MEDICAL EXPENDITURE PANEL SURVEY
HOUSEHOLD COMPONENT
MAIN STUDY
BLAISE/WVS
SHOW CARDS
Panels 12, 13, and 14
January 2009
TABLE OF CONTENTS
ROUNDS 1-5
Card Number |
Topic |
Round(s) Used
|
RE-1B |
Ethnic Background |
1, 2, 3,4,5 |
RE-2B |
Racial Background |
1, 2, 3,4,5 |
RE-2C |
Asian Ethnic Background |
1, 2, 3,4,5 |
RE-3A-3K |
Income Categories |
1, 3 |
HE-1 |
Level of Difficulty Categories |
1, 3, 5 |
CS-1 |
Scale for Child Health Supplement |
2, 4 |
CS-2 |
Scale for Child Health Supplement |
2, 4 |
CS-3 |
Scale for Child Health Supplement |
2, 4 |
CS-3A |
Number of Times Went to Doctor’s Office or Clinic |
2, 4 |
CS-5 |
Scale for Child Health Supplement |
2, 4 |
PP-1 |
Types of Health Care Providers and Facilities |
1, 2, 3, 4, 5 |
PP-2 |
Types of Hospital Services/Long Term Care Facilities |
1, 2, 3, 4, 5 |
PP-3 |
Types of Home Care Services |
1, 2, 3, 4, 5 |
PP-4 |
Types of Medical Supplies/Expenses |
1, 2, 3, 4 ,5 |
PP-4A |
Types of Additional Medical Supplies/Expenses |
3, 5 |
PP-5 |
Types of Dental Care Providers |
1, 2, 3, 4, 5 |
PP-6 |
Types of Medical Providers |
1, 2, 3, 4, 5 |
PP-7 |
Types of Hospital Services |
1, 2, 3, 4, 5 |
PP-8 |
Types of Other Medical Providers |
1, 2, 3, 4, 5 |
PP-9 |
Types of Home Care Services |
1, 2, 3, 4, 5 |
Table of Contents Continued on the Following Page |
TABLE OF CONTENTS (Cont.)
Card Number |
Topic |
Round(s) Used
|
PP-10 |
Types of Long Term Care Facilities |
1, 2, 3, 4, 5 |
PP-11 |
Types of Medical Supplies/Expenses |
1, 2, 3, 4, 5 |
PP-12 |
Types of Additional Medical Supplies/Expenses |
3, 5 |
HS-1 |
Reasons for Entering the Hospital |
1, 2, 3, 4, 5 |
ER-1 |
Care Received During ER Visit |
1, 2, 3, 4, 5 |
ER-2 |
Services Received During ER Visit |
1, 2, 3, 4, 5 |
OP-1 |
Care Received During Outpatient Visit |
1, 2, 3, 4, 5 |
OP-2 |
Treatments Received During Outpatient Visit |
1, 2, 3, 4, 5 |
OP-3 |
Services Received During Outpatient Visit |
1, 2, 3, 4, 5 |
MV-1 |
Care Received During Medical Provider Visit |
1, 2, 3, 4, 5 |
MV-2 |
Treatments Received During Medical Provider Visit |
1, 2, 3, 4, 5 |
MV-3 |
Services Received During Medical Provider Visit |
1, 2, 3, 4, 5 |
DN-1 |
Care Received During Dental Visit |
1, 2, 3, 4, 5 |
HH-1 |
Types of Home Health Care Workers |
1, 2, 3, 4, 5 |
HH-2 |
Examples of Home Health Care Received |
1, 2, 3, 4, 5 |
HH-3 |
Examples of Help With Daily Activities or Personal Care |
1, 2, 3, 4, 5 |
CP-1 |
Reasons for Not Receiving Anything in Writing |
1, 2, 3, 4, 5 |
PC-2 |
Last Use of Peak Flow Meter |
3, 5 |
AP-1 |
Weight Ranges |
3, 5 |
AC-1 |
Difficulty Scale |
2, 4 |
AC-2 |
Provider’s Race |
2, 4 |
AC-3 |
Frequency Scale |
2, 4 |
AC-4 |
Reasons for Problems |
2, 4 |
AC-5 |
Problems Scale |
2, 4 |
OE-1 |
Types of Health Insurance Coverage |
2, 3, 4, 5 |
PR-1 |
Medicare Managed Care Plan Names for STATE |
2, 3, 4, 5 |
PR-2 |
Medicaid (and Gov’t-Hosp/Phys) HMO Plan Names for STATE |
2, 3, 4, 5 |
Table of Contents Continued on the Following Page |
|
Table of Contents (continued) |
|
Card Number |
Topic |
