Attachment C - R74 Medical Provider Terminology (Sept 2015)

Attachment C - R74 Medical Provider Terminology (Sept 2015).pdf

Medicare Current Beneficiary Survey (MCBS)

Attachment C - R74 Medical Provider Terminology (Sept 2015)

OMB: 0938-0568

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0568 can be found here:
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Health Insurance Summary (HIS): Updated medical provider terminology highlighted in green
Variable Name

MR Screen Name

Question type

HISINT

HISINTRO

no entry

HISCORRB

HIS1

code one

PLAN_DELETION

HIS2

roster

PLANDVB

HIS2A

verbatim text

PLAN_CORRECT

HIS2B

code one

PLAN_CORRECT_NAME HIS2B

verbatim text

PLAN_STOPPED

roster

HIS2C

Question text/description
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.
[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?
THIS QUESTION IS ASKING ABOUT PLANS THAT WERE CURRENT
BETWEEN [SUMMARY REFERENCE DATE] AND [REFERENCE DATE].
What is the name of the plan that needs deletion?
SELECT ONLY ONE PLAN FOR DELETION AT THIS ROSTER.
BRIEFLY EXPLAIN WHY THE PLAN NEEDS TO BE DELETED.
IF THE SP WAS EVER COVERED BY THIS INSURANCE PLAN, PRESS
[PgUp] SHIFT/ENTER TO GO BACK ONE SCREEN AND SELECT A
DIFFERENT RESPONSE.
What is the name of the plan that is incorrect?
EDIT ALL PLAN NAMES AT THIS ROSTER.
What is the correct name of the plan listed below?
What is the name of the plan that (you were/he was/she was) no
longer covered by as of (REFERENCE DATE)?
SELECT ONLY ONE PLAN TO STOP IN THE PREVIOUS ROUND AT THIS
ROSTER.

Code list

Text Fill Logic

Input mask

Routing
HIS1 - HISCORRB

(01) YES, ALL CORRECT AS SHOWN
(02) NO, PLAN MISSING
(03) NO, PLAN NAME INCORRECT
(04) NO, PLAN NEEDS DELETION
(05) NO, PLAN STOPPED PRIOR TO (REFERENCE DATE)
(-8) Don't Know
(-9) Refused

[you] respondent is SP
[(SP)] respondent is proxy
[(You/(SP)] had Medicare coverage (through a
managed care plan) and (you were/he was/she was)
also covered by [READ PLAN NAMES BELOW].
respondent is SP or proxy, SP is alive and not
institutionalized, SP is alive and institutionalized
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was] respondent is proxy, SP is female

(01) HISCLOSE - ENDHIS
(02) HIS3 - ADDHITYPE
(03) HIS2B - PLAN_CORRECT
(04) HIS2 - PLAN_DELETION
(05) HIS2C - PLAN_STOPPED
(-8) HISCLOSE - ENDHIS
(-9) HISCLOSE - ENDHIS

(01) continuous answer

HIS2A - PLANDVB

(01) continuous answer

HIS1 - HISCORRB

(01) continuous answer

PLAN_CORRECT_NAME

(01) continuous answer

HIS1 - HISCORRB

(01) continuous answer
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

[you were] respondent is SP
[he was] respondent is proxy, SP male
[she was] respondent is proxy, SP female

HISSTPMM

HIS2D

date

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

HISSTPDD

HIS2D

date

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

HISSTPYY

HIS2D

date

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

PLANSVB

HIS2E

verbatim text

BRIEFLY EXPLAIN WHY THE PLAN SHOULD BE STOPPED.
IF DATE WHEN PLAN STOPPED IS NOT KNOWN, PROVIDE ANY
ADDITIONAL INFORMATION ABOUT WHEN THE PLAN STOPPED.

(01) continuous answer

HIS1 - HISCORRB

What type of insurance plan needs to be added?

(01) MEDICAID/MEDICAID MANAGED CARE PLAN
(02) PUBLIC PLAN OTHER THAN MEDICAID
(03) PRIVATE HEALTH INSURANCE PLAN
(04) MEDICARE ADVANTAGE PLAN
(05) TRICARE
(06) MEDICARE PRESCRIPTION DRUG PLAN

(01) BOX HIS2AA
(02) HIS12 - PLAN_HISPUBLIC
(03) HIS18A - EXCHGCOV
(04) HISMC1 - PLAN_HISMHMO
(05) BOX HIST1A
(06) HIS34 - PLAN_HISMPDP

ADDHITYPE

PLAN_HISMHMO

HIS3

HISMC1

code one

roster

What is the name of the Medicare Advantage Plan that covered
[you/(SP)]?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS
ROSTER.

(01) continuous answer

[your] respondent is SP
[(SP's)] respondent is proxy

HIS2D - HISSTPMM

MM

HIS2D - HISSTPDD

[your] respondent is SP
[(SP's)] respondent is proxy

DD

HIS2D - HISSTPYY

[your] respondent is SP
[(SP's)] respondent is proxy

YY

HIS2E - PLANSVB

[you] respondent is SP
[(SP)] respondent is proxy

HISMC2 - HISMHMOCURR

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
HISMHMOCURR

HISMC2

BOX HISMC1

HISMHMOCHNG

HISMC3

yes/no

routing

yes/no

[Were you/Was (SP)] covered by or enrolled in (MEDICARE
MANAGED CARE PLAN NAME) on (REFERENCE DATE)?
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.
ELSE GO TO BOX HISMC2.
I recorded previously that (PREVIOUS ROUND CURRENT MEDICARE
MANAGED CARE PLAN NAME) was [your/(SP’s)] current Medicare
Advantage Plan on (REFERENCE DATE). Has this information
changed?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Were you] respondent is SP
[Was SP] respondent is proxy

