Attachment 17 -- HC Showcards 2013

MEDICAL EXPENDITURE PANEL SURVEY

HOUSEHOLD COMPONENT

MAIN STUDY

BLAISE/WVS

SHOW CARDS

Panels 16, 17, and 18

January 2013

TABLE OF CONTENTS

ROUNDS 1-5

Card Number	Topic	Round(s) Used
RE-1	Ethnic Background	1, 2, 3,4,5
RE-2	Racial Background	1, 2, 3,4,5
RE-3	Highest Level of School Completed	1, 2, 3,4,5
PE-1	Types of Cancer	1, 2, 3,4,5
HE-1	Level of Difficulty Categories	1, 3, 5
CS-1	Scale for Child Health Supplement	2, 4
CS-2	Scale for Child Health Supplement	2, 4
CS-3	Scale for Child Health Supplement	2, 4
CS-4	Number of Times Went to Doctor’s Office or Clinic	2, 4
CS-5	Scale for Child Health Supplement	2, 4
PP-1	Types of Health Care Providers and Facilities	1, 2, 3, 4, 5
PP-2	Types of Hospital Services/Long Term Care Facilities	1, 2, 3, 4, 5
PP-3	Types of Home Care Services	1, 2, 3, 4, 5
PP-4	Types of Medical Supplies/Expenses	1, 2, 3, 4 ,5
PP-5	Types of Additional Medical Supplies/Expenses	3, 5
PP-6	Types of Dental Care Providers	1, 2, 3, 4, 5
PP-7	Types of Medical Providers	1, 2, 3, 4, 5
PP-8	Types of Hospital Services	1, 2, 3, 4, 5
PP-9	Types of Other Medical Providers	1, 2, 3, 4, 5
PP-10	Types of Home Care Services	1, 2, 3, 4, 5
PP-11	Types of Long Term Care Facilities	1, 2, 3, 4, 5
PP-12	Types of Medical Supplies/Expenses	1, 2, 3, 4, 5
PP-13	Types of Additional Medical Supplies/Expenses	3, 5
EV-1A	Examples of Where Care Received (Event Typing)	1, 2, 4
EV-1B	Examples of Where Care Received (Event Typing)	3, 5
HS-1	Reasons for Entering the Hospital	1, 2, 3, 4, 5
ER-1	Care Received During ER Visit	1, 2, 3, 4, 5
ER-2	Services Received During ER Visit	1, 2, 3, 4, 5
Table of Contents Continued on the Following Page

TABLE OF CONTENTS (Cont.)

Card Number	Topic	Round(s) Used
OP-1	Care Received During Outpatient Visit	1, 2, 3, 4, 5
OP-2	Treatments Received During Outpatient Visit	1, 2, 3, 4, 5
OP-3	Services Received During Outpatient Visit	1, 2, 3, 4, 5
MV-1	Types of Places for Medical Provider Visit	1, 2, 3, 4, 5
MV-2	Care Received During Medical Provider Visit	1, 2, 3, 4, 5
MV-3	Treatments Received During Medical Provider Visit	1, 2, 3, 4, 5
MV-4	Services Received During Medical Provider Visit	1, 2, 3, 4, 5
DN-1	Types of Dental Care Providers	1, 2, 3, 4, 5
DN-2	Care Received During Dental Visit	1, 2, 3, 4, 5
HH-1	Types of Home Health Care Workers	1, 2, 3, 4, 5
HH-2	Examples of Home Health Care Received	1, 2, 3, 4, 5
HH-3	Examples of Help With Daily Activities or Personal Care	1, 2, 3, 4, 5
CP-1	Reasons for Not Receiving Anything in Writing	1, 2, 3, 4, 5
PC-1	Last Use of Peak Flow Meter	3, 5
AP-1	Weight Ranges	3, 5
AC-1	Difficulty Scale	2, 4
AC-2	Provider’s Race	2, 4
AC-3	Frequency Scale	2, 4
AC-4	Reasons for Problems	2, 4
AC-5	Problems Scale	2, 4
HX-1	Ways in Which Health Insurance is Purchased (for STATE)	1, 2, 3, 4, 5
HX-2	Sample Medicare Card	1, 2, 3, 4, 5
HX-3	Sample Medicaid Card for STATE	1, 2, 3, 4, 5
HX-4	Source of Health Insurance (for STATE)	1, 2, 3, 4, 5
HX-5	Medicare Managed Care Plan Names for STATE	1, 2, 3, 4, 5
HX-6	Medicare HMO Premium Ranges	1, 3
HX-7	Medicare Part D Premium Ranges	1, 3
HX-8	Medicaid (and Gov’t-Hosp/Phys) HMO Plan Names for STATE	1, 2, 3, 4, 5
HX-9	Types of Health Insurance Coverage	1, 2, 3, 4, 5
Table of Contents Continued on the Following Page