Round(s) Used
|
PR-3 |
Types of Other State Programs |
2, 3, 4, 5 |
HX-1 |
Ways in Which Health Insurance is Purchased |
1, 2, 3, 4, 5 |
HX-2 |
Sample Medicare Card |
1, 2, 3, 4, 5 |
HX-3 |
Sample Medicaid Card for STATE |
1, 2, 3, 4, 5 |
HX-4 |
Source of Health Insurance |
1, 2, 3, 4, 5 |
HX-5 |
Medicare Managed Care Plan Names for STATE |
1, 2, 3, 4, 5 |
HX-6 |
Medicaid (and Gov’t-Hosp/Phys) HMO Plan Names for STATE |
1, 2, 3, 4, 5 |
HX-7 |
Types of Health Insurance Coverage |
1, 2, 3, 4, 5 |
HX-8 |
Plan Names (For Federal Civilian Employees For STATE) |
1 |
SP-1 |
Problem Scale |
2, 4 |
SP-2 |
Health Plan Scale |
2, 4 |
IN-1 |
Yearly Income Ranges |
3, 5 |
IN-1A |
Yearly Income Ranges |
3, 5 |
IN-2 |
Monthly Income Ranges |
3, 5 |
IN-2A |
TANF Program Names for STATE |
3, 5 |
IN-3 |
Other Sources of Income Categories |
3, 5 |
AS-1 AS-2 AS-3 |
Asset Ranges Asset Ranges Asset Ranges |
5 5 5 |
CARD RE-1B
RE-1B
-- Puerto Rican
-- Cuban/Cuban American
-- Dominican
-- Mexican
-- Mexican-American
-- Central or South American
CARD RE-2B
RE-2B
-- White
-- Black/African American
-- American Indian or Alaska Native
-- Asian
-- Native Hawaiian or Other Pacific Islander
CARD RE-2C
RE-2C
-- Asian Indian
-- Chinese
-- Filipino
-- Japanese
-- Korean
-- Vietnamese
CARD RE-3A
RE-3A
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $11,300 |
|
less than $942 |
B. |
$11,300 – $17,000 |
|
$942 – $1,417 |
C. |
$17,001 – $22,700 |
|
$1,418 – $1,892 |
D. |
$22,701 – $34,000 |
|
$1,893 – $2,833 |
E. |
more than $34,000 |
|
more than $2,833 |
CARD RE-3B
RE-3B
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $14,700 |
|
less than $1,225 |
B. |
$14,700 – $22,000 |
|
$1,225 – $1,833 |
C. |
$22,001 – $29,300 |
|
$1,834 – $2,442 |
D. |
$29,301 – $44,000 |
|
$2,443 – $3,667 |
E. |
more than $44,000 |
|
more than $3,667 |
CARD RE-3C
RE-3C
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $10,400 |
|
less than $867 |
B. |
$10,400 – $15,700 |
|
$867 – $1,308 |
C. |
$15,701 – $20,900 |
|
$1,309 – $1,742 |
D. |
$20,901 – $31,300 |
|
$1,743 – $2,608 |
E. |
more than $31,300 |
|
more than $2,608 |
CARD RE-3D
RE-3D
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $13,200 |
|
less than $1,100 |
B. |
$13,200 – $19,800 |
|
$1,100 – $1,650 |
C. |
$19,801 – $26,400 |
|
$1,651 – $2,200 |
D. |
$26,401 – $39,500 |
|
$2,201 – $3,292 |
E. |
more than $39,500 |
|
more than $3,292 |
CARD RE-3E
RE-3E
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $17,400 |
|
less than $1,450 |
B. |
$17,400 – $26,000 |
|
$1,450 – $2,167 |
C. |
$26,001 – $34,700 |
|
$2,168 – $2,892 |
D. |
$34,701 – $52,100 |
|
$2,893 – $4,342 |
E. |
more than $52,100 |
|
more than $4,342 |
CARD RE-3F
RE-3F
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $22,300 |
|
less than $1,858 |
B. |
$22,300 – $33,400 |
|
$1,858 – $2,783 |
C. |
$33,401 – $44,500 |
|
$2,784 – $3,708 |
D. |
$44,501 – $66,800 |
|
$3,709 – $5,567 |
E. |
more than $66,800 |
|
more than $5,567 |
CARD RE-3G
RE-3G
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $26,300 |
|