[your] respondent is SP
[(SP's)] respondent is proxy

(01) BOX HISMC1
(02) BOX HISMC2
(-8) BOX HISMC2
(-9) BOX HISMC2

BOX HISMC2

BOX HISMC2

routing

BOX HISMC2A

routing

MHMORX

HISMC4

yes/no

MHMODENT

HISMC5

yes/no

MHMOEYE

HISMC6

yes/no

MHMONH

HISMC8

yes/no

MHMOPAY

HISMC9

yes/no

MHMOAMT

HISMC10

numeric

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.
IF THIS MEDICARE MANAGED CARE PLAN WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HISMC4 MHMORX.
ELSE GO TO HIS1 - HISCORRB.
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did
[you/(SP)] have prescribed medicine coverage through (MEDICARE
(01) YES
MANAGED CARE PLAN NAME)?
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that
(-9) Refused
[you/(SP)] personally had, not what the plan offers everyone.]
(01) YES
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did
(02) NO
[you/(SP)] have dental coverage through (MEDICARE MANAGED
(-8) Don't Know
CARE PLAN NAME)?
(-9) Refused
(01) YES
Did [you/(SP)] have optical coverage through (MEDICARE MANAGED (02) NO
CARE PLAN NAME), that is, for eyeglasses or contact lenses?
(-8) Don't Know
(-9) Refused
Did [your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME) coverage
include nursing home care above and beyond what Medicare
normally covers?
(01) YES
(02) NO
[EXPLAIN IF NECESSARY: Under regular fee-for-service, Medicare
(-8) Don't Know
pays for limited skilled nursing facility (SNF) care during a benefit
(-9) Refused
period. In 2014, the first 20 days are paid in full and the next 80 days
require a copayment of up to $152.00 per day.]
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.
(01) YES
(02) NO
[EXPLAIN IF NECESSARY: Some managed care plans may charge a
(-8) Don't Know
monthly premium to cover the cost of the deductibles and
(-9) Refused
coinsurance for Medicare-covered services or because they provide
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.]
Not including the cost of [your/(SP’s)] Medicare Part B premium,
what was the additional amount that [you/(SP)] paid for
(your/his/her) (MEDICARE MANAGED CARE PLAN NAME) coverage?
(01) continuous answer
[Please do not include any copayments or any amount that may be
(-8) Don't Know
paid for anyone other than [you/(SP)].]
(-9) Refused
[PROBE IF NECESSARY: Was that per year, per month, per week, or
what?]

MHMOUNIT

HISMC10

code one

MHMOUNOS

HISMC10

verbatim text

MHMOCOST

HISMC11

yes/no

OTHER (SPECIFY)
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?
[DO NOT INCLUDE AMOUNTS PAID BY FAMILY MEMBERS.]

[you] respondent is SP
[(SP)] respondent is proxy

[you] respondent is SP
[(SP)] respondent is proxy

[you] respondent is SP
[(SP)] respondent is proxy

[your] respondent is SP
[(SP's)] respondent is proxy

[your] respondent is SP
[(SP's)] respondent is proxy

[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy

HISMC5 - MHMODENT

HISMC6 - MHMOEYE

HISMC8 - MHMONH

HISMC9 - MHMOPAY

(01) HISMC10 - MHMOAMT
(02) HIS1 - HISCORRB
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB

(01) HISMC10 - MHMOUNIT
(-8) HISMC11 - MHMOCOST
(-9) HISMC11 - MHMOCOST

(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer

(01) HISMC11 - MHMOCOST
(02) HISMC11 - MHMOCOST
(03) HISMC11 - MHMOCOST
(04) HISMC11 - MHMOCOST
(05) HISMC11 - MHMOCOST
(06) HISMC11 - MHMOCOST
(07) HISMC11 - MHMOCOST
(91) HISMC10 - MHMOUNOS
(-8) HISMC11 - MHMOCOST
(-9) HISMC11 - MHMOCOST
HISMC11 - MHMOCOST

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HISMC12 - MHMOWHO
(02) HIS1 - HISCORRB
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB

[your] respondent is SP
[(SP's)] respondent is proxy

MHMOWHO

HISMC12

code one

MHMOWHOS

HISMC12

verbatim text

BOX HIS2AA

routing

COVTIME

HIS6

code one

COVNOW

HIS7

yes/no

COVBEGMM

HIS8

date

COVBEGDD

HIS8

date

COVBEGYY

HIS8

date

COVENDMM

HIS9

date

COVENDDD

HIS9

date

COVENDYY

HIS9

date

MCAIDHMO

HIS10A

yes/no

BOX HIS2C

routing

HISMPDCOVER

MCDRXCOV

COVTIME

Who else paid all or some portion of the additional cost for
[your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME) coverage?

