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pdfHISINTRO
HISINTRO
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
HISINT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
20
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Now I'd like to review with you the information that we have about
health insurance plans that [you/(SP)] had at the time of the last
interview.
Int. Instr II:
INPUT FIELDS / ROUTING
4:39:35 PM Tuesday, March 26, 2013
Page 1 of 199
HISINTRO
Field1:
HISINT
( HIS1020 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS1 - HISCORRB ( HIS1030 )
English text: CONTINUE
Attribute
Route
Empty
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:39:36 PM Tuesday, March 26, 2013
Page 2 of 199
HIS1
HIS1
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
HISCORRB
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
30
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If SP was covered by any other health insurance plan that was
"current" at the time of the previous round interview in addition to
Medicare, display "[You/(SP)] had Medicare coverage and (you
were/he was/she was) also covered by [READ PLAN NAMES
BELOW]."
Else display statement "The only health insurance coverage
[you/(SP)] had was Medicare."
If SP was covered by a Medicare Managed Care Plan that was
"current" at the time of the previous round interview, display,
"through a managed care plan."
Else do not display.
If HIS1 is displayed more than once, display "Let's see if there are
any other changes we need to make to the health insurance
coverage [you/(SP)] had as of (REFERENCE DATE)."
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report below question text.
Display all health insurance plans that were "current" at the time of
4:39:37 PM Tuesday, March 26, 2013
Page 3 of 199
HIS1
the previous round interview. Display these plans in the following
order:
First line:
If SP was covered by a Medicare Managed care plan, display name
of this Medicare Managed care plan.
Else display "MEDICARE" for the Medicare plan.
Next list Medicaid, Tricare, all Public Plans, all Private Plans and all
Medicare Prescription Drug Plans. If there is more than one plan of
any type, display in order of entry.
Report header: PLANS AS OF (REFERENCE DATE)
Report layout:
Column 1, header="Plan Name", display PLAN.PLNAME.
Column 2, header="Plan Type", display PLAN.PLANTYPE.
If PLANTYPE=1/Medicare, display "MCAR".
If PLANTYPE=2/Medicaid, display "MCAD".
If PLANTYPE=3/PublicPlan, display "PUBL".
If PLANTYPE=4/PrivatePlan, display "PRIV".
If PLANTYPE=5/MHMO, display "MHMO".
If PLANTYPE=6/Tricare, display "TRIC".
If PLANTYPE=7/MPDP, display "MPDP".
TEXT:
Context Header:
Int. Instr I:
Question Text:
[Let’s see if there are any other changes we need to make to the
health insurance coverage [you/(SP)] had as of (REFERENCE
DATE).] [(You/(SP)] had Medicare coverage (through a managed
care plan) and (you were/he was/she was) also covered by [READ
PLAN NAMES BELOW]./The only health insurance coverage
[you/(SP)] had was Medicare (through a managed care plan)] on
(REFERENCE DATE). Is that correct?
Int. Instr II:
INPUT FIELDS / ROUTING
4:39:38 PM Tuesday, March 26, 2013
Page 4 of 199
HIS1
Field1:
HISCORRB
( HIS1030 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THISCorrectB
1
No
No
Number Label
1 Yes
FieldSize:
Min Value:
Max Value:
Mask:
Route
HISCLOSE - ENDHIS ( HIS3340 )
2
English text: YES, ALL CORRECT AS SHOWN
NoPlanMissing
HIS3 - ADDHITYPE ( HIS1110 )
3
English text: NO, PLAN MISSING
NoNameIncorrect
HIS2B - PLAN_CORRECT ( HIS1065 )
4
English text: NO, PLAN NAME INCORRECT
NoPlanDelete
HIS2 - PLAN_DELETION ( HIS1040 )
5
English text: NO, PLAN NEEDS DELETION
NoPlanStopped
HIS2C - PLAN_STOPPED ( HIS1075 )
English text: NO, PLAN STOPPED PRIOR TO (REFERENCE DATE)
Attribute
Route
Don't know
HISCLOSE - ENDHIS ( HIS3340 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
Edit #1:
Note: This soft edit message should be displayed if
HISCORR=2/NoPlanMissing.
HISCORR = 1/Yes, 3/NoNameIncorrect, 4/NoPlanDelete, or DK.
If not true, display message "VERIFY THAT THE SP WAS
COVERED BY PLAN ON (REFERENCE DATE)."
Edit #2:
Note: This soft edit should be displayed if
HISCORR=4/NoPlanDelete.
4:39:40 PM Tuesday, March 26, 2013
Page 5 of 199
HIS1
HISCORR = 1/Yes, 2/NoPlanMissing, 3/NoNameIncorrect, or DK.
If not true, display message "VERIFY THAT THE SP WAS NOT
COVERED BY PLAN ON (REFERENCE DATE)."
HARD EDIT CHECKS
Edit #1:
Note: The following edit disallows Medicare from being deleted.
If the SP was not covered by any other plans that were "current" at
the time of the previous round interview, besides Medicare,
HISCORR should ^= 4/NoPlanDelete.
If not true, display message "YOU CANNOT DELETE MEDICARE.
PLEASE SELECT ANOTHER RESPONSE."
Edit #2:
Note: The following edits disallows a Medicare Managed Care plan
that was loaded by CMS to be edited or deleted.
If the SP was covered by a Medicare Managed Care plan that was
loaded from CMS, and was not covered by any other plans at the
time of the previous round interview, besides Medicare and this
Medicare Managed Care plan that was loaded from CMS, HISCORR
should ^= 3/NoNameIncorrect and should ^= 4/NoPlanDelete.
If not true, display message "YOU CANNOT EDIT OR DELETE
(MEDICARE MANAGED CARE PLAN NAME). PLEASE SELECT
ANOTHER RESPONSE."
Edit #3:
Note: The following edit disallows Medicare, Medicaid or Tricare from
being edited.
If the SP was not covered by any other plans that were "current" at
the time of the previous round interview, besides Medicare, Medicaid
and/or Tricare, HISCORR should ^= 3/NoNameIncorrect.
If not true, display message "YOU CANNOT EDIT MEDICARE,
MEDICAID, OR TRICARE. PLEASE SELECT ANOTHER
RESPONSE."
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
51
MHMOCurrPrevRnd
Medicare Managed Care plan (Medicare Advantage plan)
"current" at time of previous round interview =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=previous
round & COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
4:39:40 PM Tuesday, March 26, 2013
Page 6 of 199
HIS1
67
MedicaidCurrentPrevRn Medicaid "current" at the time of the previous round
interview =
d
There is a PLAN where PLAN.PLANTYPE=2/Medicaid
and PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
72
TricareCurrentPrevRnd
Tricare "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round and
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
80
PublicCurrentPrevRnd
Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
81
PrivateCurrentPrevRnd
Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
343
MPDPCurrPrevRnd
Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes). Exclude Deleted Plans. See
T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
4:39:40 PM Tuesday, March 26, 2013
Page 7 of 199
HIS2
HIS2
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PLAN_DELETION
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Plan Roster
Roster Type:
Single Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
40
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all health insurance plans that were "current" at the time of
the previous round interview.
Display plans in the order of entry.
Display the following "current" plans as protected rows:
Medicare
Medicare Managed Care plan, if loaded by CMS.
Roster/Grid display:
4:39:40 PM Tuesday, March 26, 2013
COL #
HEADER
INSTRUCTIONS
1
Plan Name
Display PLAN.PLNAME.
2
Plan Type
Display PLAN.PLANTYPE:
1/Medicare, display "MCAR"
2/Medicaid, display "MCAD"
3/PublicPlan, display "PUBL"
4/PrivatePlan, display "PRIV"
5/MHMO, display "MHMO"
6/Tricare, display "TRIC"
7/MPDP, display "MPDP".
3
Plan Status
Display PREVIOUS ROUND PLAN
STATUS.
Page 8 of 199
HIS2
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What is the name of the plan that needs deletion?
Int. Instr II:
SELECT ONLY ONE PLAN FOR DELETION AT THIS ROSTER.
INPUT FIELDS / ROUTING
Field1:
PLAN_DELETION
( HIS1040 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TPlanPick8
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
8
Route
HIS2A - PLANDVB ( HIS1060 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Provider selected at HIS2.
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Provider selected at HIS2.
PLRO.PLRORND = previous round.
Set "PLAN DELETED" flag on PLAN selected at HIS2. See detailed instructions below:
PLANDFLG
Set PLAN.PLANDFLG=1/Yes.
SOFT EDIT CHECKS
HARD EDIT CHECKS
4:39:41 PM Tuesday, March 26, 2013
Page 9 of 199
HIS2
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
51
MHMOCurrPrevRnd
Medicare Managed Care plan (Medicare Advantage plan)
"current" at time of previous round interview =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=previous
round & COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
67
MedicaidCurrentPrevRn
d
Medicaid "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid
and PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
72
TricareCurrentPrevRnd
Tricare "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round and
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
80
PublicCurrentPrevRnd
Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
81
PrivateCurrentPrevRnd
Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
143
MHMOLoadedCMS
Medicare Managed Care plan (Medicare Advantage plan)
loaded by CMS =
There is PLAN where PLAN.PLANTYPE=5/MHMO and
PLAN.MHMOLRND ^= empty.
4:39:41 PM Tuesday, March 26, 2013
Page 10 of 199
HIS2
343
MPDPCurrPrevRnd
Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes). Exclude Deleted Plans. See
T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
HIS2 allows only 1 plan to be selected. It does not use the DELETE
function to delete plan. Instead, we set a "PLAN DELETED" flag on the
plan that has been selected.
4:39:41 PM Tuesday, March 26, 2013
Page 11 of 199
HIS2A
HIS2A
Page Order # :
Design Screen Type:
Verbatim Text
Fields:
Field 1:
PLANDVB
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
60
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
BRIEFLY EXPLAIN WHY THE PLAN NEEDS TO BE DELETED.
Question Text:
Int. Instr II:
IF THE SP WAS EVER COVERED BY THIS INSURANCE PLAN,
PRESS SHIFT/ENTER TO GO BACK ONE SCREEN AND SELECT
A DIFFERENT RESPONSE.
INPUT FIELDS / ROUTING
4:39:41 PM Tuesday, March 26, 2013
Page 12 of 199
HIS2A
Field1:
PLANDVB
( HIS1060 )
NONE
Cheshire Name:
REPLACES VB FIELDS IN CHESHIRE:
PLAN.PLANDVB1
PLAN.PLANDVB2
PLAN.PLANDVB3
PLAN.PLANDVB4
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Open
TOpen180
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
180
Route
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:39:42 PM Tuesday, March 26, 2013
Page 13 of 199
HIS2B
HIS2B
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PLAN_CORRECT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Plan Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
Yes
No
No
Add Line
Delete Line
No
No
Grid Functions:
75
Display as ' Edit a Plan '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all health insurance plans that were "current" at the time of
the previous round interview.
Display plans in the order of entry.
Display the following "current" plans as protected rows:
Medicare
Medicare Managed Care plan, if loaded by CMS
Medicaid
Tricare
SELECTION IS NOT REQUIRED ON THIS ROSTER.
Roster/Grid display:
COL #
1
4:39:42 PM Tuesday, March 26, 2013
HEADER
Plan Name
INSTRUCTIONS
Display PLAN.PLNAME.
Page 14 of 199
HIS2B
2
Plan Type
Display PLAN.PLANTYPE:
1/Medicare, display "MCAR"
2/Medicaid, display "MCAD"
3/PublicPlan, display "PUBL"
4/PrivatePlan, display "PRIV"
5/MHMO, display "MHMO"
6/Tricare, display "TRIC"
7/MPDP, display "MPDP".
3
Plan Status
Display PREVIOUS ROUND PLAN
STATUS.
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What is the name of the plan that is incorrect?
Int. Instr II:
EDIT ALL PLAN NAMES AT THIS ROSTER.
INPUT FIELDS / ROUTING
Field1:
Cheshire Name:
PLAN_CORRECT
( HIS1065 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TPlanPick32
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
32
Route
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Plan selected at HIS2B.
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
4:39:43 PM Tuesday, March 26, 2013
Page 15 of 199
HIS2B
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS2B.
PLRO.PLRORND = previous round.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
51
MHMOCurrPrevRnd
Medicare Managed Care plan (Medicare Advantage plan)
"current" at time of previous round interview =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=previous
round & COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
67
MedicaidCurrentPrevRn
d
Medicaid "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid
and PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
72
TricareCurrentPrevRnd
Tricare "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round and
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
80
PublicCurrentPrevRnd
Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
4:39:43 PM Tuesday, March 26, 2013
Page 16 of 199
HIS2B
81
PrivateCurrentPrevRnd
Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
143
MHMOLoadedCMS
Medicare Managed Care plan (Medicare Advantage plan)
loaded by CMS =
There is PLAN where PLAN.PLANTYPE=5/MHMO and
PLAN.MHMOLRND ^= empty.
343
MPDPCurrPrevRnd
Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes). Exclude Deleted Plans. See
T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
HIS2B should only allowing editing of Plan Names. If a PLAN is selected
when the interviewer exits the roster, do not save.
4:39:43 PM Tuesday, March 26, 2013
Page 17 of 199
HIS2C
HIS2C
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PLAN_STOPPED
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Name:
Plan Roster
Roster Type:
Single Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
76
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all health insurance plans that were "current" at the time of
the previous round interview.
Display plans in the order of entry.
Display the following "current" plans as protected rows:
Medicare
Medicare Managed Care plan, if loaded by CMS.
Roster/Grid display:
4:39:43 PM Tuesday, March 26, 2013
COL #
HEADER
INSTRUCTIONS
1
Plan Name
Display PLAN.PLNAME.
2
Plan Type
Display PLAN.PLANTYPE:
1/Medicare, display "MCAR"
2/Medicaid, display "MCAD"
3/PublicPlan, display "PUBL"
4/PrivatePlan, display "PRIV"
5/MHMO, display "MHMO"
6/Tricare, display "TRIC"
7/MPDP, display "MPDP".
3
Plan Status
Display PREVIOUS ROUND PLAN
STATUS.
Page 18 of 199
HIS2C
Report display:
TEXT:
REFERENCE DATE: (REFERENCE DATE)
Context Header:
Int. Instr I:
Question Text:
What is the name of the plan that (you were/he was/she was) no
longer covered by as of (REFERENCE DATE)?
Int. Instr II:
SELECT ONLY ONE PLAN TO STOP IN THE PREVIOUS ROUND
AT THIS ROSTER.
INPUT FIELDS / ROUTING
Field1:
PLAN_STOPPED
( HIS1075 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TPlanPick8
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
8
Route
HIS2D - HISSTPMM ( HIS1085 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Provider selected at HIS2C.
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Provider selected at HIS2C.
PLRO.PLRORND = previous round.
Set "PLAN STOPPED" flag on PLAN selected at HIS2C. See detailed instructions below:
PLANSFLG
Set PLAN.PLANSFLG = 1/Yes
SOFT EDIT CHECKS
4:39:44 PM Tuesday, March 26, 2013
Page 19 of 199
HIS2C
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
51
MHMOCurrPrevRnd
Medicare Managed Care plan (Medicare Advantage plan)
"current" at time of previous round interview =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=previous
round & COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
67
MedicaidCurrentPrevRn
d
Medicaid "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid
and PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
72
TricareCurrentPrevRnd
Tricare "current" at the time of the previous round
interview =
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round and
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
80
PublicCurrentPrevRnd
Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
81
PrivateCurrentPrevRnd
Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
4:39:44 PM Tuesday, March 26, 2013
Page 20 of 199
HIS2C
143
MHMOLoadedCMS
Medicare Managed Care plan (Medicare Advantage plan)
loaded by CMS =
There is PLAN where PLAN.PLANTYPE=5/MHMO and
PLAN.MHMOLRND ^= empty.