less than $2,192 |
B. |
$26,300 – $39,500 |
|
$2,192 – $3,292 |
C. |
$39,501 – $52,700 |
|
$3,293 – $4,392 |
D. |
$52,701 – $79,000 |
|
$4,393 – $6,583 |
E. |
more than $79,000 |
|
more than $6,583 |
CARD RE-3H
RE-3H
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $29,800 |
|
less than $2,483 |
B. |
$29,800 – $44,600 |
|
$2,483 – $3,717 |
C. |
$44,601 – $59,500 |
|
$3,718 – $4,958 |
D. |
$59,501 – $89,300 |
|
$4,959– $7,442 |
E. |
more than $89,300 |
|
more than $7,442 |
CARD RE-3I
RE-3I
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $33,700 |
|
less than $2,808 |
B. |
$33,700 – $50,500 |
|
$2,808 – $4,208 |
C. |
$50,501 – $67,400 |
|
$4,209 – $5,617 |
D. |
$67,401 – $101,100 |
|
$5,618 – $8,425 |
E. |
more than $101,100 |
|
more than $8,425 |
CARD RE-3J
RE-3J
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $37,500 |
|
less than $3,125 |
B. |
$37,500 – $56,300 |
|
$3,125 – $4,692 |
C. |
$56,301 – $75,100 |
|
$4,693 – $6,258 |
D. |
$75,101 – $112,600 |
|
$6,259 – $9,383 |
E. |
more than $112,600 |
|
more than $9,383 |
CARD RE-3K
RE-3K
Wages and Salaries |
Social Security or Railroad Retirement |
Interest or Dividends |
Private, Military, or Government Pensions |
Retirement Income or Annuities |
Survivor Benefits |
Public Assistance/TANF |
Supplemental Security Income (SSI) |
Disability Benefits |
Child Support or Alimony |
Farm or Business Income |
Rental, Estate or Trust Income |
Unemployment or Workers Compensation |
Financial assistance from outside household |
Income Categories:
|
Yearly |
|
Monthly |
A. |
less than $44,800 |
|
less than $3,733 |
B. |
$44,800 – $67,200 |
|
$3,733 – $5,600 |
C. |
$67,201 – $89,600 |
|
$5,601 – $7,467 |
D. |
$89,601 – $134,400 |
|
$7,468 – $11,200 |
E. |
more than $134,400 |
|
more than $11,200 |
CARD HE-1
HE-1
-- No Difficulty
-- Some Difficulty
-- A Lot of Difficulty
-- Completely Unable To Do It
CS-1
-- Definitely True
-- Mostly True
-- Don't Know
-- Mostly False
-- Definitely False
CS-2
No Problem
2 Some Problem
3
4 A Very Big Problem
CS-3
-- Never
-- Sometimes
-- Usually
-- Always
CARD CS-3A
None
1
CS-3A
2
3
4
5-9
10 or more
CARD CS-5
CS-5
Worst Health Care Possible
2
3
4
5
6
7
8
9
10 Best Health Care Possible
CARD PP-1
TYPES OF HEALTH CARE PROVIDERS AND FACILITIES
Medical Professionals and Practitioners:
Medical Doctor
Nurse or Nurse Practitioner
Paramedic
Health Aide
Physician’s Assistant
Midwife/Nurse Midwife
Optometrist/Ophthalmologist
Podiatrist (Foot Doctor)
Chiropractor
Acupuncturist
Therapist - Physical, Speech,
Occupational
Audiologist
Physiatrist
Physical Therapy or Rehabilitation Services
Mental Health Professionals:
Psychiatrist
Psychologist
Psychiatric Social Worker
Mental Health Therapist
Medical Facility or Clinic:
Health Clinic
Walk-in Surgi-Clinic
Company or School Clinic
Infirmary
Neighborhood Health Clinic
Family Planning Center
Mental Health Facility
Dental Care:
Dentist
Dental or Oral Surgeon
Orthodontist
Dental Hygienist
Dental Technician
Dental Assistant
CARD PP-2
TYPES OF HOSPITAL SERVICES
Hospital Stay
