MEPS-HC Core Interview

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

Attachment 51 -- HC Old Public Related Insurance Section

MEPS-HC Core Interview

OMB: 0935-0118

⚠️ Notice: This form may be outdated.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

Document [doc]

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MEPS FAMES P12R5/P13R3/P14R1 Old Public Related Insurance (PR) Section

December 8, 2008

Old Public Related Insurance (PR) Section

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

| THROUGHOUT THE SPECIFICATIONS FOR THIS CAPI |

| SECTION, FOR SCREENS THAT SPECIFY THE REFERENCE |

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

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

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

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

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

| SECOND YEAR OF THE PANEL. |

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

BOX_00

======

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

| CONTEXT HEADER DISPLAY INSTRUCTIONS: |

| DISPLAY {PERS.FULLNAME}, PRND.BEGREFMM, |

| PRND.BEGREFDD, PRND.BEGREFYY, PRND.ENDREFMM, |

| PRND.ENDREFDD, PRND.ENDREFYY. |

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

BOX_01

======

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

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

| BOTH OF THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS MEDICARE |

| AND |

| - PERSON WAS COVERED BY MEDICARE DURING THE |

| PREVIOUS ROUND, |

| CONTINUE WITH LOOP_01 |

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

| OTHERWISE, GO TO BOX_02 |

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

LOOP_01

=======

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

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

| PAIRS-ROSTER, ASK PR01A - END_LP01 |

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

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

| LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION |

| ABOUT THE COVERAGE PROVIDED THROUGH MEDICARE. |

| THIS LOOP CYCLES ON ESTABLISHMENT-PERSON-PAIRS |

| THAT MEET BOTH OF THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS MEDICARE |

| AND |

| - PERSON WAS COVERED BY MEDICARE AT ANY TIME DURING|

| THE PREVIOUS ROUND |

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

BOX_01A

=======

OMITTED.

PR01

====

OMITTED.

PR01A

=====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

During the last interview, it was recorded that (PERSON)

(were/was) enrolled in Medicare. We would like to update

information about (PERSON)’s Medicare coverage.

{Since (START DATE)/Between (START DATE) and (END DATE)},

{(have/has)/(were/was)} (PERSON) {been} covered by the new

Medicare prescribed drug coverage (also called Part D)?

YES .................................... 1 {BOX_01B}

NO ..................................... 2 {BOX_01B}

REF ................................... -7 {BOX_01B}

DK .................................... -8 {BOX_01B}

HELP AVAILABLE FOR DEFINITION OF MEDICARE PART D.

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

| DISPLAY ‘At any time since (START DATE)’ AND |

| ‘(have/has)’ IF NOT ROUND 5. DISPLAY ‘Between |

| (START DATE) and (END DATE)’ AND ‘(were/was)’ |

| IF ROUND 5. |

| |

| DISPLAY ‘been’ IF NOT ROUND 5. OTHERWISE, USE A |

| NULL DISPLAY. |

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

BOX_01B

=======

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

| NOTE: CURRENTLY ALL STATES OFFER MEDICARE |

| MANAGED CARE PLANS. |

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

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |

| DOES NOT OFFER A MEDICARE MANAGED CARE PLAN, CODE |

| PR02 AND PR03 ‘2’ (NO) AUTOMATICALLY BY CAPI AND |

| GO TO END_LP01. |

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

| IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED |

| DOES OFFER A MEDICARE MANAGED CARE PLAN, CONTINUE |

| WITH PR02 |

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

PR02

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

SHOW CARD PR-1.

As you may know, Medicare allows beneficiaries in certain parts

of the country to enroll in managed care plans such as HMOs

(health maintenance organizations) or PPOs (preferred provider

organizations) to receive their Medicare funded health care.

These plans have names like those listed on this card.

Is the name of (PERSON)’s insurance through Medicare{, between

(START DATE) and (END DATE),} listed on this card?

YES .................................... 1 {PR02OV}

NO ..................................... 2 {PR03}

REF ................................... -7 {PR03}

DK .................................... -8 {PR03}

HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED CARE.

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

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

| IF ROUND 5. OTHERWISE, USE A NULL DISPLAY. |

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

PR02OV

======

Which insurance plan is (PERSON)’s Medicare managed care plan?

CODE LETTER OF PLAN FROM SHOW CARD.

[Enter Plan Letter From Card] ......... {END_LP01}

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

| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |

| THE FOLLOWING MESSAGE: “PLEASE VERIFY PLAN |

| SELECTED: {DISPLAY PLAN NAME SELECTED}.” WHEN |

| INTERVIEWER PRESSES ENTER TO CLEAR THE MESSAGE, |

| PROCEED TO THE NEXT LOGICAL SCREEN. |

| |

| IN THE MESSAGE FOR ‘DISPLAY PLAN NAME SELECTED’ |

| DISPLAY THE ACTUAL PLAN NAME THAT CORRESPONDS TO |

| THE LETTER ENTERED FOR THAT STATE. |

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

| FLAG INSURER CODED ABOVE AS ‘CURRENT RD’S |

| MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON- |

| PAIR. |

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

PR03

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

Even though (PERSON)’s Medicare plan was not listed on the card,

{(are/is) (PERSON) currently/between (START DATE) and (END DATE)

(were/was) (PERSON)} enrolled in a Medicare managed care plan

such as an HMO (health maintenance organization) or PPO (preferred

provider organization)? When answering this question, please

include only insurance from Medicare, not any privately purchased

insurance.

YES .................................... 1 {PR04}

NO ..................................... 2 {END_LP01}

REF ................................... -7 {END_LP01}

DK .................................... -8 {END_LP01}

HELP AVAILABLE FOR DEFINITION OF MEDICARE MANAGED CARE.

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

| DISPLAY ‘(are/is) (PERSON) currently’ IF NOT |

| ROUND 5. DISPLAY ‘between (START DATE) and |

| (END DATE), (were/was) (PERSON)’ IF ROUND 5. |

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

PR03A

=====

OMITTED.

PR04

====

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

What is the name of the (PERSON)’s Medicare managed care plan?

[Enter Plan Name] ..................... {END_LP01}

REF ................................... -7 {END_LP01}

DK .................................... -8 {END_LP01}

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

| FLAG INSURER CODED ABOVE AS ‘CURRENT RD’S |

| MEDICARE INSURER’ FOR THIS ESTABLISHMENT-PERSON- |

| PAIR. |

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

PR05

====

OMITTED.

PR06

====

OMITTED.

END_LP01

========

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

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

| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |

| THE LOOP DEFINITION. |

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

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_01 AND CONTINUE WITH BOX_02 |

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

BOX_02

======

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

| IF ANY RU MEMBER HAD MEDICAID/SCHIP AS A SOURCE |

| OF INSURANCE AT ANY TIME DURING THE PREVIOUS |

| ROUND, CONTINUE WITH PR07 |

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

| OTHERWISE, GO TO BOX_05 |

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

PR07

====

{STR-DT}

{END-DT}

During the last interview, we recorded that (READ NAME(S)

BELOW) (was/were) covered by {Medicaid/{STATE NAME FOR

MEDICAID}} or {STATE CHIP NAME}.

Have all of these people been covered by {Medicaid/{STATE NAME

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

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

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

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

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

YES, ALL .............................. 1 {BOX_03}

NO, ONLY SOME ......................... 2 {PR08}

NO, NONE .............................. 3

REF ................................... -7 {BOX_05}

DK .................................... -8 {BOX_05}

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

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

| BEING CONDUCTED USES THE NAME ‘Medicaid’ DISPLAY |

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME BY STATE TO DISPLAY, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX |

| ON HX06. |

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

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

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

| ROUND 5. |

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

| IF CODED ‘1’ (YES, ALL), FLAG ALL RU MEMBERS |

| LISTED HERE AS ‘COVERED BY MEDICAID/SCHIP DURING |

| CURRENT ROUND.’ |

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

| IF CODED ‘3’ (NO, NONE), FLAG ALL RU MEMBERS |

| LISTED HERE AS ‘NOT COVERED BY MEDICAID/SCHIP |

| DURING CURRENT ROUND.’ |

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

| IF CODED ‘3’ (NO, NONE) |

| AND |

| IF ANY CURRENT RU MEMBERS NOT LISTED AT PR07, |

| GO TO PR09 |

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

| IF CODED ‘3’ (NO, NONE) |

| AND |

| IF ALL CURRENT RU MEMBERS ARE LISTED AT PR07, |

| GO TO BOX_05 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| 1. DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED |

| BY MEDICAID/SCHIP AT ANY TIME DURING THE |

| PREVIOUS ROUND. |

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

PR08

====

{STR-DT}

{END-DT}

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

{STATE CHIP NAME} {since (START DATE)/between (START DATE) and

(END DATE)}?