343
MPDPCurrPrevRnd
Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes). Exclude Deleted Plans. See
T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
HIS2 allows only 1 plan to be selected. It does not use the DELETE
function to stop a plan. Instead, we set a "PLAN STOPPED" flag on the
plan that has been selected.
4:39:44 PM Tuesday, March 26, 2013
Page 21 of 199
HIS2D
HIS2D
Page Order # :
Design Screen Type:
Date
Fields:
Field 1:
HISSTPMM
Field 2:
HISSTPDD
Field 3:
HISSTPYY
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
77
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] coverage stop?
Int. Instr II:
INPUT FIELDS / ROUTING
4:39:45 PM Tuesday, March 26, 2013
Page 22 of 199
HIS2D
Field1:
HISSTPMM
( HIS1085 )
PLAN.HISSTPMM
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS2D - HISSTPDD ( HIS1087 )
Refusal
HIS2D - HISSTPDD ( HIS1087 )
4:39:47 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
01
12
Route
HIS2D - HISSTPDD ( HIS1087 )
Page 23 of 199
HIS2D
Field2:
HISSTPDD
( HIS1087 )
PLAN.HISSTPDD
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayIntDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS2D - HISSTPYY ( HIS1089 )
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
HIS2D - HISSTPYY ( HIS1089 )
Refusal
4:39:50 PM Tuesday, March 26, 2013
Page 24 of 199
HIS2D
Field3:
HISSTPYY
( HIS1089 )
PLAN.HISSTPYY
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMcyear
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS2E - PLANSVB ( HIS1095 )
Refusal
HIS2E - PLANSVB ( HIS1095 )
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
HIS2E - PLANSVB ( HIS1095 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1:
PLAN STOP DATE, HISSTPMM/HISSTPDD/HISSTPYY, should
be on or between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE).
If not true, display message: "DATE MUST BE ON OR BETWEEN
(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).
PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
4:39:51 PM Tuesday, March 26, 2013
Page 25 of 199
HIS2E
HIS2E
Page Order # :
Design Screen Type:
Verbatim Text
Fields:
Field 1:
PLANSVB
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
78
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
BRIEFLY EXPLAIN WHY THE PLAN SHOULD BE STOPPED.
Question Text:
Int. Instr II:
IF DATE WHEN PLAN STOPPED IS NOT KNOWN, PROVIDE ANY
ADDITIONAL INFORMATION ABOUT WHEN THE PLAN STOPPED.
INPUT FIELDS / ROUTING
4:39:51 PM Tuesday, March 26, 2013
Page 26 of 199
HIS2E
Field1:
PLANSVB
( HIS1095 )
NONE
Cheshire Name:
REPLACES VB FIELDS IN CHESHIRE:
PLAN.PLANSVB1
PLAN.PLANSVB2
PLAN.PLANSVB3
PLAN.PLANSVB4
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Open
TOpen180
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
180
Route
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:39:51 PM Tuesday, March 26, 2013
Page 27 of 199
HIS3
HIS3
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
ADDHITYPE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
80
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What type of insurance plan needs to be added?
Int. Instr II:
INPUT FIELDS / ROUTING
4:39:52 PM Tuesday, March 26, 2013
Page 28 of 199
HIS3
Field1:
ADDHITYPE
( HIS1110 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TADDHIType
1
No
No
Number Label
1 Medicaid
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS2AA - (HIS1575 )
2
English text: MEDICAID/MEDICAID MANAGED CARE PLAN
PublicPlan
HIS12 - PLAN_HISPUBLIC ( HIS2280 )
3
English text: PUBLIC PLAN OTHER THAN MEDICAID
PrivatePlan
HIS20 - PLAN_HISPRIVATE ( HIS2630 )
4
English text: PRIVATE HEALTH INSURANCE PLAN
MHMO
HISMC1 - PLAN_HISMHMO ( HIS1130 )
5
English text: MEDICARE ADVANTAGE PLAN
Tricare
BOX HIST1A - (HIS1935 )
6
English text: TRICARE
MPDP
HIS34 - PLAN_HISMPDP ( HIS3331 )
English text: MEDICARE PRESCRIPTION DRUG PLAN
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1:
Note: SP can only have one Medicaid plan during a round:
If SP had Medicaid anytime during the previous round, ADDHITYPE
should = 2/PublicPlan, 3/PrivatePlan, 4/MHMO, 5/Tricare, or
6/MPDP.
If not true, display message: "MEDICAID ALREADY ON PLAN
ROSTER FOR PREVIOUS ROUND. SELECT ANOTHER PLAN
TYPE."
4:39:53 PM Tuesday, March 26, 2013
Page 29 of 199
HIS3
Edit #2:
Note: SP can only have one Tricare plan during a round:
If SP had Tricare anytime during the previous round, ADDHITYPE
should = 1/Medicaid, 2/PublicPlan, 3/PrivatePlan, 4/MHMO, or
6/MPDP.
If not true, display message: "TRICARE ALREADY ON PLAN
ROSTER FOR PREVIOUS ROUND. SELECT ANOTHER PLAN
TYPE."
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
150
MCaidAnyTimePrevRnd
SP covered by Medicaid anytime during previous round =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.
151
TricarAnyTimePrevRnd
SP covered by Tricare anytime during the previous round
=
There is a PLAN where PLAN.PLANTYPE=6/Tricare &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
4:39:53 PM Tuesday, March 26, 2013
Page 30 of 199
HISMC1
HISMC1
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PLAN_HISMHMO
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Plan Roster
Roster Type:
Single Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
100
Display as ' Add a Plan '
Display as ' Edit a Plan '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all health insurance plans from the Plan Roster.
Display plans in order of entry.
Display the following plans as protected rows:
Medicare plan
Medicare Managed Care plan if "current" at the time of the previous
round interview
Medicaid
Tricare
Public Plans
Private Plans
Medicare Prescription Drug Plans
Roster/Grid display:
COL #
1
4:39:54 PM Tuesday, March 26, 2013
HEADER
Plan Name
INSTRUCTIONS
Display PLAN.PLNAME.
Page 31 of 199
HISMC1
2
Plan Type
Display PLAN.PLANTYPE:
1/Medicare, display "MCAR"
2/Medicaid, display "MCAD"
3/PublicPlan, display "PUBL"
4/PrivatePlan, display "PRIV"
5/MHMO, display "MHMO"
6/Tricare, display "TRIC"
7/MPDP, display "MPDP".
3
Plan Status
Display PREVIOUS ROUND PLAN
STATUS.
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What is the name of the Medicare Advantage Plan that covered
[you/(SP)]?
Int. Instr II:
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT
THIS ROSTER.
INPUT FIELDS / ROUTING
Field1:
PLAN_HISMHMO
( HIS1130 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TPlanPick32
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
32
Route
HISMC2 - HISMHMOCURR ( HIS1140 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Plan selected at HIS2.
4:39:54 PM Tuesday, March 26, 2013
Page 32 of 199
HISMC1
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS2.
PLRO.PLRORND = previous round.
If Plan added, see PLAN ROSTER POP-UP specifications for pop-up window programming
instructions:
Variables populated in Plan Roster Pop-Up Window:
PLAN.PLANNUM
PLAN.PLANRNDC
PLAN.PLANTYPE
PLAN.PLNAME
For Plan selected, create previous round PLRO where PLRO.PLROPLAN =
PLAN.PLANNUM of plan selected at HISMC1 and PLRO.PLRORND = previous round.
HISMC2 and remaining PLAN details will be stored on this previous round PLRO.
Previous round PLRO may already exist.
See additional instructions below:
PLANTYPE
If Plan is added at HISMC1, set
PLAN.PLANTYPE=5/MHMO.
PLANRNDC
If Plan is added at HISMC1, set PLAN.PLANRNDC =
current round.
PLANSUMM
If Plan is added at HISMC1, set
PLAN.PLANSUMM=1/Yes.
COVANYTM
PLRO.COVANYTM=1/Yes for plan selected at
HISMC1.
PLROPLAN
PLRO.PLROPLAN = PLAN.PLANNUM of plan
selected at HISMC1.
PLRORND
PLRO.PLRORND = previous round.
PLSUMFLG
Set PLRO.PLSUMFLG = 1.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
4:39:54 PM Tuesday, March 26, 2013
Page 33 of 199
HISMC1
51
MHMOCurrPrevRnd
Medicare Managed Care plan (Medicare Advantage plan)
"current" at time of previous round interview =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=previous
round & COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
4:39:54 PM Tuesday, March 26, 2013
Page 34 of 199
HISMC2
HISMC2
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
HISMHMOCURR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
110
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MA PLAN: (MEDICARE MANAGED CARE PLAN NAME)
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by or enrolled in (MEDICARE
MANAGED CARE PLAN NAME) on (REFERENCE DATE)?
Int. Instr II:
INPUT FIELDS / ROUTING
4:39:55 PM Tuesday, March 26, 2013
Page 35 of 199
HISMC2
Field1:
HISMHMOCURR
( HIS1140 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HISMC1 - (HIS1150 )
English text: YES
No
BOX HISMC2 - (HIS1175 )
English text: NO
Attribute
Route
Don't know
BOX HISMC2 - (HIS1175 )
Refusal
BOX HISMC2 - (HIS1175 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:39:56 PM Tuesday, March 26, 2013
Page 36 of 199
BOX HISMC1
BOX HISMC1
Page Order # :
120
BOX INSTRUCTIONS
( HIS1150 )
OTHER THAN THE PLAN SELECTED AT HISMC1, IF ANOTHER MEDICARE
MANAGED CARE PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HISMC3 - HISMHMOCHNG (
HIS1160 ).
ELSE GO TO BOX HISMC2 - (HIS1175 ).
ASSIGNMENTS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
51
MHMOCurrPrevRnd
Medicare Managed Care plan (Medicare Advantage plan)
"current" at time of previous round interview =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=previous
round & COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
There is a rule that the SP can only have one "current" Medicare
Managed Care plan at the time of the interview.
BOX HISMC1 is called if the MHMO selected at HISMC2 is reported as
"current" at the time of the previous round interview at HISMC2
HISMHMOCURR.
The purpose of BOX HISMC1 is determine if there is another MHMO
flagged as "current" at the time of the previous round interview. Should
only expect to find one "other" MHMO, if it exists.
If another MHMO is flagged as "current" at the time of the previous round
interview, BOX HISMC1 is routed to HISMC3 - HISMHMOCHNG to
determine if the "other" MHMO's status has changed.
4:39:56 PM Tuesday, March 26, 2013
Page 37 of 199
HISMC3
HISMC3
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
HISMHMOCHNG
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
130
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of the "other" Medicare Managed Care Plan that
was "current" at the time of the previous round interview,
PLAN.PLNAME.
Question display:
HISMC3 is asking about the "other" MHMO that was current at the
time of the previous round interview, not the MHMO selected at
HISMC2.
Display the name of the "other" Medicare Managed Care Plan that
was "current" at the time of the previous round interview,
PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PREVIOUS ROUND MA PLAN: (PREVIOUS ROUND CURRENT
MEDICARE MANAGED CARE PLAN NAME)
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
4:39:57 PM Tuesday, March 26, 2013
I recorded previously that (PREVIOUS ROUND CURRENT
Page 38 of 199
HISMC3
MEDICARE MANAGED CARE PLAN NAME) was [your/(SP’s)]
current Medicare Advantage Plan on (REFERENCE DATE). Has
this information changed?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
HISMHMOCHNG
Cheshire Name:
( HIS1160 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HISMC2 - (HIS1175 )
English text: YES
No
BOX HISMC2 - (HIS1175 )
English text: NO
Attribute
Route
Don't know
BOX HISMC2 - (HIS1175 )
Refusal
BOX HISMC2 - (HIS1175 )
BACKGROUND VARIABLE ASSIGNMENTS
If HISMC3 - HISMHMOCHNG = 1/Yes, we need to correct the status of the (other)
Medicare Managed Care plan that was current at the time of the previous round to "NOT
CURRENT". Set on PLRO where PLRO.PLRORND=previous round and
PLRO.PLROPLAN = this PLAN.PLANNUM.
Set variables as instructed below.
FUTURE SPEC: Log change to previous round plan on TRNS.
COVCURNT
If MHISMHMOCHNG = 1/Yes, set
PLRO.COVCURNT=2/No on previous round PLRO
for Medicare Managed Care plan that was current at
the time of the previous round interview.
4:39:58 PM Tuesday, March 26, 2013
Page 39 of 199
HISMC3
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
51
MHMOCurrPrevRnd
Medicare Managed Care plan (Medicare Advantage plan)
"current" at time of previous round interview =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=previous
round & COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
4:39:58 PM Tuesday, March 26, 2013
Page 40 of 199
BOX HISMC2
BOX HISMC2
Page Order # :
140
BOX INSTRUCTIONS
( HIS1175 )
IF THE PLAN SELECTED AT HIMC1 HAS BEEN IDENTIFIED AS THE SP'S
CURRENT MEDICARE MANAGED CARE PLAN AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, SET THE PREVIOUS ROUND STATUS OF
THIS PLAN TO "CURRENT". OTHERWISE, SET THE PREVIOUS ROUND
STATUS OF THIS PLAN TO "NOT CURRENT" .
GO TO BOX HISMC2A - (HIS1177 ).
ASSIGNMENTS
Set status of Medicare Managed Care plan selected at HISMC1.
Set status variable, PLRO.COVCURNT, on PLRO where PLRO.PLRORND=previous
round and PLRO.PLROPLAN = PLAN.PLANNUM selected at HISMC1. Set as instructed
below.
COVCURNT
If (HISMHMOCURR=1/Yes and
HISMHMOCHNG=2/No,DK,RF) or
(HISMHMOCURR=2/No, DK or RF>), set
PLRO.COVCURNT=2/No.
Else if HISMHMOCURR=1/Yes and
(HISMHMOCHNG=1/Yes or EMPTY), set
PLRO.COVCURNT=1/Yes.
TECHNICAL NOTES
DESIGN NOTES
The purpose of BOX HISMC2 is to set the status of the MHMO selected at
HISMC1. Once status is set, all routes go to BOX HISMC2A.
4:39:58 PM Tuesday, March 26, 2013
Page 41 of 199
BOX HISMC2A
BOX HISMC2A
Page Order # :
145
BOX INSTRUCTIONS
( HIS1177 )
IF THIS MEDICARE MANAGED CARE PLAN WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HISMC4
MHMORX ( HIS1180 ).
ELSE GO TO HIS1 - HISCORRB ( HIS1030 ).
ASSIGNMENTS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
75
ThisMHMOCurrentPrev
Rnd
This Medicare Managed Care plan (Medicare Advantage
plan) was "current" at time of the previous round
interview =
There is a PLRO where (PLROPLAN= this PLANNUM &
PLRORND=previous round & COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
When a plan is added in HIS, it is added to the previous round data.