Emergency Room Visit
Outpatient Department Visit
TYPES OF LONG TERM CARE FACILITIES
Convalescent Home
Nursing Home
Nursing Home Unit of a Hospital
Intermediate Care Facilities
Board and Care Homes
Residential Psychiatric Institution
Facility for the Intellectually Disabled
Group Homes
Long Term Place that Provides Hospice Care
Long Term Place that Provides Respite Care
Assisted Living Facilities
CARD PP-3
PP-3
TYPES OF HOME CARE SERVICES
Skilled Medical Care
Home care from a nurse, any type of therapist, a doctor, a
social worker, or anyone else providing nursing or medical
care.
Personal Care
Home care services including bathing, dressing, help
getting around the house, or help with getting medication,
either paid or unpaid.
Household Chore Services
Help in the home with services like cooking or cleaning
either paid or unpaid.
Companionship
Services such as reading, talking, or going for a walk, a
drive, or to a restaurant either paid or unpaid.
Any Other Type of Home Care
CARD PP-4
PP-4
TYPES OF OTHER MEDICAL SUPPLIES/EXPENSES
Eyeglasses or Contact Lenses …
Bought
Replaced
Paid for Repairing
Diabetic Equipment or Supplies …
Insulin
Syringes
Test Paper
Other Diabetic Equipment or Supplies
CARD PP-4A
PP-4A
Ambulance Services
Orthopedic Items
-- Corrective shoes or inserts
-- Braces
-- Crutches
-- Canes
-- Walkers
-- Wheelchairs
-- Scooters
Hearing Devices
-- Hearing aids
-- Amplifiers for a telephone
-- Adaptive speech equipment
-- Speech synthesizer
Prostheses
-- Artificial limbs
Bathroom Aids
-- Portable commodes
-- Raised toilet seats
-- Portable tub seats
-- Handrails
-- Other bathing equipment
Medical Equipment
-- Hospital beds
-- Lifts
-- Monitors
-- Special chairs
-- Oxygen
-- Bed pans
-- Adaptive feeding equipment
-- Vaporizer or nebulizer
-- Blood pressure monitor
Disposable Supplies
-- Ostomy supplies
-- Bandages
-- Dressings
-- Tape
-- Diapers
-- Catheters
-- Syringes not prescribed by a
physician
-- IV supplies
Alterations/Modifications
-- Ramps
-- Handrails
-- Elevators
-- Automobile modifications
Other
CARD PP-5
PP-5
TYPES OF DENTAL CARE PROVIDERS
Dentist
Dental or Oral Surgeon
Orthodontist
Dental Hygienist
Dental Technician
Dental Assistant
CARD PP-6
PP-6
TYPES OF MEDICAL PROVIDERS
Medical Professionals:
Medical Doctor Physician’s Assistant
Nurse Optometrist/Ophthalmologist Nurse Practitioner Podiatrist (Foot Doctor)
Midwife/Nurse Midwife Chiropractor
Physiatrist Acupuncturist
Paramedic Audiologist
Health Aide
Physical Therapy or Rehabilitation Services
Therapist-Physical, Speech, Occupational
Mental Health Professionals:
Psychiatrist
Psychologist
Psychiatric Social Worker
Mental Health Therapist
CARD PP-7
PP-7
TYPES OF HOSPITAL SERVICES
Hospital Stay
Emergency Room Visit
Outpatient Department Visit
CARD PP-8
PP-8
TYPES OF OTHER MEDICAL PROVIDERS
Medical Professionals and Practitioners:
Paramedic
Health Aide
Physician’s Assistant
Midwife
Optometrist/Ophthalmologist
Podiatrist (Foot Doctor)
Chiropractor
Acupuncturist
Therapist - Physical, Speech, Occupational
Audiologist