PROBE: Anyone else?

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

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

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

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME BY STATE TO DISPLAY, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY MEDICAID/|

| SCHIP DURING CURRENT ROUND.’ FLAG ALL PERSONS NOT|

| SELECTED AS ‘NOT COVERED BY MEDICAID/SCHIP DURING |

| CURRENT ROUND.’ |

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

| GO TO BOX_03 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR SELECTION OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| 1. DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED |

| BY MEDICAID/SCHIP AT ANY TIME DURING THE |

| PREVIOUS ROUND. |

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

BOX_03

======

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

| IF ALL CURRENT RU MEMBERS ARE ALREADY FLAGGED AS |

| COVERED OR NOT COVERED BY MEDICAID/SCHIP DURING |

| CURRENT ROUND (I.E., ALL CURRENT RU MEMBERS WERE |

| LISTED AT PR07), GO TO LOOP_02 |

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

| OTHERWISE, CONTINUE WITH PR09 |

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

PR09

====

{STR-DT}

{END-DT}

Besides the family members we’ve just talked about, have any

additional family members been covered by {Medicaid/{STATE NAME

FOR MEDICAID}} or {STATE CHIP NAME} {since (START DATE)/between

(START DATE) and (END DATE)}?

YES ................................... 1 {PR10}

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

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

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

HELP AVAILABLE FOR DEFINITION OF MEDICAID/SCHIP.

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

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

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

| ROUND 5. |

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

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

| KNOW) AND AT LEAST ONE RU MEMBER IS FLAGGED AS |

| ‘COVERED BY MEDICAID/SCHIP DURING CURRENT ROUND,’ |

| GO TO LOOP_02 |

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

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

| KNOW) AND NO RU MEMBERS ARE FLAGGED AS ‘COVERED |

| BY MEDICAID/SCHIP DURING CURRENT ROUND,’ GO TO |

| BOX_05 |

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

PR10

====

{STR-DT}

{END-DT}

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

{STATE CHIP NAME} {since (START DATE)/between (START DATE) and

(END DATE)}?

PROBE: Anyone else?

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

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

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

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY MEDICAID/|

| SCHIP’ DURING CURRENT ROUND. FLAG ALL PERSONS |

| NOT SELECTED AS ‘NOT COVERED BY MEDICAID/SCHIP’ |

| DURING CURRENT ROUND. |

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

| GO TO LOOP_02 |

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

| ROSTER DETAILS: |

| Title: RU_MEMBERS_1 |

| |

| COL #1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

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

| OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| 1. RU MEMBERS NOT FLAGGED AS COVERED BY MEDICAID/ |

| SCHIP AT ANY TIME DURING THE PREVIOUS ROUND. |

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

LOOP_02

=======

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

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

| PAIRS-ROSTER, ASK BOX_04 - END_LP02 |

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

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

| LOOP DEFINITION: LOOP_02 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY MEDICAID/|

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

| PAIRS THAT MEET BOTH OF THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS MEDICAID/SCHIP |

| AND |

| - PERSON IS COVERED BY MEDICAID/SCHIP DURING THE |

| CURRENT ROUND |

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

BOX_04

======

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

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

| FOR THIS PAIR. |

| |

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP02 |

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

END_LP02

========

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

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

| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |

| STATED IN THE LOOP DEFINITION. |

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

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, END |

| LOOP_02 AND CONTINUE WITH PR11 |

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

PR11

====

{STR-DT}

{END-DT}

{PLAN NAME: {NAME OF PREV RD’S MEDICAID/SCHIP INSURER FOR RU}}

{Last time we recorded that (READ NAME(S) BELOW) may be

covered by (PLAN NAME).}

{Since (START DATE)/Between (START DATE) and (END DATE)}, has

there been any change in the plan name of the health insurance

the family has through {Medicaid/{STATE NAME FOR MEDICAID}} or

{STATE CHIP NAME}?

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

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

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

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

NO ..................................... 2 {BOX_04A}

REF ................................... -7 {BOX_04A}

DK .................................... -8 {BOX_04A}

HELP AVAILABLE FOR A DEFINITION OF MEDICAID/SCHIP.

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

| DISPLAY ‘PLAN NAME: {NAME OF PREV RD’S MEDICAID |

| INSURER FOR RU}’ AND ‘Last time...(PLAN NAME).’ |

| IF THERE IS AN INSURER ASSOCIATED WITH MEDICAID/ |

| SCHIP IN THE PREVIOUS ROUND. |

| |

| FOR ‘NAME OF PREV RD’S MEDICAID/SCHIP INSURER FOR |

| RU’, DISPLAY THE INSURER RECORDED FOR MEDICAID/ |

| SCHIP DURING THE PREVIOUS ROUND. |

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

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

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

| ROUND 5. |

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

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

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

| KNOW), FLAG PREVIOUS ROUND’S INSURER AS ‘CURRENT |

| RD’S MEDICAID/SCHIP INSURER’ |

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

| NOTE: STATES THAT DO NOT OFFER MEDICAID MANAGED |

| CARE PLANS ARE ALASKA, MISSISSIPPI, AND WYOMING |

| |

| ARKANSAS AND NEW HAMPSHIRE WERE REMOVED FROM THIS |

| LIST STARTING IN PANEL 12 ROUND 3. |

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

| IF CODED ‘1’ (YES) AND IF STATE IN WHICH THE |

| INTERVIEW IS BEING CONDUCTED DOES NOT OFFER A |

| MEDICAID/SCHIP MANAGED CARE PLAN, CODE PR12 ‘2’ |

| (NO) AUTOMATICALLY BY CAPI AND GO TO PR13 |

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

| IF CODED ‘1’ (YES) AND IF STATE IN WHICH THE |

| INTERVIEW IS BEING CONDUCTED DOES OFFER A |

| A MEDICAID/SCHIP MANAGED CARE PLAN, CONTINUE WITH |

| PR12 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| 1. DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED |

| BY MEDICAID/SCHIP DURING THE CURRENT ROUND. |

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

PR12

====

{STR-DT}

{END-DT}

SHOW CARD PR-2.

Some people on {Medicaid/{STATE NAME FOR MEDICAID}} or {STATE

CHIP NAME} can enroll in plans called HMOs. These plans have

names like those listed on this card.

Is the name of the health insurance through {Medicaid/{STATE

NAME FOR MEDICAID}} or {STATE CHIP NAME} {, between (START DATE)

and (END DATE),} listed on this card?

YES .................................... 1 {PR12OV}

NO ..................................... 2 {PR13}

REF ................................... -7 {PR13}

DK .................................... -8 {PR13}

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

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

| IF ROUND 5. OTHERWISE, USE A NULL DISPLAY. |

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

PR12OV

======

Which plan is the health insurance through {Medicaid/{STATE

NAME FOR MEDICAID}} or {STATE CHIP NAME}?

CODE LETTER OF PLAN FROM SHOW CARD.