When asking if Plan was "current" at the time of the previous round
interview, we are asking whether or not the Plan just added in HIS was
reported as "current" on the reference date in the current round HIS
section.
4:39:58 PM Tuesday, March 26, 2013
Page 42 of 199
HISMC4
HISMC4
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MHMORX
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
150
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Display "[you/(SP)]" in BOLD in last sentence.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PREVIOUS ROUND MA PLAN: (PREVIOUS ROUND CURRENT
MEDICARE MANAGED CARE PLAN NAME)
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [you/(SP)] have prescribed medicine coverage through
(MEDICARE MANAGED CARE PLAN NAME)?
[PROBE: I am asking about the type of insurance coverage that
4:39:59 PM Tuesday, March 26, 2013
Page 43 of 199
HISMC4
[you/(SP)] personally had, not what the plan offers everyone.]
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
MHMORX
( HIS1180 )
PLRO.MHMORX
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HISMC5 - MHMODENT ( HIS1420 )
English text: YES
No
HISMC5 - MHMODENT ( HIS1420 )
English text: NO
Attribute
Route
Don't know
HISMC5 - MHMODENT ( HIS1420 )
Refusal
HISMC5 - MHMODENT ( HIS1420 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:00 PM Tuesday, March 26, 2013
Page 44 of 199
HISMC5
HISMC5
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MHMODENT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
290
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
MA PLAN: (MEDICARE MANAGED CARE PLAN NAME)
Int. Instr I:
Question Text:
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [you/(SP)] have dental coverage through (MEDICARE
MANAGED CARE PLAN NAME)?
Int. Instr II:
4:40:01 PM Tuesday, March 26, 2013
Page 45 of 199
HISMC5
INPUT FIELDS / ROUTING
MHMODENT
Field1:
( HIS1420 )
PLRO.MHMODENT
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HISMC6 - MHMOEYE ( HIS1430 )
English text: YES
No
HISMC6 - MHMOEYE ( HIS1430 )
English text: NO
Attribute
Don't know
Route
HISMC6 - MHMOEYE ( HIS1430 )
Refusal
HISMC6 - MHMOEYE ( HIS1430 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:02 PM Tuesday, March 26, 2013
Page 46 of 199
HISMC6
HISMC6
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MHMOEYE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
300
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MA PLAN: (MEDICARE MANAGED CARE PLAN NAME)
Int. Instr I:
Question Text:
Did [you/(SP)] have optical coverage through (MEDICARE
MANAGED CARE PLAN NAME), that is, for eyeglasses or contact
lenses?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:03 PM Tuesday, March 26, 2013
Page 47 of 199
HISMC6
Field1:
MHMOEYE
( HIS1430 )
PLRO.MHMOEYE
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HISMC8 - MHMONH ( HIS1450 )
English text: YES
No
HISMC8 - MHMONH ( HIS1450 )
English text: NO
Attribute
Route
Don't know
HISMC8 - MHMONH ( HIS1450 )
Refusal
HISMC8 - MHMONH ( HIS1450 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:04 PM Tuesday, March 26, 2013
Page 48 of 199
HISMC8
HISMC8
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MHMONH
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
320
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MA PLAN: (MEDICARE MANAGED CARE PLAN NAME)
Int. Instr I:
Question Text:
Did [your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage include nursing home care over and beyond what
Medicare normally covers?
[EXPLAIN IF NECESSARY: Under regular fee-for-service, Medicare
pays for limited skilled nursing facility (SNF) care during a benefit
period. In 2013, the first 20 days are paid in full and the next 80
days require a copayment of up to $148.00 per day.]
4:40:05 PM Tuesday, March 26, 2013
Page 49 of 199
HISMC8
Int. Instr II:
INPUT FIELDS / ROUTING
MHMONH
Field1:
( HIS1450 )
PLRO.MHMONH
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HISMC9 - MHMOPAY ( HIS1460 )
English text: YES
No
HISMC9 - MHMOPAY ( HIS1460 )
English text: NO
Attribute
Route
Don't know
HISMC9 - MHMOPAY ( HIS1460 )
Refusal
HISMC9 - MHMOPAY ( HIS1460 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:06 PM Tuesday, March 26, 2013
Page 50 of 199
HISMC9
HISMC9
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MHMOPAY
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
330
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MA PLAN: (MEDICARE MANAGED CARE PLAN NAME)
Int. Instr I:
Question Text:
Besides the cost of [your/(SP’s)] Medicare Part B premium, was
there an additional cost for [your/(SP’s)] (MEDICARE MANAGED
CARE PLAN NAME) coverage? Please do not include any amount
that [you/(SP)] may have paid as a co-payment for an office visit or a
prescribed medicine.
[EXPLAIN IF NECESSARY: Some managed care plans may charge
a monthly premium to cover the cost of the deductibles and
coinsurance for Medicare-covered services or because they provide
4:40:06 PM Tuesday, March 26, 2013
Page 51 of 199
HISMC9
services that are not covered by Medicare such as prescribed
medicines, routine exams, and dental, eye, or hearing. Plans that
have premiums typically charge from $50 to $75 per month.]
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
MHMOPAY
( HIS1460 )
PLRO.MHMOPAY
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HISMC10 - MHMOAMT ( HIS1470 )
English text: YES
No
HIS1 - HISCORRB ( HIS1030 )
English text: NO
Attribute
Route
Don't know
HIS1 - HISCORRB ( HIS1030 )
Refusal
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
4:40:08 PM Tuesday, March 26, 2013
Page 52 of 199
HISMC9
DESIGN NOTES
4:40:08 PM Tuesday, March 26, 2013
Page 53 of 199
HISMC10
HISMC10
Page Order # :
Design Screen Type:
Quantity Unit Hybrid
Fields:
Field 1:
MHMOAMT
Field 2:
MHMOUNIT
Field 3:
MHMOUNOS
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
340
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Always display "[Please do not include any copayments or...]" in
brackets.
Display "additional" in BOLD.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MA PLAN: (MEDICARE MANAGED CARE PLAN NAME)
Int. Instr I:
Question Text:
4:40:09 PM Tuesday, March 26, 2013
Not including the cost of [your/(SP’s)] Medicare Part B premium,
Page 54 of 199
HISMC10
what was the additional amount that [you/(SP)] paid for (your/his/her)
(MEDICARE MANAGED CARE PLAN NAME) coverage? [Please do
not include any copayments or any amount that may be paid for
anyone other than [you/(SP)].]
[PROBE IF NECESSARY: Was that per year, per month, per week,
or what?]
Int. Instr II:
INPUT FIELDS / ROUTING
MHMOAMT
Field1:
( HIS1470 )
PLRO.MHMOAMT
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
AMOUNT:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TMippamt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HISMC11 - MHMOCOST ( HIS1500 )
Refusal
HISMC11 - MHMOCOST ( HIS1500 )
4:40:12 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
0.01
99999.99
Dollars
Route
HISMC10 - MHMOUNIT ( HIS1480 )
Page 55 of 199
HISMC10
Field2:
MHMOUNIT
( HIS1480 )
PLRO.MHMOUNIT
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TMippunit
1
No
No
Number Label
1 PerYear
FieldSize:
Min Value:
Max Value:
Mask:
Route
HISMC11 - MHMOCOST ( HIS1500 )
2
English text: PER YEAR
Quarterly
3
English text: QUARTERLY/EVERY 3 MONTHS
Bimonthly
HISMC11 - MHMOCOST ( HIS1500 )
4
English text: BIMONTHLY/EVERY 2 MONTHS
PerMonth
HISMC11 - MHMOCOST ( HIS1500 )
5
English text: PER MONTH
PerWeek
HISMC11 - MHMOCOST ( HIS1500 )
6
English text: PER WEEK
SemiAnnually
HISMC11 - MHMOCOST ( HIS1500 )
7
English text: SEMI-ANNUALLY/2 TIMES PER YEAR
SemiMonthly
HISMC11 - MHMOCOST ( HIS1500 )
91
English text: SEMI-MONTHLY/2 TIMES PER MONTH
Other
HISMC10 - MHMOUNOS ( HIS1490 )
HISMC11 - MHMOCOST ( HIS1500 )
English text: OTHER
Attribute
Route
Don't know
HISMC11 - MHMOCOST ( HIS1500 )
Refusal
HISMC11 - MHMOCOST ( HIS1500 )
4:40:15 PM Tuesday, March 26, 2013
Page 56 of 199
HISMC10
Field3:
MHMOUNOS
( HIS1490 )
PLRO.MHMOUNOS
Cheshire Name:
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
OTHER (SPECIFY)
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
HISMC11 - MHMOCOST ( HIS1500 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
If MHMOAMT ^= DK and MHMOAMT ^= RF then,
If MHMOUNIT = 1/PerYear, then MHMOAMT = $50.00 - 10,000.00.
Else If MHMOUNIT = 2/Quarterly, then MHMOAMT = $15.00 -
2500.00.
Else If MHMOUNIT = 3/Bimonthly, then MHMOAMT = $10.00 -
1650.00.
Else If MHMOUNIT = 4/PerMonth, then MHMOAMT = $5.00 -
850.00.
Else If MHMOUNIT = 5/PerWeek, then MHMOAMT = $5.00 - 200.00.
Else If MHMOUNIT = 6/Semiannually, then MHMOAMT = $25.00 -
5,000.00.
Else If MHMOUNIT = 7/Semimonthly, then MHMOAMT = $2.00 -
425.00.
Else If MHMOUNIT = 91/Other, then MHMOAMT = $5.00 - 15,000.00.
If not true, display message "THE AMOUNT ENTERED SEEMS
UNLIKELY. PLEASE VERIFY."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:15 PM Tuesday, March 26, 2013
Page 57 of 199
HISMC11
HISMC11
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MHMOCOST
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
350
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MA PLAN: (MEDICARE MANAGED CARE PLAN NAME)
Int. Instr I:
Question Text:
Did anyone else, such as an employer, a union or professional
organization pay all or some portion of the additional cost for
[your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:16 PM Tuesday, March 26, 2013
Page 58 of 199
HISMC11
Field1:
MHMOCOST
( HIS1500 )
PLRO.MHMOCOST
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HISMC12 - MHMOWHO ( HIS1510 )
English text: YES
No
HIS1 - HISCORRB ( HIS1030 )
English text: NO
Attribute
Route
Don't know
HIS1 - HISCORRB ( HIS1030 )
Refusal
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:17 PM Tuesday, March 26, 2013
Page 59 of 199
HISMC12
HISMC12
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MHMOWHO
Field 2:
MHMOWHOS
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
360
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Question display:
Display the name of this Medicare Managed Care Plan selected at
HISMC1, PLAN.PLNAME.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MA PLAN: (MEDICARE MANAGED CARE PLAN NAME)
Int. Instr I:
Question Text:
Who else paid all or some portion of the additional cost for
[your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:18 PM Tuesday, March 26, 2013
Page 60 of 199
HISMC12
Field1:
MHMOWHO
PLRO.MHMOWHO
Cheshire Name:
Item Text display:
( HIS1510 )
[(SP's)/(MIP's)]: Display (SP's), SP's name, in response
text for "1/CurrentEmployer", "2/FormerEmployer", and
"3/Union".
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TMhmowho
1
No
No
Number Label
1 CurrentEmployer
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS1 - HISCORRB ( HIS1030 )
2
English text: [(SP's)/(MIP's)] CURRENT EMPLOYER
FormerEmployer
HIS1 - HISCORRB ( HIS1030 )
3
English text: (SP's/MIP's) FORMER EMPLOYER
Union
HIS1 - HISCORRB ( HIS1030 )
4
English text: (SP's/MIP's) UNION
SpousesCurrentEmployer
5
English text: SPOUSE'S CURRENT EMPLOYER
SpousesFormerEmployer
HIS1 - HISCORRB ( HIS1030 )
6
English text: SPOUSE'S FORMER EMPLOYER
ProfessionalOrg
HIS1 - HISCORRB ( HIS1030 )
7
English text: PROFESSIONAL/FRATERNAL ORGANIZATION
Medicaid
HIS1 - HISCORRB ( HIS1030 )
91
HIS1 - HISCORRB ( HIS1030 )
English text: MEDICAID/MEDICAL ASSISTANCE
Other
HISMC12 - MHMOWHOS ( HIS1520 )
English text: OTHER
Attribute
Don't know
Route
HIS1 - HISCORRB ( HIS1030 )
Refusal
HIS1 - HISCORRB ( HIS1030 )
4:40:20 PM Tuesday, March 26, 2013
Page 61 of 199
HISMC12
Field2:
MHMOWHOS
( HIS1520 )
PLRO.MHMOWHOS
Cheshire Name:
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
OTHER (SPECIFY)
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:21 PM Tuesday, March 26, 2013
Page 62 of 199
BOX HIS2AA
BOX HIS2AA
4:40:21 PM Tuesday, March 26, 2013
Page Order # :
405
Page 63 of 199
BOX HIS2AA
BOX INSTRUCTIONS
( HIS1575 )
CREATE MEDICAID PLAN IN THE PREVIOUS ROUND .
GO TO HIS6 - COVTIME ( HIS1580 ).
ASSIGNMENTS
Medicaid details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Medicaid plan identified or created in HIS.
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Medicaid plan identified or created in HIS.
PLRO.PLRORND = previous round.
CREATE MEDICAID PLAN IN THE PREVIOUS ROUND:
If there is a PLAN where PLAN.PLANTYPE=2/Medicaid, regardless if
PLAN.PLANDFLG=1/Yes, LOSEPLFG ^= empty, or PLAN.PLANSFLG=1/Yes, this
stopped Medicaid plan will be restarted. See detailed instructions below.
Else if there is no PLAN where PLAN.PLANTYPE=2/Medicaid, create a new PLAN where
PLAN.PLANNUM equals the next sequential plan number.
Regardless if PLAN is new or restarted, create a previous round PLRO where
PLRO.PLROPLAN = this PLAN.PLANNUM if it does not already exist. Collect HIS6 and
remaining PLAN details on this previous round PLRO.
See detailed instructions below:
PLSUMFLG
PLSUMFLG
Set PLRO.PLSUMFLG = 1.
PLANNUM
If creating a new PLAN, set PLAN.PLANNUM =
highest PLAN.PLANNUM + 01.
PLANRNDC
If creating a new PLAN, set PLAN.PLANRNDC =
current round.
PLANTYPE
If creating a new PLAN, set PLAN.PLANTYPE =
2/Medicaid.
PLNAME
If creating a new PLAN, set PLNAME = "MEDICAID".
PLANSUMM
If creating a new PLAN, set PLAN.PLANSUMM =
1/Yes.
PLANDFLG
If restarting an existing MEDICAID plan and
PLAN.PLANDLFG=1/Yes, update PLAN.PLANDFLG
= empty.
LOSEPLFG
If restarting an existing MEDICAID plan and
PLAN.LOSEPLFG ^= empty, update
PLAN.LOSEPLFG = empty.
PLROPLAN
If creating a previous round PLRO, set
PLRO.PLROPLAN = this PLAN.PLANNUM.
PLRORND
If creating a previous round PLRO, set
PLRO.PLRORND = previous round.
4:40:21 PM Tuesday, March 26, 2013
Page 64 of 199
BOX HIS2AA
PLANSFLG
If restarting an existing MEDICAID plan and
PLAN.PLANSLFG=1/Yes, update PLAN.PLANSFLG
= empty.
