 )

HISMC5 - MHMODENT ( HIS1420 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:37:14 AM Friday, February 13, 2009

Page 34 of 190

HISMC5

HISMC5

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MHMODENT

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

290

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [you/(SP)] have dental coverage through (MEDICARE
MANAGED CARE PLAN NAME)?

Int. Instr II:
INPUT FIELDS / ROUTING

10:37:16 AM Friday, February 13, 2009	

Page 35 of 190

HISMC5
MHMODENT

Field1:

( HIS1420 )

PLRO.MHMODENT

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISMC6 - MHMOEYE ( HIS1430 )

English text: YES
No

HISMC6 - MHMOEYE ( HIS1430 )

English text: NO
Attribute
Don't know

Route
HISMC6 - MHMOEYE ( HIS1430 )

Refusal

HISMC6 - MHMOEYE ( HIS1430 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:37:20 AM Friday, February 13, 2009

Page 36 of 190

HISMC6

HISMC6

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MHMOEYE

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

300

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

Did [you/(SP)] have optical coverage through (MEDICARE
MANAGED CARE PLAN NAME), that is, for eyeglasses or contact
lenses?

Int. Instr II:

INPUT FIELDS / ROUTING


10:37:23 AM Friday, February 13, 2009	

Page 37 of 190

HISMC6
MHMOEYE

Field1:

( HIS1430 )

PLRO.MHMOEYE

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISMC7 - MHMOPCAR ( HIS1440 )

English text: YES
No

HISMC7 - MHMOPCAR ( HIS1440 )

English text: NO
Attribute
Don't know

Route
HISMC7 - MHMOPCAR ( HIS1440 )

Refusal

HISMC7 - MHMOPCAR ( HIS1440 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:37:27 AM Friday, February 13, 2009

Page 38 of 190

HISMC7

HISMC7

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MHMOPCAR

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

310

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

Did [you/(SP)] have coverage for preventive care such as routine
annual physicals through (MEDICARE MANAGED CARE PLAN
NAME)?

Int. Instr II:
INPUT FIELDS / ROUTING

10:37:30 AM Friday, February 13, 2009	

Page 39 of 190

HISMC7
MHMOPCAR

Field1:

( HIS1440 )

PLRO.MHMOPCAR

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISMC8 - MHMONH ( HIS1450 )

English text: YES
No

HISMC8 - MHMONH ( HIS1450 )

English text: NO
Attribute
Don't know

Route
HISMC8 - MHMONH ( HIS1450 )

Refusal

HISMC8 - MHMONH ( HIS1450 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:37:34 AM Friday, February 13, 2009

Page 40 of 190

HISMC8

HISMC8

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MHMONH

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

320

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

Did [your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage include nursing home care over and beyond what
Medicare normally covers?
[EXPLAIN IF NECESSARY: Under regular fee-for-service, Medicare
pays for limited skilled nursing facility (SNF) care during a benefit
period. In 2009, the first 20 days are paid in full and the next 80
days require a copayment of up to $133.50 per day.]

Int. Instr II:
10:37:36 AM Friday, February 13, 2009	

Page 41 of 190

HISMC8
INPUT FIELDS / ROUTING
MHMONH

Field1:

( HIS1450 )

PLRO.MHMONH

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISMC9 - MHMOPAY ( HIS1460 )

English text: YES
No
English text: NO

Attribute
Don't know

Route
HISMC9 - MHMOPAY ( HIS1460 )

Refusal

HISMC9 - MHMOPAY ( HIS1460 )

HISMC9 - MHMOPAY ( HIS1460 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:37:40 AM Friday, February 13, 2009

Page 42 of 190

HISMC9

HISMC9

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MHMOPAY

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

330

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

Besides the cost of [your/(SP’s)] Medicare Part B premium, was
there an additional cost for [your/(SP’s)] (MEDICARE MANAGED
CARE PLAN NAME) coverage? Please do not include any amount
that [you/(SP)] may have paid as a co-payment for an office visit or a
prescribed medicine.
[EXPLAIN IF NECESSARY: Some managed care plans may charge
a monthly premium to cover the cost of the deductibles and
coinsurance for Medicare-covered services or because they provide
services that are not covered by Medicare such as prescribed

10:37:43 AM Friday, February 13, 2009	

Page 43 of 190

HISMC9
medicines, routine exams, and dental, eye, or hearing. Plans that
have premiums typically charge from $50 to $75 per month.]
Int. Instr II:

INPUT FIELDS / ROUTING

MHMOPAY

Field1:

( HIS1460 )

PLRO.MHMOPAY

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISMC10 - MHMOAMT ( HIS1470 )

English text: YES
No

HIS1 - HISCORR ( HIS1030 )

English text: NO
Attribute
Don't know

Route
HIS1 - HISCORR ( HIS1030 )

Refusal

HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
10:37:47 AM Friday, February 13, 2009

Page 44 of 190

HISMC10

HISMC10

Page Order # :

Design Screen Type:

Quantity Unit Hybrid

Fields:

Field 1:

MHMOAMT

Field 2:

MHMOUNIT

Field 3:

MHMOUNOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No


Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

340

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Always display "[Please do not include any copayments or...]" in
brackets.
Display "additional" in BOLD.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

10:37:53 AM Friday, February 13, 2009

Not including the cost of [your/(SP’s)] Medicare Part B premium,
	
what was the additional amount that [you/(SP)] paid for (your/his/her)
Page 45 of 190

HISMC10
(MEDICARE MANAGED CARE PLAN NAME) coverage? [Please do
not include any copayments or any amount that may be paid for
anyone other than [you/(SP)].]
[PROBE IF NECESSARY: Was that per year, per month, per week,
or what?]
Int. Instr II:
INPUT FIELDS / ROUTING
MHMOAMT

Field1:

( HIS1470 )

PLRO.MHMOAMT

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:


AMOUNT:
Left

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Real
TMippamt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HISMC11 - MHMOCOST ( HIS1500 )

Refusal

HISMC11 - MHMOCOST ( HIS1500 )

10:38:05 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

0.01
99999.99
Dollars

Route
HISMC10 - MHMOUNIT ( HIS1480 )

Page 46 of 190

HISMC10
MHMOUNIT

Field2:

( HIS1480 )

PLRO.MHMOUNIT

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TMippunit
1
No
No

Number Label
1 PerYear
2

English text: PER YEAR
Quarterly

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISMC11 - MHMOCOST ( HIS1500 )
HISMC11 - MHMOCOST ( HIS1500 )

4

English text: QUARTERLY/EVERY 3 MONTHS
Bimonthly
HISMC11 - MHMOCOST ( HIS1500 )
English text: BIMONTHLY/EVERY 2 MONTHS
PerMonth
HISMC11 - MHMOCOST ( HIS1500 )

5

English text: PER MONTH
PerWeek

HISMC11 - MHMOCOST ( HIS1500 )

6

English text: PER WEEK
SemiAnnually

HISMC11 - MHMOCOST ( HIS1500 )

7

English text: SEMI-ANNUALLY/2 TIMES PER YEAR
SemiMonthly
HISMC11 - MHMOCOST ( HIS1500 )

91

English text: SEMI-MONTHLY/2 TIMES PER MONTH
Other
HISMC10 - MHMOUNOS ( HIS1490 )

3

English text: OTHER
Attribute
Don't know

Route
HISMC11 - MHMOCOST ( HIS1500 )

Refusal

HISMC11 - MHMOCOST ( HIS1500 )

10:38:20 AM Friday, February 13, 2009

Page 47 of 190

HISMC10

Field3:

MHMOUNOS

( HIS1490 )

PLRO.MHMOUNOS

Cheshire Name:
Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.


Item Text:

OTHER (SPECIFY)


Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


String

TOthrspec
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

30

Route
HISMC11 - MHMOCOST ( HIS1500 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
If MHMOAMT ^= DK and MHMOAMT ^= RF then, 

If MHMOUNIT = 1/PerYear, then MHMOAMT = $50.00 - 10,000.00.

Else If MHMOUNIT = 2/Quarterly, then MHMOAMT = $15.00 - 

2500.00.

Else If MHMOUNIT = 3/Bimonthly, then MHMOAMT = $10.00 ­
1650.00.

Else If MHMOUNIT = 4/PerMonth, then MHMOAMT = $5.00 - 

850.00.

Else If MHMOUNIT = 5/PerWeek, then MHMOAMT = $5.00 - 200.00.

Else If MHMOUNIT = 6/Semiannually, then MHMOAMT = $25.00 - 

5,000.00.

Else If MHMOUNIT = 7/Semimonthly, then MHMOAMT = $2.00 - 

425.00.

Else If MHMOUNIT = 91/Other, then MHMOAMT = $5.00 - 15,000.00.

If not true, display message "THE AMOUNT ENTERED SEEMS
UNLIKELY. PLEASE VERIFY."
HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:38:22 AM Friday, February 13, 2009

Page 48 of 190

HISMC11

HISMC11

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MHMOCOST

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

350

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

Did anyone else, such as an employer, a union or professional
organization pay all or some portion of the additional cost for
[your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage?

Int. Instr II:

INPUT FIELDS / ROUTING


10:38:25 AM Friday, February 13, 2009	

Page 49 of 190

HISMC11
MHMOCOST

Field1:

( HIS1500 )

PLRO.MHMOCOST

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HISMC12 - MHMOWHO ( HIS1510 )

English text: YES
No

HIS1 - HISCORR ( HIS1030 )

English text: NO
Attribute
Don't know

Route
HIS1 - HISCORR ( HIS1030 )

Refusal

HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:38:29 AM Friday, February 13, 2009

Page 50 of 190

HISMC12

HISMC12

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

MHMOWHO

Field 2:

MHMOWHOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

Enable Functions:	

360

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

Who else paid all or some portion of the additional cost for

[your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage?

Int. Instr II:
INPUT FIELDS / ROUTING

10:38:34 AM Friday, February 13, 2009	

Page 51 of 190

HISMC12
MHMOWHO

Field1:

PLRO.MHMOWHO

Cheshire Name:
Item Text display:

( HIS1510 )

[(SP's)/(MIP's)]: Display (SP's), SP's name, in response
text for "1/CurrentEmployer", "2/FormerEmployer", and
"3/Union".

Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Enumerated
TMhmowho
1
No
No

Number Label
1 CurrentEmployer

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS1 - HISCORR ( HIS1030 )

3

English text: [(SP's)/(MIP's)] CURRENT EMPLOYER
FormerEmployer
HIS1 - HISCORR ( HIS1030 )
English text: (SP's/MIP's) FORMER EMPLOYER
Union
HIS1 - HISCORR ( HIS1030 )

4

English text: (SP's/MIP's) UNION
SpousesCurrentEmployer

2

HIS1 - HISCORR ( HIS1030 )

6

English text: SPOUSE'S CURRENT EMPLOYER
SpousesFormerEmployer
HIS1 - HISCORR ( HIS1030 )
English text: SPOUSE'S FORMER EMPLOYER
ProfessionalOrg
HIS1 - HISCORR ( HIS1030 )

7

English text: PROFESSIONAL/FRATERNAL ORGANIZATION
Medicaid
HIS1 - HISCORR ( HIS1030 )

5

91

English text: MEDICAID/MEDICAL ASSISTANCE
Other
HISMC12 - MHMOWHOS ( HIS1520 )
English text: OTHER

Attribute
Don't know

Route
HIS1 - HISCORR ( HIS1030 )

Refusal

HIS1 - HISCORR ( HIS1030 )

10:38:47 AM Friday, February 13, 2009

Page 52 of 190

HISMC12

Field2:

MHMOWHOS

( HIS1520 )

PLRO.MHMOWHOS

Cheshire Name:
Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.