Physical Therapy or Rehabilitation Services
Medical Facility or Clinic:
Health Clinic
Walk-in Surgi-Clinic
Company or School Clinic
Infirmary
Neighborhood Health Clinic
Family Planning Center
Mental Health Facility
Mental Health Professionals:
Psychiatric Social Worker
Mental Health Therapist
CARD PP-9
PP-9
TYPES OF HOME CARE SERVICES
Skilled Medical Care
Home care from a nurse, any type of therapist, a doctor, a
social worker, or anyone else providing nursing or medical
care.
Personal Care
Home care services including bathing, dressing, help
getting around the house, or help with getting medication, either paid or unpaid.
Household Chore Services
Help in the home with services like cooking or cleaning
either paid or unpaid.
Companionship
Services such as reading, talking, or going for a walk, a
drive, or to a restaurant either paid or unpaid.
Any Other Type of Home Care
CARD PP-10
PP-10
TYPES OF LONG TERM CARE FACILITIES
Convalescent Home
Nursing Home
Nursing Home Unit of a Hospital
Intermediate Care Facilities
Board and Care Homes
Residential Psychiatric Institution
Facility for the Intellectually Disabled
Group Homes
Long Term Place that Provides Hospice Care
Long Term Place that Provides Respite Care
Assisted Living Facilities
CARD PP-11
PP-11
TYPES OF OTHER MEDICAL SUPPLIES/EXPENSES
Eyeglasses or Contact Lenses …
Bought
Replaced
Paid for Repairing
Diabetic Equipment or Supplies …
Insulin
Syringes
Test Paper
Other Diabetic Equipment or Supplies
CARD PP-12
PP-12
Ambulance Services
Orthopedic Items
-- Corrective shoes or inserts
-- Braces
-- Crutches
-- Canes
-- Walkers
-- Wheelchairs
-- Scooters
Hearing Devices
-- Hearing aids
-- Amplifiers for a telephone
-- Adaptive speech equipment
-- Speech synthesizer
Prostheses
-- Artificial limbs
Bathroom Aids
-- Portable commodes
-- Raised toilet seats
-- Portable tub seats
-- Handrails
-- Other bathing equipment
Medical Equipment
-- Hospital beds
-- Lifts
-- Monitors
-- Special chairs
-- Oxygen
-- Bed pans
-- Adaptive feeding equipment
-- Vaporizer or nebulizer
-- Blood pressure monitor
Disposable Supplies
-- Ostomy supplies
-- Bandages
-- Dressings
-- Tape
-- Diapers
-- Catheters
-- Syringes not prescribed by a
physician
-- IV supplies
Alterations/Modifications
-- Ramps
-- Handrails
-- Elevators
-- Automobile modifications
Other
CARD HS-1
HS-1
-- Operation or Surgical Procedure
-- Treatment or Therapy, Not Including Surgery
-- Diagnostic Tests Only
-- Give Birth to a Baby - Normal or
Caesarean Section (Mother)
-- To Be Born (Baby)
-- Pregnancy-Related Complications
CARD ER-1
ER-1
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health
Counseling
-- Follow-up or Post-Operative Visit
-- Immunization or Shots
-- Pregnancy-Related
(Including Prenatal Care and Delivery)
CARD ER-2
ER-2
-- Laboratory Tests
-- Throat Swab
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
CARD OP-1
OP-1
-- General Checkup
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health Counseling
-- Follow-up or Post-Operative Visit
-- Immunizations or Shots
-- Vision Exam