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

(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer

(01) THE WHOLE TIME
[Were you/Was (SP)] covered by Medicaid the whole time between
(02) PART OF THE TIME
(SUMMARY REFERENCE DATE) and (REFERENCE DATE), or only part of
(-8) Don't Know
the time?
(-9) Refused
(01) YES
(02) NO
[Were you/Was (SP)] covered by Medicaid on (REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
(01) continuous answer
On what date did [your/(SP’s)] Medicaid start between (SUMMARY
(-8) Don't Know
REFERENCE DATE) and (REFERENCE DATE)?
(-9) Refused
(01) continuous answer
On what date did [your/(SP’s)] Medicaid start between (SUMMARY
(-8) Don't Know
REFERENCE DATE) and (REFERENCE DATE)?
(-9) Refused
(01) continuous answer
On what date did [your/(SP’s)] Medicaid start between (SUMMARY
(-8) Don't Know
REFERENCE DATE) and (REFERENCE DATE)?
(-9) Refused
(01) continuous answer
On what date between (SUMMARY REFERENCE DATE) and
(-8) Don't Know
(REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?
(-9) Refused
(01) continuous answer
On what date between (SUMMARY REFERENCE DATE) and
(-8) Don't Know
(REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?
(-9) Refused
(01) continuous answer
On what date between (SUMMARY REFERENCE DATE) and
(-8) Don't Know
(REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?
(-9) Refused
Some states now use managed care plans, such as HMOs (Health
(01) YES
Maintenance Organizations), to provide some or all health care for
(02) NO
Medicaid beneficiaries. [Were you/Was (SP)] enrolled in a Medicaid
(-8) Don't Know
Managed Care Plan on [(REFERENCE DATE)/(PLAN COVERAGE STOP
(-9) Refused
DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
IF THERE IS A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS
"CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO
TO HIS1 - HISCORRB.
ELSE GO TO HIS10B1 - HISMPDCOVER.

yes/no

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, (01) YES
although the beneficiary may choose to switch to a different plan.
(02) NO
(-8) Don't Know
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE),
(-9) Refused
[were you/was (SP)] enrolled in a Medicare Prescription Drug plan
that covered medicines prescribed by a doctor or other health
professional?

HIS10C

yes/no

Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did
[your/(SP’s)] Medicaid plan cover medicines prescribed by a doctor
or other health professional?

BOX HIST1A

routing

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

code one

(01) THE WHOLE TIME
[Were you/Was (SP)] covered by TRICARE the whole time between
(02) PART OF THE TIME
(SUMMARY REFERENCE DATE) and (REFERENCE DATE), or only part of
(-8) Don't Know
the time?
(-9) Refused

HIS10B1

HIST1

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HIS1 - HISCORRB
(02) HIS1 - HISCORRB
(03) HIS1 - HISCORRB
(04) HIS1 - HISCORRB
(05) HIS1 - HISCORRB
(06) HIS1 - HISCORRB
(07) HIS1 - HISCORRB
(91) HISMC12 - MHMOWHOS
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB
HIS1 - HISCORRB

[your] respondent is SP
[(SP's)] respondent is proxy

(01) HIS10A - MCAIDHMO
(02) HIS7 - COVNOW
(-8) HIS7 - COVNOW
(-9) HIS7 - COVNOW
(01) HIS8 - COVBEGMM
(02) HIS9 - COVENDMM
(-8) HIS10A - MCAIDHMO
(-9) HIS10A - MCAIDHMO

[Were you] respondent is SP
[Was SP] respondent is proxy

[Were you] respondent is SP
[Was SP] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy

MM

HIS8 - COVBEGDD

[your] respondent is SP
[(SP's)] respondent is proxy

DD

HIS8 - COVBEGYY

[your] respondent is SP
[(SP's)] respondent is proxy

YY

HIS10A - MCAIDHMO

[your] respondent is SP
[(SP's)] respondent is proxy

MM

HIS9 - COVENDDD

[your] respondent is SP
[(SP's)] respondent is proxy

DD

HIS9 - COVENDYY

[your] respondent is SP
[(SP's)] respondent is proxy

YY

HIS10A - MCAIDHMO

[Were you] respondent is SP
[Was SP] respondent is proxy

BOX HIS2C

[Were you] respondent is SP
[Was SP] respondent is proxy

(01) HIS34 - PLAN_HISMPDP
(02) HIS10C - MCDRXCOV
(-8) HIS10C - MCDRXCOV
(-9) HIS10C - MCDRXCOV

[your] respondent is SP
[(SP's)] respondent is proxy

HIS1 - HISCORRB

[Were you] respondent is SP
[Was (SP)] respondent is proxy

(01) HIST3 - TRIRXCOV
(02) HIST2 - COVNOW
(-8) HIST2 - COVNOW
(-9) HIST2 - COVNOW

COVNOW

TRIRXCOV

HIST2

HIST3

yes/no

yes/no

TRIMEDS

HIST3AA

code one

TRIMEDOS

HIST3AA

verebatim text

PLAN_HISPUBLIC

HIS12

roster

NAVIGATOR

HIS12_IN

instance navigator

COVTIME

HIS13

code one

COVNOW

HIS14

yes/no

COVBEGMM

HIS15

date

COVBEGDD

HIS15

date

COVBEGYY

HIS15

date

COVENDMM

HIS16

date

COVENDDD

HIS16

date

COVENDYY

HIS16

date

BOX HIS2B1

routing

HIS16A

yes/no

BOX HIS3

routing

PUBRXCOV

EXCHGCOV

HIS18A

yes/no

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

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did
[your/(SP’s)] TRICARE plan cover medicines prescribed by a doctor or (01) YES
other health professional?
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that
(-9) Refused
[you/(SP)] personally had, not what the plan offers everyone.]
(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE),
(02) A TRICARE RETAIL PHARMACY NETWORK PHARMACY
where did [you/(SP)] usually obtain (your/his/her) medicines? Did
(TRRX)
[you/(SP)] usually obtain them at a TRICARE mail order pharmacy
(03) A MILITARY TREATMENT FACILITY PHARMACY (MTF)
(TMOP), a TRICARE retail pharmacy network pharmacy (TRRx), a
(04) A NON-NETWORK RETAIL PHARMACY
military treatment facility pharmacy (MTF), a non-network retail
(91) SOMEWHERE ELSE
pharmacy, or somewhere else?
(-8) Don't Know
(-9) Refused
SOMEWHERE ELSE (SPECIFY)
(01) continuous answer
What is the name of the public program that covered [you/(SP)]?
(01) continuous answer
SELECT OR ADD ALL PUBLIC PROGRAM NAMES AT THIS ROSTER.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) THE WHOLE TIME
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) the whole
(02) PART OF THE TIME
time between (SUMMARY REFERENCE DATE) and (REFERENCE DATE),
(-8) Don't Know
or only part of the time?
(-9) Refused
(01) YES
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) on
(02) NO
(REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
(01) continuous answer
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start
(-8) Don't Know
between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
(-9) Refused
(01) continuous answer
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start
(-8) Don't Know
between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
(-9) Refused
(01) continuous answer
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start
(-8) Don't Know
between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
(-9) Refused
On what date between (SUMMARY REFERENCE DATE) and
(01) continuous answer
(REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME) coverage (-8) Don't Know
stop?
(-9) Refused
On what date between (SUMMARY REFERENCE DATE) and
(01) continuous answer
(REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME) coverage (-8) Don't Know
stop?
(-9) Refused
On what date between (SUMMARY REFERENCE DATE) and
(01) continuous answer
(REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME) coverage (-8) Don't Know
stop?
(-9) Refused
GO TO HIS16A - PUBRXCOV.
(01) YES
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did
(02) NO
[your/(SP’s)] (PUBLIC PLAN NAME) plan cover medicines prescribed
(-8) Don't Know
by a doctor or other health professional?
(-9) Refused
GO TO HIS12_IN - NAVIGATOR.
SHOW CARD HI5
As you may know, every state now offers a health insurance
marketplace, also referred to as an exchange.
The marketplace, known as (STATE MARKETPLACE NAME), allows
residents to compare and purchase available health insurance
options that meet their needs. While most Medicare beneficiaries
are not eligible for insurance from a health insurance marketplace,
there are some special circumstances that allow enrollment.
Please look at this card. At any time between (SUMMARY REFERENCE
DATE) and (REFERENCE DATE) [were you/was (SP)] enrolled in or
covered by one of these exchange plans?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Were you] respondent is SP
[Was (SP)] respondent is proxy

HIST3 - TRIRXCOV

[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy

(01) HIST3AA - TRIMEDS
(02) HIS1 - HISCORRB
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB

[you] respondent is SP
[(SP)] respondent is proxy

(01) HIS1 - HISCORRB
(02) HIS1 - HISCORRB
(03) HIS1 - HISCORRB
(04) HIS1 - HISCORRB
(91) HIST3AA - TRIMEDOS
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB
HIS1 - HISCORRB

[you] respondent is SP
[(SP)] respondent is proxy

HIS12_IN - NAVIGATOR
(01) HIS13 - COVTIME
(02) HIS1 - HISCORRB
(01) BOX HIS2B1
(02) HIS14 - COVNOW
(-8) HIS14 - COVNOW
(-9) HIS14 - COVNOW
(01) HIS15 - COVBEGMM
(02) HIS16 - COVENDMM
(-8) BOX HIS2B1
(-9) BOX HIS2B1

[Were you] respondent is SP
[Was SP] respondent is proxy

[Were you] respondent is SP
[Was SP] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy

MM

HIS15 - COVBEGDD

[your] respondent is SP
[(SP's)] respondent is proxy

DD

HIS15 - COVBEGYY

[your] respondent is SP
[(SP's)] respondent is proxy

YY

BOX HIS2B1

[your] respondent is SP
[(SP's)] respondent is proxy

MM

HIS16 - COVENDDD

[your] respondent is SP
[(SP's)] respondent is proxy

DD

HIS16 - COVENDYY

[your] respondent is SP
[(SP's)] respondent is proxy

YY

BOX HIS2B1

[your] respondent is SP
[(SP's)] respondent is proxy

[were you] respondent is SP
[was (SP)] respondent is proxy

BOX HIS3

HIS20 - PLAN_HISPRIVATE

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)?
SELECT OR ADD ONE PRIVATE PLAN NAME AT THIS ROSTER.

PLAN_HISPRIVATE

HIS20

roster

NAVIGATOR

HIS20_IN

instance navigator

COVTIME

HIS21

code one

[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?

COVNOW

HIS22

yes/no

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

COVBEGMM

HIS23

date

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

COVBEGDD

HIS23

date

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

COVBEGYY

HIS23

date

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

COVENDMM

HIS24

date

COVENDDD

HIS24

date

COVENDYY

HIS24

date

BOX HIS3A1

routing

PPRVHMO

HIS25

yes/no

PERS_HISMIPNUM

HIS26

roster

PPRVGET

HIS27

code one

PPRVGTOS

HIS27

verbatim text

PRVNMCOV

HIS29

numeric

(01) continuous answer
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) stop?
On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) stop?
On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) stop?
GO TO HIS25 - PPRVHMO.
CODE WITHOUT ASKING IF VOLUNTEERED.
Was this a managed care plan, such as an HMO (Health Maintenance
Organization) or PPO (Preferred Provider Organization)?
(01) YES
(02) NO
[EXPLAIN IF NECESSARY: Managed care plans generally provide a full (-8) Don't Know
range of health care services for a prepaid fee. Health care is
(-9) Refused
generally provided by primary care doctors, specialists, or hospitals
on the plan’s list (network) except in an emergency.]
Who was listed as the main insured person on the (PRIVATE PLAN
NAME) policy or contract?
(01) continuous answer
SELECT OR ADD ONLY ONE PERSON.
(01) DIRECTLY
(02) (MIP'S) CURRENT EMPLOYER
(03) (MIP'S) FORMER EMPLOYER
(04) (MIP'S) UNION
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up directly (05) (MIP'S) FAMILY BUSINESS
with the (insurance company/managed care plan), or did [you/(MIP)] (06) AARP
get this insurance through a current employer, a former employer, a (07) DECEASED SPOUSE'S EMPLOYER
union, a family business, AARP, or some other way?
(08) DECEASED SPOUSE'S UNION
(09) PROFESSIONAL/FRATERNAL ORGANIZATION
(91) SOME OTHER WAY
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
(01) continuous answer
How many family members, including [yourself/(SP)], were covered
by [your/(MIP’s)] (PRIVATE PLAN NAME) between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE)?