Item Text:

OTHER (SPECIFY)


Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


String

TOthrspec
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

30

Route
HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:38:49 AM Friday, February 13, 2009

Page 53 of 190

BOX HIS2AA

BOX HIS2AA

10:38:49 AM Friday, February 13, 2009

Page Order # :

405


Page 54 of 190


BOX HIS2AA
BOX INSTRUCTIONS
( HIS1575 )

CREATE MEDICAID PLAN IN THE PREVIOUS ROUND .
GO TO HIS6 - COVTIME ( HIS1580 ).

ASSIGNMENTS
Medicaid details will be collected on PLAN and PLRO:

PLAN key = PLAN.PLANBASE + PLAN.PLANNUM

PLAN.PLANNUM = Number of Medicaid plan identified or created in HIS.

PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND

PLRO.PLROPLAN = PLAN.PLANNUM of Medicaid plan identified or created in HIS.

PLRO.PLRORND = previous round.

CREATE MEDICAID PLAN IN THE PREVIOUS ROUND:

If there is a PLAN where PLAN.PLANTYPE=2/Medicaid, regardless if 

PLAN.PLANDFLG=1/Yes or LOSEPLFG ^= empty, this stopped Medicaid plan will be

restarted. See detailed instructions below.

Else if there is no PLAN where PLAN.PLANTYPE=2/Medicaid, create a new PLAN where

PLAN.PLANNUM equals the next sequential plan number.

Regardless if PLAN is new or restarted, create a previous round PLRO where

PLRO.PLROPLAN = this PLAN.PLANNUM if it does not already exist. Collect HIS6 and

remaining PLAN details on this previous round PLRO.

See detailed instructions below:

PLANNUM	

If creating a new PLAN, set PLAN.PLANNUM =
highest PLAN.PLANNUM + 01.

PLANRNDC	

If creating a new PLAN, set PLAN.PLANRNDC =
current round.

PLANTYPE	

If creating a new PLAN, set PLAN.PLANTYPE =
2/Medicaid.

PLNAME	

If creating a new PLAN, set PLNAME = "MEDICAID".

PLANSUMM	

If creating a new PLAN, set PLAN.PLANSUMM =
1/Yes.

PLANDFLG	

If restarting an existing MEDICAID plan and
PLAN.PLANDLFG=1/Yes, update PLAN.PLANDFLG
= empty.

LOSEPLFG	

If restarting an existing MEDICAID plan and
PLAN.LOSEPLFG ^= empty, update
PLAN.LOSEPLFG = empty.

PLROPLAN	

If creating a previous round PLRO, set
PLRO.PLROPLAN = this PLAN.PLANNUM.

PLRORND	

If creating a previous round PLRO, set
PLRO.PLRORND = previous round.

TECHNICAL NOTES

DESIGN NOTES
10:38:49 AM Friday, February 13, 2009	

Page 55 of 190

BOX HIS2AA

10:38:49 AM Friday, February 13, 2009

Page 56 of 190


HIS6

HIS6

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

COVTIME

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

410

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:
Question Text:	

[Were you/Was (SP)] covered by Medicaid the whole time between
(SUMMARY REFERENCE DATE) and (REFERENCE DATE), or
only part of the time?

Int. Instr II:
INPUT FIELDS / ROUTING

10:38:52 AM Friday, February 13, 2009	

Page 57 of 190

HIS6
( HIS1580 )

COVTIME

Field1:
Cheshire Name:

PLRO.COVTIME

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TCovtime

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 WholeTime
2

Route
HIS10A - MCAIDHMO ( HIS1670 )

English text: THE WHOLE TIME
PartOfTime

HIS7 - COVNOW ( HIS1590 )

English text: PART OF THE TIME
Attribute
Don't know

Route
HIS7 - COVNOW ( HIS1590 )

Refusal

HIS7 - COVNOW ( HIS1590 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans	

10:38:59 AM Friday, February 13, 2009	

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

Page 58 of 190

HIS6
53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

DESIGN NOTES

10:38:59 AM Friday, February 13, 2009

Page 59 of 190

HIS7

HIS7

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

COVNOW

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

420

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

[Were you/Was (SP)] covered by Medicaid on (REFERENCE

DATE)?

Int. Instr II:
INPUT FIELDS / ROUTING

10:39:03 AM Friday, February 13, 2009

Page 60 of 190

HIS7
COVNOW

Field1:

( HIS1590 )

PLRO.COVNOW

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS8 - COVBEGMM ( HIS1600 )

English text: YES
No

HIS9 - COVENDMM ( HIS1630 )

English text: NO
Attribute
Don't know

Route
HIS10A - MCAIDHMO ( HIS1670 )

Refusal

HIS10A - MCAIDHMO ( HIS1670 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:39:07 AM Friday, February 13, 2009

Page 61 of 190

HIS8

HIS8

Page Order # :

Design Screen Type:

Date

Fields:

Field 1:

COVBEGMM

Field 2:

COVBEGDD

Field 3:

COVBEGYY

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No


Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

430

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Horizontal Alignment


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

On what date did [your/(SP’s)] Medicaid start between (SUMMARY
	
REFERENCE DATE) and (REFERENCE DATE)?

Int. Instr II:

INPUT FIELDS / ROUTING


10:39:11 AM Friday, February 13, 2009

Page 62 of 190

HIS8
COVBEGMM

Field1:

( HIS1600 )

PLRO.COVBEGMM

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

MM
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMonthInt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS8 - COVBEGDD ( HIS1610 )

Refusal

HIS8 - COVBEGDD ( HIS1610 )

10:39:18 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
HIS8 - COVBEGDD ( HIS1610 )

Page 63 of 190

HIS8
COVBEGDD

Field2:

( HIS1610 )

PLRO.COVBEGDD

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

DD
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TDayDKRF
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS8 - COVBEGYY ( HIS1620 )

Refusal

HIS8 - COVBEGYY ( HIS1620 )

10:39:26 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
HIS8 - COVBEGYY ( HIS1620 )

Page 64 of 190

HIS8
COVBEGYY

Field3:

( HIS1620 )

PLRO.COVBEGYY

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

YY
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMcyear
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS10A - MCAIDHMO ( HIS1670 )

Refusal

HIS10A - MCAIDHMO ( HIS1670 )

FieldSize:

Min Value:
Max Value:
Mask:


0

99


Route
HIS10A - MCAIDHMO ( HIS1670 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
Edit #1:

PLAN BEGIN DATE, COVBEGMM/COVBEGDD/COVBEGYY,

should be on or between (SUMMARY REFERENCE DATE) and

(REFERENCE DATE).

If not true, display message: "DATE MUST BE ON OR BETWEEN

(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).

PLEASE REENTER."

TECHNICAL NOTES

DESIGN NOTES

10:39:28 AM Friday, February 13, 2009

Page 65 of 190

HIS9

HIS9

Page Order # :

Design Screen Type:

Date

Fields:

Field 1:

COVENDMM

Field 2:

COVENDDD

Field 3:

COVENDYY

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No


Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

440

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Horizontal Alignment


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

On what date between (SUMMARY REFERENCE DATE) and

(REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?

Int. Instr II:

INPUT FIELDS / ROUTING


10:39:32 AM Friday, February 13, 2009

Page 66 of 190

HIS9
COVENDMM

Field1:

( HIS1630 )

PLRO.COVENDMM

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

MM
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMonthInt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS9 - COVENDDD ( HIS1640 )

Refusal

HIS9 - COVENDDD ( HIS1640 )

10:39:40 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
HIS9 - COVENDDD ( HIS1640 )

Page 67 of 190

HIS9
COVENDDD

Field2:

( HIS1640 )

PLRO.COVENDDD

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

DD
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TDayDKRF
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS9 - COVENDYY ( HIS1650 )

Refusal

HIS9 - COVENDYY ( HIS1650 )

10:39:47 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
HIS9 - COVENDYY ( HIS1650 )

Page 68 of 190

HIS9
COVENDYY

Field3:

( HIS1650 )

PLRO.COVENDYY

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

YY
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMcyear
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS10A - MCAIDHMO ( HIS1670 )

Refusal

HIS10A - MCAIDHMO ( HIS1670 )

FieldSize:

Min Value:
Max Value:
Mask:


0

99


Route
HIS10A - MCAIDHMO ( HIS1670 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
Edit #1:

PLAN END DATE, COVENDMM/COVENDDD/COVENDYY, should

be on or between (SUMMARY REFERENCE DATE) and 

(REFERENCE DATE).

If not true, display message: "DATE MUST BE ON OR BETWEEN

(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).

PLEASE REENTER."

TECHNICAL NOTES

DESIGN NOTES

10:39:50 AM Friday, February 13, 2009

Page 69 of 190

HIS10A

HIS10A

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

MCAIDHMO

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

460

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If this Medicaid plan was reported as "current" on the previous
round interview date, display "(REFERENCE DATE)".
Else if HIS9 - COVENDMM, COVENDDD or COVENDYY = DK or
RF, display "the date [your/(SP’s)] Medicaid coverage stopped".
Else, display "(PLAN COVERAGE STOP DATE)".
Always display "(Health Maintenance Organizations)" in parenthesis.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

10:39:53 AM Friday, February 13, 2009

Some states now use managed care plans, such as HMOs (Health
Maintenance Organizations), to provide some or all health care for
Medicaid beneficiaries. [Were you/Was (SP)] enrolled in a Medicaid
Managed Care Plan on [(REFERENCE DATE)/(PLAN COVERAGE
STOP DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
Page 70 of 190

HIS10A
Int. Instr II:
INPUT FIELDS / ROUTING
( HIS1670 )

MCAIDHMO

Field1:

PLRO.MCAIDHMO

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS10B - CHOICHMO ( HIS1680 )

English text: YES
No

BOX HIS2C - (HIS1683 )

English text: NO
Attribute
Don't know

Route
BOX HIS2C - (HIS1683 )

Refusal

BOX HIS2C - (HIS1683 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
148

ThisPlanCurrPrevRnd

10:39:59 AM Friday, February 13, 2009

This Plan was reported as "current" on prev. round
interview date=
For this PLAN, there is PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=prev. round &

Page 71 of 190

HIS10A
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES

10:39:59 AM Friday, February 13, 2009

Page 72 of 190

HIS10B

HIS10B

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

CHOICHMO

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

470

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:
Question Text:	

As far as you can recall, [were you/was (SP)] given a choice to enroll
in a Medicaid Managed Care Plan, or did (you/he/she) have to enroll
to receive Medicaid benefits?

Int. Instr II:
INPUT FIELDS / ROUTING

10:40:03 AM Friday, February 13, 2009	

Page 73 of 190

HIS10B
CHOICHMO

Field1:

( HIS1680 )

PLRO.CHOICHMO

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TChoichmo
1
No
No

Number Label
1 GivenChoice

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS2C - (HIS1683 )

2

English text: GIVEN A CHOICE TO ENROLL
HadToEnroll
BOX HIS2C - (HIS1683 )

3

English text: HAD TO ENROLL
DoesntRemember

BOX HIS2C - (HIS1683 )

English text: DOESN'T REMEMBER
Attribute
Refusal

Route
BOX HIS2C - (HIS1683 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:40:08 AM Friday, February 13, 2009

Page 74 of 190

BOX HIS2C

BOX HIS2C

Page Order # :

473

BOX INSTRUCTIONS
( HIS1683 )	

IF THERE IS A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS
"CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO
TO HIS1 - HISCORR ( HIS1030 ).
ELSE GO TO HIS10B1 - HISMPDCOVER ( HIS1685 ).