[Enter Plan Letter From Card] ......... {BOX_04A}

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |

| THE FOLLOWING MESSAGE: “PLEASE VERIFY PLAN |

| SELECTED: {DISPLAY PLAN NAME SELECTED}.” WHEN |

| INTERVIEWER CLEARS THE MESSAGE, PROCEED TO THE |

| NEXT LOGICAL SCREEN. |

| |

| FOR ‘DISPLAY PLAN NAME SELECTED’ IN THIS MESSAGE, |

| DISPLAY THE PLAN NAME THAT CORRESPONDS TO THE |

| LETTER ENTERED FOR THIS STATE. |

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

| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |

| INSURER FOR MEDICAID/SCHIP.’ |

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

PR13

====

{STR-DT}

{END-DT}

Under {Medicaid/{STATE NAME FOR MEDICAID}} or {STATE CHIP NAME}

{(are/is)/(were/was)} (READ NAME(S) BELOW) signed up with an HMO,

that is a Health Maintenance Organization {between (START DATE)

and (END DATE)}?

[With an HMO, you must generally receive care from HMO

physicians. If another doctor is seen, the expense is not

covered unless you were referred by the HMO, or there was a

medical emergency.]

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

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

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

YES, ALL ARE ........................... 1 {PR15}

YES, SOME ARE .......................... 2 {PR15}

NO, NONE ARE ........................... 3 {PR14}

REF ................................... -7 {PR14}

DK .................................... -8 {PR14}

[Code One]

HELP AVAILABLE FOR DEFINITION OF HMO.

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

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

| DISPLAY ‘(are/is)’ IF NOT ROUND 5. DISPLAY |

| ‘(were/was)’ IF ROUND 5. |

| |

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

| ROUND 5. OTHERWISE, USE A NULL DISPLAY. |

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

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| 1. DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED |

| BY MEDICAID/SCHIP DURING THE CURRENT ROUND. |

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

PR14

====

{STR-DT}

{END-DT}

{Does/Between (START DATE) and (END DATE), did} {Medicaid/{STATE

NAME FOR MEDICAID}} or {STATE CHIP NAME} require (READ NAME(S) BELOW)

to sign up with a certain primary care doctor, group of doctors, or

with a certain clinic which they must go to for all of their routine

care?

PROBE: Do not include emergency care or care from a specialist

they were referred to.

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

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

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

YES, ALL REQUIRED ...................... 1 {PR15}

YES, SOME REQUIRED ..................... 2 {PR15}

NO, NONE REQUIRED ...................... 3 {BOX_04A}

REF ................................... -7 {BOX_04A}

DK .................................... -8 {BOX_04A}

[Code One]

HELP AVAILABLE FOR DEFINITION OF PRIMARY CARE DOCTOR AND ROUTINE CARE.

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

| DISPLAY ‘Does’ IF NOT ROUND 5. DISPLAY ‘Between |

| (START DATE) and (END DATE), did’ IF ROUND 5. |

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

| IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED), |

| OR ‘-8’ (DON’T KNOW), THERE IS NO INSURER |

| ASSOCIATED WITH THE CURRENT ROUND FOR MEDICAID/ |

| SCHIP. |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| 1. DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED |

| BY MEDICAID/SCHIP DURING THE CURRENT ROUND. |

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

PR15

====

{STR-DT}

{END-DT}

What is the name of the {Medicaid/{STATE NAME FOR MEDICAID}} or

{STATE CHIP NAME} {HMO/health insurance}?

[Enter Plan Name] ..................... {BOX_04A}

REF ................................... -7 {BOX_04A}

DK .................................... -8 {BOX_04A}

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

| DISPLAY ‘HMO’ IF PR13 IS CODED ‘1’ (YES, ALL ARE) |

| OR ‘2’ (YES, SOME ARE). DISPLAY ‘health |

| insurance’ IF PR14 IS CODED ‘1’ (YES, ALL |

| REQUIRED) OR ‘2’ (YES, SOME REQUIRED). |

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

| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |

| MEDICAID/SCHIP INSURER’. |

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

BOX_04A

=======

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

| IF ROUND 1 OR ROUND 3, CONTINUE WITH PR16 |

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

| OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO |

| BOX_05 |

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

PR16

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT PR12OV}/{NAME OF PLAN FROM

PR15}}}

For the coverage through {(PLAN NAME)/{Medicaid/{STATE NAME FOR

MEDICAID}} or {STATE CHIP NAME}}, does anyone in the family pay

anything for this coverage?

[Do not include the cost of any copayments, coinsurance, or

deductibles anyone in the family may have had to pay.]

YES .................................... 1 {PR17}

NO ..................................... 2 {PR18}

REF ................................... -7 {BOX_05}

DK .................................... -8 {BOX_05}

[Code One]

HELP AVAILABLE FOR DEFINITION OF

PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

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

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| INSURANCE. OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘(PLAN NAME ENTERED AT PR12OV)’ IF A PLAN |

| WAS ENTERED AT PR12OV. DISPLAY THE ACTUAL PLAN |

| NAME THAT CORRESPONDS TO THE LETTER ENTERED AT |

| PR12OV FOR THIS STATE. |

| |

| DISPLAY ‘(NAME OF PLAN FROM PR15)’ IF A PLAN NAME |

| WAS ENTERED AT PR15. DISPLAY THE ACTUAL PLAN NAME |

| THAT WAS ENTERED. |

| |

| DISPLAY ‘(PLAN NAME)’ IF THERE IS A CURRENT ROUND |

| INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| INSURANCE. OTHERWISE, DISPLAY ‘{Medicaid/{STATE |

| NAME FOR MEDICAID}} or {STATE CHIP NAME}’ |

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

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

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

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

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

| INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME |

| ‘Medicaid’. FOR THE SPECIFIC MEDICAID PROGRAM |

| NAME TO DISPLAY BY STATE, SEE BOX ON HX06. |

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

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

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

| SUBSTITUTING THE REAL STATE NAME FOR PROGRAM. |

| FOR THE SPECIFIC NAME TO DISPLAY BY STATE, SEE BOX|

| ON HX06. |

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

PR17

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT PR12OV}/{NAME OF PLAN FROM

PR15}}}

How much does anyone in the family pay for {the (PLAN NAME)/

that} coverage?

[Enter Amount in Dollars] .............. {PR17OV1}

REF ................................... -7 {PR18}

DK .................................... -8 {PR18}

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

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| INSURANCE. OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘(PLAN NAME ENTERED AT PR12OV)’ IF A PLAN |

| WAS ENTERED AT PR12OV. DISPLAY THE ACTUAL PLAN |

| NAME THAT CORRESPONDS TO THE LETTER ENTERED AT |

| PR12OV FOR THIS STATE. |

| |

| DISPLAY ‘(NAME OF PLAN FROM PR15)’ IF A PLAN NAME |

| WAS ENTERED AT PR15. DISPLAY THE ACTUAL PLAN NAME |

| THAT WAS ENTERED. |

| |

| DISPLAY ‘the (PLAN NAME)’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| INSURANCE. OTHERWISE, DISPLAY ‘that’. |

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

PR17OV1

=======

Is that per year, per month, per week, or what?

ENTER UNIT OF COVERAGE:

PER YEAR ............................... 1 {PR18}

QUARTERLY/EVERY 3 MONTHS ............... 2 {PR18}

BIMONTHLY/EVERY 2 MONTHS ............... 3 {PR18}

PER MONTH .............................. 4 {PR18}

PER WEEK ............................... 5 {PR18}

BIWEEKLY/EVERY 2 WEEKS ................. 6 {PR18}

SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {PR18}

SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {PR18}

OTHER ................................. 91 {PR17OV2}

REF ................................... -7 {PR18}

DK .................................... -8 {PR18}

[Code One]

PR17OV2

=======

ENTER OTHER:

[Enter Other Specify] .................. {PR18}

REF ................................... -7 {PR18}

DK .................................... -8 {PR18}

PR18

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT PR12OV}/{NAME OF PLAN

FROM PR15}}}

Who {else} pays {some of/for} the premium or cost

of this insurance?

CHECK ALL THAT APPLY.