	Table of Contents (continued)
Card Number	Topic	Round(s) Used
HX-10	Plan Names (For Federal Civilian Employees For STATE)	1
HX-11	Types of Other State Programs	2, 3, 4, 5
SP-1	Problem Scale	2, 4
SP-2	Health Plan Scale	2, 4
IN-1	Yearly Income Ranges	3, 5
IN-2	Yearly Income Ranges	3, 5
IN-3	Monthly Income Ranges	3, 5
IN-4	Other Sources of Income Categories	3, 5
AS-1	Asset Ranges	5
AS-2	Asset Ranges	5
AS-3	Asset Ranges	5
AS-4	Other Financial Assets	5
AS-5	Other Property and Assets	5

CARD RE-1

RE-1

-- Puerto Rican

-- Cuban/Cuban American

-- Dominican

-- Mexican

-- Mexican-American/Chicano

-- Central or South American

One or more may be selected.

CARD RE-2

RE-2

-- White

-- Black or African American

-- American Indian or Alaska Native

-- Asian Indian

-- Chinese

-- Filipino

-- Japanese

-- Korean

-- Vietnamese

-- Other Asian

-- Native Hawaiian

-- Guamanian or Chamorro

-- Samoan

-- Other Pacific Islander

One or more may be selected.

CARD RE-3

-- Less than 1^st Grade

-- 1^st Grade

-- 2^nd Grade

-- 3^rd Grade

-- 4^th Grade

-- 5^th Grade

-- 6^th Grade

-- 7^th Grade

-- 8^th Grade

-- 9^th Grade

-- 10^th Grade

-- 11^th Grade

-- 12^th Grade, No Diploma

-- GED or Equivalent

-- High School Diploma

-- Some College, No Degree

-- Associate Degree: Occupational, Technical, or Vocational Program

-- Associate Degree: Academic Program

-- Bachelor’s Degree (Example: BA, AB, BS, BBA)

-- Master’s Degree (Example: MA, MS, MEng, MEd, MBA)

-- Professional School (Example: MD, DDS, DVM, JD)

-- Doctorate Degree (Example: PhD, EdD)

RE-3

CARD PE-1

PE-1

-- Bladder -- Blood -- Bone -- Brain -- Breast -- Cervix -- Colon -- Esophagus -- Gallbladder -- Kidney -- Larynx-Windpipe -- Leukemia -- Liver -- Lung -- Lymphoma

-- Melanoma -- Mouth/Tongue/Lip -- Ovary -- Pancreas -- Prostate -- Rectum -- Skin – Non-Melanoma -- Skin (unknown type) -- Soft tissue muscle or fat -- Stomach -- Testis -- Throat-Pharynx -- Thyroid -- Uterus -- Other

CARD HE-1

HE-1

-- No Difficulty

-- Some Difficulty

-- A Lot of Difficulty

-- Completely Unable To Do It

CARD CS-1

CS-1

-- Definitely True

-- Mostly True

-- Don't Know

-- Mostly False

-- Definitely False

CARD CS-2

CS-2

0. No Problem

2 Some Problem

3

4 A Very Big Problem

CARD CS-3

CS-3

-- Never

-- Sometimes

-- Usually

-- Always

CARD CS-4

CS-4

None

1

2

3

4

5-9

10 or more

CARD CS-5

CS-5

0. Worst Health Care Possible

2

3

4

5

6

7

8

9

10 Best Health Care Possible

PP-1

CARD PP-1

TYPES OF HEALTH CARE PROVIDERS AND FACILITIES

Medical Professionals and Practitioners:

Medical Doctor

Nurse or Nurse Practitioner

Paramedic

Health Aide

Physician’s Assistant

Midwife/Nurse Midwife

Optometrist/Ophthalmologist

Podiatrist (Foot Doctor)

Chiropractor

Acupuncturist

Therapist - Physical, Speech,
Occupational

Audiologist

Physiatrist

Physical Therapy or
Rehabilitation Services

Mental Health Professionals:

Psychiatrist

Psychologist

Psychiatric Social Worker

Mental Health Therapist

Medical Facility or Clinic:

Health Clinic

Walk-in Surgi-Clinic

Company or School Clinic

Infirmary

Neighborhood Health Clinic

Family Planning Center

Mental Health Facility

Retail Clinic (e.g., Pharmacy/
Grocery Store Clinic)

Dental Care:

Dentist

Dental or Oral Surgeon

Orthodontist

Dental Hygienist

Dental Technician

Dental Assistant

PP-2

CARD PP-2

TYPES OF HOSPITAL SERVICES

Hospital Stay

Emergency Room Visit

Outpatient Department Visit

TYPES OF LONG TERM CARE FACILITIES

Convalescent Home

Nursing Home

Nursing Home Unit of a Hospital

Intermediate Care Facilities

Board and Care Homes

Residential Psychiatric Institution

Facility for the Intellectually Disabled

Group Homes

Long Term Place that Provides Hospice Care

Long Term Place that Provides Respite Care

Assisted Living Facilities

CARD PP-3

PP-3

TYPES OF HOME CARE SERVICES

Skilled Medical Care

Home care from a nurse, any type of therapist, a doctor, a

social worker, or anyone else providing nursing or medical

care.

Personal Care

Home care services including bathing, dressing, help

getting around the house, or help with getting medication,

either paid or unpaid.

Household Chore Services

Help in the home with services like cooking or cleaning

either paid or unpaid.

Companionship

Services such as reading, talking, or going for a walk, a

drive, or to a restaurant either paid or unpaid.

Any Other Type of Home Care

CARD PP-4

PP-4

TYPES OF OTHER MEDICAL SUPPLIES/EXPENSES

Eyeglasses or Contact Lenses …

Bought

Replaced

Paid for Repairing

Diabetic Equipment or Supplies …

Insulin

Syringes

Test Paper

Other Diabetic Equipment or Supplies

CARD PP-5

Ambulance Services

Orthopedic Items

-- Corrective shoes or inserts

-- Braces

-- Crutches

-- Canes

-- Walkers

-- Wheelchairs

-- Scooters

Hearing Devices

-- Hearing aids

-- Amplifiers for a telephone

-- Adaptive speech equipment

-- Speech synthesizer

Prostheses

-- Artificial limbs

Bathroom Aids

-- Portable commodes

-- Raised toilet seats

-- Portable tub seats

-- Handrails

-- Other bathing equipment

PP-5

Medical Equipment

-- Hospital beds

-- Lifts

-- Monitors

-- Special chairs

-- Oxygen

-- Bed pans

-- Adaptive feeding equipment

-- Vaporizer or nebulizer

-- Blood pressure monitor

Disposable Supplies

-- Ostomy supplies

-- Bandages

-- Dressings

-- Tape

-- Adult disposable diapers

-- Catheters

-- Syringes not prescribed by a

physician

-- IV supplies

Alterations/Modifications

-- Ramps

-- Handrails

-- Elevators

-- Automobile modifications

Other

CARD PP-6

PP-6

TYPES OF DENTAL CARE PROVIDERS

Dentist

Dental or Oral Surgeon

Orthodontist

Dental Hygienist

Dental Technician

Dental Assistant

CARD PP-7

PP-7

TYPES OF MEDICAL PROVIDERS

Medical Professionals:

Medical Doctor Physician’s Assistant

Nurse Optometrist/Ophthalmologist Nurse Practitioner Podiatrist (Foot Doctor)

Midwife/Nurse Midwife Chiropractor

Physiatrist Acupuncturist

Paramedic Audiologist

Health Aide

Physical Therapy or Rehabilitation Services

Therapist-Physical, Speech, Occupational

Mental Health Professionals:

Psychiatrist

Psychologist

Psychiatric Social Worker

Mental Health Therapist

CARD PP-8

PP-8

TYPES OF HOSPITAL SERVICES

Hospital Stay

Emergency Room Visit

Outpatient Department Visit

CARD PP-9

PP-9

TYPES OF OTHER MEDICAL PROVIDERS

Medical Professionals and Practitioners:

Paramedic

Health Aide

Physician’s Assistant

Midwife

Optometrist/Ophthalmologist

Podiatrist (Foot Doctor)