ASSIGNMENTS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

343

MPDPCurrPrevRnd

Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:40:09 AM Friday, February 13, 2009	

Page 75 of 190

HIS10B1

HIS10B1

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

HISMPDCOVER

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

478

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:
Question Text:

Some people who receive Medicaid benefits are also enrolled in a
Medicare Prescription Drug plan, or Medicare Part D plan, that pays
for some or all of their prescribed medicines. The Medicare program
automatically enrolls such beneficiaries into a Prescription Drug
plan, although the beneficiary may choose to switch to a different
plan.
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), [were you/was (SP)] enrolled in a Medicare Prescription
Drug plan that covered medicines prescribed by a doctor?

10:40:12 AM Friday, February 13, 2009

Page 76 of 190

HIS10B1
Int. Instr II:

INPUT FIELDS / ROUTING

HISMPDCOVER

Field1:

( HIS1685 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS34 - PLAN_HISMPDP ( HIS3331 )

English text: YES
No

HIS10C - MCDRXCOV ( HIS1690 )

English text: NO
Attribute
Don't know

Route
HIS10C - MCDRXCOV ( HIS1690 )

Refusal

HIS10C - MCDRXCOV ( HIS1690 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
If HIS10B1 - HISMPDCOVER = 1/Yes, we are going to call MPDP plan

questions at HIS34 to collect the name of the MPDP plan before returning 


10:40:17 AM Friday, February 13, 2009

Page 77 of 190

HIS10B1
to HIS1. We will not collect HIS10C - MCDRXCOV for the MEDICAID plan
just added.

10:40:18 AM Friday, February 13, 2009

Page 78 of 190

HIS10C

HIS10C

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

MCDRXCOV

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

480

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

Between (SUMMARY REFERENCE DATE) and (REFERENCE 

DATE), did [your/(SP’s)] Medicaid plan cover medicines prescribed
by a doctor?

Int. Instr II:
INPUT FIELDS / ROUTING

10:40:21 AM Friday, February 13, 2009

Page 79 of 190

HIS10C
MCDRXCOV

Field1:

( HIS1690 )

PLRO.MCDRXCOV

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS1 - HISCORR ( HIS1030 )

English text: YES
No

HIS1 - HISCORR ( HIS1030 )

English text: NO
Attribute
Don't know

Route
HIS1 - HISCORR ( HIS1030 )

Refusal

HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS
HIS10C is Medicaid detail which is collected on PLAN and PLRO:

PLAN key = PLAN.PLANBASE + PLAN.PLANNUM

PLAN.PLANNUM = Number of Medicaid plan identified or created in HIS.

PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND

PLRO.PLROPLAN = PLAN.PLANNUM of Medicaid plan identified or created in HIS.

PLRO.PLRORND = previous round.


SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
10:40:25 AM Friday, February 13, 2009

Page 80 of 190

BOX HIST1A

BOX HIST1A

10:40:25 AM Friday, February 13, 2009

Page Order # :

625


Page 81 of 190


BOX HIST1A
BOX INSTRUCTIONS
( HIS1935 )	

CREATE TRICARE PLAN IN THE PREVIOUS ROUND .
GO TO HIST1 - COVTIME ( HIS1940 ).

ASSIGNMENTS
Tricare details will be collected on PLAN and PLRO:

PLAN key = PLAN.PLANBASE + PLAN.PLANNUM

PLAN.PLANNUM = Number of Tricare plan identified or created in HIS.

PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND

PLRO.PLROPLAN = PLAN.PLANNUM of Tricare plan identified or created in HIS.

PLRO.PLRORND = previous round.

CREATE TRICARE PLAN IN THE PREVIOUS ROUND:

If there is a PLAN where PLAN.PLANTYPE=6/Tricare, regardless if 

PLAN.PLANDFLG=1/Yes or LOSEPLFG ^= empty, this stopped Tricare plan will be

restarted. See detailed instructions below.

Else if there is no PLAN where PLAN.PLANTYPE=6/Tricare, create a new PLAN where

PLAN.PLANNUM equals the next sequential plan number.

Regardless if PLAN is new or restarted, create a previous round PLRO where

PLRO.PLROPLAN = this PLAN.PLANNUM if it does not already exist. Collect HIST1 and

remaining PLAN details on this previous round PLRO.

See detailed instructions below:

PLANNUM	

If creating a new PLAN, set PLAN.PLANNUM =
highest PLAN.PLANNUM + 01.

PLANRNDC	

If creating a new PLAN, set PLAN.PLANRNDC =
current round.

PLANTYPE	

If creating a new plan, set PLAN.PLANTYPE =
6/Tricare.

PLNAME	

If creating a new plan, set PLAN.PLNAME =
"TRICARE".

PLANSUMM	

If creating a new plan, set PLAN.PLANSUMM =
1/Yes.

PLANDFLG	

If restarting an existing TRICARE plan and
PLAN.PLANDFLG=1/Yes, update PLAN.PLANDFLG
= empty.

LOSEPLFG	

If restarting an existing TRICARE plan and
PLAN.LOSEPLFG ^= empty, update
PLAN.LOSEPLFG = empty.

PLROPLAN	

If creating a previous round PLRO, set
PLRO.PLROPLAN = this PLAN.PLANNUM.

PLRORND	

If creating a previous round PLRO, set
PLRO.PLRORND = previous round.

TECHNICAL NOTES

10:40:25 AM Friday, February 13, 2009	

Page 82 of 190

BOX HIST1A
DESIGN NOTES

10:40:25 AM Friday, February 13, 2009

Page 83 of 190


HIST1

HIST1

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

COVTIME

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

630

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:
Question Text:	

[Were you/Was (SP)] covered by TRICARE the whole time between
(SUMMARY REFERENCE DATE) and (REFERENCE DATE), or
only part of the time?

Int. Instr II:
INPUT FIELDS / ROUTING

10:40:28 AM Friday, February 13, 2009	

Page 84 of 190

HIST1
( HIS1940 )

COVTIME

Field1:
Cheshire Name:

PLRO.COVTIME

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TCovtime

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 WholeTime
2

Route
HIST3 - TRIRXCOV ( HIS1960 )

English text: THE WHOLE TIME
PartOfTime

HIST2 - COVNOW ( HIS1950 )

English text: PART OF THE TIME
Attribute
Don't know

Route
HIST2 - COVNOW ( HIS1950 )

Refusal

HIST2 - COVNOW ( HIS1950 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans	

10:40:34 AM Friday, February 13, 2009	

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

Page 85 of 190

HIST1
53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

DESIGN NOTES

10:40:34 AM Friday, February 13, 2009

Page 86 of 190

HIST2

HIST2

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

COVNOW

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

640

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

[Were you/Was (SP)] covered by TRICARE on (REFERENCE

DATE)?

Int. Instr II:
INPUT FIELDS / ROUTING

10:40:37 AM Friday, February 13, 2009

Page 87 of 190

HIST2
COVNOW

Field1:

( HIS1950 )

PLRO.COVNOW

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIST3 - TRIRXCOV ( HIS1960 )

English text: YES
No

HIST3 - TRIRXCOV ( HIS1960 )

English text: NO
Attribute
Don't know

Route
HIST3 - TRIRXCOV ( HIS1960 )

Refusal

HIST3 - TRIRXCOV ( HIS1960 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:40:52 AM Friday, February 13, 2009

Page 88 of 190

HIST3

HIST3

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

TRIRXCOV

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

650

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display "[you/(SP)]" in BOLD in last paragraph.


Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:
Question Text:

Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [your/(SP’s)] TRICARE plan cover medicines prescribed
by a doctor?
[PROBE: I am asking about the type of insurance coverage that
[you/(SP)] personally had, not what the plan offers everyone.]

Int. Instr II:

INPUT FIELDS / ROUTING


10:40:56 AM Friday, February 13, 2009	

Page 89 of 190

HIST3
TRIRXCOV

Field1:

( HIS1960 )

PLRO.TRIRXCOV

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIST3AA - TRIMEDS ( HIS1973 )

English text: YES
No

HIS1 - HISCORR ( HIS1030 )

English text: NO
Attribute
Don't know

Route
HIS1 - HISCORR ( HIS1030 )

Refusal

HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:41:02 AM Friday, February 13, 2009

Page 90 of 190

HIST3AA

HIST3AA

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

TRIMEDS

Field 2:

TRIMEDOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

Enable Functions:	

655

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display "usually" in BOLD in first sentence.

Always display "(TMOP)", "(TRRx)", and "(MTF)" in parenthesis.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

10:41:08 AM Friday, February 13, 2009	

Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), where did [you/(SP)] usually obtain (your/his/her) medicines?
Did [you/(SP)] usually obtain them at a TRICARE mail order
pharmacy (TMOP), a TRICARE retail pharmacy network pharmacy
(TRRx), a military treatment facility pharmacy (MTF), a non-network
retail pharmacy, or somewhere else?

Page 91 of 190

HIST3AA
Int. Instr II:

INPUT FIELDS / ROUTING

TRIMEDS

Field1:

( HIS1973 )

PLRO.TRIMEDS

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
Ttrimeds
1
No
No

FieldSize:
Min Value:
Max Value:
Mask:

Number Label
1 TMOP
2

Route
HIS1 - HISCORR ( HIS1030 )
English text: A TRICARE MAIL ORDER PHARMACY (TMOP)
TRRX
HIS1 - HISCORR ( HIS1030 )

3

English text: A TRICARE RETAIL PHARMACY NETWORK PHARMACY (TRRX)
MTF
HIS1 - HISCORR ( HIS1030 )

4
91

English text: A MILITARY TREATMENT FACILITY PHARMACY (MTF)
NonNetworkRetail
HIS1 - HISCORR ( HIS1030 )
English text: A NON-NETWORK RETAIL PHARMACY
Other
HIST3AA - TRIMEDOS ( HIS1975 )
English text: SOMEWHERE ELSE

Attribute
Don't know

Route
HIS1 - HISCORR ( HIS1030 )

Refusal

HIS1 - HISCORR ( HIS1030 )

10:41:18 AM Friday, February 13, 2009

Page 92 of 190

HIST3AA

Field2:

TRIMEDOS

( HIS1975 )

PLRO.TRIMEDOS

Cheshire Name:
Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.


Item Text:

SOMEWHERE ELSE (SPECIFY)


Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


String

TOthrspec
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

30

Route
HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:41:20 AM Friday, February 13, 2009

Page 93 of 190

HIS12

HIS12

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

PLAN_HISPUBLIC

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Plan Roster

Roster Type:

Multiple Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No

Yes


Grid Functions:

Add Line
Delete Line

No
No

850

Display as ' Add a Plan '

Display as ' Edit a Plan '


DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:

Display all health insurance plans from the Plan Roster.
Display plans in order of entry.
Display the following plans as protected rows:
Medicare
Medicare Managed Care plans.
Medicaid
Tricare
Private plans
Public plans that were "current" at the time of the previous round
interview
Medicare Prescription Drug plans.

Roster/Grid display:

COL #
1

10:41:21 AM Friday, February 13, 2009

HEADER
Plan Name

INSTRUCTIONS
Display PLAN.PLNAME.