FEDERAL GOVERNMENT .................... 1

STATE GOVERNMENT ...................... 2

LOCAL GOVERNMENT ...................... 3

SOME GOVERNMENT ....................... 4

OTHER ................................. 91 {PR18OV}

REF ................................... -7 {BOX_05}

DK .................................... -8 {BOX_05}

[Code All That Apply)

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

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE MEDICAID/SCHIP |

| INSURANCE. OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘(PLAN NAME ENTERED AT PR12OV)’ IF A PLAN |

| WAS ENTERED AT PR12OV. DISPLAY THE ACTUAL PLAN |

| NAME THAT CORRESPONDS TO THE LETTER ENTERED AT |

| PR12OV FOR THIS STATE. |

| |

| DISPLAY ‘(NAME OF PLAN FROM PR15)’ IF A PLAN NAME |

| WAS ENTERED AT PR15. DISPLAY THE ACTUAL PLAN NAME |

| THAT WAS ENTERED. |

| |

| DISPLAY ‘else’ IF PR16 IS CODED ‘1’ (YES). |

| OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘some of’ IF PR16 IS CODED ‘1’ (YES). |

| DISPLAY ‘for’ IF PR16 IS CODED ‘2’ (NO). |

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

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

| FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT |

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

| COMBINATION WITH ANY OTHER CODE. |

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

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

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

| WITH ANY OTHER CODE, CONTINUE WITH PR18OV |

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

| OTHERWISE, GO TO BOX_05 |

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

PR18OV

======

ENTER OTHER:

[Enter Other Specify] .................. {BOX_05}

REF ................................... -7 {BOX_05}

DK .................................... -8 {BOX_05}

BOX_05

======

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

| IF ANY RU MEMBER HAD TRICARE/CHAMPVA AS A SOURCE |

| OF INSURANCE DURING PREVIOUS ROUND, CONTINUE WITH |

| PR19 |

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

| OTHERWISE, GO TO BOX_08 |

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

PR19

====

{STR-DT}

{END-DT}

During the last interview, we recorded that (READ NAME(S)

BELOW) (was/were) covered by TRICARE or CHAMPVA.

Have all of these people been covered by TRICARE or CHAMPVA at

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

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

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

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

YES, ALL .............................. 1 {PR19A}

NO, ONLY SOME ......................... 2 {PR19A}

NO, NONE .............................. 3

REF ................................... -7 {BOX_08}

DK .................................... -8 {BOX_08}

HELP AVAILABLE FOR DEFINITION OF TRICARE/CHAMPVA.

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

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

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

| ROUND IS 5. |

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

| IF CODED ‘3’ (NO, NONE), FLAG ALL RU MEMBERS |

| LISTED HERE AS ‘NOT COVERED BY TRICARE/CHAMPVA |

| DURING CURRENT ROUND.’ |

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

| IF CODED ‘3’ (NO, NONE) |

| AND |

| IF ANY CURRENT RU MEMBERS NOT LISTED IN PR19, |

| GO TO PR21 |

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

| IF CODED ‘3’ (NO, NONE), |

| AND |

| IF ALL CURRENT RU MEMBERS ARE LISTED IN PR19, |

| GO TO BOX_08 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY |

| TRICARE/CHAMPVA AT ANY TIME DURING THE PREVIOUS |

| ROUND. |

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

PR19A

=====

{STR-DT}

{END-DT}

Which plan is it? Is it...

INTERVIEWER: CODE MORE THAN ONE PLAN ONLY IF DIFFERENT

RU MEMBERS HAVE DIFFERENT PLANS.

CHECK ALL THAT APPLY.

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

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

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

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

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

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

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

[Code All That Apply]

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

| IF PR19 IS CODED ‘1’ (YES, ALL), FLAG ALL RU |

| MEMBERS LISTED HERE AS ‘COVERED BY TRICARE/CHAMPVA|

| DURING CURRENT ROUND.’ THEN GO TO BOX_06 |

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

| IF PR19 IS CODED ‘2’ (NO, ONLY SOME), CONTINUE |

| WITH PR20 |

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

PR20

====

{STR-DT}

{END-DT}

Who has been covered by TRICARE or CHAMPVA {since (START DATE)/

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

PROBE: Anyone else?

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

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

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

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY TRICARE/ |

| CHAMPVA’ DURING CURRENT ROUND. FLAG ALL PERSONS |

| NOT SELECTED AS ‘NOT COVERED BY TRICARE/CHAMPVA ‘ |

| DURING CURRENT ROUND. |

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

| GO TO BOX_06 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR SELECTION OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY |

| TRICARE/CHAMPVA AT ANY TIME DURING THE PREVIOUS |

| ROUND. |

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

BOX_06

======

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

| IF ALL CURRENT RU MEMBERS ALREADY FLAGGED AS |

| COVERED OR NOT COVERED BY TRICARE/CHAMPVA DURING |

| CURRENT ROUND (I.E., ALL CURRENT RU MEMBERS WERE |

| LISTED IN PR19), GO TO LOOP_03 |

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

| OTHERWISE, CONTINUE WITH PR21 |

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

PR21

====

{STR-DT}

{END-DT}

Besides the family members we’ve just talked about, have any

additional family members been covered by TRICARE or CHAMPVA

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

YES ................................... 1 {PR21A}

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

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

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

HELP AVAILABLE FOR DEFINITION OF TRICARE/CHAMPVA.

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

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

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

| ROUND 5. |

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

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

| KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS |

| COVERED BY TRICARE/CHAMPVA DURING CURRENT ROUND, |

| GO TO LOOP_03 |

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

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

| KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY |

| TRICARE/CHAMPVA DURING CURRENT ROUND, GO TO BOX_08|

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

PR21A

=====

{STR-DT}

{END-DT}

Which plan is it? Is it...

INTERVIEWER: CODE MORE THAN ONE PLAN ONLY IF DIFFERENT RU

MEMBERS HAVE DIFFERENT PLANS.

CHECK ALL THAT APPLY.

TRICARE Standard; ...................... 1 {PR22}

TRICARE Prime; ......................... 2 {PR22}

TRICARE Extra; ......................... 3 {PR22}

TRICARE for Life; or ................... 4 {PR22}

CHAMPVA? ............................... 5 {PR22}

REF ................................... -7 {PR22}

DK .................................... -8 {PR22}

[Code All That Apply]

PR22

====

{STR-DT}

{END-DT}

Who has been covered by TRICARE or CHAMPVA {since (START DATE)/

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

PROBE: Anyone else?

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

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

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

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

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

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

| ROUND IS 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY TRICARE/ |

| CHAMPVA’ DURING CURRENT ROUND. FLAG ALL PERSONS |

| NOT SELECTED AS ‘NOT COVERED BY TRICARE/CHAMPVA’ |

| DURING CURRENT ROUND. |

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

| GO TO LOOP_03 |

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

| ROSTER DETAILS: |

| Title: RU_MEMBERS_1 |

| |

| COL #1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

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

| OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE NOT FLAGGED|

| AS COVERED BY TRICARE/CHAMPVA AT ANY TIME DURING |

| THE PREVIOUS ROUND. |

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

LOOP_03

=======

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

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

| PAIRS-ROSTER, ASK BOX_07 - END_LP03 |

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

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

| LOOP DEFINITION: LOOP_03 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY TRICARE/ |

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

| PAIRS THAT MEET BOTH OF THE FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS TRICARE/CHAMPVA |

| AND |

| - PERSON IS COVERED BY TRICARE/CHAMPVA DURING THE |

| CURRENT ROUND |

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

BOX_07

======

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

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

| FOR THIS PAIR. |

| |

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP03 |

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

END_LP03

========

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

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

| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |

| STATED IN THE LOOP DEFINITION. |

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

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_03 AND CONTINUE WITH BOX_07A |

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

BOX_07A

=======

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

| IF ROUND 1 OR ROUND 3, CONTINUE WITH PR22A |

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

| OTHERWISE, (I.E., IF ROUNDS 2, 4, OR 5), GO TO |

| BOX_08 |

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

PR22A

=====

{STR-DT}

{END-DT}

Does anyone in the family pay anything for the coverage through

TRICARE or CHAMPVA?

[Do not include the cost of any copayments, coinsurance or

deductibles anyone in the family may have had to pay.]