-- Pregnancy-Related
(Including Prenatal Care and Delivery)
-- Well Child Exam
-- Laser Eye Surgery
CARD OP-2
OP-2
-- Physical Therapy
-- Occupational Therapy
-- Speech Therapy
-- Chemotherapy
-- Radiation Therapy
-- Kidney Dialysis
-- IV Therapy
-- Drug or Alcohol Treatment
-- Allergy Shot
-- Psychotherapy/Counseling
-- Shots, Other than Allergy
CARD OP-3
OP-3
-- Laboratory Tests
-- Throat Swab
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
CARD MV-1
MV-1
-- General Checkup
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health Counseling
-- Follow-up or Post-Operative Visit
-- Immunizations or Shots
-- Vision Exam
-- Pregnancy-Related
(Including Prenatal Care and Delivery)
-- Well Child Exam
-- Laser Eye Surgery
CARD MV-2
MV-2
-- Physical Therapy
-- Occupational Therapy
-- Speech Therapy
-- Chemotherapy
-- Radiation Therapy
-- Kidney Dialysis
-- IV Therapy
-- Drug or Alcohol Treatment
-- Allergy Shot
-- Psychotherapy/Counseling
-- Shots, Other than Allergy
CARD MV-3
MV-3
-- Laboratory Tests
-- Throat Swab
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
CARD DN-1
DN-1
* DIAGNOSTIC OR PREVENTATIVE
-- General Exam, Checkup or Consultation
-- Cleaning, Prophylaxis, or Polishing
-- X-Rays, Radiographs, or Bitewings
-- Fluoride Treatment
-- Sealant (Plastic Coatings on Back Teeth)
* RESTORATIVE OR ENDODONTIC
-- Fillings
-- Inlays
-- Crowns or Caps
-- Root Canal
* PERIODONTIC (GUM TREATMENT)
-- Periodontal Scaling, Root Planing, or Gum Surgery
-- Periodontal Recall Visit (Periodic or Regular)
* ORAL SURGERY
-- Extraction, Tooth Pulled
-- Implants
-- Abscess or Infection Treatment
-- Other Oral Surgery
* PROSTHETICS
-- Fixed Bridges
-- Dentures or Removable Partial Dentures
-- Relining or Repair of Bridges or Dentures
* ORTHODONTICS
-- Orthodontia, Braces, or Retainers
* ADDITIONAL PROCEDURES
-- Bonding, Whitening, or Bleaching
-- Treatment for TMD or TMJ
CARD HH-1
HH-1
-- Certified Nursing Assistant (CNA)
-- Companion
-- Dietitian/Nutritionist
-- Home Health/Home Care Aide
-- Hospice Worker
-- Homemaker
-- I.V. or Infusion Therapist
-- Medical Doctor
-- Nurse/Nurse Practitioner
-- Nurse’s Aide
-- Occupational Therapist
-- Personal Care Attendant
-- Physical Therapist
-- Respiratory Therapist
-- Social Worker
-- Speech Therapist
CARD HH-2
HH-2
Medical Treatments
Changing bandages, wound care, giving medication, taking blood pressure, giving shots or injections, any type of therapy, other medical treatments
Help Using Medical Equipment or Assistive Device (Examples)
Oxygen tank, wheelchair, walker, hospital bed, tub seat, special railing, special commode, other medical equipment or assistive device
Help With Daily Activities or Personal Care
(Examples)
Using the telephone, paying bills, shopping, driving, housework, preparing meals, bathing, dressing, using the toilet, getting in or out of a bed or chair, walking, eating, other daily activities or personal care
CARD HH-3
HH-3
Help With Daily
Activities or Personal Care
(Examples)