Page 94 of 190

HIS12
2

Plan Type	

Display PLAN.PLANTYPE:
1/Medicare, display "(MCAR)"
2/Medicaid, display "(MCAD)"
3/PublicPlan, display "(PUBL)"
4/PrivatePlan, display "(PRIV)"
5/MHMO, display "(MHMO)"
6/Tricare, display "(TRIC)"
7/MPDP, display "(MPDP)".

3

Plan Status	

Display PREVIOUS ROUND PLAN
STATUS.

Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

What is the name of the public program that covered [you/(SP)]?


Int. Instr II:

SELECT OR ADD ALL PUBLIC PROGRAM NAMES AT THIS

ROSTER.

INPUT FIELDS / ROUTING

Field1:	
Cheshire Name:

PLAN_HISPUBLIC

( HIS2280 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:


String
TPlanPick32
1

No
No


Number Label	
1 [Continuous answer.]	

FieldSize:
Min Value:

Max Value:

Mask:


32

Route
HIS12_IN - NAVIGATOR ( HIS2285 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:

PLAN key = PLAN.PLANBASE + PLAN.PLANNUM

PLAN.PLANNUM = Number of Plan selected at HIS12.


10:41:23 AM Friday, February 13, 2009	

Page 95 of 190

HIS12
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS12.
PLRO.PLRORND = previous round.
If Plan added, see PLAN ROSTER POP-UP specifications for pop-up window programming
instructions:
Variables populated in Plan Roster Pop-Up Window:
PLAN.PLANNUM
PLAN.PLANRNDC
PLAN.PLANTYPE
PLAN.PLNAME
For each Plan selected, create previous round PLRO where PLRO.PLROPLAN =
PLAN.PLANNUM of plan selected at HIS12 and PLRO.PLRORND = previous round.
HIS13 and remaining PLAN details will be stored on this previous round PLRO.
Previous round PLRO may already exist.
Set variables as instructed below:
PLANTYPE	

If plan is added at HIS12, set PLAN.PLANTYPE =
3/PubicPlan.

PLANRNDC	

If plan is added at HIS12, set PLAN.PLANRNDC =
current round.

PLANSUMM	

If plan is added at HIS12, set PLAN.PLANSUMM =
1/Yes.

PLROPLAN	

PLRO.PLROPLAN = PLAN.PLANNUM of plan
selected at HIS12.

PLRORND	

PLRO.PLRORND = previous round.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

80

PublicCurrentPrevRnd

Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
10:41:23 AM Friday, February 13, 2009	

Page 96 of 190

HIS12
Begin Loop 1: Collect plan details for all public plans selected at HIS12.

10:41:23 AM Friday, February 13, 2009

Page 97 of 190


HIS12_IN

HIS12_IN

Page Order # :

Design Screen Type:

Instance Navigator

Fields:

Field 1:

NAVIGATOR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

855

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display Plans selected at HIS12.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

10:41:25 AM Friday, February 13, 2009

Page 98 of 190

HIS12_IN
NAVIGATOR

Field1:

( HIS2285 )

N/A

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TInstanceNavigator
1
No
No

Number Label
1 SelectItemInList
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS13 - COVTIME ( HIS2290 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
HIS1 - HISCORR ( HIS1030 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:41:28 AM Friday, February 13, 2009

Page 99 of 190

HIS13

HIS13

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

COVTIME

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

860

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Display plan name for the plan being asked about, PLAN.PLNAME.

Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:	

PUBLIC INSURANCE PLAN = (PUBLIC PLAN NAME)

Int. Instr I:
Question Text:	

[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) the whole
time between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), or only part of the time?

Int. Instr II:
INPUT FIELDS / ROUTING

10:41:30 AM Friday, February 13, 2009	

Page 100 of 190

HIS13
COVTIME

Field1:

( HIS2290 )

PLRO.COVTIME

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TCovtime
1
No
No

Number Label
1 WholeTime
2

English text: THE WHOLE TIME
PartOfTime

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS2B1 - (HIS2362 )
HIS14 - COVNOW ( HIS2300 )

English text: PART OF THE TIME
Attribute
Don't know

Route
HIS14 - COVNOW ( HIS2300 )

Refusal

HIS14 - COVNOW ( HIS2300 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:41:35 AM Friday, February 13, 2009

Page 101 of 190

HIS14

HIS14

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

COVNOW

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

870

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.


Multi Field display:


Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) on

(REFERENCE DATE)?

Int. Instr II:
INPUT FIELDS / ROUTING

10:41:37 AM Friday, February 13, 2009	

Page 102 of 190

HIS14
COVNOW

Field1:

( HIS2300 )

PLRO.COVNOW

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS15 - COVBEGMM ( HIS2310 )

English text: YES
No

HIS16 - COVENDMM ( HIS2340 )

English text: NO
Attribute
Don't know

Route
BOX HIS2B1 - (HIS2362 )

Refusal

BOX HIS2B1 - (HIS2362 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:41:41 AM Friday, February 13, 2009

Page 103 of 190

HIS15

HIS15

Page Order # :

Design Screen Type:

Date

Fields:

Field 1:

COVBEGMM

Field 2:

COVBEGDD

Field 3:

COVBEGYY

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No


Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

880

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.


Multi Field display:

Horizontal Alignment


Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start
	
between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE)?

Int. Instr II:

INPUT FIELDS / ROUTING


10:41:45 AM Friday, February 13, 2009

Page 104 of 190

HIS15
COVBEGMM

Field1:

( HIS2310 )

PLRO.COVBEGMM

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

MM
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMonthInt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS15 - COVBEGDD ( HIS2320 )

Refusal

HIS15 - COVBEGDD ( HIS2320 )

10:41:52 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
HIS15 - COVBEGDD ( HIS2320 )

Page 105 of 190

HIS15
COVBEGDD

Field2:

( HIS2320 )

PLRO.COVBEGDD

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

DD
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TDayDKRF
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS15 - COVBEGYY ( HIS2330 )

Refusal

HIS15 - COVBEGYY ( HIS2330 )

10:42:00 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
HIS15 - COVBEGYY ( HIS2330 )

Page 106 of 190

HIS15
COVBEGYY

Field3:

( HIS2330 )

PLRO.COVBEGYY

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

YY
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMcyear
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
BOX HIS2B1 - (HIS2362 )

Refusal

BOX HIS2B1 - (HIS2362 )

FieldSize:

Min Value:
Max Value:
Mask:


0

99


Route
BOX HIS2B1 - (HIS2362 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
PLAN BEGIN DATE, COVBEGMM/COVBEGDD/COVBEGYY,

should be on or between (SUMMARY REFERENCE DATE) and

(REFERENCE DATE).

If not true, display message: "DATE MUST BE ON OR BETWEEN

(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).

PLEASE REENTER."

TECHNICAL NOTES

DESIGN NOTES

10:42:02 AM Friday, February 13, 2009

Page 107 of 190

HIS16

HIS16

Page Order # :

Design Screen Type:

Date

Fields:

Field 1:

COVENDMM

Field 2:

COVENDDD

Field 3:

COVENDYY

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No


Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

890

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Horizontal Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

On what date between (SUMMARY REFERENCE DATE) and

(REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME)
coverage stop?

Int. Instr II:

INPUT FIELDS / ROUTING


10:42:07 AM Friday, February 13, 2009

Page 108 of 190

HIS16
COVENDMM

Field1:

( HIS2340 )

PLRO.COVENDMM

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

MM
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMonthInt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS16 - COVENDDD ( HIS2350 )

Refusal

HIS16 - COVENDDD ( HIS2350 )

10:42:14 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
HIS16 - COVENDDD ( HIS2350 )

Page 109 of 190

HIS16
COVENDDD

Field2:

( HIS2350 )

PLRO.COVENDDD

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

DD
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TDayDKRF
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS16 - COVENDYY ( HIS2360 )

Refusal

HIS16 - COVENDYY ( HIS2360 )

10:42:21 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
HIS16 - COVENDYY ( HIS2360 )

Page 110 of 190

HIS16
COVENDYY

Field3:

( HIS2360 )

PLRO.COVENDYY

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

YY
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMcyear
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
BOX HIS2B1 - (HIS2362 )

Refusal

BOX HIS2B1 - (HIS2362 )

FieldSize:

Min Value:
Max Value:
Mask:


0

99


Route
BOX HIS2B1 - (HIS2362 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
PLAN END DATE, COVENDMM/COVENDDD/COVENDYY, should

be on or between (SUMMARY REFERENCE DATE) and 

(REFERENCE DATE).

If not true, display message: "DATE MUST BE ON OR BETWEEN

(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).

PLEASE REENTER."

TECHNICAL NOTES

DESIGN NOTES

10:42:24 AM Friday, February 13, 2009

Page 111 of 190

BOX HIS2B1

BOX HIS2B1

Page Order # :

895

BOX INSTRUCTIONS
( HIS2362 )

GO TO HIS16A - PUBRXCOV ( HIS2370 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

10:42:24 AM Friday, February 13, 2009

Page 112 of 190

HIS16A

HIS16A

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

PUBRXCOV

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

900

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.


Multi Field display:


Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

Between (SUMMARY REFERENCE DATE) and (REFERENCE 

DATE), did [your/(SP’s)] (PUBLIC PLAN NAME) plan cover
medicines prescribed by a doctor?

Int. Instr II:
INPUT FIELDS / ROUTING

10:42:27 AM Friday, February 13, 2009	

Page 113 of 190

HIS16A
PUBRXCOV

Field1:

( HIS2370 )

PLRO.PUBRXCOV

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS3 - (HIS2620 )

English text: YES
No

BOX HIS3 - (HIS2620 )

English text: NO
Attribute
Don't know

Route
BOX HIS3 - (HIS2620 )

Refusal

BOX HIS3 - (HIS2620 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:42:31 AM Friday, February 13, 2009

Page 114 of 190

BOX HIS3

BOX HIS3

Page Order # :

1050

BOX INSTRUCTIONS
( HIS2620 )

GO TO HIS12_IN - NAVIGATOR ( HIS2285 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

10:42:31 AM Friday, February 13, 2009

Page 115 of 190

HIS20

HIS20

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

PLAN_HISPRIVATE

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Plan Roster

Roster Type:

Multiple Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No

No


Grid Functions:

Add Line
Delete Line

No
No

1060

Display as ' Add a Plan '

Display as ' Edit a Plan '


DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "(other)" in parenthesis.
If SP is deceased or institutionalized, display "provided".
Else display "provide".

Multi Field display:

Roster/Grid Instructions:

Display all health insurance plans from the Plan Roster.
Display plans in order of entry.
Display the following plans as protected rows:
Medicare
Medicare Managed Care plans.
Medicaid
Tricare
Public plans
Private plans that were "current" at the time of the previous round
interview
Medicare Prescription Drug plans.

Roster/Grid display:

COL #
1

10:42:32 AM Friday, February 13, 2009

HEADER
Plan Name

INSTRUCTIONS
Display PLAN.PLNAME.

Page 116 of 190

HIS20
2

Plan Type

Display PLAN.PLANTYPE:
1/Medicare, display "(MCAR)"
2/Medicaid, display "(MCAD)"
3/PublicPlan, display "(PUBL)"
4/PrivatePlan, display "(PRIV)"
5/MHMO, display "(MHMO)"
6/Tricare, display "(TRIC)"
7/MPDP, display "(MPDP)".

3

Plan Status

Display PREVIOUS ROUND PLAN
STATUS.

Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

What is the name of each of the (other) private plans that provided
[your/(SP’s)] medical insurance coverage between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE)?

Int. Instr II:

SELECT OR ADD ALL PRIVATE PLAN NAMES AT THIS ROSTER.

INPUT FIELDS / ROUTING

Field1:

PLAN_HISPRIVATE

( HIS2630 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:


String
TPlanPick32
1

No
No


Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:


32

Route
HIS20_IN - NAVIGATOR ( HIS2635 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:

PLAN key = PLAN.PLANBASE + PLAN.PLANNUM

PLAN.PLANNUM = Number of Plan selected at HIS20.


10:42:34 AM Friday, February 13, 2009

Page 117 of 190

HIS20
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS20.
PLRO.PLRORND = previous round.
If Plan added, see PLAN ROSTER POP-UP specifications for pop-up window programming
instructions:
Variables populated in Plan Roster Pop-Up Window:
PLAN.PLANNUM
PLAN.PLANRNDC
PLAN.PLANTYPE
PLAN.PLNAME
For each Plan selected, create previous round PLRO where PLRO.PLROPLAN =
PLAN.PLANNUM of plan selected at HIS20 and PLRO.PLRORND = previous round.
HIS21 and remaining PLAN details will be stored on this previous round PLRO.
Previous round PLRO may already be created.
Set variables as instructed below:
PLANTYPE	

If adding PLAN, set PLAN.PLANTYPE =
4/PrivatePlan.

PLANRNDC	

If adding PLAN, set PLAN.PLANRNDC = current
round.

PLANSUMM	

If adding PLAN, set PLAN.PLANSUMM = 1/Yes.

PLROPLAN	

PLRO.PLROPLAN = PLAN.PLANNUM of plan
selected at HIS20.

PLRORND	

PLRO.PLRORND = previous round.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
59

SPStatus

SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.

52

DeletedPlans

10:42:34 AM Friday, February 13, 2009	

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

Page 118 of 190

HIS20
53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

81

PrivateCurrentPrevRnd

Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
Begin Loop 2: Collect plan details (HIS21-HIS33C) for all private plans
selected at HIS20.

10:42:34 AM Friday, February 13, 2009

Page 119 of 190

HIS20_IN

HIS20_IN

Page Order # :

Design Screen Type:

Instance Navigator

Fields:

Field 1:

NAVIGATOR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

1065

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display Plans selected at HIS20.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

10:42:36 AM Friday, February 13, 2009

Page 120 of 190

HIS20_IN
NAVIGATOR

Field1:

( HIS2635 )

N/A

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TInstanceNavigator
1
No
No

Number Label
1 SelectItemInList
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS21 - COVTIME ( HIS2650 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
HIS1 - HISCORR ( HIS1030 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:42:42 AM Friday, February 13, 2009

Page 121 of 190

HIS21

HIS21

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

COVTIME

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

1070

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Display plan name for the plan being asked about, PLAN.PLNAME.

Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:	

PRIVATE INSURANCE PLAN = (PRIVATE PLAN NAME)

Int. Instr I:
Question Text:	

[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole
time between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), or only part of the time?

Int. Instr II:
INPUT FIELDS / ROUTING

10:42:45 AM Friday, February 13, 2009	

Page 122 of 190

HIS21
COVTIME

Field1:

( HIS2650 )

PLRO.COVTIME

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TCovtime
1
No
No

Number Label
1 WholeTime
2

English text: THE WHOLE TIME
PartOfTime

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS3A1 - (HIS2722 )
HIS22 - COVNOW ( HIS2660 )

English text: PART OF THE TIME
Attribute
Don't know

Route
HIS22 - COVNOW ( HIS2660 )

Refusal

HIS22 - COVNOW ( HIS2660 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:42:49 AM Friday, February 13, 2009

Page 123 of 190

HIS22

HIS22

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

COVNOW

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

1080

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.


Multi Field display:


Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) on

(REFERENCE DATE)?

Int. Instr II:
INPUT FIELDS / ROUTING

10:42:52 AM Friday, February 13, 2009	

Page 124 of 190

HIS22
COVNOW

Field1:

( HIS2660 )

PLRO.COVNOW

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS23 - COVBEGMM ( HIS2670 )

English text: YES
No

HIS24 - COVENDMM ( HIS2700 )

English text: NO
Attribute
Don't know

Route
BOX HIS3A1 - (HIS2722 )

Refusal

BOX HIS3A1 - (HIS2722 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:42:57 AM Friday, February 13, 2009

Page 125 of 190

HIS23

HIS23

Page Order # :

Design Screen Type:

Date

Fields:

Field 1:

COVBEGMM

Field 2:

COVBEGDD

Field 3:

COVBEGYY

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

1090

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Horizontal Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

On what date did [your/(SP’s)] coverage under (PRIVATE PLAN
	
NAME) start between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE)?

Int. Instr II:

INPUT FIELDS / ROUTING


10:43:01 AM Friday, February 13, 2009

Page 126 of 190

HIS23
COVBEGMM

Field1:

( HIS2670 )

PLRO.COVBEGMM

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

MM
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMonthInt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS23 - COVBEGDD ( HIS2680 )

Refusal

HIS23 - COVBEGDD ( HIS2680 )

10:43:09 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
HIS23 - COVBEGDD ( HIS2680 )

Page 127 of 190

HIS23
COVBEGDD

Field2:

( HIS2680 )

PLRO.COVBEGDD

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

DD
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TDayDKRF
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS23 - COVBEGYY ( HIS2690 )

Refusal

HIS23 - COVBEGYY ( HIS2690 )

10:43:17 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
HIS23 - COVBEGYY ( HIS2690 )

Page 128 of 190

HIS23
COVBEGYY

Field3:

( HIS2690 )

PLRO.COVBEGYY

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

YY
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMcyear
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
BOX HIS3A1 - (HIS2722 )

Refusal

BOX HIS3A1 - (HIS2722 )

FieldSize:

Min Value:
Max Value:
Mask:


0

99


Route
BOX HIS3A1 - (HIS2722 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
PLAN BEGIN DATE, COVBEGMM/COVBEGDD/COVBEGYY,

should be on or between (SUMMARY REFERENCE DATE) and

(REFERENCE DATE).

If not true, display message: "DATE MUST BE ON OR BETWEEN

(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).

PLEASE REENTER."

TECHNICAL NOTES

DESIGN NOTES

10:43:20 AM Friday, February 13, 2009

Page 129 of 190

HIS24

HIS24

Page Order # :

Design Screen Type:

Date

Fields:

Field 1:

COVENDMM

Field 2:

COVENDDD

Field 3:

COVENDYY

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

1100

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Horizontal Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

On what date between (SUMMARY REFERENCE DATE) and

(REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE
PLAN NAME) stop?

Int. Instr II:

INPUT FIELDS / ROUTING


10:43:23 AM Friday, February 13, 2009

Page 130 of 190

HIS24
COVENDMM

Field1:

( HIS2700 )

PLRO.COVENDMM

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMonthInt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS24 - COVENDDD ( HIS2710 )

Refusal

HIS24 - COVENDDD ( HIS2710 )

10:43:31 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
HIS24 - COVENDDD ( HIS2710 )

Page 131 of 190

HIS24
COVENDDD

Field2:

( HIS2710 )

PLRO.COVENDDD

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

DD
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TDayDKRF
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS24 - COVENDYY ( HIS2720 )

Refusal

HIS24 - COVENDYY ( HIS2720 )

10:43:39 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
HIS24 - COVENDYY ( HIS2720 )

Page 132 of 190

HIS24
COVENDYY

Field3:

( HIS2720 )

PLRO.COVENDYY

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

YY
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMcyear
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
BOX HIS3A1 - (HIS2722 )

Refusal

BOX HIS3A1 - (HIS2722 )

FieldSize:

Min Value:
Max Value:
Mask:


0

99


Route
BOX HIS3A1 - (HIS2722 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
PLAN END DATE, COVENDMM/COVENDDD/COVENDYY, should

be on or between (SUMMARY REFERENCE DATE) and 

(REFERENCE DATE).

If not true, display message: "DATE MUST BE ON OR BETWEEN

(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).

PLEASE REENTER."

TECHNICAL NOTES

DESIGN NOTES

10:43:43 AM Friday, February 13, 2009

Page 133 of 190

BOX HIS3A1

BOX HIS3A1

Page Order # :

1105

BOX INSTRUCTIONS
( HIS2722 )

GO TO HIS25 - PPRVHMO ( HIS2730 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

10:43:43 AM Friday, February 13, 2009

Page 134 of 190

HIS25

HIS25

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

PPRVHMO

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

1110

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Display plan name for the plan being asked about, PLAN.PLNAME.

Question display:

Always display "(Health Maintenance Organization)" and (Preferred
Provider Organization) in parenthesis.
Always display "(network)" in parenthesis.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

PRIVATE INSURANCE PLAN = (PRIVATE PLAN NAME)

Int. Instr I:

CODE WITHOUT ASKING IF VOLUNTEERED.

Question Text:

Was this a managed care plan, such as an HMO (Health
Maintenance Organization) or PPO (Preferred Provider
Organization)?
[EXPLAIN IF NECESSARY: Managed care plans generally provide
a full range of health care services for a prepaid fee. Health care is
generally provided by primary care doctors, specialists, or hospitals
on the plan’s list (network) except in an emergency.]

10:43:46 AM Friday, February 13, 2009

Page 135 of 190

HIS25
Int. Instr II:

INPUT FIELDS / ROUTING

( HIS2730 )

PPRVHMO

Field1:	

PLRO.PPRVHMO

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label	
1 Yes	
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS26 - PERS_HISMIPNUM ( HIS2750 )

English text: YES
No	

HIS26 - PERS_HISMIPNUM ( HIS2750 )

English text: NO
Attribute
Don't know

Route
HIS26 - PERS_HISMIPNUM ( HIS2750 )

Refusal

HIS26 - PERS_HISMIPNUM ( HIS2750 )

BACKGROUND VARIABLE ASSIGNMENTS
If PLAN is new (added at HIS20), store response to HI25 - PPRVHMO also on PLAN
record. Set variable as instructed below:
If PLAN is new, set PLAN.PRVHMO =
PLRO.PPRVHMO.

PRVHMO	
SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
155

ThisPlanNewPrevRnd

10:43:51 AM Friday, February 13, 2009

This Plan added in HIS and is a new Plan during the
previous round reference period =

Page 136 of 190

HIS25
PLAN.PLANRNDC=current round and

PLAN.PLANSUMM = 1/Yes.

Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:43:51 AM Friday, February 13, 2009

Page 137 of 190

HIS26

HIS26

Page Order # :

Design Screen Type:	

Roster

Fields:	

Field 1:

PERS_HISMIPNUM

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Person Roster

Roster Type:

Single Item Select

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:	

Add Line
Delete Line

No
No

1120

Display as ' Add a Person '
Display as ' Edit a Person '

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:	

Display all persons from the Person Roster.
Display SP on first line, followed by the name of the SP's spouse.
Display remaining persons in the order that they were entered in
Person Roster.
Do not allow SP to be edited.

Roster/Grid display:	

COL #

HEADER

INSTRUCTIONS

1

First Name	

Display ROST.ROSTFNAM.

2

Last Name	

Display ROST.ROSTLNAM.

3

Relationship to SP	

Display Relationship:
If ROST. ROSTREL=91/OtherRelative or
92/OtherNon-Relative, display
ROST.ROSTREOS.
Else display ROST.ROSTREL
relationship.