YES .................................... 1 {PR22B}

NO ..................................... 2 {BOX_08}

REF ................................... -7 {BOX_08}

DK .................................... -8 {BOX_08}

HELP AVAILABLE FOR DEFINITION OF PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

PR22B

=====

{STR-DT}

{END-DT}

How much does anyone in the family pay for the coverage through

TRICARE or CHAMPVA?

[Enter Amount in Dollars] .............. {PR22BOV1}

REF ................................... -7 {BOX_08}

DK .................................... -8 {BOX_08}

PR22BOV1

========

Is that per year, per month, per week, or what?

UNIT OF COVERAGE:

PER YEAR ............................... 1 {BOX_08}

QUARTERLY/EVERY 3 MONTHS ............... 2 {BOX_08}

BIMONTHLY/EVERY 2 MONTHS ............... 3 {BOX_08}

PER MONTH .............................. 4 {BOX_08}

PER WEEK ............................... 5 {BOX_08}

BIWEEKLY/EVERY 2 WEEKS ................. 6 {BOX_08}

SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {BOX_08}

SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {BOX_08}

OTHER ................................. 91 {PR22BOV2}

REF ................................... -7 {BOX_08}

DK .................................... -8 {BOX_08}

[Code One]

PR22BOV2

========

OTHER:

[Enter Other Specify] .................. {BOX_08}

REF ................................... -7 {BOX_08}

DK .................................... -8 {BOX_08}

BOX_08

======

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

| IF ANY RU MEMBER HAD GOVT-HOSPITAL/PHYSICIAN AS A |

| SOURCE OF INSURANCE AT ANY TIME DURING PREVIOUS |

| ROUND, CONTINUE WITH PR23 |

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

| OTHERWISE, GO TO BOX_11 |

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

PR23

====

{STR-DT}

{END-DT}

During the last interview, we recorded that (READ NAME(S)

BELOW) (was/were) covered by a program sponsored by a

state or local government agency which provided hospital and

physician benefits.

Have all of these people been covered by a program sponsored by a

state or local government agency at any time {since (START DATE)/

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

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

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

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

YES, ALL .............................. 1 {BOX_09}

NO, ONLY SOME ......................... 2 {PR24}

NO, NONE .............................. 3

REF ................................... -7 {BOX_11}

DK .................................... -8 {BOX_11}

HELP AVAILABLE FOR DEFINITION OF THIS TYPE OF PROGRAM.

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

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

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

| ROUND 5. |

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

| IF CODED ‘3’ (NO, NONE), FLAG ALL RU MEMBERS |

| LISTED HERE AS ‘NOT COVERED BY GOVT-HOSPITAL/ |

| PHYSICIAN’ DURING CURRENT ROUND. |

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

| IF CODED ‘1’ (YES, ALL), FLAG ALL RU MEMBERS |

| LISTED HERE AS ‘COVERED BY GOVT-HOSPITAL/ |

| PHYSICIAN’ DURING CURRENT ROUND. |

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

| IF CODED ‘3’ (NO, NONE) |

| AND |

| IF ANY CURRENT RU MEMBERS NOT LISTED AT PR23, |

| GO TO PR25 |

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

| IF CODED ‘3’ (NO, NONE) |

| AND |

| IF ALL CURRENT RU MEMBERS ARE LISTED AT PR23, |

| GO TO BOX_11 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE FLAGGED AS |

| COVERED BY GOVT-HOSPITAL/PHYSICIAN AT ANY TIME |

| DURING THE PREVIOUS ROUND. |

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

PR24

====

{STR-DT}

{END-DT}

Who has been covered by this program {since (START DATE)/between

(START DATE) and (END DATE)}?

PROBE: Anyone else?

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

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

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

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY |

| GOVT-HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND. |

| FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY |

| GOVT-HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND. |

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

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

| GO TO BOX_09 |

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

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR SELECTION OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY |

| GOVT-HOSPITAL/PHYSICIAN AT ANY TIME DURING THE |

| PREVIOUS ROUND. |

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

BOX_09

======

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

| IF ALL CURRENT RU MEMBERS ALREADY FLAGGED AS |

| COVERED OR NOT COVERED BY THE GOVT-HOSPITAL/ |

| PHYSICIAN DURING CURRENT ROUND (I.E., ALL CURRENT |

| RU MEMBERS WERE LISTED IN PR23), GO TO LOOP_04 |

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

| OTHERWISE, CONTINUE WITH PR25 |

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

PR25

====

{STR-DT}

{END-DT}

Besides the family members we’ve just talked about, have any

additional family members been covered by this program {since

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

YES ................................... 1 {PR26}

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

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

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

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

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

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

| ROUND 5. |

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

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

| KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS |

| ‘COVERED BY GOVT-HOSPITAL/PHYSICIAN’ DURING |

| CURRENT ROUND, GO TO LOOP_04 |

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

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

| KNOW) AND NO RU MEMBERS FLAGGED AS ‘COVERED |

| BY GOVT-HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND, |

| GO TO BOX_11 |

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

PR26

====

{STR-DT}

{END-DT}

Who has been covered by this program?

PROBE: Who else has been covered by a program sponsored by a

state or local government agency which provides hospital and

physician benefits {since (START DATE)/between (START DATE) and

(END DATE)}?

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

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

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

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY GOVT- |

| HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND. FLAG |

| ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY |

| GOVT-HOSPITAL/PHYSICIAN’ DURING CURRENT ROUND. |

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

| GO TO LOOP_04 |

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

| ROSTER DETAILS: |

| Title: RU_MEMBERS_1 |

| |

| COL #1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

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

| OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE NOT FLAGGED|

| AS COVERED BY GOVT-HOSPITAL/PHYSICIAN AT ANY TIME |

| DURING THE PREVIOUS ROUND. |

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

LOOP_04

=======

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

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

| PAIRS-ROSTER, ASK BOX_10 - END_LP04 |

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

| LOOP DEFINITION: LOOP_04 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY GOVT- |

| HOSPITAL/PHYSICIAN. THIS LOOP CYCLES ON |

| ESTABLISHMENT-PERSON-PAIRS THAT MEET BOTH OF THE |

| FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS GOVT-HOSPITAL/PHYSICIAN |

| AND |

| - PERSON IS FLAGGED AS COVERED BY GOVT-HOSPITAL/ |

| PHYSICIAN DURING THE CURRENT ROUND |

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

BOX_10

======

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

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

| FOR THIS PAIR. |

| |

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP04 |

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

END_LP04

========

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

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

| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |

| THE LOOP DEFINITION. |

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

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, END |

| LOOP_04 AND CONTINUE WITH PR27 |

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

PR27

====

{STR-DT}

{END-DT}

{PLAN NAME: {NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN

INSURER FOR RU}}

{Last time we recorded that (READ NAME(S) BELOW) may be

covered by (PLAN NAME).}

{Since (START DATE)/Between (START DATE) and (END DATE)}, has

there been any change in the plan name of the health insurance

the family has through the program sponsored by a state or local

government agency which provides hospital and physician benefits?

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

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

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

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

NO ..................................... 2 {PR32}

REF ................................... -7 {PR32}

DK .................................... -8 {PR32}

HELP AVAILABLE FOR A DEFINITION OF THIS TYPE OF PROGRAM.