TECHNICAL NOTES
DESIGN NOTES
4:40:21 PM Tuesday, March 26, 2013
Page 65 of 199
HIS6
HIS6
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
COVTIME
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
410
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by Medicaid the whole time between
(SUMMARY REFERENCE DATE) and (REFERENCE DATE), or
only part of the time?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:22 PM Tuesday, March 26, 2013
Page 66 of 199
HIS6
Field1:
( HIS1580 )
COVTIME
Cheshire Name:
PLRO.COVTIME
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TCovtime
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 WholeTime
2
Route
HIS10A - MCAIDHMO ( HIS1670 )
English text: THE WHOLE TIME
PartOfTime
HIS7 - COVNOW ( HIS1590 )
English text: PART OF THE TIME
Attribute
Route
Don't know
HIS7 - COVNOW ( HIS1590 )
Refusal
HIS7 - COVNOW ( HIS1590 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
4:40:23 PM Tuesday, March 26, 2013
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
Page 67 of 199
HIS6
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
DESIGN NOTES
4:40:23 PM Tuesday, March 26, 2013
Page 68 of 199
HIS7
HIS7
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
COVNOW
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
420
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by Medicaid on (REFERENCE
DATE)?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:24 PM Tuesday, March 26, 2013
Page 69 of 199
HIS7
Field1:
COVNOW
( HIS1590 )
PLRO.COVNOW
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS8 - COVBEGMM ( HIS1600 )
English text: YES
No
HIS9 - COVENDMM ( HIS1630 )
English text: NO
Attribute
Route
Don't know
HIS10A - MCAIDHMO ( HIS1670 )
Refusal
HIS10A - MCAIDHMO ( HIS1670 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:25 PM Tuesday, March 26, 2013
Page 70 of 199
HIS8
HIS8
Page Order # :
Design Screen Type:
Date
Fields:
Field 1:
COVBEGMM
Field 2:
COVBEGDD
Field 3:
COVBEGYY
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
430
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Horizontal Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
On what date did [your/(SP’s)] Medicaid start between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE)?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:26 PM Tuesday, March 26, 2013
Page 71 of 199
HIS8
Field1:
COVBEGMM
( HIS1600 )
PLRO.COVBEGMM
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS8 - COVBEGDD ( HIS1610 )
Refusal
HIS8 - COVBEGDD ( HIS1610 )
4:40:28 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
01
12
Route
HIS8 - COVBEGDD ( HIS1610 )
Page 72 of 199
HIS8
Field2:
COVBEGDD
( HIS1610 )
PLRO.COVBEGDD
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS8 - COVBEGYY ( HIS1620 )
Refusal
HIS8 - COVBEGYY ( HIS1620 )
4:40:30 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
HIS8 - COVBEGYY ( HIS1620 )
Page 73 of 199
HIS8
Field3:
COVBEGYY
( HIS1620 )
PLRO.COVBEGYY
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMcyear
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS10A - MCAIDHMO ( HIS1670 )
Refusal
HIS10A - MCAIDHMO ( HIS1670 )
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
HIS10A - MCAIDHMO ( HIS1670 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1:
PLAN BEGIN DATE, COVBEGMM/COVBEGDD/COVBEGYY,
should be on or between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE).
If not true, display message: "DATE MUST BE ON OR BETWEEN
(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).
PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
4:40:31 PM Tuesday, March 26, 2013
Page 74 of 199
HIS9
HIS9
Page Order # :
Design Screen Type:
Date
Fields:
Field 1:
COVENDMM
Field 2:
COVENDDD
Field 3:
COVENDYY
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
440
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Horizontal Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:32 PM Tuesday, March 26, 2013
Page 75 of 199
HIS9
Field1:
COVENDMM
( HIS1630 )
PLRO.COVENDMM
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS9 - COVENDDD ( HIS1640 )
Refusal
HIS9 - COVENDDD ( HIS1640 )
4:40:35 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
01
12
Route
HIS9 - COVENDDD ( HIS1640 )
Page 76 of 199
HIS9
Field2:
COVENDDD
( HIS1640 )
PLRO.COVENDDD
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS9 - COVENDYY ( HIS1650 )
Refusal
HIS9 - COVENDYY ( HIS1650 )
4:40:37 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
HIS9 - COVENDYY ( HIS1650 )
Page 77 of 199
HIS9
Field3:
COVENDYY
( HIS1650 )
PLRO.COVENDYY
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMcyear
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS10A - MCAIDHMO ( HIS1670 )
Refusal
HIS10A - MCAIDHMO ( HIS1670 )
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
HIS10A - MCAIDHMO ( HIS1670 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1:
PLAN END DATE, COVENDMM/COVENDDD/COVENDYY, should
be on or between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE).
If not true, display message: "DATE MUST BE ON OR BETWEEN
(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).
PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
4:40:38 PM Tuesday, March 26, 2013
Page 78 of 199
HIS10A
HIS10A
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MCAIDHMO
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
460
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
If this Medicaid plan was reported as "current" on the previous round
interview date, display "(REFERENCE DATE)".
Else if HIS9 - COVENDMM, COVENDDD or COVENDYY = DK or
RF, display "DK".
Else, display "(PLAN COVERAGE STOP DATE)".
Question display:
If this Medicaid plan was reported as "current" on the previous
round interview date, display "(REFERENCE DATE)".
Else if HIS9 - COVENDMM, COVENDDD or COVENDYY = DK or
RF, display "the date [your/(SP’s)] Medicaid coverage stopped".
Else, display "(PLAN COVERAGE STOP DATE)".
Always display "(Health Maintenance Organizations)" in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MEDICAID REFERNECE DATE: [(REFERENCE DATE)/(PLAN
COVERAGE STOP DATE)]
Int. Instr I:
4:40:38 PM Tuesday, March 26, 2013
Page 79 of 199
HIS10A
Some states now use managed care plans, such as HMOs (Health
Maintenance Organizations), to provide some or all health care for
Medicaid beneficiaries. [Were you/Was (SP)] enrolled in a Medicaid
Managed Care Plan on [(REFERENCE DATE)/(PLAN COVERAGE
STOP DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
MCAIDHMO
Field1:
( HIS1670 )
PLRO.MCAIDHMO
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS2C - (HIS1683 )
English text: YES
No
BOX HIS2C - (HIS1683 )
English text: NO
Attribute
Don't know
Route
BOX HIS2C - (HIS1683 )
Refusal
BOX HIS2C - (HIS1683 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
4:40:40 PM Tuesday, March 26, 2013
Page 80 of 199
HIS10A
148
ThisPlanCurrPrevRnd
This Plan was reported as "current" on prev. round
interview date=
For this PLAN, there is PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=prev. round &
(COVTIME=1/WholeTime or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
4:40:40 PM Tuesday, March 26, 2013
Page 81 of 199
BOX HIS2C
BOX HIS2C
Page Order # :
473
BOX INSTRUCTIONS
( HIS1683 )
IF THERE IS A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS
"CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO
TO HIS1 - HISCORRB ( HIS1030 ).
ELSE GO TO HIS10B1 - HISMPDCOVER ( HIS1685 ).
ASSIGNMENTS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
343
MPDPCurrPrevRnd
Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes). Exclude Deleted Plans. See
T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
4:40:40 PM Tuesday, March 26, 2013
Page 82 of 199
HIS10B1
HIS10B1
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
HISMPDCOVER
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
478
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
Some people who receive Medicaid benefits are also enrolled in a
Medicare Prescription Drug plan, or Medicare Part D plan, that pays
for some or all of their prescribed medicines. The Medicare program
automatically enrolls such beneficiaries into a Prescription Drug
plan, although the beneficiary may choose to switch to a different
plan.
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), [were you/was (SP)] enrolled in a Medicare Prescription
Drug plan that covered medicines prescribed by a doctor?
4:40:40 PM Tuesday, March 26, 2013
Page 83 of 199
HIS10B1
Int. Instr II:
INPUT FIELDS / ROUTING
HISMPDCOVER
Field1:
( HIS1685 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS34 - PLAN_HISMPDP ( HIS3331 )
English text: YES
No
HIS10C - MCDRXCOV ( HIS1690 )
English text: NO
Attribute
Route
Don't know
HIS10C - MCDRXCOV ( HIS1690 )
Refusal
HIS10C - MCDRXCOV ( HIS1690 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
If HIS10B1 - HISMPDCOVER = 1/Yes, we are going to call MPDP plan
questions at HIS34 to collect the name of the MPDP plan before returning
4:40:42 PM Tuesday, March 26, 2013
Page 84 of 199
HIS10B1
to HIS1. We will not collect HIS10C - MCDRXCOV for the MEDICAID plan
just added.
4:40:42 PM Tuesday, March 26, 2013
Page 85 of 199
HIS10C
HIS10C
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MCDRXCOV
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
480
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [your/(SP’s)] Medicaid plan cover medicines prescribed
by a doctor?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:43 PM Tuesday, March 26, 2013
Page 86 of 199
HIS10C
Field1:
MCDRXCOV
( HIS1690 )
PLRO.MCDRXCOV
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS1 - HISCORRB ( HIS1030 )
English text: YES
No
HIS1 - HISCORRB ( HIS1030 )
English text: NO
Attribute
Route
Don't know
HIS1 - HISCORRB ( HIS1030 )
Refusal
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
HIS10C is Medicaid detail which is collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Medicaid plan identified or created in HIS.
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Medicaid plan identified or created in HIS.
PLRO.PLRORND = previous round.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:44 PM Tuesday, March 26, 2013
Page 87 of 199
BOX HIST1A
BOX HIST1A
4:40:44 PM Tuesday, March 26, 2013
Page Order # :
625
Page 88 of 199
BOX HIST1A
BOX INSTRUCTIONS
( HIS1935 )
CREATE TRICARE PLAN IN THE PREVIOUS ROUND .
GO TO HIST1 - COVTIME ( HIS1940 ).
ASSIGNMENTS
Tricare details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Tricare plan identified or created in HIS.
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Tricare plan identified or created in HIS.
PLRO.PLRORND = previous round.
CREATE TRICARE PLAN IN THE PREVIOUS ROUND:
If there is a PLAN where PLAN.PLANTYPE=6/Tricare, regardless if
PLAN.PLANDFLG=1/Yes, LOSEPLFG ^= empty or PLAN.PLANSFLG=1/Yes, this stopped
Tricare plan will be restarted. See detailed instructions below.
Else if there is no PLAN where PLAN.PLANTYPE=6/Tricare, create a new PLAN where
PLAN.PLANNUM equals the next sequential plan number.
Regardless if PLAN is new or restarted, create a previous round PLRO where
PLRO.PLROPLAN = this PLAN.PLANNUM if it does not already exist. Collect HIST1 and
remaining PLAN details on this previous round PLRO.
See detailed instructions below:
PLANNUM
If creating a new PLAN, set PLAN.PLANNUM =
highest PLAN.PLANNUM + 01.
PLANRNDC
If creating a new PLAN, set PLAN.PLANRNDC =
current round.
PLANTYPE
If creating a new plan, set PLAN.PLANTYPE =
6/Tricare.
PLNAME
If creating a new plan, set PLAN.PLNAME =
"TRICARE".
PLANSUMM
If creating a new plan, set PLAN.PLANSUMM =
1/Yes.
PLANDFLG
If restarting an existing TRICARE plan and
PLAN.PLANDFLG=1/Yes, update PLAN.PLANDFLG
= empty.
LOSEPLFG
If restarting an existing TRICARE plan and
PLAN.LOSEPLFG ^= empty, update
PLAN.LOSEPLFG = empty.
PLROPLAN
If creating a previous round PLRO, set
PLRO.PLROPLAN = this PLAN.PLANNUM.
PLRORND
If creating a previous round PLRO, set
PLRO.PLRORND = previous round.
PLSUMFLG
Set PLRO.PLSUMFLG = 1.
4:40:44 PM Tuesday, March 26, 2013
Page 89 of 199
BOX HIST1A
PLANSFLG
If restarting an existing TRICARE plan and
PLAN.PLANSFLG=1/Yes, update PLAN.PLANSFLG
= empty.
TECHNICAL NOTES
DESIGN NOTES
4:40:44 PM Tuesday, March 26, 2013
Page 90 of 199
HIST1
HIST1
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
COVTIME
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
630
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by TRICARE the whole time between
(SUMMARY REFERENCE DATE) and (REFERENCE DATE), or
only part of the time?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:44 PM Tuesday, March 26, 2013
Page 91 of 199
HIST1
Field1:
( HIS1940 )
COVTIME
Cheshire Name:
PLRO.COVTIME
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TCovtime
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 WholeTime
2
Route
HIST3 - TRIRXCOV ( HIS1960 )
English text: THE WHOLE TIME
PartOfTime
HIST2 - COVNOW ( HIS1950 )
English text: PART OF THE TIME
Attribute
Route
Don't know
HIST2 - COVNOW ( HIS1950 )
Refusal
HIST2 - COVNOW ( HIS1950 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
4:40:46 PM Tuesday, March 26, 2013
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
Page 92 of 199
HIST1
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
DESIGN NOTES
4:40:46 PM Tuesday, March 26, 2013
Page 93 of 199
HIST2
HIST2
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
COVNOW
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
640
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by TRICARE on (REFERENCE
DATE)?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:47 PM Tuesday, March 26, 2013
Page 94 of 199
HIST2
Field1:
COVNOW
( HIS1950 )
PLRO.COVNOW
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIST3 - TRIRXCOV ( HIS1960 )
English text: YES
No
HIST3 - TRIRXCOV ( HIS1960 )
English text: NO
Attribute
Route
Don't know
HIST3 - TRIRXCOV ( HIS1960 )
Refusal
HIST3 - TRIRXCOV ( HIS1960 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:48 PM Tuesday, March 26, 2013
Page 95 of 199
HIST3
HIST3
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
TRIRXCOV
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
650
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display "[you/(SP)]" in BOLD in last paragraph.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [your/(SP’s)] TRICARE plan cover medicines prescribed
by a doctor?
[PROBE: I am asking about the type of insurance coverage that
[you/(SP)] personally had, not what the plan offers everyone.]
Int. Instr II:
4:40:48 PM Tuesday, March 26, 2013
Page 96 of 199
HIST3
INPUT FIELDS / ROUTING
TRIRXCOV
Field1:
( HIS1960 )
PLRO.TRIRXCOV
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIST3AA - TRIMEDS ( HIS1973 )
English text: YES
No
HIS1 - HISCORRB ( HIS1030 )
English text: NO
Attribute
Don't know
Route
HIS1 - HISCORRB ( HIS1030 )
Refusal
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:49 PM Tuesday, March 26, 2013
Page 97 of 199
HIST3AA
HIST3AA
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
TRIMEDS
Field 2:
TRIMEDOS
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
655
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display "usually" in BOLD in first sentence.
Always display "(TMOP)", "(TRRx)", and "(MTF)" in parenthesis.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
4:40:50 PM Tuesday, March 26, 2013
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), where did [you/(SP)] usually obtain (your/his/her) medicines?
Did [you/(SP)] usually obtain them at a TRICARE mail order
pharmacy (TMOP), a TRICARE retail pharmacy network pharmacy
(TRRx), a military treatment facility pharmacy (MTF), a non-network
retail pharmacy, or somewhere else?