Report display:

TEXT:

10:43:53 AM Friday, February 13, 2009	

Page 138 of 190

HIS26
Context Header:
Int. Instr I:
Question Text:

Who was listed as the main insured person on the (PRIVATE PLAN
NAME) policy or contract?

Int. Instr II:

SELECT OR ADD ONLY ONE PERSON.

INPUT FIELDS / ROUTING

Field1:

PERS_HISMIPNUM

( HIS2750 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:


String
TRostPick4
1

No
No


Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:


4

Route
HIS27 - PPRVGET ( HIS2770 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on ROST:

ROST key = ROST.ROSTBASE + ROST.ROSTNUM

ROST.ROSTNUM = Number of Person selected at HIS26.

If Person added, see PERSON ROSTER POP-UP specifications for pop-up window

programming instructions.

Variables populated in Person Roster Pop-Up Window:

ROST.ROSTNUM

ROST.ROSTRNDC

ROST.ROSTFNAM

ROST.ROSTLNAM

ROST.ROSTREL

ROST.ROSTREOS

Set reason why person was added. See additional instructions below.

Person selected at HIS26 is the Main Insured Person (MIP). The ROST.ROSTNUM for the

MIP is stored on PLAN and the PLAN's previous round PLRO. Set variables as instructed

below.


10:43:55 AM Friday, February 13, 2009

Page 139 of 190

HIS26
ROSTREAS

If person added, set ROST.ROSTREAS = 6/MIP.

MIPNUM

PLRO.MIPNUM = ROST.ROSTNUM of person
selected.

PLMIPNUM

PLAN.PLMIPNUM = PLRO.MIPNUM. (NOTE: will
need to TRNS variable in future design).

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
96

SPsSpouse	

SP's Spouse =
There is a ROST where ROST.ROSTREL=2/Spouse.

DESIGN NOTES

10:43:55 AM Friday, February 13, 2009	

Page 140 of 190

HIS27

HIS27

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

PPRVGET

Field 3:

PPRVGTOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

Enable Functions:	

1130

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.
If the respondent is the MIP, display "you" .
Else display the name of the MIP.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up
directly with the (insurance company/managed care plan), or did
[you/(MIP)] get this insurance through a current employer, a former
employer, a union, a family business, AARP, or some other way?

Int. Instr II:

10:44:00 AM Friday, February 13, 2009	

Page 141 of 190

HIS27
INPUT FIELDS / ROUTING

10:44:11 AM Friday, February 13, 2009

Page 142 of 190


HIS27
PPRVGET

Field1:

PLRO.PPRVGET

Cheshire Name:
Item Text display:

( HIS2770 )

Display name of MIP in response categories

Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TPrvget
1
No
No

Number Label
1 Directly
2

English text: DIRECTLY
CurrentEmployer

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS29 - PRVNMCOV ( HIS2920 )
HIS29 - PRVNMCOV ( HIS2920 )

4

English text: (MIP'S) CURRENT EMPLOYER
FormerEmployer
HIS29 - PRVNMCOV ( HIS2920 )
English text: (MIP'S) FORMER EMPLOYER
Union
HIS29 - PRVNMCOV ( HIS2920 )

5

English text: (MIP'S) UNION
FamilyBusiness

HIS29 - PRVNMCOV ( HIS2920 )

6

English text: (MIP'S) FAMILY BUSINESS
Aarp

HIS29 - PRVNMCOV ( HIS2920 )

7

English text: AARP
DecSpousesEmployer

HIS29 - PRVNMCOV ( HIS2920 )

8

English text: DECEASED SPOUSE'S EMPLOYER
DecSpousesUnion
HIS29 - PRVNMCOV ( HIS2920 )

9

English text: DECEASED SPOUSE'S UNION
ProfessionalOrg

3

91

HIS29 - PRVNMCOV ( HIS2920 )

English text: PROFESSIONAL/FRATERNAL ORGANIZATION
Other
HIS27 - PPRVGTOS ( HIS2790 )
English text: SOME OTHER WAY

Attribute
Don't know

Route
HIS29 - PRVNMCOV ( HIS2920 )

Refusal

HIS29 - PRVNMCOV ( HIS2920 )

10:44:23 AM Friday, February 13, 2009

Page 143 of 190

HIS27
( HIS2790 )

PPRVGTOS

Field3:
Cheshire Name:

PLAN.PRVGETOS

Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.


Item Text:

OTHER (SPECIFY)


Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


String

TOthrspec

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 [Continuous answer.]	

30

Route
HIS29 - PRVNMCOV ( HIS2920 )

BACKGROUND VARIABLE ASSIGNMENTS
If PLAN is new (added at HIS20), store response to HI27 - PPRVGET and PPRVGTOS
also on PLAN record. Set variable as instructed below:
PRVGET	

If PLAN is new, set
PLAN.PRVGET=PLRO.PPRVGET.

PRVGETOS	

if PLAN is new, set
PLAN.PRVGETOS=PLRO.PPRVGTOS.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
4

Respondent

On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.

208

MIPPrevRnd

10:44:26 AM Friday, February 13, 2009	

Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.

Page 144 of 190

HIS27
DESIGN NOTES

10:44:26 AM Friday, February 13, 2009

Page 145 of 190


HIS29

HIS29

Page Order # :

Design Screen Type:	

Numeric

Fields:	

Field 1:

PRVNMCOV

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

1180

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

If the respondent is the MIP, display "your".

Else display the name of the MIP.
Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

How many family members, including [yourself/(SP)], were covered

by [your/(MIP’s)] (PRIVATE PLAN NAME) between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE)?

Int. Instr II:

INPUT FIELDS / ROUTING


10:44:28 AM Friday, February 13, 2009	

Page 146 of 190

HIS29
PRVNMCOV

Field1:

( HIS2920 )

PLRO.PRVNMCOV

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

NUMBER COVERED:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TPrvnmcov

FieldSize:

Min Value:
Max Value:
Mask:


1
No
No

Number Label
1 [Continuous answer.]

1

15


Route
HIS31A - PRVRXCOV ( HIS2925 )

Attribute
Don't know

Route
HIS31A - PRVRXCOV ( HIS2925 )

Refusal

HIS31A - PRVRXCOV ( HIS2925 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
PRVNMCOV should = 1-4, DK or RF.

If not true, display message "THE AMOUNT ENTERED SEEMS

UNLIKELY. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES
4

Respondent

On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.

10:44:31 AM Friday, February 13, 2009

Page 147 of 190

HIS29
208

MIPPrevRnd

Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.

DESIGN NOTES

10:44:31 AM Friday, February 13, 2009

Page 148 of 190

HIS31A

HIS31A

Page Order # :

Design Screen Type:

List

Fields:

Field 1:

PRVRXCOV

Field 2:

PRVMSCOV

Field 3:

PRVIPCOV

Field 4:

PRVNHCOV

Field 5:

MHMODENT

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

1185

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.
If the respondent is the MIP reported at HIS26, display "your".
Else display the name of the MIP reported at HIS26.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

10:44:37 AM Friday, February 13, 2009

Supplemental insurance plans may cover a variety of services or 

may be specific to only certain services, such as prescribed
Page 149 of 190

HIS31A
medicines or dental coverage. I’d like to know what [your/(SP’s)]
(PRIVATE PLAN NAME) coverage included between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE).
[PROBE: I am asking about the type of insurance coverage that
[you/(SP)] personally had, not what the plan offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
Int. Instr II:

INPUT FIELDS / ROUTING

PRVRXCOV

Field1:

( HIS2925 )

PLRO.PRVRXCOV

Cheshire Name:
Item Text display:

Display "a." before the question text.

Item Text:

prescribed medicines?

Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS31A - PRVMSCOV ( HIS2930 )

English text: YES
No

HIS31A - PRVMSCOV ( HIS2930 )

English text: NO
Attribute
Don't know

Route
HIS31A - PRVMSCOV ( HIS2930 )

Refusal

HIS31A - PRVMSCOV ( HIS2930 )

10:44:47 AM Friday, February 13, 2009

Page 150 of 190

HIS31A
PRVMSCOV

Field2:

( HIS2930 )

PLRO.PRVMSCOV

Cheshire Name:
Item Text display:

Display "b." before the question text.

Item Text:

doctor visits or lab work?

Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS31A - PRVIPCOV ( HIS2935 )

English text: YES
No

HIS31A - PRVIPCOV ( HIS2935 )

English text: NO
Attribute
Don't know

Route
HIS31A - PRVIPCOV ( HIS2935 )

Refusal

HIS31A - PRVIPCOV ( HIS2935 )

10:44:57 AM Friday, February 13, 2009

Page 151 of 190

HIS31A
PRVIPCOV

Field3:

( HIS2935 )

PLRO.PRVIPCOV

Cheshire Name:
Item Text display:

Display "c." before the question text.

Item Text:

inpatient hospital care?

Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS31A - PRVNHCOV ( HIS2940 )

English text: YES
No

HIS31A - PRVNHCOV ( HIS2940 )

English text: NO
Attribute
Don't know

Route
HIS31A - PRVNHCOV ( HIS2940 )

Refusal

HIS31A - PRVNHCOV ( HIS2940 )

10:45:08 AM Friday, February 13, 2009

Page 152 of 190

HIS31A
PRVNHCOV

Field4:

( HIS2940 )

PLRO.PRVNHCOV

Cheshire Name:
Item Text display:

Display "d." before the question text.

Item Text:

nursing home or long term care?

Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS31A - MHMODENT ( HIS2945 )

English text: YES
No

HIS31A - MHMODENT ( HIS2945 )

English text: NO
Attribute
Don't know

Route
HIS31A - MHMODENT ( HIS2945 )

Refusal

HIS31A - MHMODENT ( HIS2945 )

10:45:18 AM Friday, February 13, 2009

Page 153 of 190

HIS31A
MHMODENT

Field5:

( HIS2945 )

PLRO.MHMODENT

Cheshire Name:
Item Text display:

Display "e." before the question text.

Item Text:

dental care?

Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS32 - MIPPINS ( HIS3240 )

English text: YES
No

HIS32 - MIPPINS ( HIS3240 )

English text: NO
Attribute
Don't know

Route
HIS32 - MIPPINS ( HIS3240 )

Refusal

HIS32 - MIPPINS ( HIS3240 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
4

Respondent

On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.

10:45:24 AM Friday, February 13, 2009

Page 154 of 190

HIS31A
208

MIPPrevRnd

Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.

DESIGN NOTES

10:45:24 AM Friday, February 13, 2009

Page 155 of 190

HIS32

HIS32

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MIPPINS

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

1195

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.
Always display, "[Do not include the cost of any deductibles...]" in
brackets.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

Was there a premium or cost for the (PRIVATE PLAN NAME)

coverage?
[Do not include the cost of any deductibles [you/(SP)] or [your/(SP’s)]
family may have had to pay.]

Int. Instr II:

10:45:26 AM Friday, February 13, 2009	

Page 156 of 190

HIS32
INPUT FIELDS / ROUTING
MIPPINS

Field1:

( HIS3240 )

PLRO.MIPPINS

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS33 - MIPPAMT ( HIS3250 )

English text: YES
No
English text: NO

Attribute
Don't know

Route
HIS33A - MHMOCOST ( HIS3280 )

Refusal

HIS33A - MHMOCOST ( HIS3280 )

HIS33A - MHMOCOST ( HIS3280 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:45:30 AM Friday, February 13, 2009

Page 157 of 190

HIS33

HIS33

Page Order # :

Design Screen Type:

Quantity Unit Hybrid

Fields:

Field 1:

MIPPAMT

Field 2:

MIPPUNIT

Field 3:

MIPPUNOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No


Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

1205

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If respondent is MIP, display "you".
Else display the name of the MIP.
Display plan name for the plan being asked about, PLAN.PLNAME.
Always display "[Please do not include any…]" in brackets.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

10:45:37 AM Friday, February 13, 2009

How much did [you/(MIP)] pay for the (PRIVATE PLAN NAME)

coverage?