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

| DISPLAY ‘PLAN NAME: {NAME OF PREV RD’S GOVT- |

| HOSPITAL/PHYSICIAN INSURER FOR RU}’ AND ‘Last |

| time .... (PLAN NAME).’ IF THERE IS AN INSURER |

| ASSOCIATED WITH GOVT-HOSPITAL/PHYSICIAN IN THE |

| PREVIOUS ROUND. |

| |

| FOR ‘NAME OF PREV RD’S GOVT-HOSPITAL/PHYSICIAN |

| INSURER FOR RU’, DISPLAY THE INSURER RECORDED FOR |

| GOVT-HOSPITAL/PHYSICIAN AT ANY TIME DURING THE |

| PREVIOUS ROUND. |

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

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

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

| ROUND 5. |

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

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

| KNOW), FLAG PREVIOUS ROUND’S INSURER AS CURRENT |

| ROUND’S INSURER FOR GOVT-HOSPITAL/PHYSICIAN. |

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

| NOTE: STATES THAT DO NOT OFFER GOVT-HOSPITAL/ |

| PHYSICIAN (MEDICAID/SCHIP) MANAGED CARE PLANS ARE |

| ALASKA, MISSISSIPPI, AND WYOMING. |

| |

| ARKANSAS AND NEW HAMPSHIRE WERE REMOVED FROM THIS |

| LIST STARTING IN PANEL 12 ROUND 3. |

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

| IF CODED ‘1’ (YES) AND IF STATE IN WHICH THE |

| INTERVIEW IS BEING CONDUCTED DOES NOT OFFER A |

| GOVT-HOSPITAL/PHYSICIAN (MEDICAID/SCHIP) MANAGED |

| CARE PLAN, CODE PR28 ‘2’ (NO) AUTOMATICALLY BY |

| CAPI AND GO TO PR29 |

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

| IF CODED ‘1’ (YES) AND IF STATE IN WHICH THE |

| INTERVIEW IS BEING CONDUCTED DOES OFFER A GOVT- |

| HOSPITAL/PHYSICIAN (MEDICAID/SCHIP) MANAGED CARE |

| PLAN, CONTINUE WITH PR28 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO ARE FLAGGED AS |

| COVERED BY GOVT-HOSPITAL/PHYSICIAN DURING THE |

| CURRENT ROUND. |

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

PR28

====

{STR-DT}

{END-DT}

SHOW CARD PR-2.

Is the name of the health insurance through the program

sponsored by a state or local government agency which provides

hospital and physician benefits{, between (START DATE) and

(END DATE),} listed on this card?

YES .................................... 1 {PR28OV}

NO ..................................... 2 {PR29}

REF ................................... -7 {PR29}

DK .................................... -8 {PR29}

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

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

| IF ROUND 5. OTHERWISE, USE A NULL DISPLAY. |

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

PR28OV

======

Which plan is the health insurance through this program?

CODE LETTER OF PLAN FROM SHOW CARD.

[Enter Plan Letter From Card] ......... {PR32}

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

| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |

| INSURER FOR GOVT-HOSPITAL/PHYSICIAN.’ |

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

| WHEN INTERVIEWER ENTERS LETTER OF PLAN, DISPLAY |

| THE FOLLOWING MESSAGE: “PLEASE VERIFY PLAN |

| SELECTED: {DISPLAY PLAN NAME SELECTED}.” WHEN |

| INTERVIEWER CLEARS THE MESSAGE, PROCEED TO THE |

| NEXT LOGICAL SCREEN. |

| |

| IN THIS MESSAGE FOR ‘DISPLAY PLAN NAME SELECTED’, |

| DISPLAY THE ACTUAL PLAN NAME THAT CORRESPONDS TO |

| THE LETTER ENTERED FOR THIS STATE. |

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

PR29

====

{STR-DT}

{END-DT}

Under the program sponsored by a state or local government

agency which provides hospital and physician benefits {(are/is)/

(were/was)} (READ NAME(S) BELOW) signed up with an HMO, that is a

Health Maintenance Organization {between (START DATE) and (END DATE)}?

[With an HMO, you must generally receive care from HMO

physicians. If another doctor is seen, the expense is not

covered unless you were referred by the HMO, or there was a

medical emergency.]

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

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

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

YES, ALL ARE ........................... 1 {PR31}

YES, SOME ARE .......................... 2 {PR31}

NO, NONE ARE ........................... 3 {PR30}

REF ................................... -7 {PR30}

DK .................................... -8 {PR30}

[Code One]

HELP AVAILABLE FOR DEFINITION OF HMO.

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

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

| ROUND 5. OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘(are/is)’ IF NOT ROUND 5. DISPLAY |

| ‘(were/was)’ IF ROUND 5. |

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

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED BY |

| GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND. |

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

PR30

====

{STR-DT}

{END-DT}

{Does/Between (START DATE) and (END DATE), did} the program

sponsored by a state or local government agency which provides

hospital and physician benefits require (READ NAME(S) BELOW) to

with a certain clinic which they must go to for all of their

routine care?

PROBE: Do not include emergency care or care from a specialist

they were referred to.

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

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

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

YES, ALL REQUIRED ...................... 1 {PR31}

YES, SOME REQUIRED ..................... 2 {PR31}

NO, NONE REQUIRED ...................... 3 {PR32}

REF ................................... -7 {PR32}

DK .................................... -8 {PR32}

[Code One]

HELP AVAILABLE FOR DEFINITION OF PRIMARY CARE DOCTOR AND ROUTINE CARE.

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

| DISPLAY ‘Does’ IF NOT ROUND 5. DISPLAY ‘Between |

| (START DATE) and (END DATE), did’ IF ROUND 5. |

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

| IF CODED ‘3’ (NO, NONE REQUIRED), ‘-7’ (REFUSED), |

| OR ‘-8’ (DON’T KNOW), THERE IS NO INSURER |

| ASSOCIATED WITH THE CURRENT ROUND FOR |

| GOVT-HOSPITAL/PHYSICIAN. |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO ARE COVERED BY |

| GOVT-HOSPITAL/PHYSICIAN DURING THE CURRENT ROUND. |

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

PR31

====

{STR-DT}

{END-DT}

What is the name of the {HMO/health insurance} from the program

sponsored by a state or local government agency which provides

hospital and physician benefits?

[Enter Plan Name] ..................... {PR32}

REF ................................... -7 {PR32}

DK .................................... -8 {PR32}

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

| DISPLAY ‘HMO’ IF PR29 IS CODED ‘1’ (YES, ALL ARE) |

| OR ‘2’ (YES, SOME ARE). DISPLAY ‘health |

| insurance’ IF PR30 CODED ‘1’ (YES, ALL REQUIRED) |

| OR ‘2’ (YES, SOME REQUIRED). |

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

| FLAG INSURER CODED ABOVE AS ‘CURRENT ROUND’S |

| INSURER FOR GOVT-HOSPITAL/PHYSICIAN.’ |

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

PR32

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT PR28OV}/{NAME OF PLAN FROM

PR31}}}

For the coverage through {(PLAN NAME)/the program sponsored by

a state or local government agency which provides hospital and

physician benefits}, does anyone in the family pay anything for

this coverage?

[Do not include the cost of any copayments, coinsurance, or

deductibles anyone in the family may have had to pay.]

YES .................................... 1 {PR33}

NO ..................................... 2 {PR34}

REF ................................... -7 {BOX_11}

DK .................................... -8 {BOX_11}

[Code One]

HELP AVAILABLE FOR DEFINITION OF

PREMIUM/COPAYMENT/COINSURANCE/DEDUCTIBLE.

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

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |

| PHYSICIAN INSURANCE. OTHERWISE, USE A NULL DISPLAY.|

| |

| DISPLAY ‘(PLAN NAME ENTERED AT PR28OV)’ IF A PLAN |

| WAS ENTERED AT PR28OV. DISPLAY THE ACTUAL PLAN |

| NAME THAT CORRESPONDS TO THE LETTER ENTERED AT |

| PR28OV FOR THIS STATE. |

| |

| DISPLAY ‘(NAME OF PLAN FROM PR31)’ IF A PLAN NAME |

| WAS ENTERED AT PR31. DISPLAY THE ACTUAL PLAN NAME |

| THAT WAS ENTERED. |

| |

| DISPLAY ‘(PLAN NAME)’ IF THERE IS A CURRENT ROUND |

| INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/PHYSICIAN|

| INSURANCE. OTHERWISE, DISPLAY ‘the program |

| sponsored ...’. |

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

PR33

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT PR28OV}/{NAME OF PLAN FROM

PR31}}}

How much does anyone in the family pay for {the (PLAN NAME)/

that} coverage?