(01) continuous answer
(-8) Don't Know
(-9) Refused

[your] respondent is SP
[(SP's)] respondent is proxy

HIS20_IN - NAVIGATOR
(01) HIS21 - COVTIME
(02) HIS1 - HISCORRB
(01) BOX HIS3A1
(02) HIS22 - COVNOW
(-8) HIS22 - COVNOW
(-9) HIS22 - COVNOW
(01) HIS23 - COVBEGMM
(02) HIS24 - COVENDMM
(-8) BOX HIS3A1
(-9) BOX HIS3A1

[Were you] respondent is SP
[Was SP] respondent is proxy

[Were you] respondent is SP
[Was SP] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy

MM

HIS23 - COVBEGDD

[your] respondent is SP
[(SP's)] respondent is proxy

DD

HIS23 - COVBEGYY

[your] respondent is SP
[(SP's)] respondent is proxy

YY

BOX HIS3A1

[your] respondent is SP
[(SP's)] respondent is proxy

MM

HIS24 - COVENDDD

[your] respondent is SP
[(SP's)] respondent is proxy

DD

HIS24 - COVENDYY

[your] respondent is SP
[(SP's)] respondent is proxy

YY

BOX HIS3A1

HIS26 - PERS_HISMIPNUM

HIS27 - PPRVGET

[you] respondent is MIP
[MIP] respondent is not MIP

[yourself] respondent is MIP
(SP) respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP

(01) HIS29 - PRVNMCOV
(02) HIS29 - PRVNMCOV
(03) HIS29 - PRVNMCOV
(04) HIS29 - PRVNMCOV
(05) HIS29 - PRVNMCOV
(06) HIS29 - PRVNMCOV
(07) HIS29 - PRVNMCOV
(08) HIS29 - PRVNMCOV
(09) HIS29 - PRVNMCOV
(91) HIS27 - PPRVGTOS
(-8) HIS29 - PRVNMCOV
(-9) HIS29 - PRVNMCOV
HIS29 - PRVNMCOV
HIS31A - PRVRXCOV

PRVRXCOV

PRVMSCOV

PRVIPCOV

PRVNHCOV

MHMODENT

HIS31A

HIS31A

HIS31A

HIS31A

HIS31A

list

list

list

list

list

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)
(01) YES
and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that
(-9) Refused
[you/(SP)] personally had, not what the plan offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
prescribed medicines?
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)
(01) YES
and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that
(-9) Refused
[you/(SP)] personally had, not what the plan offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
doctor visits or lab work?
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)
(01) YES
and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that
(-9) Refused
[you/(SP)] personally had, not what the plan offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
inpatient hospital care?
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)
(01) YES
and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that
(-9) Refused
[you/(SP)] personally had, not what the plan offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
nursing home or long term care?
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)
(01) YES
and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that
(-9) Refused
[you/(SP)] personally had, not what the plan offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
dental care?
Was there a premium or cost for the (PRIVATE PLAN NAME)
coverage?

MIPPINS

MIPPAMT

HIS32

HIS33

yes/no

numeric

(01) YES
(02) NO
(-8) Don't Know
[Do not include the cost of any deductibles [you/(SP)] or [your/(SP’s)]
(-9) Refused
family may have had to pay.]
How much did [you/(MIP)] pay for the (PRIVATE PLAN NAME)
coverage?
(01) continuous answer
[Please do not include any amount that may be paid for anyone other
(-8) Don't Know
than [you/(SP)].]
(-9) Refused
[PROBE IF NECESSARY: Was that per year, per month, per week, or
what?]

[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP

HIS31A - PRVMSCOV

[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP

HIS31A - PRVIPCOV

[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP

HIS31A - PRVNHCOV

[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP

HIS31A - MHMODENT

[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP

HIS32 - MIPPINS

[you] respondent is SP
(SP]respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy

(01) HIS33 - MIPPAMT
(02) HIS33A - MHMOCOST
(-8) HIS33A - MHMOCOST
(-9) HIS33A - MHMOCOST

[you] respondent is MIP
[MIP] respondent is not MIP
[you] respondent is SP
[(SP)] respondent is proxy

(01) HIS33 - MIPPUNIT
(-8) HIS33A - MHMOCOST
(-9) HIS33A - MHMOCOST

MIPPUNIT

HIS33

code one

MIPPUNOS

HIS33

verbatim text

MHMOCOST

HIS33A

yes/no

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

(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HIS33A - MHMOCOST
(02) HIS33A - MHMOCOST
(03) HIS33A - MHMOCOST
(04) HIS33A - MHMOCOST
(05) HIS33A - MHMOCOST
(06) HIS33A - MHMOCOST
(07) HIS33A - MHMOCOST
(91) HIS33 - MIPPUNOS
(-8) HIS33A - MHMOCOST
(-9) HIS33A - MHMOCOST
HIS33A - MHMOCOST

[your] respondent is MIP
[MIP's] respondent is not MIP

(01) HIS33B - MHMOWHO
(02) BOX HIS3B
(03) BOX HIS3B
(04) BOX HIS3B

[DO NOT INCLUDE AMOUNTS PAID BY FAMILY MEMBERS.]