Page 158 of 190

HIS33
[Please do not include any amount that may be paid for anyone
other than [you/(SP)].]
[PROBE IF NECESSARY: Was that per year, per month, per week,
or what?]
Int. Instr II:
INPUT FIELDS / ROUTING
MIPPAMT

Field1:

( HIS3250 )

PLRO.MIPPAMT

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:


AMOUNT:
Left

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Real
TMippamt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
HIS33A - MHMOCOST ( HIS3280 )

Refusal

HIS33A - MHMOCOST ( HIS3280 )

10:45:48 AM Friday, February 13, 2009

FieldSize:
Min Value:
Max Value:
Mask:

0.01
99999.99
Dollars

Route
HIS33 - MIPPUNIT ( HIS3260 )

Page 159 of 190

HIS33
MIPPUNIT

Field2:

( HIS3260 )

PLRO.MIPPUNIT

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TMippunit
1
No
No

Number Label
1 PerYear
2

English text: PER YEAR
Quarterly

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS33A - MHMOCOST ( HIS3280 )
HIS33A - MHMOCOST ( HIS3280 )

4

English text: QUARTERLY/EVERY 3 MONTHS
Bimonthly
HIS33A - MHMOCOST ( HIS3280 )
English text: BIMONTHLY/EVERY 2 MONTHS
PerMonth
HIS33A - MHMOCOST ( HIS3280 )

5

English text: PER MONTH
PerWeek

HIS33A - MHMOCOST ( HIS3280 )

6

English text: PER WEEK
SemiAnnually

HIS33A - MHMOCOST ( HIS3280 )

7

English text: SEMI-ANNUALLY/2 TIMES PER YEAR
SemiMonthly
HIS33A - MHMOCOST ( HIS3280 )

3

91

English text: SEMI-MONTHLY/2 TIMES PER MONTH
Other
HIS33 - MIPPUNOS ( HIS3270 )
English text: OTHER

Attribute
Don't know

Route
HIS33A - MHMOCOST ( HIS3280 )

Refusal

HIS33A - MHMOCOST ( HIS3280 )

10:46:01 AM Friday, February 13, 2009

Page 160 of 190

HIS33
( HIS3270 )

MIPPUNOS

Field3:

PLRO.MIPPUNOS

Cheshire Name:
Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.


Item Text:

OTHER (SPECIFY)


Label:

Label Position:


VERIFY THAT RESPONDENT IS REPORTING A DEDUCTIBLE AND NOT A CO­
PAY.

Under


Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


String

TOthrspec

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 [Continuous answer.]

30

Route
HIS33A - MHMOCOST ( HIS3280 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
If MPPAMT ^= DK and MPPAMT ^= RF then, 

If MIPPUNIT = 1/PerYear, then MIPPAMT = $50.00 - 10,000.00.

Else if MIPPUNIT = 2/Quarterly, then MIPPAMT = $15.00 - 2500.00.

Else if MIPPUNIT = 3/Bimonthly, then MIPPAMT = $10.00 - 1650.00.

Else if MIPPUNIT = 4/PerMonth, then MIPPAMT = $5.00 - 850.00.

Else if MIPPUNIT = 5/PerWeek, then MIPPAMT = $5.00 - 200.00.

Else if MIPPUNIT = 6/SemiAnnually, then MIPPAMT = $25.00 - 

5,000.00.

Else if MIPPUNIT = 7/SemiMonthly, then MIPPAMT = $2.00 - 425.00.

Else if MIPPUNIT = 91/Other ,then MIPPAMT = $5.00 - 15,000.00.

If not true, display message "THE AMOUNT ENTERED SEEMS

UNLIKELY. PLEASE VERIFY.".

HARD EDIT CHECKS

TECHNICAL NOTES
4

Respondent

On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.

10:46:03 AM Friday, February 13, 2009

Page 161 of 190

HIS33
MRES.RROSTNUM='01'.
208

MIPPrevRnd	

Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.

DESIGN NOTES

10:46:03 AM Friday, February 13, 2009	

Page 162 of 190

HIS33A

HIS33A

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MHMOCOST

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

1215

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

If respondent is MIP, display "you".

Else display the name of the MIP.
Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did anyone else, such as an employer, a union or
professional organization pay all or some portion of the premium or
cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?

Int. Instr II:

10:46:05 AM Friday, February 13, 2009	

Page 163 of 190

HIS33A
INPUT FIELDS / ROUTING
MHMOCOST

Field1:

( HIS3280 )

PLRO.MHMOCOST

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS33B - MHMOWHO ( HIS3290 )

English text: YES
No
English text: NO

BOX HIS3B - (HIS3310 )

Attribute
Don't know

Route
BOX HIS3B - (HIS3310 )

Refusal

BOX HIS3B - (HIS3310 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
4

Respondent

On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.

10:46:11 AM Friday, February 13, 2009

Page 164 of 190

HIS33A
MRES.RROSTNUM='01'.
208

MIPPrevRnd	

Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.

DESIGN NOTES

10:46:11 AM Friday, February 13, 2009	

Page 165 of 190

HIS33B

HIS33B

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

MHMOWHO

Field 2:

MHMOWHOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

Enable Functions:	

1225

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

If respondent is MIP, display "you".

Else display the name of the MIP.
Display plan name for the plan being asked about, PLAN.PLNAME.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

Who else paid all or some portion of the cost for [your/[MIP’s)]
	
(PRIVATE PLAN NAME) coverage?

Int. Instr II:

INPUT FIELDS / ROUTING

10:46:15 AM Friday, February 13, 2009	

Page 166 of 190

HIS33B
MHMOWHO

Field1:

PLRO.MHMOWHO

Cheshire Name:
Item Text display:

( HIS3290 )

[(SP'S)/(MIP'S)]: Display (MIP's), name of Main Insured
person, in response text for "1/CurrentEmployer",
"2/FormerEmployer", and "3/Union".

Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Enumerated
TMhmowho
1
No
No

Number Label
1 CurrentEmployer

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS3B - (HIS3310 )

3

English text: [(SP's)/(MIP's)] CURRENT EMPLOYER
FormerEmployer
BOX HIS3B - (HIS3310 )
(SP's/MIP's)
FORMER
EMPLOYER
English text:
Union
BOX HIS3B - (HIS3310 )

4

English text: (SP's/MIP's) UNION
SpousesCurrentEmployer

2

BOX HIS3B - (HIS3310 )

6

English text: SPOUSE'S CURRENT EMPLOYER
SpousesFormerEmployer
BOX HIS3B - (HIS3310 )
English text: SPOUSE'S FORMER EMPLOYER
ProfessionalOrg
BOX HIS3B - (HIS3310 )

7

English text: PROFESSIONAL/FRATERNAL ORGANIZATION
Medicaid
BOX HIS3B - (HIS3310 )

5

91

English text: MEDICAID/MEDICAL ASSISTANCE
Other
HIS33B - MHMOWHOS ( HIS3300 )
English text: OTHER

Attribute
Don't know

Route
BOX HIS3B - (HIS3310 )

Refusal

BOX HIS3B - (HIS3310 )

10:46:28 AM Friday, February 13, 2009

Page 167 of 190

HIS33B
MHMOWHOS

Field2:

( HIS3300 )

PLRO.MHMOWHOS

Cheshire Name:
Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.


Item Text:

OTHER (SPECIFY)


Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


String

TOthrspec

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 [Continuous answer.]

30

Route
BOX HIS3B - (HIS3310 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
4

Respondent

On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.

208

MIPPrevRnd

Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.

DESIGN NOTES

10:46:30 AM Friday, February 13, 2009

Page 168 of 190

BOX HIS3B

BOX HIS3B

Page Order # :

1235

BOX INSTRUCTIONS
( HIS3310 )	

IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO HIS33C ­
MHMOPOS ( HIS3320 ).
ELSE GO TO BOX HIS4 - (HIS3330 ).

ASSIGNMENTS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

209

ThisPrivPlanHMOPrevR
nd

This private plan was a managed care plan in the
previous round =
For this PLAN, there is a PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.PPRVHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:46:30 AM Friday, February 13, 2009	

Page 169 of 190

HIS33C

HIS33C

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

MHMOPOS

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

1245

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display plan name for the plan being asked about, PLAN.PLNAME.


Multi Field display:


Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

Some managed care plans offer a point-of-service option which
allows members to receive services from out-of-plan providers even
in non-emergency situations. Between (SUMMARY REFERENCE
DATE) and (REFERENCE DATE), [were you/was (SP)] enrolled in a
point-of-service option offered by (PRIVATE PLAN NAME)?
[EXPLAIN IF NECESSARY: In a point-of-service option, the
member typically pays a higher copayment when seeing an out-of­
plan provider. For example, if a member sees an in-plan provider,
there may only be a $10 copayment. However, the member may
have to pay 20 percent of the cost and the managed care plan will

10:46:32 AM Friday, February 13, 2009	

Page 170 of 190

HIS33C
pay 80 percent of the cost to receive the same service from an outof-plan provider.]
Int. Instr II:

INPUT FIELDS / ROUTING

MHMOPOS

Field1:

( HIS3320 )

PLRO.MHMOPOS

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS4 - (HIS3330 )

English text: YES
No

BOX HIS4 - (HIS3330 )

English text: NO
Attribute
Don't know

Route
BOX HIS4 - (HIS3330 )

Refusal

BOX HIS4 - (HIS3330 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
10:46:36 AM Friday, February 13, 2009

Page 171 of 190

BOX HIS4

BOX HIS4

Page Order # :

1255

BOX INSTRUCTIONS
( HIS3330 )

GO TO HIS20_IN - NAVIGATOR ( HIS2635 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

10:46:37 AM Friday, February 13, 2009

Page 172 of 190

HIS34

HIS34

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

PLAN_HISMPDP

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
No

Roster Name:

Plan Roster

Roster Type:

Single Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:

Add Line
Delete Line

No
No

1265

Display as ' Add a Plan '
Display as ' Edit a Plan '

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:

Display all health insurance plans from the Plan Roster.
Display plans in order of entry.
Display the following plans as protected rows:
Medicare plan
Medicare Managed Care plan
Medicaid
Tricare
Public Plans
Private Plans
Medicare Prescription Drug Plan if "current" at the time of the
previous round interview

Roster/Grid display:

COL #
1

10:46:38 AM Friday, February 13, 2009

HEADER
Plan Name

INSTRUCTIONS
Display PLAN.PLNAME.

Page 173 of 190

HIS34
2

Plan Type

Display PLAN.PLANTYPE:
1/Medicare, display "(MCAR)"
2/Medicaid, display "(MCAD)"
3/PublicPlan, display "(PUBL)"
4/PrivatePlan, display "(PRIV)"
5/MHMO, display "(MHMO)"
6/Tricare, display "(TRIC)"
7/MPDP, display "(MPDP)".

3

Plan Status

Display PREVIOUS ROUND PLAN
STATUS.

Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

What is the name of the Medicare Prescription Drug plan that
covered [you/(SP)]?