[Enter Amount in Dollars] .............. {PR33OV1}

REF ................................... -7 {PR34}

DK .................................... -8 {PR34}

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

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |

| PHYSICIAN INSURANCE. OTHERWISE, USE A NULL DISPLAY.|

| |

| DISPLAY ‘{PLAN NAME ENTERED AT PR28OV}’ IF A PLAN |

| WAS ENTERED AT PR28OV. DISPLAY THE ACTUAL PLAN |

| NAME THAT CORRESPONDS TO THE LETTER ENTERED AT |

| PR28OV FOR THIS STATE. |

| |

| DISPLAY ‘{NAME OF PLAN FROM PR31}’ IF A PLAN NAME |

| WAS ENTERED AT PR31. DISPLAY THE ACTUAL PLAN NAME |

| THAT WAS ENTERED. |

| |

| DISPLAY ‘the (PLAN NAME)’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |

| PHYSICIAN INSURANCE. OTHERWISE, DISPLAY ‘that’. |

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

PR33OV1

=======

Is that per year, per month, per week, or what?

ENTER UNIT OF COVERAGE:

PER YEAR ............................... 1 {PR34}

QUARTERLY/EVERY 3 MONTHS ............... 2 {PR34}

BIMONTHLY/EVERY 2 MONTHS ............... 3 {PR34}

PER MONTH .............................. 4 {PR34}

PER WEEK ............................... 5 {PR34}

BIWEEKLY/EVERY 2 WEEKS ................. 6 {PR34}

SEMI-ANNUALLY/2 TIMES PER YEAR ......... 7 {PR34}

SEMI-MONTHLY/2 TIMES PER MONTH ......... 8 {PR34}

OTHER ................................. 91 {PR33OV2}

REF ................................... -7 {PR34}

DK .................................... -8 {PR34}

[Code One]

PR33OV2

=======

ENTER OTHER:

[Enter Other Specify] .................. {PR34}

REF ................................... -7 {PR34}

DK .................................... -8 {PR34}

BOX_10A

=======

OMITTED.

PR34

====

{STR-DT}

{END-DT}

{PLAN NAME: {{PLAN NAME ENTERED AT PR28OV}/{NAME OF PLAN

FROM PR31}}}

Who {else} pays {some of/for} the premium or cost

of this insurance?

CHECK ALL THAT APPLY.

FEDERAL GOVERNMENT .................... 1

STATE GOVERNMENT ...................... 2

LOCAL GOVERNMENT ...................... 3

SOME GOVERNMENT ....................... 4

OTHER ................................. 91 {PR34OV}

REF ................................... -7 {BOX_11}

DK .................................... -8 {BOX_11}

[Code All That Apply)

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

| DISPLAY ‘PLAN NAME: ...’ IF THERE IS A CURRENT |

| ROUND INSURER ASSOCIATED WITH THE GOVT-HOSPITAL/ |

| PHYSICIAN INSURANCE. OTHERWISE, USE A NULL DISPLAY.|

| |

| DISPLAY ‘{PLAN NAME ENTERED AT PR28OV}’ IF A PLAN |

| WAS ENTERED AT PR28OV. DISPLAY THE ACTUAL PLAN |

| NAME THAT CORRESPONDS TO THE LETTER ENTERED AT |

| PR28OV FOR THIS STATE. DISPLAY THE ACTUAL PLAN |

| NAME ENTERED AT PR31 FOR ‘{NAME OF PLAN FROM PR31}’|

| IF A PLAN NAME WAS ENTERED. |

| |

| DISPLAY ‘else’ IF PR32 IS CODED ‘1’ (YES). |

| OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘some of’ IF PR32 IS CODED ‘1’ (YES). |

| DISPLAY ‘for’ IF PR32 IS CODED ‘2’ (NO). |

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

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

| FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT |

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

| COMBINATION WITH ANY OTHER CODE. |

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

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

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

| WITH ANY OTHER CODE, CONTINUE WITH PR34OV |

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

| OTHERWISE, GO TO BOX_11 |

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

PR34OV

======

ENTER OTHER:

[Enter Other Specify] .................. {BOX_11}

REF ................................... -7 {BOX_11}

DK .................................... -8 {BOX_11}

BOX_11

======

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

| IF ANY RU MEMBER HAD OTHER PUBLIC (GROUP 1 OR 2) |

| AS A SOURCE OF INSURANCE AT ANY TIME DURING |

| PREVIOUS ROUND, CONTINUE WITH BOX_12 |

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

| OTHERWISE, GO TO BOX_18 |

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

BOX_12

======

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

| IF ANY CURRENT RU MEMBER HAD ANY GROUP 1 OTHER |

| PUBLIC INSURANCE AT ANY TIME DURING PREVIOUS |

| ROUND, CONTINUE WITH PR35 |

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

| OTHERWISE, GO TO BOX_15 |

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

| NOTE: FOR BOTH GROUP 1 AND GROUP 2 PUBLIC |

| PROGRAMS, WE ASSUME THE PROGRAM IS THE SAME FROM |

| THE PREVIOUS ROUND. ALTHOUGH WE SHOW THE SHOW |

| CARD AND ASK IF THE FAMILY STILL HAD COVERAGE |

| FROM ANY OF THOSE PROGRAMS, WE DO NOT ASK WHICH |

| ONES. IF WE WERE TO ASK WHICH ONES, WE WOULD NEED|

| TO ADD SEVERAL QUESTIONS, LIKE THE OTHER PUBLIC |

| SERIES IN HX. |

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

PR35

====

{STR-DT}

{END-DT}

During the last interview, we recorded that (READ NAMES BELOW)

were covered by one or more of the following programs:

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

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

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

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

Have all of these people been covered by any of these programs at

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

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

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

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

YES, ALL .............................. 1 {BOX_13}

NO, ONLY SOME ......................... 2 {PR36}

NO, NONE .............................. 3

REF ................................... -7 {BOX_15}

DK .................................... -8 {BOX_15}

HELP AVAILABLE FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.

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

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

| STATE PROGRAMS (AS LISTED IN HX16) FOR ‘STATE NAME |

| FOR PROGRAM #N’. |

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

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

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

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

| ROUND 5. |

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

| IF PR35 IS CODED ‘1’ (YES, ALL), MARK ALL RU |

| MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER |

| PUBLIC INSURANCE DURING CURRENT ROUND. |

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

| IF PR35 IS CODED ‘3’ (NO, NONE), FLAG ALL RU |

| MEMBERS LISTED HERE AS ‘NOT COVERED BY GROUP 1 |

| OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND. |

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

| IF CODED ‘3’ (NO, NONE) |

| AND |

| IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, |

| GO TO PR37 |

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

| IF CODED ‘3’ (NO, NONE), |

| AND |

| IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, |

| GO TO BOX_15 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY |

| GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING |

| THE PREVIOUS ROUND. |

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

PR36

====

{STR-DT}

{END-DT}

Who has been covered by any of these programs {since (START

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

PROBE: Anyone else?

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

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

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

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY GROUP 1 |

| OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND. |

| FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY |

| GROUP 1 OTHER PUBLIC INSURANCE’ DURING CURRENT |

| ROUND. |

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

| GO TO BOX_13 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR SELECTION OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY |

| GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING |

| THE PREVIOUS ROUND. |

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

BOX_13

======

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

| IF ALL CURRENT RU MEMBERS ALREADY FLAGGED AS |

| COVERED OR NOT COVERED BY GROUP 1 OTHER PUBLIC |

| INSURANCE DURING CURRENT ROUND (I.E., ALL CURRENT |

| RU MEMBERS WERE LISTED IN PR35), GO TO LOOP_05 |

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

| OTHERWISE, CONTINUE WITH PR37 |

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

PR37

====

{STR-DT}

{END-DT}

Besides the family members we’ve just talked about, have any

additional family members been covered by any of the following

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

(READ PROGRAM NAMES BELOW.)

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

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

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

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

YES ................................... 1 {PR38}

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

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

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

HELP AVAILABLE FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.

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

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

| STATE PROGRAMS (AS LISTED IN HX16) FOR ‘STATE NAME |

| FOR PROGRAM #N’. |

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

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

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

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

| ROUND 5. |

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

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

| KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS |

| COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING |

| CURRENT ROUND, GO TO LOOP_05 |

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

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

| KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY |

| GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT |

| ROUND, GO TO BOX_15 |

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

PR38

====

{STR-DT}

{END-DT}

Who has been covered by any of these programs {since (START

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

PROBE: Anyone else?