Page 98 of 199
HIST3AA
Int. Instr II:
INPUT FIELDS / ROUTING
TRIMEDS
Field1:
( HIS1973 )
PLRO.TRIMEDS
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
Ttrimeds
1
No
No
Number Label
1 TMOP
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS1 - HISCORRB ( HIS1030 )
2
English text: A TRICARE MAIL ORDER PHARMACY (TMOP)
TRRX
HIS1 - HISCORRB ( HIS1030 )
3
English text: A TRICARE RETAIL PHARMACY NETWORK PHARMACY (TRRX)
MTF
HIS1 - HISCORRB ( HIS1030 )
4
English text: A MILITARY TREATMENT FACILITY PHARMACY (MTF)
NonNetworkRetail
HIS1 - HISCORRB ( HIS1030 )
91
English text: A NON-NETWORK RETAIL PHARMACY
Other
HIST3AA - TRIMEDOS ( HIS1975 )
English text: SOMEWHERE ELSE
Attribute
Route
Don't know
HIS1 - HISCORRB ( HIS1030 )
Refusal
HIS1 - HISCORRB ( HIS1030 )
4:40:53 PM Tuesday, March 26, 2013
Page 99 of 199
HIST3AA
Field2:
TRIMEDOS
( HIS1975 )
PLRO.TRIMEDOS
Cheshire Name:
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
SOMEWHERE ELSE (SPECIFY)
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:53 PM Tuesday, March 26, 2013
Page 100 of 199
HIS12
HIS12
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PLAN_HISPUBLIC
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Plan Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
Yes
Grid Functions:
Add Line
Delete Line
No
No
850
Display as ' Add a Plan '
Display as ' Edit a Plan '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all health insurance plans from the Plan Roster.
Display plans in order of entry.
Display the following plans as protected rows:
Medicare
Medicare Managed Care plans.
Medicaid
Tricare
Private plans
Public plans that were "current" at the time of the previous round
interview
Medicare Prescription Drug plans.
Roster/Grid display:
COL #
1
4:40:54 PM Tuesday, March 26, 2013
HEADER
Plan Name
INSTRUCTIONS
Display PLAN.PLNAME.
Page 101 of 199
HIS12
2
Plan Type
Display PLAN.PLANTYPE:
1/Medicare, display "MCAR"
2/Medicaid, display "MCAD"
3/PublicPlan, display "PUBL"
4/PrivatePlan, display "PRIV"
5/MHMO, display "MHMO"
6/Tricare, display "TRIC"
7/MPDP, display "MPDP".
3
Plan Status
Display PREVIOUS ROUND PLAN
STATUS.
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What is the name of the public program that covered [you/(SP)]?
Int. Instr II:
SELECT OR ADD ALL PUBLIC PROGRAM NAMES AT THIS
ROSTER.
INPUT FIELDS / ROUTING
Field1:
Cheshire Name:
PLAN_HISPUBLIC
( HIS2280 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TPlanPick32
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
32
Route
HIS12_IN - NAVIGATOR ( HIS2285 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Plan selected at HIS12.
4:40:54 PM Tuesday, March 26, 2013
Page 102 of 199
HIS12
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS12.
PLRO.PLRORND = previous round.
If Plan added, see PLAN ROSTER POP-UP specifications for pop-up window programming
instructions:
Variables populated in Plan Roster Pop-Up Window:
PLAN.PLANNUM
PLAN.PLANRNDC
PLAN.PLANTYPE
PLAN.PLNAME
For each Plan selected, create previous round PLRO where PLRO.PLROPLAN =
PLAN.PLANNUM of plan selected at HIS12 and PLRO.PLRORND = previous round.
HIS13 and remaining PLAN details will be stored on this previous round PLRO.
Previous round PLRO may already exist.
Set variables as instructed below:
PLANTYPE
If plan is added at HIS12, set PLAN.PLANTYPE =
3/PubicPlan.
PLANRNDC
If plan is added at HIS12, set PLAN.PLANRNDC =
current round.
PLANSUMM
If plan is added at HIS12, set PLAN.PLANSUMM =
1/Yes.
PLROPLAN
PLRO.PLROPLAN = PLAN.PLANNUM of plan
selected at HIS12.
PLSUMFLG
Set PLRO.PLSUMFLG = 1.
PLRORND
PLRO.PLRORND = previous round.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
4:40:54 PM Tuesday, March 26, 2013
Page 103 of 199
HIS12
80
PublicCurrentPrevRnd
Public plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=3/PublicPlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=previous round & (COVTIME=1/WholeTime
or COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
Begin Loop 1: Collect plan details for all public plans selected at HIS12.
4:40:54 PM Tuesday, March 26, 2013
Page 104 of 199
HIS12_IN
HIS12_IN
Page Order # :
Design Screen Type:
Instance Navigator
Fields:
Field 1:
NAVIGATOR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
855
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display Plans selected at HIS12.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:55 PM Tuesday, March 26, 2013
Page 105 of 199
HIS12_IN
Field1:
NAVIGATOR
( HIS2285 )
N/A
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TInstanceNavigator
1
No
No
Number Label
1 SelectItemInList
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS13 - COVTIME ( HIS2290 )
English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
HIS1 - HISCORRB ( HIS1030 )
English text: CONTINUE INTERVIEW SELECTED
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:55 PM Tuesday, March 26, 2013
Page 106 of 199
HIS13
HIS13
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
COVTIME
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
860
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PUBLIC PLAN: (PUBLIC PLAN NAME)
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) the whole
time between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), or only part of the time?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:56 PM Tuesday, March 26, 2013
Page 107 of 199
HIS13
Field1:
COVTIME
( HIS2290 )
PLRO.COVTIME
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TCovtime
1
No
No
Number Label
1 WholeTime
2
English text: THE WHOLE TIME
PartOfTime
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS2B1 - (HIS2362 )
HIS14 - COVNOW ( HIS2300 )
English text: PART OF THE TIME
Attribute
Route
Don't know
HIS14 - COVNOW ( HIS2300 )
Refusal
HIS14 - COVNOW ( HIS2300 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:57 PM Tuesday, March 26, 2013
Page 108 of 199
HIS14
HIS14
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
COVNOW
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
870
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PUBLIC PLAN: (PUBLIC PLAN NAME)
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) on
(REFERENCE DATE)?
Int. Instr II:
INPUT FIELDS / ROUTING
4:40:58 PM Tuesday, March 26, 2013
Page 109 of 199
HIS14
Field1:
COVNOW
( HIS2300 )
PLRO.COVNOW
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS15 - COVBEGMM ( HIS2310 )
English text: YES
No
HIS16 - COVENDMM ( HIS2340 )
English text: NO
Attribute
Route
Don't know
BOX HIS2B1 - (HIS2362 )
Refusal
BOX HIS2B1 - (HIS2362 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:40:59 PM Tuesday, March 26, 2013
Page 110 of 199
HIS15
HIS15
Page Order # :
Design Screen Type:
Date
Fields:
Field 1:
COVBEGMM
Field 2:
COVBEGDD
Field 3:
COVBEGYY
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
880
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Horizontal Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PUBLIC PLAN: (PUBLIC PLAN NAME)
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start
between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE)?
Int. Instr II:
4:41:01 PM Tuesday, March 26, 2013
Page 111 of 199
HIS15
INPUT FIELDS / ROUTING
COVBEGMM
Field1:
( HIS2310 )
PLRO.COVBEGMM
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS15 - COVBEGDD ( HIS2320 )
Refusal
HIS15 - COVBEGDD ( HIS2320 )
4:41:03 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
01
12
Route
HIS15 - COVBEGDD ( HIS2320 )
Page 112 of 199
HIS15
Field2:
COVBEGDD
( HIS2320 )
PLRO.COVBEGDD
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS15 - COVBEGYY ( HIS2330 )
Refusal
HIS15 - COVBEGYY ( HIS2330 )
4:41:05 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
HIS15 - COVBEGYY ( HIS2330 )
Page 113 of 199
HIS15
Field3:
COVBEGYY
( HIS2330 )
PLRO.COVBEGYY
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMcyear
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
BOX HIS2B1 - (HIS2362 )
Refusal
BOX HIS2B1 - (HIS2362 )
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
BOX HIS2B1 - (HIS2362 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
PLAN BEGIN DATE, COVBEGMM/COVBEGDD/COVBEGYY,
should be on or between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE).
If not true, display message: "DATE MUST BE ON OR BETWEEN
(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).
PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
4:41:06 PM Tuesday, March 26, 2013
Page 114 of 199
HIS16
HIS16
Page Order # :
Design Screen Type:
Date
Fields:
Field 1:
COVENDMM
Field 2:
COVENDDD
Field 3:
COVENDYY
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
890
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Horizontal Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PUBLIC PLAN: (PUBLIC PLAN NAME)
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME)
coverage stop?
Int. Instr II:
4:41:07 PM Tuesday, March 26, 2013
Page 115 of 199
HIS16
INPUT FIELDS / ROUTING
COVENDMM
Field1:
( HIS2340 )
PLRO.COVENDMM
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS16 - COVENDDD ( HIS2350 )
Refusal
HIS16 - COVENDDD ( HIS2350 )
4:41:09 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
01
12
Route
HIS16 - COVENDDD ( HIS2350 )
Page 116 of 199
HIS16
Field2:
COVENDDD
( HIS2350 )
PLRO.COVENDDD
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS16 - COVENDYY ( HIS2360 )
Refusal
HIS16 - COVENDYY ( HIS2360 )
4:41:12 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
HIS16 - COVENDYY ( HIS2360 )
Page 117 of 199
HIS16
Field3:
COVENDYY
( HIS2360 )
PLRO.COVENDYY
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMcyear
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
BOX HIS2B1 - (HIS2362 )
Refusal
BOX HIS2B1 - (HIS2362 )
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
BOX HIS2B1 - (HIS2362 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
PLAN END DATE, COVENDMM/COVENDDD/COVENDYY, should
be on or between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE).
If not true, display message: "DATE MUST BE ON OR BETWEEN
(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).
PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
4:41:13 PM Tuesday, March 26, 2013
Page 118 of 199
BOX HIS2B1
BOX HIS2B1
Page Order # :
895
BOX INSTRUCTIONS
( HIS2362 )
GO TO HIS16A - PUBRXCOV ( HIS2370 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
4:41:13 PM Tuesday, March 26, 2013
Page 119 of 199
HIS16A
HIS16A
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
PUBRXCOV
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
900
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PUBLIC PLAN: (PUBLIC PLAN NAME)
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [your/(SP’s)] (PUBLIC PLAN NAME) plan cover
medicines prescribed by a doctor?
Int. Instr II:
INPUT FIELDS / ROUTING
4:41:14 PM Tuesday, March 26, 2013
Page 120 of 199
HIS16A
Field1:
PUBRXCOV
( HIS2370 )
PLRO.PUBRXCOV
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS3 - (HIS2620 )
English text: YES
No
BOX HIS3 - (HIS2620 )
English text: NO
Attribute
Route
Don't know
BOX HIS3 - (HIS2620 )
Refusal
BOX HIS3 - (HIS2620 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:41:15 PM Tuesday, March 26, 2013
Page 121 of 199
BOX HIS3
BOX HIS3
Page Order # :
1050
BOX INSTRUCTIONS
( HIS2620 )
GO TO HIS12_IN - NAVIGATOR ( HIS2285 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
4:41:15 PM Tuesday, March 26, 2013
Page 122 of 199
HIS20
HIS20
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PLAN_HISPRIVATE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Plan Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
1060
Display as ' Add a Plan '
Display as ' Edit a Plan '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(other)" in parenthesis.
If SP is deceased or institutionalized, display "provided".
Else display "provide".
Multi Field display:
Roster/Grid Instructions:
Display all health insurance plans from the Plan Roster.
Display plans in order of entry.
Display the following plans as protected rows:
Medicare
Medicare Managed Care plans.
Medicaid
Tricare
Public plans
Private plans that were "current" at the time of the previous round
interview
Medicare Prescription Drug plans.
Roster/Grid display:
COL #
1
4:41:15 PM Tuesday, March 26, 2013
HEADER
Plan Name
INSTRUCTIONS
Display PLAN.PLNAME.
Page 123 of 199
HIS20
2
Plan Type
Display PLAN.PLANTYPE:
1/Medicare, display "MCAR"
2/Medicaid, display "MCAD"
3/PublicPlan, display "PUBL"
4/PrivatePlan, display "PRIV"
5/MHMO, display "MHMO"
6/Tricare, display "TRIC"
7/MPDP, display "MPDP".
3
Plan Status
Display PREVIOUS ROUND PLAN
STATUS.
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What is the name of each of the (other) private plans that provided
[your/(SP’s)] medical insurance coverage between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE)?
Int. Instr II:
SELECT OR ADD ALL PRIVATE PLAN NAMES AT THIS ROSTER.
INPUT FIELDS / ROUTING
Field1:
PLAN_HISPRIVATE
( HIS2630 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TPlanPick32
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
32
Route
HIS20_IN - NAVIGATOR ( HIS2635 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Plan selected at HIS20.
4:41:16 PM Tuesday, March 26, 2013
Page 124 of 199
HIS20
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS20.
PLRO.PLRORND = previous round.
If Plan added, see PLAN ROSTER POP-UP specifications for pop-up window programming
instructions:
Variables populated in Plan Roster Pop-Up Window:
PLAN.PLANNUM
PLAN.PLANRNDC
PLAN.PLANTYPE
PLAN.PLNAME
For each Plan selected, create previous round PLRO where PLRO.PLROPLAN =
PLAN.PLANNUM of plan selected at HIS20 and PLRO.PLRORND = previous round.
HIS21 and remaining PLAN details will be stored on this previous round PLRO.
Previous round PLRO may already be created.
Set variables as instructed below:
PLANTYPE
If adding PLAN, set PLAN.PLANTYPE =
4/PrivatePlan.
PLANRNDC
If adding PLAN, set PLAN.PLANRNDC = current
round.
PLANSUMM
If adding PLAN, set PLAN.PLANSUMM = 1/Yes.
PLROPLAN
PLRO.PLROPLAN = PLAN.PLANNUM of plan
selected at HIS20.
PLRORND
PLRO.PLRORND = previous round.
PLSUMFLG
Set PLRO.PLSUMFLG = 1.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
59
SPStatus
SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.
52
DeletedPlans
4:41:16 PM Tuesday, March 26, 2013
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
Page 125 of 199
HIS20
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
81
PrivateCurrentPrevRnd
Private plan "current" at the time of previous round
interview =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRORND=prev. round & (COVTIME=1/WholeTime or
COVNOW=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
Begin Loop 2: Collect plan details (HIS21-HIS33C) for all private plans
selected at HIS20.
4:41:16 PM Tuesday, March 26, 2013
Page 126 of 199
HIS20_IN
HIS20_IN
Page Order # :
Design Screen Type:
Instance Navigator
Fields:
Field 1:
NAVIGATOR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1065
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display Plans selected at HIS20.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
4:41:16 PM Tuesday, March 26, 2013
Page 127 of 199
HIS20_IN
Field1:
NAVIGATOR
( HIS2635 )
N/A
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TInstanceNavigator
1
No
No
Number Label
1 SelectItemInList
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS21 - COVTIME ( HIS2650 )
English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
HIS1 - HISCORRB ( HIS1030 )
English text: CONTINUE INTERVIEW SELECTED
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:41:17 PM Tuesday, March 26, 2013
Page 128 of 199
HIS21
HIS21
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
COVTIME
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1070
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATEPLAN NAME)
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole
time between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), or only part of the time?