Chiropractor

Acupuncturist

Therapist - Physical, Speech, Occupational

Audiologist

Physical Therapy or Rehabilitation Services

Medical Facility or Clinic:

Health Clinic

Walk-in Surgi-Clinic

Company or School Clinic

Infirmary

Neighborhood Health Clinic

Family Planning Center

Mental Health Facility

Retail Clinic (e.g., Pharmacy/Grocery Store Clinic)

Mental Health Professionals:

Psychiatric Social Worker

Mental Health Therapist

CARD PP-10

PP-10

TYPES OF HOME CARE SERVICES

Skilled Medical Care

Home care from a nurse, any type of therapist, a doctor, a

social worker, or anyone else providing nursing or medical

care.

Personal Care

Home care services including bathing, dressing, help

getting around the house, or help with getting medication, either paid or unpaid.

Household Chore Services

Help in the home with services like cooking or cleaning

either paid or unpaid.

Companionship

Services such as reading, talking, or going for a walk, a

drive, or to a restaurant either paid or unpaid.

Any Other Type of Home Care

CARD PP-11

PP-11

TYPES OF LONG TERM CARE FACILITIES

Convalescent Home

Nursing Home

Nursing Home Unit of a Hospital

Intermediate Care Facilities

Board and Care Homes

Residential Psychiatric Institution

Facility for the Intellectually Disabled

Group Homes

Long Term Place that Provides Hospice Care

Long Term Place that Provides Respite Care

Assisted Living Facilities

CARD PP-12

PP-12

TYPES OF OTHER MEDICAL SUPPLIES/EXPENSES

Eyeglasses or Contact Lenses …

Bought

Replaced

Paid for Repairing

Diabetic Equipment or Supplies …

Insulin

Syringes

Test Paper

Other Diabetic Equipment or Supplies

CARD PP-13

Ambulance Services

Orthopedic Items

-- Corrective shoes or inserts

-- Braces

-- Crutches

-- Canes

-- Walkers

-- Wheelchairs

-- Scooters

Hearing Devices

-- Hearing aids

-- Amplifiers for a telephone

-- Adaptive speech equipment

-- Speech synthesizer

Prostheses

-- Artificial limbs

Bathroom Aids

-- Portable commodes

-- Raised toilet seats

-- Portable tub seats

-- Handrails

-- Other bathing equipment

PP-13

Medical Equipment

-- Hospital beds

-- Lifts

-- Monitors

-- Special chairs

-- Oxygen

-- Bed pans

-- Adaptive feeding equipment

-- Vaporizer or nebulizer

-- Blood pressure monitor

Disposable Supplies

-- Ostomy supplies

-- Bandages

-- Dressings

-- Tape

-- Adult disposable diapers

-- Catheters

-- Syringes not prescribed by a

physician

-- IV supplies

Alterations/Modifications

-- Ramps

-- Handrails

-- Elevators

-- Automobile modifications

Other

CARD EV-1A (Rounds 1, 2 and 4)

EV-1A

-- Hospital Stay

-- Hospital Emergency Room

-- Hospital Outpatient Department

-- Medical Provider

• e.g., Doctor’s Office, Group Practice, Clinic, HMO, Lab, Mental Health Care, Alternative Care

-- Dental Office/Dental Clinic

-- At Home

-- Other Medical Expenses

• Eyeglasses or Contact Lenses

• Insulin, Other Diabetic Equipment/Supplies

-- Institutional/Long Term Care Stay

• e.g., Nursing Home, Rehabilitation Facility, Drug Treatment, Psychiatric Facility

CARD EV-1B (Rounds 3 and 5)

EV-1B

-- Hospital Stay

-- Hospital Emergency Room

-- Hospital Outpatient Department

-- Medical Provider

• e.g., Doctor’s Office, Group Practice, Clinic, HMO, Lab, Mental Health Care, Alternative Care

-- Dental Office/Dental Clinic

-- At Home

-- Other Medical Expenses

• Eyeglasses or Contact Lenses

• Insulin, Other Diabetic Equipment/Supplies

• Ambulance, Orthopedic Items, Hearing Devices, Prostheses, Bathroom Aids, Medical Equipment, Disposable Supplies, Alterations/Modifications

-- Institutional/Long Term Care Stay

• e.g., Nursing Home, Rehabilitation Facility, Drug Treatment, Psychiatric Facility