MHMOWHO

HIS33B

code one

MHMOWHOS

HIS33B

verbatim text

BOX HIS3B

routing

MHMOPOS

PLAN_HISMPDP

HIS33C

yes/no

BOX HIS4

routing

HIS34

roster

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

OTHER (SPECIFY)
IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO HIS33C MHMOPOS.
ELSE GO TO BOX HIS4.
Some managed care plans offer a point-of-service option which
allows members to receive services from out-of-plan providers even
in non-emergency situations. Between (SUMMARY REFERENCE
DATE) and (REFERENCE DATE), [were you/was (SP)] enrolled in a
point-of-service option offered by (PRIVATE PLAN NAME)?
[EXPLAIN IF NECESSARY: In a point-of-service option, the member
typically pays a higher copayment when seeing an out-of-plan
provider. For example, if a member sees an in-plan provider, there
may only be a $10 copayment. However, the member may have to
pay 20 percent of the cost and the managed care plan will pay 80
percent of the cost to receive the same service from an out-of-plan
provider.]
GO TO HIS20_IN - NAVIGATOR.
What is the name of the Medicare Prescription Drug plan that
covered [you/(SP)]?
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN AT
THIS ROSTER.

(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer

[your] respondent is MIP
[MIP's] respondent is not MIP

(01) BOX HIS3B
(02) BOX HIS3B
(03) BOX HIS3B
(04) BOX HIS3B
(05) BOX HIS3B
(06) BOX HIS3B
(07) BOX HIS3B
(91) HIS33B - MHMOWHOS
(-8) BOX HIS3B
(-9) BOX HIS3B
BOX HIS3B

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Were you] respondent is SP
[Was (SP)] respondent is proxy

BOX HIS4

(01) continuous answer

[you] respondent is SP
[(SP)] respondent is proxy

HIS35 - HISMPDPCURR

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Were you] respondent is SP
[Was (SP)] respondent is proxy

(01) BOX HIS5A
(02) BOX HIS6
(-8) BOX HIS6
(-9) BOX HIS6

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[your] respondent is SP
[(SP's)] respondent is proxy

BOX HIS6

[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
HISMPDPCURR

HIS35

BOX HIS5A

HISMPDPCHNG

HIS36

yes/no

[Were you/Was (SP)] covered by or enrolled in (MEDICARE
PRESCRIPTION DRUG PLAN NAME) on (REFERENCE DATE)?

routing

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.
ELSE GO TO BOX HIS6.

yes/no

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

BOX HIS6

routing

BOX HIS6A

routing

PDPYSTOP

HIS37

code one

PDPYSTOS

HIS37

verbatim text

ENDHIS

HISCLOSE

no entry

BOX HIS5

routing

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

What is the most important reason [you/(SP)] stopped the
(MEDICARE PRESCRIPTION DRUG PLAN NAME) coverage?

OTHER (SPECIFY)
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).
GO TO NEXT SECTION (HIQ)

(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH PLAN'S COVERAGE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET DIFFERENT HEALTH CARE COVERAGE
(05) PLAN NO LONGER CONTRACTS FOR MEDICARE RX
COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) SP MOVED OUT OF PLAN AREA
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer

[you] respondent is SP
[(SP)] respondent is proxy

(01) HIS1 - HISCORRB
(02) HIS1 - HISCORRB
(03) HIS1 - HISCORRB
(04) HIS1 - HISCORRB
(05) HIS1 - HISCORRB
(06) HIS1 - HISCORRB
(07) HIS1 - HISCORRB
(91) HIS37 - PDPYSTOS
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB
HIS1 - HISCORRB

[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy

BOX HIS5

Health Insurance (HIQ): Updated medical provider terminology highlighted in green
Variable Name
MR Screen Name
Question type
Question text/description)
Code list
IF (SP IS IN THE SUPPLEMENTAL SAMPLE), GO TO HIMCINTR 5 BOX HIBEG
routing
HIINTR1.
ELSE GO TO BOX MC1AA.
SHOW CARD HI1
The next questions are about [your/(SP's)] health insurance
benefits. This card outlines the types of health insurance that I’ll be
asking you about. [INTERVIEWER SHOULD POINT TO HEALTH
INSURANCE OPTIONS ON FRONT OF SHOWCARD HIMC1.] Please
refer to this card as we talk about [your/(SP’s)] health insurance
coverage.
HIINTR1

HIMCINTR

no entry

It would also be helpful if I could look at a health plan card or
something with the plan name on it. These materials will ensure
that I record the information accurately.

Text Fill Logic

Input mask

Routing

[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy

BOX MC1AA

[you are] respondent is SP
[(SP) is] respondent is proxy

(01) BOX HIMC1
(02) MC2 - WHATWRNG
(-8) MC11 - REFERMED
(-9) BOX HIMC4

(EXPAIN IF NECESSARY: We ask about health insurance coverage
because it is important to understand how beneficiaries cover the
costs of their medical care, such as doctor visits, prescribed
medicines, and hospital stays.)

BOX MC1AA

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (SP HAS A LOADED
CMS MEDICARE MANAGED CARE PLAN), GO TO MC1 - LOADCORR.
ELSE IF (SP IS NOT IN THE SUPPLEMENTAL SAMPLE) AND (SP HAS A
MEDICARE MANAGED CARE PLAN THAT WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW), GO TO HIMC1A MHMOSAME.
ELSE GO TO HIMC1 - MHMOCOV.
As you (may) know, Medicare beneficiaries can enroll in either
Original Medicare or a Medicare Advantage plan, such as an HMO
(Health Maintenance Organization) and PPO (Preferred Provider
Organization).