Using the telephone, paying bills, shopping, driving, housework, preparing meals, bathing, dressing, using the toilet, getting in or out of a bed or chair, walking, eating, other daily activities or personal care
CARD CP-1 (Panel 13)
CP-1
-- Paid at Time of Visit
-- Made a Co-payment
-- Bill Sent Directly to Other Source
-- Bill Has Not Arrived
-- No Bill Sent:
-- HMO Plan
-- VA (Veterans Administration)/CHAMPVA
-- Indian Health Service (IHS)
-- Military Facility
-- Public Assistance/Medicaid/SCHIP
-- Worker’s Compensation
-- School, Employer, or Other Private Health
Center/Clinic
-- Public Clinic/Health Center or Private
Charity (Include Community and Migrant
Health Center, Federally Qualified
Health Center)
-- No Charge: Telephone Call
-- Free From Provider
(Professional Courtesy/Free Sample)
-- Government-Financed Research And
Clinical Trials
CARD CP-1 (Panel 12)
CP-1
-- Made a Co-payment
-- Bill Sent Directly to Other Source
-- Bill Has Not Arrived
-- No Bill Sent:
-- HMO Plan
-- VA (Veterans Administration)
-- Indian Health Service (IHS)
-- Military Facility
-- Public Assistance/Medicaid/SCHIP
-- Worker’s Compensation
-- School, Employer, or Other Private Health
Center/Clinic
-- Public Clinic/Health Center or Private
Charity (Include Community and Migrant
Health Center, Federally Qualified
Health Center)
-- No Charge: Telephone Call
-- Free From Provider
(Professional Courtesy/Free Sample)
-- Government-Financed Research And
Clinical Trials
CARD PC-2
PC-1
PC-2
-- Within the last 7 days
-- More than 7 days ago, but within last 30 days
-- More than 30 days ago
CARD AP-1
AP-1
-- 99 pounds or less
-- 100 to 149 pounds
-- 150 to 199 pounds
-- 200 to 249 pounds
-- 250 to 299 pounds
-- 300 pounds or more
CARD AC-1
AC-1
-- Very Difficult
-- Somewhat Difficult
-- Not Too Difficult
-- Not At All Difficult
CARD AC-2
AC-2
-- White
-- Black/African American
-- Asian
-- Indian/Native American Alaska Native
-- Other Pacific Islander
-- Some Other Race
CARD AC-3
AC-3
-- Never
-- Sometimes
-- Usually
-- Always
CARD AC-4
AC-4
-- Couldn’t Afford Care
-- Insurance Company Wouldn’t Approve, Cover Or Pay For Care
-- Doctor Refused To Accept Family’s Insurance Plan
-- Problems Getting to Doctor’s Office
-- Different Language
-- Couldn’t Get Time Off Work
-- Didn’t Know Where To Go To Get Care
-- Was Refused Services
-- Couldn’t Get Child Care
-- Didn’t Have Time Or Took Too Long
CARD AC-5
AC-5
-- A Big Problem
-- A Small Problem
-- Not A Problem
CARD OE-1
OE-1
-- Hospital and Physician Benefits, Including
Coverage Through an HMO
-- Dental
-- Prescription Drugs
-- Vision
-- Medicare Supplement or Medigap
-- Long-Term Care in a Nursing Home
-- Extra Cash for Hospital Stays
-- Serious Disease or Dread Disease
CARD PR-1
PR-1
Medicare Managed Care Plans
[State Name Here]
(One for Each State)
CARD PR-2
PR-2
Plan Names
[State Name Here]
(One for Each State)
CARD PR-3 (Panel 13)
PR-3
-- TANF (Temporary Aid for Needy Families)
-- SSI (Supplemental Security Income)
-- WIC (Women, Infants and Children)
-- IHS (Indian Health Service)
-- Public Health Clinic