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

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

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

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY GROUP 1 |

| OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND. |

| FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY |

| GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT |

| ROUND.’ |

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

| GO TO LOOP_05 |

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

| ROSTER DETAILS: |

| Title: RU_MEMBERS_1 |

| |

| COL #1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

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

| OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE NOT FLAGGED|

| AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE |

| AT ANY TIME DURING THE PREVIOUS ROUND. |

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

LOOP_05

=======

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

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

| PAIRS-ROSTER, ASK BOX_14 - END_LP05 |

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

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

| LOOP DEFINITION: LOOP_05 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY GROUP 1 |

| OTHER PUBLIC INSURANCE. THIS LOOP CYCLES ON |

| ESTABLISHMENT-PERSON-PAIRS THAT MEET BOTH OF THE |

| FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS GROUP 1 OTHER PUBLIC INSURANCE |

| AND |

| - PERSON IS COVERED BY GROUP 1 OTHER PUBLIC |

| INSURANCE DURING THE CURRENT ROUND |

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

BOX_14

======

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

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

| FOR THIS PAIR. |

| |

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP05 |

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

END_LP05

========

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

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

| PERSON-PAIRS-ROSTER THAT MEETS THE CONDITIONS |

| STATED IN THE LOOP DEFINITION. |

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

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, |

| END LOOP_05 AND CONTINUE WITH BOX_15 |

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

BOX_15

======

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

| IF ANY CURRENT RU MEMBER HAD ANY ELIGIBLE GROUP 2 |

| OTHER PUBLIC INSURANCE AT ANY TIME DURING THE |

| PREVIOUS ROUND, CONTINUE WITH PR39 |

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

| OTHERWISE, GO TO BOX_18 |

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

PR39

====

{STR-DT}

{END-DT}

SHOW CARD PR-3.

During the last interview, we recorded that (READ NAMES BELOW)

were covered by one or more of the public programs listed

on this card.

Have all of these people been covered by any of these programs

at any time {since (START DATE)/between (START DATE) and (END DATE)}?

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

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

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

YES, ALL .............................. 1 {BOX_16}

NO, ONLY SOME ......................... 2 {PR40}

NO, NONE .............................. 3

REF ................................... -7 {BOX_18}

DK .................................... -8 {BOX_18}

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

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

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

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

| ROUND 5. |

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

| IF CODED ‘1’ (YES, ALL), FLAG ALL RU MEMBERS |

| LISTED HERE AS ‘COVERED BY GROUP 2 OTHER PUBLIC |

| INSURANCE’ DURING CURRENT ROUND. |

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

| IF CODED ‘3’ (NO, NONE), FLAG ALL RU MEMBERS |

| LISTED HERE AS ‘NOT COVERED BY GROUP 2 OTHER |

| PUBLIC INSURANCE’ DURING CURRENT ROUND. |

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

| IF CODED ‘3’ (NO, NONE) |

| AND |

| IF ANY CURRENT RU MEMBERS NOT LISTED AT PR39, |

| GO TO PR41 |

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

| IF CODED ‘3’ (NO, NONE), |

| AND |

| IF ALL CURRENT RU MEMBERS ARE LISTED AT PR39, |

| GO TO BOX_18 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR DISPLAY OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY |

| GROUP 2 OTHER PUBLIC INSURANCE AT ANY TIME DURING |

| THE PREVIOUS ROUND. |

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

PR40

====

{STR-DT}

{END-DT}

SHOW CARD PR-3.

Who has been covered by any of these programs {since (START

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

PROBE: Anyone else?

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

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

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

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY GROUP 2 |

| OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND. |

| FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY |

| GROUP 2 OTHER PUBLIC INSURANCE’ DURING CURRENT |

| ROUND. |

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

| GO TO BOX_16 |

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

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS RU-ESTABLISHMENT-PERSON-PAIRS- |

| ROSTER FOR SELECTION OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE COVERED BY |

| GROUP 2 OTHER PUBLIC INSURANCE AT ANY TIME DURING |

| THE PREVIOUS ROUND. |

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

BOX_16

======

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

| IF ALL CURRENT RU MEMBERS ALREADY FLAGGED AS |

| COVERED OR NOT COVERED BY GROUP 2 OTHER PUBLIC |

| INSURANCE DURING CURRENT ROUND (I.E., ALL CURRENT |

| RU MEMBERS WERE LISTED AT PR39), GO TO LOOP_06 |

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

| OTHERWISE, CONTINUE WITH PR41 |

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

PR41

====

{STR-DT}

{END-DT}

SHOW CARD PR-3.

Besides the family members we’ve just talked about, have any

additional family members been covered by any of these programs

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

YES ................................... 1 {PR42}

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

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

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

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

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

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

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

| ROUND 5. |

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

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

| KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS |

| COVERED BY GROUP 2 OTHER PUBLIC INSURANCE |

| DURING CURRENT ROUND, GO TO LOOP_06 |

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

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

| KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY |

| GROUP 2 OTHER PUBLIC INSURANCE DURING CURRENT |

| ROUND, GO TO BOX_18 |

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

PR42

====

{STR-DT}

{END-DT}

SHOW CARD PR-3.

Who has been covered by any of these programs {since (START

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

PROBE: Anyone else?

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

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

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

HELP AVAILABLE FOR DEFINITION OF ITEMS ON SHOW CARD.

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

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

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

| ROUND 5. |

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

| FLAG ALL PERSONS SELECTED AS ‘COVERED BY GROUP 2 |

| OTHER PUBLIC INSURANCE’ DURING CURRENT ROUND. |

| FLAG ALL PERSONS NOT SELECTED AS ‘NOT COVERED BY |

| GROUP 2 OTHER PUBLIC INSURANCE DURING CURRENT |

| ROUND.’ |

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

| GO TO LOOP_06 |

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

| ROSTER DETAILS: |

| Title: RU_MEMBERS_1 |

| |

| COL #1 HEADER: NAME |

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

| AND LAST NAMES (PERS.FULLNAME) |

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

| ROSTER DEFINITION: |

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

| OF RU-MEMBERS. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE RU MEMBERS WHO WERE NOT FLAGGED|

| AS COVERED BY GROUP 2 OTHER PUBLIC INSURANCE AT |

| ANY TIME DURING THE PREVIOUS ROUND. |

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

LOOP_06

=======

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

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

| PAIRS-ROSTER, ASK BOX_17 - END_LP06 |

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

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

| LOOP DEFINITION: LOOP_06 COLLECTS TIME PERIOD |

| COVERAGE DETAIL FOR RU MEMBERS COVERED BY GROUP 2 |

| OTHER PUBLIC INSURANCE. THIS LOOP CYCLES ON |

| ESTABLISHMENT-PERSON-PAIRS THAT MEET BOTH OF THE |

| FOLLOWING CONDITIONS: |

| - ESTABLISHMENT IS GROUP 2 OTHER PUBLIC INSURANCE |

| AND |

| - PERSON IS COVERED BY GROUP 2 OTHER PUBLIC |

| INSURANCE DURING THE CURRENT ROUND |

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

BOX_17

======

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

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

| FOR THIS PAIR. |

| |

| AT COMPLETION OF THE HQ SECTION, CONTINUE WITH |

| END_LP06 |

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

END_LP06

========

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

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

| PAIRS ROSTER THAT MEETS THE CONDITIONS STATED IN |

| THE LOOP DEFINITION. |

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

| IF NO MORE PAIRS MEET THE STATED CONDITIONS, END |

| LOOP_06 AND CONTINUE WITH BOX_18 |

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

BOX_18

======

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

| RETURN TO THE HEALTH INSURANCE (HX) SECTION. |

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

28-345

File Type	application/msword
File Title	MEPS Old Public Related Insurance - P12R5/P13R3/P14R1
Subject	PR Section Item Specifications
Author	Agency for Healthcare Research and Quality
Last Modified By	wcarroll
File Modified	2009-07-10
File Created	2009-07-10