LOADCORR

MC1

yes/no

(01) YES
(02) NO
According to Medicare records, [you are/(SP) is] currently enrolled
(-8) Don't Know
in a Medicare Advantage Plan called (CMS MEDICARE MANAGED
(-9) Refused
CARE PLAN NAME). Is this information correct?
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

WHATWRNG

YDISNROL

MC2

MC2B

code 1

code 1

(01) SP DISENROLLED FROM (CMS MHMO PLAN
NAME), ENROLLED IN NEW MEDICARE ADVANTAGE
PLAN
(02) SP HAS PLAN CALLED (CMS MHMO PLAN NAME),
R DOESN'T THINK IT'S A MEDICARE ADVANTAGE PLAN
How is this information incorrect?
(03) SP NOW DISENROLLED FROM (CMS MHMO PLAN
SELECT ONLY ONE. IF MORE THAN ONE RESPONSE IS APPLICABLE,
NAME), NO LONGER IN ANY MEDICARE ADVANTAGE
SELECT THE RESPONSE THAT IS CLOSEST TO THE TOP OF THE LIST.
PLAN
(04) SP ENROLLED IN MEDICARE ADVANTAGE PLAN,
BUT NEVER (CMS MHMO PLAN NAME)
(05) SP NEVER COVERED BY OR ENROLLED IN (CMS
MHMO PLAN NAME)

What is the most important reason [you/(SP)] stopped the (CMS
MEDICARE MANAGED CARE PLAN NAME) coverage?

(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) MC2B - YDISNROL
(02) MC3 - PRIMPHYS
(03) MC2B - YDISNROL
(04) MC4 - SAMEPLAN
(05) MC11 - REFERMED

[you] respondent is SP
[(SP)] respondent is proxy

(01) BOX MC1A
(02) BOX MC1A
(03) BOX MC1A
(04) BOX MC1A
(05) BOX MC1A
(06) BOX MC1A
(07) BOX MC1A
(08) BOX MC1A
(09) BOX MC1A
(10) BOX MC1A
(11) BOX MC1A
(91) MC2B - YDISNROS
(-8) BOX MC1A
(-9) BOX MC1A

YDISNROS

MC2B
BOX MC1A

PRIMPHYS

SAMEPLAN

PLAN_MHMOMCA

MC3

MC4

MC5

verbatim text
routing

yes/no

code 1

roster

[you] respondent is SP
[(SP)] respondent is proxy

BOX MC1A

[Do you] respondent is SP
[Does (SP)] respondent is proxy

BOX HIMC1

[your] respondent is SP
[(SP's)] respondent is proxy

(01) BOX HIMC1
(02) MC5 - PLAN_MHMOMCA
(-8) MC5 - PLAN_MHMOMCA
(-9) MC5 - PLAN_MHMOMCA

[your] respondent is SP
[(SP's)] respondent is proxy

BOX HIMC1

[your] respondent is SP
[(SP's)] respondent is proxy

(01) BOX HIMC4
(02) MC12 - PLAN_MHMOMCB
(-8) BOX HIMC4
(-9) BOX HIMC4

[your] respondent is SP
[(SP's)] respondent is proxy

BOX HIMC1

[you were] respondent is SP
[(SP) was] respondent is proxy
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP not deceased or
institutionalized
[Was (SP) covered by (MEDICARE MANAGED CARE PLAN
NAME) on (DATE OF DEATH)?] respondent is proxy, SP
deceased
[Was (SP) covered by (MEDICARE MANAGED CARE PLAN
NAME) on (DATE OF INSTITUTIONALIZATION)?]
respondent is proxy, SP institutionalized

(01) BOX HIMC1
(02) HIMC1B1 - YDISNROL
(-8) HIMC1C - MHMOOTHR
(-9) BOX HIMC4

(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
(-9) Refused

[you] respondent is SP
[(SP)] respondent is proxy

(01) HIMC1C - MHMOOTHR
(02) HIMC1C - MHMOOTHR
(03) HIMC1C - MHMOOTHR
(04) HIMC1C - MHMOOTHR
(05) HIMC1C - MHMOOTHR
(06) HIMC1C - MHMOOTHR
(07) HIMC1C - MHMOOTHR
(08) HIMC1C - MHMOOTHR
(09) HIMC1C - MHMOOTHR
(10) HIMC1C - MHMOOTHR
(11) HIMC1C - MHMOOTHR
(91) HIMC1B1 - YDISNROS
(-8) HIMC1C - MHMOOTHR
(-9) HIMC1C - MHMOOTHR

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased

OTHER (SPECIFY)
IF MC2 - WHATWRNG = 1/EnrolledNewPlan, GO TO MC5 PLAN_MHMOMCA.
ELSE GO TO HIMC16 - MHMOMORE.
In many Medicare Advantage Plans, such as HMOs or PPOs, the
health plan gives the patient a list of doctors from which he
chooses a primary care physician. This primary care physician
provides the patient’s usual medical care and can refer the patient
to specialists, if necessary. [Do you/Does (SP)] have a primary care
physician?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) SAME PLANS
Is it possible that [your/(SP’s)] current insurance plan is just another
(02) NOT THE SAME PLANS
name for (CMS MEDICARE MANAGED CARE PLAN NAME), or are
(-8) Don't Know
they not the same plans?
(-9) Refused
What is the name of the Medicare Advantage Plan that provides
[your/(SP’s)] health care benefits?
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
Do you refer to [your/(SP’s)] Medicare coverage by any name
besides Medicare?