-- VA (Veterans Administration)/CHAMPVA
CARD PR-3 (Panel 12)
PR-3
-- SSI (Supplemental Security Income)
-- WIC (Women, Infants and Children)
-- IHS (Indian Health Service)
-- Public Health Clinic
-- VA (Veterans Administration)
CARD HX-1
HX-1
-- From a Professional Association
-- From a Small Business Group
-- From a Union
-- Directly From an Insurance Agent
-- Directly From Insurance Company
-- Directly From an HMO
-- From a Previous Employer
-- From a Previous Employer (COBRA)
CARD HX-2
HX-2
Sample Medicare Card
CARD HX-3
HX-3
Sample Medicaid Card
[State Name Here]
(One for Each State)
CARD HX-4
HX-4
-- From a Group or Association
-- Directly Through a School
-- Directly From an Insurance Agent
-- Directly From Insurance Company
-- Directly From an HMO
-- From a Union
-- From Anyone’s Previous Employer (COBRA)
-- From Anyone’s Previous Employer
(Not COBRA)
-- From Spouse’s/Deceased Spouse’s Previous
Employer
-- From Some Other Employer
-- Under Plan of Someone Not Living Here
CARD HX-5
HX-5
Medicare Managed Care Plans
[State Name Here]
(One for Each State)
CARD HX-6
HX-6
State-Specific Plan Names
[State Name Here]
(One for Each State)
CARD HX-7
HX-7
-- Hospital and Physician Benefits, Including
Coverage Through an HMO
-- Dental
-- Prescription Drugs
-- Vision
-- Medicare Supplement or Medigap
-- Long-Term Care in a Nursing Home
-- Extra Cash for Hospital Stays
-- Serious Disease or Dread Disease
CARD HX-8
HX-8
Plan Name (for Federal Civilian Employees)
[State Name Here]
(One for Each State)
CARD SP-1
SP-1
-- A Big Problem
-- A Small Problem
-- Not a Problem
CARD SP-2
Worst Health Plan Possible
1
2
3
4
5
6
SP-2
7
8
9
10 Best Health Plan Possible
CARD IN-1
IN-1
-- 1 - 5,000
-- 5,001 - 10,000
-- 10,001 - 15,000
-- 15,001 - 25,000
-- 25,001 - 50,000
-- 50,001 - 100,000
-- 100,001 or more
CARD IN-1A
-- 1 - 100
-- 101 - 500
-- 501 - 1,000
-- 1,001 - 5,000
-- 5,001 - 15,000
-- 15,001 or more
IN-1A
IN-2
-- 1 - 250
-- 251 - 500
-- 501 - 750
-- 751 - 1,000
-- 1,001 or more
CARD IN-2A
State-Specific TANF Program
IN-2A
(One for Each State)
CARD IN-3
-- Wages and salary
-- Farm income (or loss)
-- Business income (or loss)
-- Social Security/Railroad Retirement
IN-3
-- Private, military, or government pensions
-- Interest
-- Dividends
-- Rental income (or loss)
-- Other source
CARD AS-1
-- 0 - 10,000
-- 10,001 - 25,000
-- 25,001 - 50,000
-- 50,001 - 100,000
-- 100,001 - 250,000
AS-1
-- 250,001 - 500,000
-- 500,001 - 1,000,000
-- 1,000,001 or more
CARD AS-2
-- 0 - 100
-- 101 - 500
-- 501 - 1,000
-- 1,001 - 5,000
-- 5,001 - 10,000
-- 10,001 - 25,000
-- 25,001 - 50,000
-- 50,001 - 100,000
-- 100,001 or more
AS-2
AS-3
-- 0 - 1,000
-- 1,001 - 5,000
-- 5,001 - 10,000
-- 10,001 - 25,000
-- 25,001 - 50,000
-- 50,001 - 100,000
-- 100,001 - 250,000
-- 250,001 - 500,000
-- 500,001 or more
Blaise/WVS Version, Spring 2007
File Type | application/msword |
File Title | MEDICAL EXPENDITURE PANEL SURVEY |
Author | Linda Allers |
Last Modified By | wcarroll |
File Modified | 2009-07-08 |
File Created | 2009-07-08 |