CARD HS-1

HS-1

-- Operation or Surgical Procedure

-- Treatment or Therapy, Not Including Surgery

-- Diagnostic Tests Only

-- Give Birth to a Baby - Normal or

Caesarean Section (Mother)

-- To Be Born (Baby)

-- Pregnancy-Related Complications

CARD ER-1

ER-1

-- Diagnosis or Treatment

-- Emergency (e.g., Accident or Injury)

-- Psychotherapy or Mental Health

Counseling

-- Follow-up or Post-Operative Visit

-- Immunization or Shots

-- Pregnancy-Related

(Including Prenatal Care and Delivery)

CARD ER-2

ER-2

-- Laboratory Tests

-- Throat Swab

-- Sonogram or Ultrasound

-- X-Rays

-- Mammogram

-- MRI or CAT Scan

-- EKG or ECG

-- EEG

-- Vaccination

-- Anesthesia

CARD OP-1

OP-1

-- General Checkup

-- Diagnosis or Treatment

-- Emergency (e.g., Accident or Injury)

-- Psychotherapy or Mental Health Counseling

-- Follow-up or Post-Operative Visit

-- Immunizations or Shots

-- Vision Exam

-- Pregnancy-Related

(Including Prenatal Care and Delivery)

-- Well Child Exam

-- Laser Eye Surgery

CARD OP-2

OP-2

-- Physical Therapy

-- Occupational Therapy

-- Speech Therapy

-- Chemotherapy

-- Radiation Therapy

-- Kidney Dialysis

-- IV Therapy

-- Drug or Alcohol Treatment

-- Allergy Shot

-- Psychotherapy/Counseling

-- Shots, Other than Allergy

CARD OP-3

OP-3

-- Laboratory Tests

-- Throat Swab

-- Sonogram or Ultrasound

-- X-Rays

-- Mammogram

-- MRI or CAT Scan

-- EKG or ECG

-- EEG

-- Vaccination

-- Anesthesia

CARD MV-1

MV-1

-- Doctor’s Office or Group Practice

-- Managed Care Plan Center/HMO

-- Medical Clinic

-- Rural Health Clinic

-- Company Clinic

-- School Clinic

-- Other Clinic

-- Neighborhood Family Health Center

-- Community Health Center

-- Birthing Center

-- Walk-in Urgent Care

-- Laboratory/X-ray Facility

-- Laser Eye Surgery Center

-- Other Freestanding Surgical Center

-- VA Facility

-- Indian Health Service (IHS) Facility

-- Some Other Place

CARD MV-2

MV-2

-- General Checkup

-- Diagnosis or Treatment

-- Emergency (e.g., Accident or Injury)

-- Psychotherapy or Mental Health Counseling

-- Follow-up or Post-Operative Visit

-- Immunizations or Shots

-- Vision Exam

-- Pregnancy-Related

(Including Prenatal Care and Delivery)

-- Well Child Exam

-- Laser Eye Surgery

CARD MV-3

MV-3

-- Physical Therapy

-- Occupational Therapy

-- Speech Therapy

-- Chemotherapy

-- Radiation Therapy

-- Kidney Dialysis

-- IV Therapy

-- Drug or Alcohol Treatment

-- Allergy Shot

-- Psychotherapy/Counseling

-- Shots, Other than Allergy

CARD MV-4

-- Laboratory Tests

-- Throat Swab

-- Sonogram or Ultrasound

-- X-Rays

-- Mammogram

MV-4

-- MRI or CAT Scan

-- EKG or ECG

-- EEG

-- Vaccination

-- Anesthesia

CARD DN-1

DN-1

-- General Dentist

-- Hygienist (Dental)

-- Technician (Dental)

-- Dental Surgeon

-- Orthodontist

-- Endodontist

-- Periodontist

-- Other

CARD DN-2

DN-2

* DIAGNOSTIC OR PREVENTATIVE

-- General Exam, Checkup or Consultation

-- Cleaning, Prophylaxis, or Polishing

-- X-Rays, Radiographs, or Bitewings

-- Fluoride Treatment

-- Sealant (Plastic Coatings on Back Teeth)

* RESTORATIVE OR ENDODONTIC

-- Fillings

-- Inlays

-- Crowns or Caps

-- Root Canal

* PERIODONTIC (GUM TREATMENT)

-- Periodontal Scaling, Root Planing, or Gum Surgery

-- Periodontal Recall Visit (Periodic or Regular)