Int. Instr II:

SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG
PLAN AT THIS ROSTER.

INPUT FIELDS / ROUTING

Field1:

PLAN_HISMPDP

( HIS3331 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:


String
TPlanPick32
1

No
No


Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:


32

Route
HIS35 - HISMPDPCURR ( HIS3332 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:

PLAN key = PLAN.PLANBASE + PLAN.PLANNUM

PLAN.PLANNUM = Number of Plan selected at HIS34.


10:46:40 AM Friday, February 13, 2009

Page 174 of 190

HIS34
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS34.
PLRO.PLRORND = previous round.
If Plan added, see PLAN ROSTER POP-UP specifications for pop-up window programming
instructions:
Variables populated in Plan Roster Pop-Up Window:
PLAN.PLANNUM
PLAN.PLANRNDC
PLAN.PLANTYPE
PLAN.PLNAME
For Plan selected, create previous round PLRO where PLRO.PLROPLAN =
PLAN.PLANNUM of plan selected at HIS34 and PLRO.PLRORND = previous round.
Applicable remaining PLAN details will be stored on this previous round PLRO.
Previous round PLRO may already exist.
See additional instructions below:
PLANTYPE	

If Plan is added at HIS34, set
PLAN.PLANTYPE=7/MPDP.

PLANRNDC	

If Plan is added at HIS34, set PLAN.PLANRNDC =
current round.

PLANSUMM	

If Plan is added at HIS34, set
PLAN.PLANSUMM=1/Yes.

COVANYTM	

PLRO.COVANYTM=1/Yes for plan selected at HIS34.

PLROPLAN	

PLRO.PLROPLAN = PLAN.PLANNUM of plan
selected at HIS34.

PLRORND	

PLRO.PLRORND = previous round.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

10:46:40 AM Friday, February 13, 2009	

Page 175 of 190

HIS34
343

MPDPCurrPrevRnd	

Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
HIS34 is also called from HIS10B1 when a Medicare Prescription Drug
Plan is reported through Medicaid coverage.

10:46:40 AM Friday, February 13, 2009	

Page 176 of 190

HIS35

HIS35

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

HISMPDPCURR

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

1275

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display the name of this Medicare Prescription Drug Plan selected
at HIS34, PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

[Were you/Was (SP)] covered by or enrolled in (MEDICARE

PRESCRIPTION DRUG PLAN NAME) on (REFERENCE DATE)?

Int. Instr II:
INPUT FIELDS / ROUTING

10:46:42 AM Friday, February 13, 2009	

Page 177 of 190

HIS35
HISMPDPCURR

Field1:

( HIS3332 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS5A - (HIS3333 )

English text: YES
No

BOX HIS6 - (HIS3335 )

English text: NO
Attribute
Don't know

Route
BOX HIS6 - (HIS3335 )

Refusal

BOX HIS6 - (HIS3335 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:46:49 AM Friday, February 13, 2009

Page 178 of 190

BOX HIS5A

BOX HIS5A

Page Order # :

1285

BOX INSTRUCTIONS
( HIS3333 )	

OTHER THAN THE PLAN SELECTED AT HIS34, IF ANOTHER MEDICARE
PRESCRIPTION DRUG PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HIS36 - HISMPDPCHNG (
HIS3334 ).
ELSE GO TO BOX HIS6 - (HIS3335 ).

ASSIGNMENTS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

343

MPDPCurrPrevRnd

Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
There is a rule that the SP can only have one "current" Medicare
Prescription Drug plan at the time of the interview.
BOX HIS5A is called if the MPDP selected at HIS34 is reported as
"current" at the time of the previous round interview at HIS35 ­
HISMPDPCURR.
The purpose of BOX HIS5A is determine if there is another MPDP
flagged as "current" at the time of the previous round interview. Should
only expect to find one "other" MPDP, if it exists.
If another MPDP is flagged as "current" at the time of the previous round
interview, BOX HIS5A is routed to HIS36 - HISMPDPCHNG to determine
if the "other" MPDP's status has changed.

10:46:49 AM Friday, February 13, 2009	

Page 179 of 190

HIS36

HIS36

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

HISMPDPCHNG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

1305

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

HIS36 is asking about the "other" MPDP that was current at the time
of the previous round interview, not the MPDP selected at HIS34.
Display the name of the "other" Medicare Prescription Drug Plan
that was "current" at the time of the previous round interview,
PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

I recorded previously that (PREVIOUS ROUND CURRENT
MEDICARE PRESCRIPTION DRUG PLAN NAME) was [your/(SP’s)]
current Medicare Prescription Drug Plan on (REFERENCE DATE).
Has this information changed?

Int. Instr II:
10:46:52 AM Friday, February 13, 2009

Page 180 of 190

HIS36
INPUT FIELDS / ROUTING
HISMPDPCHNG

Field1:
Cheshire Name:

( HIS3334 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS6 - (HIS3335 )

English text: YES
No
English text: NO

Attribute
Don't know

Route
BOX HIS6 - (HIS3335 )

Refusal

BOX HIS6 - (HIS3335 )

BOX HIS6 - (HIS3335 )

BACKGROUND VARIABLE ASSIGNMENTS
If HIS36 - HISMPDPCHNG = 1/Yes, we need to correct the status of the (other) Medicare
Prescription Drug plan that was current at the time of the previous round to "NOT
CURRENT". Set on PLRO where PLRO.PLRORND=previous round and
PLRO.PLROPLAN = this PLAN.PLANNUM.
Set variables as instructed below.
FUTURE SPEC: Log change to previous round plan on TRNS.
COVCURNT	

If MHISMPDPCHNG = 1/Yes, set
PLRO.COVCURNT=2/No on previous round PLRO
for Medicare Prescription Drug plan that was current
at the time of the previous round interview.

SOFT EDIT CHECKS

HARD EDIT CHECKS
10:46:57 AM Friday, February 13, 2009	

Page 181 of 190

HIS36

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

343

MPDPCurrPrevRnd

Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:46:57 AM Friday, February 13, 2009

Page 182 of 190

BOX HIS6

BOX HIS6

Page Order # :

1310

BOX INSTRUCTIONS
( HIS3335 )	

IF THE PLAN SELECTED AT HIS34 HAS BEEN IDENTIFIED AS THE SP'S
CURRENT MEDICARE PRESCRIPTION DRUG PLAN AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, SET THE PREVIOUS ROUND STATUS
OF THIS PLAN TO "CURRENT". OTHERWISE, SET THE PREVIOUS
ROUND STATUS OF THIS PLAN TO "NOT CURRENT" .
GO TO BOX HIS6A - (HIS3336 ).

ASSIGNMENTS
Set status of Medicare Prescription Drug plan selected at HIS34.
Set status variable, PLRO.COVCURNT, on PLRO where PLRO.PLRORND=previous
round and PLRO.PLROPLAN = PLAN.PLANNUM selected at HIS34. Set as instructed
below.
COVCURNT	

If (HISMPDPCURR=1/Yes and
HISMPDPCHNG=2/No,DK,RF) or
(HISMPDPCURR=2/No, DK or RF>), set
PLRO.COVCURNT=2/No.
Else if HISMPDPCURR=1/Yes and
(HISMPDPCHNG=1/Yes or EMPTY), set
PLRO.COVCURNT=1/Yes.

TECHNICAL NOTES

DESIGN NOTES
The purpose of BOX HIS6 is to set the status of the MPDP selected at
HIS34. Once status is set, all routes go to BOX HIS6A.

10:46:57 AM Friday, February 13, 2009	

Page 183 of 190

BOX HIS6A

BOX HIS6A

Page Order # :

1315

BOX INSTRUCTIONS
( HIS3336 )	

IF ((HIS35 - HISMPDPCURR = 2/No) OR (HIS36 - HISMPDPCHNG = 2/No)),
GO TO HIS37 - PDPYSTOP ( HIS3338 ).
ELSE GO TO HIS1 - HISCORR ( HIS1030 ).

ASSIGNMENTS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

349

ThisMPDPCurrentPrevR
nd

This MPDP Plan was "current" at the time of the previous
round interview =
For this PLAN, there is a PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

10:46:57 AM Friday, February 13, 2009	

Page 184 of 190

HIS37

HIS37

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

PDPYSTOP

Field 2:

PDPYSTOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

Enable Functions:	

1325

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display the name of this Medicare Prescription Drug Plan selected
at HIS34, PLAN.PLNAME.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

What is the most important reason [you/(SP)] stopped the

(MEDICARE PRESCRIPTION DRUG PLAN NAME) coverage?

Int. Instr II:

INPUT FIELDS / ROUTING


10:47:03 AM Friday, February 13, 2009	

Page 185 of 190

HIS37
PDPYSTOP

Field1:

( HIS3338 )

PLRO.PDPYSTOP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TPdpStop
1
No
No

Number Label
1 TooExpensive

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIS1 - HISCORR ( HIS1030 )

2

English text: TOO EXPENSIVE OR COULDN'T AFFORD
DissatisfiedWithCoverage
HIS1 - HISCORR ( HIS1030 )

3

English text: SP DISSATISFIED WITH PLAN'S COVERAGE
GetRxCoverage
HIS1 - HISCORR ( HIS1030 )

4

English text: TO GET RX COVERAGE IN ANOTHER PLAN
DiffHealthCareCov
HIS1 - HISCORR ( HIS1030 )

5

English text: TO GET DIFFERENT HEALTH CARE COVERAGE
NotMedicareRx
HIS1 - HISCORR ( HIS1030 )

6

English text: PLAN NO LONGER CONTRACTS FOR MEDICARE RX COVERAGE
ChangedName
HIS1 - HISCORR ( HIS1030 )

7

English text: PLAN NAME CHANGED OR PLAN WAS BOUGHT BY/MERGED WITH
ANOTHER PLAN
SPMoved
HIS1 - HISCORR ( HIS1030 )

91

English text: SP MOVED OUT OF PLAN AREA
Other
HIS37 - PDPYSTOS ( HIS3339 )
English text: OTHER

Attribute
Don't know

Route
HIS1 - HISCORR ( HIS1030 )

Refusal

HIS1 - HISCORR ( HIS1030 )

10:47:15 AM Friday, February 13, 2009

Page 186 of 190

HIS37

Field2:

PDPYSTOS

( HIS3339 )

PLRO.PDPYSTOS

Cheshire Name:
Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.


Item Text:

OTHER (SPECIFY)


Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


String

TOthrspec
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

30

Route
HIS1 - HISCORR ( HIS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:47:17 AM Friday, February 13, 2009

Page 187 of 190

HISCLOSE

HISCLOSE

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

ENDHIS

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

1470

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:
Question Text:

That covers the health insurance [you/(SP)] had at the time of the
last interview. The next questions are about [your/(SP’s)] insurance
coverage between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION).

Int. Instr II:
INPUT FIELDS / ROUTING

10:47:19 AM Friday, February 13, 2009

Page 188 of 190

HISCLOSE
ENDHIS

Field1:

( HIS3340 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HIS5 - (HIS3345 )

English text: CONTINUE
Attribute
Empty

Route
BOX HIS5 - (HIS3345 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:47:22 AM Friday, February 13, 2009

Page 189 of 190

BOX HIS5

BOX HIS5

Page Order # :

1480

BOX INSTRUCTIONS
( HIS3345 )

GO TO NEXT SECTION .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES
All SPs who receive HIS, also receive HI.

10:47:22 AM Friday, February 13, 2009

Page 190 of 190


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