Int. Instr II:
INPUT FIELDS / ROUTING
4:41:17 PM Tuesday, March 26, 2013
Page 129 of 199
HIS21
Field1:
COVTIME
( HIS2650 )
PLRO.COVTIME
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TCovtime
1
No
No
Number Label
1 WholeTime
2
English text: THE WHOLE TIME
PartOfTime
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS3A1 - (HIS2722 )
HIS22 - COVNOW ( HIS2660 )
English text: PART OF THE TIME
Attribute
Route
Don't know
HIS22 - COVNOW ( HIS2660 )
Refusal
HIS22 - COVNOW ( HIS2660 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:41:18 PM Tuesday, March 26, 2013
Page 130 of 199
HIS22
HIS22
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
COVNOW
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1080
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATE PLAN NAME)
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) on
(REFERENCE DATE)?
Int. Instr II:
INPUT FIELDS / ROUTING
4:41:19 PM Tuesday, March 26, 2013
Page 131 of 199
HIS22
Field1:
COVNOW
( HIS2660 )
PLRO.COVNOW
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS23 - COVBEGMM ( HIS2670 )
English text: YES
No
HIS24 - COVENDMM ( HIS2700 )
English text: NO
Attribute
Route
Don't know
BOX HIS3A1 - (HIS2722 )
Refusal
BOX HIS3A1 - (HIS2722 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:41:20 PM Tuesday, March 26, 2013
Page 132 of 199
HIS23
HIS23
Page Order # :
Design Screen Type:
Date
Fields:
Field 1:
COVBEGMM
Field 2:
COVBEGDD
Field 3:
COVBEGYY
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
1090
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Horizontal Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATEPLAN NAME)
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) start between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE)?
Int. Instr II:
4:41:21 PM Tuesday, March 26, 2013
Page 133 of 199
HIS23
INPUT FIELDS / ROUTING
COVBEGMM
Field1:
( HIS2670 )
PLRO.COVBEGMM
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS23 - COVBEGDD ( HIS2680 )
Refusal
HIS23 - COVBEGDD ( HIS2680 )
4:41:24 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
01
12
Route
HIS23 - COVBEGDD ( HIS2680 )
Page 134 of 199
HIS23
Field2:
COVBEGDD
( HIS2680 )
PLRO.COVBEGDD
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS23 - COVBEGYY ( HIS2690 )
Refusal
HIS23 - COVBEGYY ( HIS2690 )
4:41:26 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
HIS23 - COVBEGYY ( HIS2690 )
Page 135 of 199
HIS23
Field3:
COVBEGYY
( HIS2690 )
PLRO.COVBEGYY
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMcyear
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
BOX HIS3A1 - (HIS2722 )
Refusal
BOX HIS3A1 - (HIS2722 )
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
BOX HIS3A1 - (HIS2722 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
PLAN BEGIN DATE, COVBEGMM/COVBEGDD/COVBEGYY,
should be on or between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE).
If not true, display message: "DATE MUST BE ON OR BETWEEN
(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).
PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
4:41:27 PM Tuesday, March 26, 2013
Page 136 of 199
HIS24
HIS24
Page Order # :
Design Screen Type:
Date
Fields:
Field 1:
COVENDMM
Field 2:
COVENDDD
Field 3:
COVENDYY
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
1100
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Horizontal Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATEPLAN NAME)
SUMMARY REFERENCE PERIOD: (SUMMARY REFERENCE
DATE) - (REFERENCE DATE)
Int. Instr I:
Question Text:
On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE
PLAN NAME) stop?
Int. Instr II:
4:41:28 PM Tuesday, March 26, 2013
Page 137 of 199
HIS24
INPUT FIELDS / ROUTING
COVENDMM
Field1:
( HIS2700 )
PLRO.COVENDMM
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS24 - COVENDDD ( HIS2710 )
Refusal
HIS24 - COVENDDD ( HIS2710 )
4:41:31 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
01
12
Route
HIS24 - COVENDDD ( HIS2710 )
Page 138 of 199
HIS24
Field2:
COVENDDD
( HIS2710 )
PLRO.COVENDDD
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
HIS24 - COVENDYY ( HIS2720 )
Refusal
HIS24 - COVENDYY ( HIS2720 )
4:41:33 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
HIS24 - COVENDYY ( HIS2720 )
Page 139 of 199
HIS24
Field3:
COVENDYY
( HIS2720 )
PLRO.COVENDYY
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMcyear
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Don't know
BOX HIS3A1 - (HIS2722 )
Refusal
BOX HIS3A1 - (HIS2722 )
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
BOX HIS3A1 - (HIS2722 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
PLAN END DATE, COVENDMM/COVENDDD/COVENDYY, should
be on or between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE).
If not true, display message: "DATE MUST BE ON OR BETWEEN
(SUMMARY REFERENCE DATE) AND (REFERENCE DATE).
PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
4:41:34 PM Tuesday, March 26, 2013
Page 140 of 199
BOX HIS3A1
BOX HIS3A1
Page Order # :
1105
BOX INSTRUCTIONS
( HIS2722 )
GO TO HIS25 - PPRVHMO ( HIS2730 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
4:41:34 PM Tuesday, March 26, 2013
Page 141 of 199
HIS25
HIS25
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
PPRVHMO
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1110
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Always display "(Health Maintenance Organization)" and (Preferred
Provider Organization) in parenthesis.
Always display "(network)" in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE INSURANCE PLAN = (PRIVATE PLAN NAME)
Int. Instr I:
CODE WITHOUT ASKING IF VOLUNTEERED.
Question Text:
Was this a managed care plan, such as an HMO (Health
Maintenance Organization) or PPO (Preferred Provider
Organization)?
[EXPLAIN IF NECESSARY: Managed care plans generally provide
a full range of health care services for a prepaid fee. Health care is
generally provided by primary care doctors, specialists, or hospitals
on the plan’s list (network) except in an emergency.]
4:41:35 PM Tuesday, March 26, 2013
Page 142 of 199
HIS25
Int. Instr II:
INPUT FIELDS / ROUTING
( HIS2730 )
PPRVHMO
Field1:
PLRO.PPRVHMO
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS26 - PERS_HISMIPNUM ( HIS2750 )
English text: YES
No
HIS26 - PERS_HISMIPNUM ( HIS2750 )
English text: NO
Attribute
Route
Don't know
HIS26 - PERS_HISMIPNUM ( HIS2750 )
Refusal
HIS26 - PERS_HISMIPNUM ( HIS2750 )
BACKGROUND VARIABLE ASSIGNMENTS
If PLAN is new (added at HIS20), store response to HI25 - PPRVHMO also on PLAN
record. Set variable as instructed below:
If PLAN is new, set PLAN.PRVHMO =
PLRO.PPRVHMO.
PRVHMO
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
155
ThisPlanNewPrevRnd
4:41:36 PM Tuesday, March 26, 2013
This Plan added in HIS and is a new Plan during the
previous round reference period =
Page 143 of 199
HIS25
PLAN.PLANRNDC=current round and
PLAN.PLANSUMM = 1/Yes.
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
4:41:36 PM Tuesday, March 26, 2013
Page 144 of 199
HIS26
HIS26
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PERS_HISMIPNUM
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Person Roster
Roster Type:
Single Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
1120
Display as ' Add a Person '
Display as ' Edit a Person '
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Display all persons from the Person Roster.
Display SP on first line, followed by the name of the SP's spouse.
Display remaining persons in the order that they were entered in
Person Roster.
Do not allow SP to be edited.
Roster/Grid display:
COL #
HEADER
INSTRUCTIONS
1
First Name
Display ROST.ROSTFNAM.
2
Last Name
Display ROST.ROSTLNAM.
3
Relationship to SP
Display Relationship:
If ROST. ROSTREL=91/OtherRelative or
92/OtherNon-Relative, display
ROST.ROSTREOS.
Else display ROST.ROSTREL
relationship.
Report display:
TEXT:
4:41:36 PM Tuesday, March 26, 2013
Page 145 of 199
HIS26
PRIVATE PLAN: (PRIVATE PLAN NAME)
Context Header:
Int. Instr I:
Question Text:
Who was listed as the main insured person on the (PRIVATE PLAN
NAME) policy or contract?
Int. Instr II:
SELECT OR ADD ONLY ONE PERSON.
INPUT FIELDS / ROUTING
Field1:
PERS_HISMIPNUM
( HIS2750 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TRostPick4
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
4
Route
HIS27 - PPRVGET ( HIS2770 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on ROST:
ROST key = ROST.ROSTBASE + ROST.ROSTNUM
ROST.ROSTNUM = Number of Person selected at HIS26.
If Person added, see PERSON ROSTER POP-UP specifications for pop-up window
programming instructions.
Variables populated in Person Roster Pop-Up Window:
ROST.ROSTNUM
ROST.ROSTRNDC
ROST.ROSTFNAM
ROST.ROSTLNAM
ROST.ROSTREL
ROST.ROSTREOS
Set reason why person was added. See additional instructions below.
If a Person is edited then the following fields may be updated in the Person Roster Pop-Up:
If the Person's relationship is updated and ROST.ROSTSEX ^= Null and the Person's
gender no longer matches the Person's relationship, update ROST.ROSTSEX based on
the specifications below. Note, if ROST.ROSTSEX has never been collected,
4:41:37 PM Tuesday, March 26, 2013
Page 146 of 199
HIS26
ROST.ROSTSEX = Null, do not set ROST.ROSTSEX.
If the Person's relationship is updated and original relationship = 91/OtherRelative or
92/OtherNon_Relative and updated relationship ^= 91/OtherRelative and ^=
92/OtherNon_Relative, update ROST.ROSTREOS = empty.
Person selected at HIS26 is the Main Insured Person (MIP). The ROST.ROSTNUM for the
MIP is stored on PLAN and the PLAN's previous round PLRO. Set variables as instructed
below.
ROSTREAS
If person added, set ROST.ROSTREAS = 6/MIP.
MIPNUM
PLRO.MIPNUM = ROST.ROSTNUM of person
selected.
PLMIPNUM
PLAN.PLMIPNUM = PLRO.MIPNUM. (NOTE: will
need to TRNS variable in future design).
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
96
SPsSpouse
SP's Spouse =
There is a ROST where ROST.ROSTREL=2/Spouse.
DESIGN NOTES
4:41:37 PM Tuesday, March 26, 2013
Page 147 of 199
HIS27
HIS27
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
PPRVGET
Field 3:
PPRVGTOS
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
1130
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
MIP:
If the respondent is the MIP, display "SP" .
Else display the name of the MIP.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
If the respondent is the MIP, display "you" .
Else display the name of the MIP.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATE PLAN NAME)
MIP: [SP/(MIP)]
Int. Instr I:
Question Text:
4:41:38 PM Tuesday, March 26, 2013
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up
directly with the (insurance company/managed care plan), or did
Page 148 of 199
HIS27
[you/(MIP)] get this insurance through a current employer, a former
employer, a union, a family business, AARP, or some other way?
Int. Instr II:
INPUT FIELDS / ROUTING
4:41:40 PM Tuesday, March 26, 2013
Page 149 of 199
HIS27
Field1:
PPRVGET
PLRO.PPRVGET
Cheshire Name:
Item Text display:
( HIS2770 )
Display name of MIP in response categories
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TPrvget
1
No
No
Number Label
1 Directly
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS29 - PRVNMCOV ( HIS2920 )
2
English text: DIRECTLY
CurrentEmployer
3
English text: (MIP'S) CURRENT EMPLOYER
FormerEmployer
HIS29 - PRVNMCOV ( HIS2920 )
4
English text: (MIP'S) FORMER EMPLOYER
Union
HIS29 - PRVNMCOV ( HIS2920 )
5
English text: (MIP'S) UNION
FamilyBusiness
HIS29 - PRVNMCOV ( HIS2920 )
6
English text: (MIP'S) FAMILY BUSINESS
Aarp
HIS29 - PRVNMCOV ( HIS2920 )
7
English text: AARP
DecSpousesEmployer
HIS29 - PRVNMCOV ( HIS2920 )
8
English text: DECEASED SPOUSE'S EMPLOYER
DecSpousesUnion
HIS29 - PRVNMCOV ( HIS2920 )
9
English text: DECEASED SPOUSE'S UNION
ProfessionalOrg
91
HIS29 - PRVNMCOV ( HIS2920 )
HIS29 - PRVNMCOV ( HIS2920 )
English text: PROFESSIONAL/FRATERNAL ORGANIZATION
Other
HIS27 - PPRVGTOS ( HIS2790 )
English text: SOME OTHER WAY
Attribute
Route
Don't know
HIS29 - PRVNMCOV ( HIS2920 )
Refusal
HIS29 - PRVNMCOV ( HIS2920 )
4:41:43 PM Tuesday, March 26, 2013
Page 150 of 199
HIS27
Field3:
( HIS2790 )
PPRVGTOS
Cheshire Name:
PLAN.PRVGETOS
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
OTHER (SPECIFY)
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 [Continuous answer.]
30
Route
HIS29 - PRVNMCOV ( HIS2920 )
BACKGROUND VARIABLE ASSIGNMENTS
If PLAN is new (added at HIS20), store response to HI27 - PPRVGET and PPRVGTOS
also on PLAN record. Set variable as instructed below:
PRVGET
If PLAN is new, set
PLAN.PRVGET=PLRO.PPRVGET.
PRVGETOS
if PLAN is new, set
PLAN.PRVGETOS=PLRO.PPRVGTOS.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
4
Respondent
On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.
208
MIPPrevRnd
4:41:43 PM Tuesday, March 26, 2013
Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.
Page 151 of 199
HIS27
DESIGN NOTES
4:41:44 PM Tuesday, March 26, 2013
Page 152 of 199
HIS29
HIS29
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
PRVNMCOV
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1180
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
MIP:
If the respondent is the MIP, display "SP" .
Else display the name of the MIP.
Question display:
If the respondent is the MIP, display "your".
Else display the name of the MIP.
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATE PLAN NAME)
MIP: [(SP)/(MIP)]]
REFERENCE PERIOD: (REFERENCE DATE)
REFERENCE DATE)
- (SUMMARY
Int. Instr I:
Question Text:
4:41:44 PM Tuesday, March 26, 2013
How many family members, including [yourself/(SP)], were covered
by [your/(MIP’s)] (PRIVATE PLAN NAME) between (SUMMARY
Page 153 of 199
HIS29
REFERENCE DATE) and (REFERENCE DATE)?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
PRVNMCOV
( HIS2920 )
PLRO.PRVNMCOV
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
NUMBER COVERED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TPrvnmcov
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 [Continuous answer.]
1
15
Route
HIS31A - PRVRXCOV ( HIS2925 )
Attribute
Don't know
Route
HIS31A - PRVRXCOV ( HIS2925 )
Refusal
HIS31A - PRVRXCOV ( HIS2925 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
PRVNMCOV should = 1-4, DK or RF.
If not true, display message "THE AMOUNT ENTERED SEEMS
UNLIKELY. PLEASE VERIFY."
HARD EDIT CHECKS
TECHNICAL NOTES
4
Respondent
On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
4:41:45 PM Tuesday, March 26, 2013
Page 154 of 199
HIS29
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.