* ORAL SURGERY

-- Extraction, Tooth Pulled

-- Implants

-- Abscess or Infection Treatment

-- Other Oral Surgery

* PROSTHETICS

-- Fixed Bridges

-- Dentures or Removable Partial Dentures

-- Relining or Repair of Bridges or Dentures

* ORTHODONTICS

-- Orthodontia, Braces, or Retainers

* ADDITIONAL PROCEDURES

-- Bonding, Whitening, or Bleaching

-- Treatment for TMD or TMJ

CARD HH-1

-- Certified Nursing Assistant (CNA)

-- Companion

-- Dietitian/Nutritionist

-- Home Health/Home Care Aide

-- Hospice Worker

-- Homemaker

-- I.V. or Infusion Therapist

-- Medical Doctor

-- Nurse/Nurse Practitioner

-- Nurse’s Aide

HH-1

-- Occupational Therapist

-- Personal Care Attendant

-- Physical Therapist

-- Respiratory Therapist

-- Social Worker

-- Speech Therapist

CARD HH-2

HH-2

Medical Treatments

Changing bandages, wound care, giving medication, taking blood pressure, giving shots or injections, any type of therapy, other medical treatments

Help Using Medical Equipment or Assistive Device (Examples)

Oxygen tank, wheelchair, walker, hospital bed, tub seat, special railing, special commode, other medical equipment or assistive device

Help With Daily Activities or Personal Care

(Examples)

Using the telephone, paying bills, shopping, driving, housework, preparing meals, bathing, dressing, using the toilet, getting in or out of a bed or chair, walking, eating, other daily activities or personal care

CARD HH-3

HH-3

Help With Daily

Activities or Personal Care

(Examples)

Using the telephone, paying bills, shopping, driving, housework, preparing meals, bathing, dressing, using the toilet, getting in or out of a bed or chair, walking, eating, other daily activities or personal care

CARD CP-1

CP-1

-- Paid at Time of Visit

-- Made a Co-payment

-- Bill Sent Directly to Other Source

-- Bill Has Not Arrived

-- No Bill Sent:

-- HMO Plan

-- VA (Veterans Administration)/CHAMPVA

-- Military Facility

-- Public Assistance/Medicaid/SCHIP

-- Indian Health Service (IHS)

-- Worker’s Compensation

-- School, Employer, or Other Private Health

Center/Clinic

-- Public Clinic/Health Center or Private

Charity (Include Community and Migrant

Health Center, Federally Qualified

Health Center)

-- No Charge: Telephone Call

-- Free From Provider

(Professional Courtesy/Free Sample)

-- Government-Financed Research And

Clinical Trials

CARD PC-1

PC-1

-- Within the last 7 days

-- More than 7 days ago, but within last 30 days

-- More than 30 days ago

CARD AP-1

AP-1

-- 99 pounds or less

-- 100 to 149 pounds

-- 150 to 199 pounds

-- 200 to 249 pounds

-- 250 to 299 pounds

-- 300 pounds or more

CARD AC-1

AC-1

-- Very Difficult

-- Somewhat Difficult

-- Not Too Difficult

-- Not At All Difficult

CARD AC-2

AC-2

-- White

-- Black/African American

-- Asian

-- Indian/Native American Alaska Native

-- Other Pacific Islander

-- Some Other Race

CARD AC-3

-- Never

-- Sometimes

-- Usually

-- Always

AC-3

CARD AC-4

AC-4

-- Couldn’t Afford Care

-- Insurance Company Wouldn’t Approve, Cover Or Pay For Care

-- Doctor Refused To Accept Family’s Insurance Plan

-- Problems Getting to Doctor’s Office

-- Different Language

-- Couldn’t Get Time Off Work

-- Didn’t Know Where To Go To Get Care

-- Was Refused Services

-- Couldn’t Get Child Care

-- Didn’t Have Time Or Took Too Long

CARD AC-5

AC-5

-- A Big Problem

-- A Small Problem

-- Not A Problem

CARD HX-1

HX-1

-- From a Professional Association

-- From a Small Business Group

-- From a Union

-- Directly From an Insurance Agent

-- Directly From Insurance Company

-- Directly From an HMO

-- Directly From a High Risk Pool

-- From a Previous Employer

-- From a Previous Employer (COBRA)

CARD HX-2

HX-2

Sample Medicare Card

CARD HX-3

HX-3

Sample Medicaid Card

[State Name Here]

(One for Each State)

CARD HX-4

HX-4

-- From a Group or Association

-- Directly Through a School

-- Directly From an Insurance Agent

-- Directly From Insurance Company

-- Directly From an HMO

-- Directly From an High Risk Pool

-- From a Union

-- From Anyone’s Previous Employer (COBRA)

-- From Anyone’s Previous Employer

(Not COBRA)

-- From Spouse’s/Deceased Spouse’s Previous

Employer

-- From Some Other Employer

-- Under Plan of Someone Not Living Here

CARD HX-5

HX-5

Medicare Managed Care Plans

[State Name Here]

(One for Each State)

CARD HX-6

HX-6

-- 1 - 50

-- 51 - 100

-- 101 - 200

-- 201 - 300

-- 301 or more

CARD HX-7

HX-7

-- 1 - 30

-- 31 - 60

-- 61 - 90

-- 91 - 120

-- 121 or more

CARD HX-8

HX-8

State-Specific Plan Names

[State Name Here]

(One for Each State)

CARD HX-9

HX-9

-- Hospital and Physician Benefits, Including

Coverage Through an HMO

-- Dental

-- Prescription Drugs

-- Vision

-- Medicare Supplement or Medigap

-- Long-Term Care in a Nursing Home

-- Extra Cash for Hospital Stays

-- Serious Disease or Dread Disease

CARD HX-10

HX-10

Plan Name (for Federal Civilian Employees)

[State Name Here]

(One for Each State)

CARD HX-11

HX-11

-- TANF (Temporary Aid for Needy Families)

-- SSI (Supplemental Security Income)

-- WIC (Women, Infants and Children)

-- IHS (Indian Health Service)

-- Public Health Clinic

-- VA (Veterans Administration)/CHAMPVA

CARD SP-1

SP-1

-- A Big Problem

-- A Small Problem

-- Not a Problem

CARD SP-2

0. Worst Health Plan Possible

1

2

3

4

5

6

SP-2

7

8

9

10 Best Health Plan Possible

CARD IN-1

IN-1

-- 1 - 5,000

-- 5,001 - 10,000

-- 10,001 - 15,000

-- 15,001 - 25,000

-- 25,001 - 50,000

-- 50,001 - 100,000

-- 100,001 or more

CARD IN-2

-- 1 - 100

-- 101 - 500

-- 501 - 1,000

-- 1,001 - 5,000

-- 5,001 - 15,000

-- 15,001 or more

IN-2

CARD IN-3

IN-3

-- 1 - 250

-- 251 - 500

-- 501 - 750

-- 751 - 1,000

-- 1,001 or more

CARD IN-4

-- Wages and salary

-- Farm income (or loss)

-- Business income (or loss)

-- Social Security/Railroad Retirement

IN-4

-- Private, military, or government pensions

-- Interest

-- Dividends

-- Rental income (or loss)

-- Other source

CARD AS-1

-- 0 - 10,000

-- 10,001 - 25,000

-- 25,001 - 50,000

-- 50,001 - 100,000

-- 100,001 - 250,000

AS-1

-- 250,001 - 500,000

-- 500,001 - 1,000,000

-- 1,000,001 or more

CARD AS-2

-- 0 - 100

-- 101 - 500

-- 501 - 1,000

-- 1,001 - 5,000

-- 5,001 - 10,000

-- 10,001 - 25,000

-- 25,001 - 50,000

-- 50,001 - 100,000

-- 100,001 or more

AS-2

CARD AS-3

AS-3

-- 0 - 1,000

-- 1,001 - 5,000

-- 5,001 - 10,000

-- 10,001 - 25,000

-- 25,001 - 50,000

-- 50,001 - 100,000

-- 100,001 - 250,000

-- 250,001 - 500,000

-- 500,001 or more

CARD AS-4

AS-4

-- Certificates of Deposit (CDs)

-- Government savings bonds

-- Individual development accounts

-- Treasury bills

-- Bonds

-- Bond mutual funds

-- Shares of stock

-- Stock mutual funds

-- Education savings accounts

-- Annuities

-- Trusts

-- Other financial assets

CARD AS-5

-- Second homes

-- Rental real estate

-- Business or Farm

-- Money owed to you by persons
outside of the family

-- Boats or other recreational vehicles

-- Other significant assets such as jewelry, art work or antiques

AS-5

Blaise/WVS Version, Spring 2007