208
MIPPrevRnd
Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.
DESIGN NOTES
4:41:45 PM Tuesday, March 26, 2013
Page 155 of 199
HIS31A
HIS31A
Page Order # :
Design Screen Type:
List
Fields:
Field 1:
PRVRXCOV
Field 2:
PRVMSCOV
Field 3:
PRVIPCOV
Field 4:
PRVNHCOV
Field 5:
MHMODENT
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
1185
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
MIP:
If the respondent is the MIP, display "SP" .
Else display the name of the MIP.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
If the respondent is the MIP reported at HIS26, display "your".
Else display the name of the MIP reported at HIS26.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
4:41:47 PM Tuesday, March 26, 2013
PRIVATE PLAN: (PRIVATE PLAN NAME) [
MIP: [(SP)/(MIP)]]
Page 156 of 199
HIS31A
REFERENCE PERIOD: (REFERENCE DATE) - (SUMMARY
REFERENCE DATE)
Int. Instr I:
Supplemental insurance plans may cover a variety of services or
may be specific to only certain services, such as prescribed
medicines or dental coverage. I’d like to know what [your/(SP’s)]
(PRIVATE PLAN NAME) coverage included between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE).
Question Text:
[PROBE: I am asking about the type of insurance coverage that
[you/(SP)] personally had, not what the plan offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
Int. Instr II:
INPUT FIELDS / ROUTING
PRVRXCOV
Field1:
( HIS2925 )
PLRO.PRVRXCOV
Cheshire Name:
Item Text display:
Display "a." before the question text.
Item Text:
prescribed medicines?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS31A - PRVMSCOV ( HIS2930 )
English text: YES
No
HIS31A - PRVMSCOV ( HIS2930 )
English text: NO
Attribute
Don't know
Route
HIS31A - PRVMSCOV ( HIS2930 )
Refusal
HIS31A - PRVMSCOV ( HIS2930 )
4:41:49 PM Tuesday, March 26, 2013
Page 157 of 199
HIS31A
Field2:
PRVMSCOV
( HIS2930 )
PLRO.PRVMSCOV
Cheshire Name:
Item Text display:
Display "b." before the question text.
Item Text:
doctor visits or lab work?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS31A - PRVIPCOV ( HIS2935 )
English text: YES
No
HIS31A - PRVIPCOV ( HIS2935 )
English text: NO
Attribute
Route
Don't know
HIS31A - PRVIPCOV ( HIS2935 )
Refusal
HIS31A - PRVIPCOV ( HIS2935 )
4:41:52 PM Tuesday, March 26, 2013
Page 158 of 199
HIS31A
Field3:
PRVIPCOV
( HIS2935 )
PLRO.PRVIPCOV
Cheshire Name:
Item Text display:
Display "c." before the question text.
Item Text:
inpatient hospital care?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS31A - PRVNHCOV ( HIS2940 )
English text: YES
No
HIS31A - PRVNHCOV ( HIS2940 )
English text: NO
Attribute
Route
Don't know
HIS31A - PRVNHCOV ( HIS2940 )
Refusal
HIS31A - PRVNHCOV ( HIS2940 )
4:41:54 PM Tuesday, March 26, 2013
Page 159 of 199
HIS31A
Field4:
PRVNHCOV
( HIS2940 )
PLRO.PRVNHCOV
Cheshire Name:
Item Text display:
Display "d." before the question text.
Item Text:
nursing home or long term care?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS31A - MHMODENT ( HIS2945 )
English text: YES
No
HIS31A - MHMODENT ( HIS2945 )
English text: NO
Attribute
Route
Don't know
HIS31A - MHMODENT ( HIS2945 )
Refusal
HIS31A - MHMODENT ( HIS2945 )
4:41:57 PM Tuesday, March 26, 2013
Page 160 of 199
HIS31A
Field5:
MHMODENT
( HIS2945 )
PLRO.MHMODENT
Cheshire Name:
Item Text display:
Display "e." before the question text.
Item Text:
dental care?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS32 - MIPPINS ( HIS3240 )
English text: YES
No
HIS32 - MIPPINS ( HIS3240 )
English text: NO
Attribute
Route
Don't know
HIS32 - MIPPINS ( HIS3240 )
Refusal
HIS32 - MIPPINS ( HIS3240 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
4
Respondent
On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.
4:41:58 PM Tuesday, March 26, 2013
Page 161 of 199
HIS31A
208
MIPPrevRnd
Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.
DESIGN NOTES
4:41:58 PM Tuesday, March 26, 2013
Page 162 of 199
HIS32
HIS32
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MIPPINS
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1195
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Always display, "[Do not include the cost of any deductibles...]" in
brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATE PLAN NAME)
Int. Instr I:
Question Text:
Was there a premium or cost for the (PRIVATE PLAN NAME)
coverage?
[Do not include the cost of any deductibles [you/(SP)] or [your/(SP’s)]
family may have had to pay.]
Int. Instr II:
4:41:59 PM Tuesday, March 26, 2013
Page 163 of 199
HIS32
INPUT FIELDS / ROUTING
MIPPINS
Field1:
( HIS3240 )
PLRO.MIPPINS
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS33 - MIPPAMT ( HIS3250 )
English text: YES
No
HIS33A - MHMOCOST ( HIS3280 )
English text: NO
Attribute
Don't know
Route
HIS33A - MHMOCOST ( HIS3280 )
Refusal
HIS33A - MHMOCOST ( HIS3280 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:42:00 PM Tuesday, March 26, 2013
Page 164 of 199
HIS33
HIS33
Page Order # :
Design Screen Type:
Quantity Unit Hybrid
Fields:
Field 1:
MIPPAMT
Field 2:
MIPPUNIT
Field 3:
MIPPUNOS
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
1205
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
MIP:
If the respondent is the MIP, display "SP" .
Else display the name of the MIP.
Question display:
If respondent is MIP, display "you".
Else display the name of the MIP.
Display plan name for the plan being asked about, PLAN.PLNAME.
Always display "[Please do not include any…]" in brackets.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
4:42:02 PM Tuesday, March 26, 2013
PRIVATE PLAN: (PRIVATE PLAN NAME)
MIP: [SP/(MIP)]
Page 165 of 199
HIS33
Int. Instr I:
How much did [you/(MIP)] pay for the (PRIVATE PLAN NAME)
coverage?
Question Text:
[Please do not include any amount that may be paid for anyone
other than [you/(SP)].]
[PROBE IF NECESSARY: Was that per year, per month, per week,
or what?]
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
MIPPAMT
( HIS3250 )
PLRO.MIPPAMT
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
AMOUNT:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TMippamt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
HIS33A - MHMOCOST ( HIS3280 )
Refusal
HIS33A - MHMOCOST ( HIS3280 )
4:42:04 PM Tuesday, March 26, 2013
FieldSize:
Min Value:
Max Value:
Mask:
0.01
99999.99
Dollars
Route
HIS33 - MIPPUNIT ( HIS3260 )
Page 166 of 199
HIS33
Field2:
MIPPUNIT
( HIS3260 )
PLRO.MIPPUNIT
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TMippunit
1
No
No
Number Label
1 PerYear
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS33A - MHMOCOST ( HIS3280 )
2
English text: PER YEAR
Quarterly
3
English text: QUARTERLY/EVERY 3 MONTHS
Bimonthly
HIS33A - MHMOCOST ( HIS3280 )
4
English text: BIMONTHLY/EVERY 2 MONTHS
PerMonth
HIS33A - MHMOCOST ( HIS3280 )
5
English text: PER MONTH
PerWeek
HIS33A - MHMOCOST ( HIS3280 )
6
English text: PER WEEK
SemiAnnually
HIS33A - MHMOCOST ( HIS3280 )
7
English text: SEMI-ANNUALLY/2 TIMES PER YEAR
SemiMonthly
HIS33A - MHMOCOST ( HIS3280 )
91
HIS33A - MHMOCOST ( HIS3280 )
English text: SEMI-MONTHLY/2 TIMES PER MONTH
Other
HIS33 - MIPPUNOS ( HIS3270 )
English text: OTHER
Attribute
Route
Don't know
HIS33A - MHMOCOST ( HIS3280 )
Refusal
HIS33A - MHMOCOST ( HIS3280 )
4:42:07 PM Tuesday, March 26, 2013
Page 167 of 199
HIS33
Field3:
( HIS3270 )
MIPPUNOS
PLRO.MIPPUNOS
Cheshire Name:
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
OTHER (SPECIFY)
Label:
Label Position:
VERIFY THAT RESPONDENT IS REPORTING A DEDUCTIBLE AND NOT A CO
PAY.
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 [Continuous answer.]
30
Route
HIS33A - MHMOCOST ( HIS3280 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
If MPPAMT ^= DK and MPPAMT ^= RF then,
If MIPPUNIT = 1/PerYear, then MIPPAMT = $50.00 - 10,000.00.
Else if MIPPUNIT = 2/Quarterly, then MIPPAMT = $15.00 - 2500.00.
Else if MIPPUNIT = 3/Bimonthly, then MIPPAMT = $10.00 - 1650.00.
Else if MIPPUNIT = 4/PerMonth, then MIPPAMT = $5.00 - 850.00.
Else if MIPPUNIT = 5/PerWeek, then MIPPAMT = $5.00 - 200.00.
Else if MIPPUNIT = 6/SemiAnnually, then MIPPAMT = $25.00 -
5,000.00.
Else if MIPPUNIT = 7/SemiMonthly, then MIPPAMT = $2.00 - 425.00.
Else if MIPPUNIT = 91/Other ,then MIPPAMT = $5.00 - 15,000.00.
If not true, display message "THE AMOUNT ENTERED SEEMS
UNLIKELY. PLEASE VERIFY.".
HARD EDIT CHECKS
TECHNICAL NOTES
4
Respondent
On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
4:42:08 PM Tuesday, March 26, 2013
Page 168 of 199
HIS33
MRES.RROSTNUM='01'.
208
MIPPrevRnd
Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.
DESIGN NOTES
4:42:08 PM Tuesday, March 26, 2013
Page 169 of 199
HIS33A
HIS33A
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MHMOCOST
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1215
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
MIP:
If the respondent is the MIP, display "SP" .
Else display the name of the MIP.
Question display:
If respondent is MIP, display "you".
Else display the name of the MIP.
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATE PLAN NAME)
MIP: [(SP)/(MIP)]
REFERENCE PERIOD: (REFERENCE DATE)
REFERENCE DATE)
- (SUMMARY
Int. Instr I:
Question Text:
4:42:08 PM Tuesday, March 26, 2013
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did anyone else, such as an employer, a union or
Page 170 of 199
HIS33A
professional organization pay all or some portion of the premium or
cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
MHMOCOST
( HIS3280 )
PLRO.MHMOCOST
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS33B - MHMOWHO ( HIS3290 )
English text: YES
No
BOX HIS3B - (HIS3310 )
English text: NO
Attribute
Route
Don't know
BOX HIS3B - (HIS3310 )
Refusal
BOX HIS3B - (HIS3310 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
4
Respondent
On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
4:42:10 PM Tuesday, March 26, 2013
Page 171 of 199
HIS33A
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.
208
MIPPrevRnd
Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.
DESIGN NOTES
4:42:10 PM Tuesday, March 26, 2013
Page 172 of 199
HIS33B
HIS33B
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MHMOWHO
Field 2:
MHMOWHOS
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
1225
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
MIP:
If the respondent is the MIP, display "SP" .
Else display the name of the MIP.
Question display:
If respondent is MIP, display "you".
Else display the name of the MIP.
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATE PLAN NAME)
MIP: [(SP)/(MIP)]
Int. Instr I:
Question Text:
4:42:11 PM Tuesday, March 26, 2013
Who else paid all or some portion of the cost for [your/[MIP’s)]
(PRIVATE PLAN NAME) coverage?
Page 173 of 199
HIS33B
Int. Instr II:
INPUT FIELDS / ROUTING
4:42:12 PM Tuesday, March 26, 2013
Page 174 of 199
HIS33B
Field1:
MHMOWHO
PLRO.MHMOWHO
Cheshire Name:
Item Text display:
( HIS3290 )
[(SP'S)/(MIP'S)]: Display (MIP's), name of Main Insured
person, in response text for "1/CurrentEmployer",
"2/FormerEmployer", and "3/Union".
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TMhmowho
1
No
No
Number Label
1 CurrentEmployer
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS3B - (HIS3310 )
2
English text: [(SP's)/(MIP's)] CURRENT EMPLOYER
FormerEmployer
BOX HIS3B - (HIS3310 )
3
English text: (SP's/MIP's) FORMER EMPLOYER
Union
BOX HIS3B - (HIS3310 )
4
English text: (SP's/MIP's) UNION
SpousesCurrentEmployer
5
English text: SPOUSE'S CURRENT EMPLOYER
SpousesFormerEmployer
BOX HIS3B - (HIS3310 )
6
English text: SPOUSE'S FORMER EMPLOYER
ProfessionalOrg
BOX HIS3B - (HIS3310 )
7
English text: PROFESSIONAL/FRATERNAL ORGANIZATION
Medicaid
BOX HIS3B - (HIS3310 )
91
BOX HIS3B - (HIS3310 )
English text: MEDICAID/MEDICAL ASSISTANCE
Other
HIS33B - MHMOWHOS ( HIS3300 )
English text: OTHER
Attribute
Don't know
Route
BOX HIS3B - (HIS3310 )
Refusal
BOX HIS3B - (HIS3310 )
4:42:15 PM Tuesday, March 26, 2013
Page 175 of 199
HIS33B
Field2:
MHMOWHOS
( HIS3300 )
PLRO.MHMOWHOS
Cheshire Name:
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
OTHER (SPECIFY)
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 [Continuous answer.]
30
Route
BOX HIS3B - (HIS3310 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
4
Respondent
On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.
208
MIPPrevRnd
Main insured person (MIP) for this PLAN from previous
round =
PLAN.PLMIPNUM.
MIP name = ROST.ROSTFNAM + ROST.ROSTLNAM on
ROST where ROST.ROSTNUM = PLAN.PLMIPNUM.
DESIGN NOTES
4:42:15 PM Tuesday, March 26, 2013
Page 176 of 199
BOX HIS3B
BOX HIS3B
Page Order # :
1235
BOX INSTRUCTIONS
( HIS3310 )
IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO HIS33C
MHMOPOS ( HIS3320 ).
ELSE GO TO BOX HIS4 - (HIS3330 ).
ASSIGNMENTS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
209
ThisPrivPlanHMOPrevR
nd
This private plan was a managed care plan in the
previous round =
For this PLAN, there is a PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.PPRVHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
4:42:15 PM Tuesday, March 26, 2013
Page 177 of 199
HIS33C
HIS33C
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MHMOPOS
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1245
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display plan name for the plan being asked about, PLAN.PLNAME.
MIP:
If the respondent is the MIP, display "SP" .
Else display the name of the MIP.
Question display:
Display plan name for the plan being asked about, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PRIVATE PLAN: (PRIVATE PLAN NAME)
MIP: [(SP)/(MIP)]
REFERENCE PERIOD: (REFERENCE DATE)
REFERENCE DATE)
- (SUMMARY
Int. Instr I:
Question Text:
4:42:16 PM Tuesday, March 26, 2013
Some managed care plans offer a point-of-service option which
allows members to receive services from out-of-plan providers even
in non-emergency situations. Between (SUMMARY REFERENCE
DATE) and (REFERENCE DATE), [were you/was (SP)] enrolled in a
point-of-service option offered by (PRIVATE PLAN NAME)?
Page 178 of 199
HIS33C
[EXPLAIN IF NECESSARY: In a point-of-service option, the
member typically pays a higher copayment when seeing an out-of
plan provider. For example, if a member sees an in-plan provider,
there may only be a $10 copayment. However, the member may
have to pay 20 percent of the cost and the managed care plan will
pay 80 percent of the cost to receive the same service from an out-of
plan provider.]
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
MHMOPOS
( HIS3320 )
PLRO.MHMOPOS
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS4 - (HIS3330 )
English text: YES
No
BOX HIS4 - (HIS3330 )
English text: NO
Attribute
Route
Don't know
BOX HIS4 - (HIS3330 )
Refusal
BOX HIS4 - (HIS3330 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
4:42:17 PM Tuesday, March 26, 2013
Page 179 of 199
HIS33C
TECHNICAL NOTES
DESIGN NOTES
4:42:17 PM Tuesday, March 26, 2013
Page 180 of 199
BOX HIS4
BOX HIS4
Page Order # :
1255
BOX INSTRUCTIONS
( HIS3330 )
GO TO HIS20_IN - NAVIGATOR ( HIS2635 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
4:42:17 PM Tuesday, March 26, 2013
Page 181 of 199
HIS34
HIS34
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PLAN_HISMPDP
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Name:
Plan Roster
Roster Type:
Single Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
1265
Display as ' Add a Plan '
Display as ' Edit a Plan '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all health insurance plans from the Plan Roster.
Display plans in order of entry.
Display the following plans as protected rows:
Medicare plan
Medicare Managed Care plan
Medicaid
Tricare
Public Plans
Private Plans
Medicare Prescription Drug Plan if "current" at the time of the
previous round interview
Roster/Grid display:
COL #
1
4:42:18 PM Tuesday, March 26, 2013
HEADER
Plan Name
INSTRUCTIONS
Display PLAN.PLNAME.
Page 182 of 199
HIS34
2
Plan Type
Display PLAN.PLANTYPE:
1/Medicare, display "MCAR"
2/Medicaid, display "MCAD"
3/PublicPlan, display "PUBL"
4/PrivatePlan, display "PRIV"
5/MHMO, display "MHMO"
6/Tricare, display "TRIC"
7/MPDP, display "MPDP".
3
Plan Status
Display PREVIOUS ROUND PLAN
STATUS.
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What is the name of the Medicare Prescription Drug plan that
covered [you/(SP)]?
Int. Instr II:
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG
PLAN AT THIS ROSTER.
INPUT FIELDS / ROUTING
Field1:
PLAN_HISMPDP
( HIS3331 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TPlanPick32
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
32
Route
HIS35 - HISMPDPCURR ( HIS3332 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PLAN and PLRO:
PLAN key = PLAN.PLANBASE + PLAN.PLANNUM
PLAN.PLANNUM = Number of Plan selected at HIS34.
4:42:19 PM Tuesday, March 26, 2013
Page 183 of 199
HIS34
PLRO key = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
PLRO.PLROPLAN = PLAN.PLANNUM of Plan selected at HIS34.
PLRO.PLRORND = previous round.
If Plan added, see PLAN ROSTER POP-UP specifications for pop-up window programming
instructions:
Variables populated in Plan Roster Pop-Up Window:
PLAN.PLANNUM
PLAN.PLANRNDC
PLAN.PLANTYPE
PLAN.PLNAME
For Plan selected, create previous round PLRO where PLRO.PLROPLAN =
PLAN.PLANNUM of plan selected at HIS34 and PLRO.PLRORND = previous round.
Applicable remaining PLAN details will be stored on this previous round PLRO.
Previous round PLRO may already exist.
See additional instructions below:
PLANTYPE
If Plan is added at HIS34, set
PLAN.PLANTYPE=7/MPDP.
PLANRNDC
If Plan is added at HIS34, set PLAN.PLANRNDC =
current round.
PLANSUMM
If Plan is added at HIS34, set
PLAN.PLANSUMM=1/Yes.
COVANYTM
PLRO.COVANYTM=1/Yes for plan selected at HIS34.
PLROPLAN
PLRO.PLROPLAN = PLAN.PLANNUM of plan
selected at HIS34.
PLRORND
PLRO.PLRORND = previous round.
PLSUMFLG
Set PLRO.PLSUMFLG = 1.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
4:42:19 PM Tuesday, March 26, 2013
Page 184 of 199
HIS34
343
MPDPCurrPrevRnd
Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes). Exclude Deleted Plans. See
T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
HIS34 is also called from HIS10B1 when a Medicare Prescription Drug Plan
is reported through Medicaid coverage.
4:42:19 PM Tuesday, March 26, 2013
Page 185 of 199
HIS35
HIS35
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
HISMPDPCURR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1275
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Prescription Drug Plan selected at
HIS34, PLAN.PLNAME.
Question display:
Display the name of this Medicare Prescription Drug Plan selected
at HIS34, PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MPDP: (PREVIOUS ROUND CURRENT MEDICARE MANAGED
CARE PLAN NAME)
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
[Were you/Was (SP)] covered by or enrolled in (MEDICARE
PRESCRIPTION DRUG PLAN NAME) on (REFERENCE DATE)?
Int. Instr II:
INPUT FIELDS / ROUTING
4:42:19 PM Tuesday, March 26, 2013
Page 186 of 199
HIS35
Field1:
HISMPDPCURR
( HIS3332 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS5A - (HIS3333 )
English text: YES
No
BOX HIS6 - (HIS3335 )
English text: NO
Attribute
Route
Don't know
BOX HIS6 - (HIS3335 )
Refusal
BOX HIS6 - (HIS3335 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:42:20 PM Tuesday, March 26, 2013
Page 187 of 199
BOX HIS5A
BOX HIS5A
Page Order # :
1285
BOX INSTRUCTIONS
( HIS3333 )
OTHER THAN THE PLAN SELECTED AT HIS34, IF ANOTHER MEDICARE
PRESCRIPTION DRUG PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HIS36 - HISMPDPCHNG (
HIS3334 ).
ELSE GO TO BOX HIS6 - (HIS3335 ).
ASSIGNMENTS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
343
MPDPCurrPrevRnd
Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes). Exclude Deleted Plans. See
T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
DESIGN NOTES
There is a rule that the SP can only have one "current" Medicare
Prescription Drug plan at the time of the interview.
BOX HIS5A is called if the MPDP selected at HIS34 is reported as
"current" at the time of the previous round interview at HIS35
HISMPDPCURR.
The purpose of BOX HIS5A is determine if there is another MPDP
flagged as "current" at the time of the previous round interview. Should
only expect to find one "other" MPDP, if it exists.
If another MPDP is flagged as "current" at the time of the previous round
interview, BOX HIS5A is routed to HIS36 - HISMPDPCHNG to determine
if the "other" MPDP's status has changed.
4:42:20 PM Tuesday, March 26, 2013
Page 188 of 199
HIS36
HIS36
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
HISMPDPCHNG
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1305
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of the "other" Medicare Prescription Drug Plan that
was "current" at the time of the previous round interview,
PLAN.PLNAME.
Question display:
HIS36 is asking about the "other" MPDP that was current at the time
of the previous round interview, not the MPDP selected at HIS34.
Display the name of the "other" Medicare Prescription Drug Plan
that was "current" at the time of the previous round interview,
PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MPDP: (PREVIOUS ROUND CURRENT MEDICARE MANAGED
CARE PLAN NAME)
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
4:42:21 PM Tuesday, March 26, 2013
I recorded previously that (PREVIOUS ROUND CURRENT
MEDICARE PRESCRIPTION DRUG PLAN NAME) was [your/(SP’s)]
Page 189 of 199
HIS36
current Medicare Prescription Drug Plan on (REFERENCE DATE).
Has this information changed?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
HISMPDPCHNG
Cheshire Name:
( HIS3334 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS6 - (HIS3335 )
English text: YES
No
BOX HIS6 - (HIS3335 )
English text: NO
Attribute
Route
Don't know
BOX HIS6 - (HIS3335 )
Refusal
BOX HIS6 - (HIS3335 )
BACKGROUND VARIABLE ASSIGNMENTS
If HIS36 - HISMPDPCHNG = 1/Yes, we need to correct the status of the (other) Medicare
Prescription Drug plan that was current at the time of the previous round to "NOT
CURRENT". Set on PLRO where PLRO.PLRORND=previous round and
PLRO.PLROPLAN = this PLAN.PLANNUM.
Set variables as instructed below.
FUTURE SPEC: Log change to previous round plan on TRNS.
COVCURNT
If MHISMPDPCHNG = 1/Yes, set
PLRO.COVCURNT=2/No on previous round PLRO
for Medicare Prescription Drug plan that was current
at the time of the previous round interview.
4:42:22 PM Tuesday, March 26, 2013
Page 190 of 199
HIS36
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
343
MPDPCurrPrevRnd
Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes). Exclude Deleted Plans. See
T.N. 52.
Exclude plans stopped in HIS. See T.N. 476.
476
HISStoppedPlans
Plans stopped in HIS that are not valid for displays or
checks =
Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN
stopped in HIS.
DESIGN NOTES
4:42:22 PM Tuesday, March 26, 2013
Page 191 of 199
BOX HIS6
BOX HIS6
Page Order # :
1310
BOX INSTRUCTIONS
( HIS3335 )
IF THE PLAN SELECTED AT HIS34 HAS BEEN IDENTIFIED AS THE SP'S
CURRENT MEDICARE PRESCRIPTION DRUG PLAN AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, SET THE PREVIOUS ROUND STATUS OF
THIS PLAN TO "CURRENT". OTHERWISE, SET THE PREVIOUS ROUND
STATUS OF THIS PLAN TO "NOT CURRENT" .
GO TO BOX HIS6A - (HIS3336 ).
ASSIGNMENTS
Set status of Medicare Prescription Drug plan selected at HIS34.
Set status variable, PLRO.COVCURNT, on PLRO where PLRO.PLRORND=previous
round and PLRO.PLROPLAN = PLAN.PLANNUM selected at HIS34. Set as instructed
below.
COVCURNT
If (HISMPDPCURR=1/Yes and
HISMPDPCHNG=2/No,DK,RF) or
(HISMPDPCURR=2/No, DK or RF>), set
PLRO.COVCURNT=2/No.
Else if HISMPDPCURR=1/Yes and
(HISMPDPCHNG=1/Yes or EMPTY), set
PLRO.COVCURNT=1/Yes.
TECHNICAL NOTES
DESIGN NOTES
The purpose of BOX HIS6 is to set the status of the MPDP selected at
HIS34. Once status is set, all routes go to BOX HIS6A.
4:42:23 PM Tuesday, March 26, 2013
Page 192 of 199
BOX HIS6A
BOX HIS6A
Page Order # :
1315
BOX INSTRUCTIONS
( HIS3336 )
IF ((HIS35 - HISMPDPCURR = 2/No) OR (HIS36 - HISMPDPCHNG = 2/No)),
GO TO HIS37 - PDPYSTOP ( HIS3338 ).
ELSE GO TO HIS1 - HISCORRB ( HIS1030 ).
ASSIGNMENTS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
349
ThisMPDPCurrentPrevR
nd
This MPDP Plan was "current" at the time of the previous
round interview =
For this PLAN, there is a PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
4:42:23 PM Tuesday, March 26, 2013
Page 193 of 199
HIS37
HIS37
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
PDPYSTOP
Field 2:
PDPYSTOS
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
1325
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the name of this Medicare Prescription Drug Plan selected at
HIS34, PLAN.PLNAME.
Question display:
Display the name of this Medicare Prescription Drug Plan selected
at HIS34, PLAN.PLNAME.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
MPDP: (MEDICARE PRESCRIPTION DRUG PLAN NAME)
Int. Instr I:
Question Text:
What is the most important reason [you/(SP)] stopped the
(MEDICARE PRESCRIPTION DRUG PLAN NAME) coverage?
Int. Instr II:
INPUT FIELDS / ROUTING
4:42:24 PM Tuesday, March 26, 2013
Page 194 of 199
HIS37
Field1:
PDPYSTOP
( HIS3338 )
PLRO.PDPYSTOP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TPdpStop
1
No
No
Number Label
1 TooExpensive
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIS1 - HISCORRB ( HIS1030 )
2
English text: TOO EXPENSIVE OR COULDN'T AFFORD
DissatisfiedWithCoverage
HIS1 - HISCORRB ( HIS1030 )
3
English text: SP DISSATISFIED WITH PLAN'S COVERAGE
GetRxCoverage
HIS1 - HISCORRB ( HIS1030 )
4
English text: TO GET RX COVERAGE IN ANOTHER PLAN
DiffHealthCareCov
HIS1 - HISCORRB ( HIS1030 )
5
English text: TO GET DIFFERENT HEALTH CARE COVERAGE
NotMedicareRx
HIS1 - HISCORRB ( HIS1030 )
6
English text: PLAN NO LONGER CONTRACTS FOR MEDICARE RX COVERAGE
ChangedName
HIS1 - HISCORRB ( HIS1030 )
7
English text: PLAN NAME CHANGED OR PLAN WAS BOUGHT BY/MERGED WITH
ANOTHER PLAN
SPMoved
HIS1 - HISCORRB ( HIS1030 )
91
English text: SP MOVED OUT OF PLAN AREA
Other
HIS37 - PDPYSTOS ( HIS3339 )
English text: OTHER
Attribute
Don't know
Route
HIS1 - HISCORRB ( HIS1030 )
Refusal
HIS1 - HISCORRB ( HIS1030 )
4:42:26 PM Tuesday, March 26, 2013
Page 195 of 199
HIS37
Field2:
PDPYSTOS
( HIS3339 )
PLRO.PDPYSTOS
Cheshire Name:
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
OTHER (SPECIFY)
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
HIS1 - HISCORRB ( HIS1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:42:27 PM Tuesday, March 26, 2013
Page 196 of 199
HISCLOSE
HISCLOSE
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
ENDHIS
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1470
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
REFERENCE DATE: (REFERENCE DATE)
Int. Instr I:
Question Text:
That covers the health insurance [you/(SP)] had at the time of the
last interview. The next questions are about [your/(SP’s)] insurance
coverage between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION).
Int. Instr II:
INPUT FIELDS / ROUTING
4:42:27 PM Tuesday, March 26, 2013
Page 197 of 199
HISCLOSE
Field1:
ENDHIS
( HIS3340 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX HIS5 - (HIS3345 )
English text: CONTINUE
Attribute
Route
Empty
BOX HIS5 - (HIS3345 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
4:42:28 PM Tuesday, March 26, 2013
Page 198 of 199
BOX HIS5
BOX HIS5
Page Order # :
1480
BOX INSTRUCTIONS
( HIS3345 )
GO TO NEXT SECTION .
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
All SPs who receive HIS, also receive HI.
4:42:28 PM Tuesday, March 26, 2013
Page 199 of 199
| File Type | application/pdf |
| File Title | HIS_13.01.0001.pdf |
| Subject | HIS_13.01.0001.pdf |
| Author | CMS |
| File Modified | 2013-07-01 |
| File Created | 2013-03-26 |