REFERMED

PLAN_MHMOMCB

MHMOSAME

MC11

MC12

HIMC1A

code 1

roster

yes/no

[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
What do you call [your/(SP’s)] coverage?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS
ROSTER.
At the time of the last interview [you were/(SP) was] covered by
the Medicare Advantage Plan named (MEDICARE MANAGED CARE
PLAN NAME).
[[Are you/Is (SP)] now covered by (MEDICARE MANAGED CARE
PLAN NAME)?] [Was (SP) covered by (MEDICARE MANAGED CARE
PLAN NAME) on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)?]
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE
THE PREVIOUS INTERVIEW DATE, BUT PICKED UP THE COVERAGE
AGAIN AND CURRENTLY IS COVERED BY THE NAMED PLAN, SELECT
“YES” FOR THIS QUESTION.]

YDISNROL

HIMC1B1

code 1

What is the most important reason [you/(SP)] stopped the
(MEDICARE MANAGED CARE PLAN NAME) coverage?

YDISNROS

HIMC1B1

verbatim text

OTHER (SPECIFY)

MHMOOTHR

HIMC1C

yes/no

SHOW CARD HI2
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE
OF DEATH/INSTITUTIONALIZATION)], [have you/has (SP) been/was
(SP)] covered by any other Medicare Advantage Plans besides
(MEDICARE MANAGED CARE PLAN)?

(01) MEDICARE ONLY
(02) OTHER NAME
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

HIMC1C - MHMOOTHR

(01) HIMC3 - MHMOCURR
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4

SHOW CARD HI2
As you (may) know, Medicare beneficiaries can enroll in either
Original Medicare or a Medicare Advantage plan, such as an HMO
(Health Maintenance Organization) and PPO(Preferred Provider
Organization).
MHMOCOV

HIMC1

yes/no

(01) YES
(Please look at this card.) At any time [since (REFERENCE
(02) NO
DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF (-8) Don't Know
INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been
(-9) Refused
enrolled in or covered by [any/(one of these/any)] Medicare
Advantage plans?
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

MHMOCURR

PLAN_MHMO

HIMC3

HIMC5

yes/no

roster

[Are you/Is (SP)/Was (SP)] (currently) covered by or enrolled in a
Medicare Advantage Plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

What is the name of the Medicare Advantage Plan that [currently
covers/covered] [you/(SP)] [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS
ROSTER.
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

BOX HIMC1

routing

HIMC6A

BOX HIMC1CC1

MHMODENT

MHMOEYE

MHMONH

HIMC7

HIMC8

HIMC10

yes/no

(01) HIMC3 - MHMOCURR
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4

[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive and not
insitutionalized
[currently] SP is not deceased or institutionalized
[Was (SP)] respondent is proxy, SP deceased
[on (DATE OF DEATH)] SP deceased
[on (DATE OF INSTITUTIONALIZATION)] SP
institutionalize

(01) HIMC5 - PLAN_MHMO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2

[currently covers] SP alive
[covered] SP deceased or institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
[on (DATE OF DEATH)] SP is deceased
[on (DATE OF INSTITUTIONALIZATION)] SP is
institutionalized

BOX HIMC1

[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased
[you personally have] respondent is SP
[(SP) personally has] respondent is proxy, SP alive
[(SP personally had] respondent is proxy, SP deceased

BOX HIMC1CC1

[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased

HIMC8 - MHMOEYE

[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased

HIMC10 - MHMONH

[Does your] respondent is SP
[Does (SP's)] respondent is proxy, SP alive
[Did (SP's)] respondent is proxy, SP deceased

HIMC11 - MHMOPAY

THIS PLAN IS THE SP'S CURRENT MEDICARE MANAGED CARE PLAN
IF (THIS MEDICARE MANAGED CARE PLAN IS NEW OR HAS BEEN
"RESTARTED") OR THIS IS A FALL ROUND GO TO HIMC6A MHMORXTM.
ELSE GO TO BOX HIMC1CC1
[Do you/Does (SP)/Did (SP)] have prescribed medicine coverage
through (CURRENT MEDICARE MANAGED CARE PLAN)?

MHMORXTM

[Since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[any] only one Medicare Advantage plan
[one of these] more than one Medicare Advantage plan

(01) YES
(02) NO
[PROBE: I am asking about the type of insurance coverage that [you (-8) Don't Know
personally have/(SP) personally has/(SP) personally had], not what (-9) Refused
the plan offers everyone.]

routing

IF (THIS MEDICARE MANAGED CARE PLAN IS NEW OR HAS BEEN
"RESTARTED"), GO TO HIMC7 - MHMODENT.
ELSE GO TO BOX HIMC2.

yes/no

[Do you/Does (SP)/Did (SP)] have dental coverage through
(CURRENT MEDICARE MANAGED CARE PLAN NAME)?

yes/no

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

yes/no

[Does your/Does (SP’s)/Did (SP’s)] (CURRENT MEDICARE MANAGED
CARE PLAN NAME) coverage include nursing home care above and
beyond what Medicare normally covers?
(01) YES
(02) NO
(EXPLAIN IF NECESSARY: Under regular fee-for-service, Medicare (-8) Don't Know
pays for limited skilled nursing facility (SNF) care during a benefit (-9) Refused
period. In 2014, the first 20 days are paid in full and the next 80
days require a copayment of up to $152.00 per day.)

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Besides the cost of [your/(SP’s)] Medicare Part B premium, [is/was]
there an additional cost for [your/(SP’s)] (CURRENT MEDICARE
MANAGED CARE PLAN NAME) coverage? Please do not include any
amount that [you/(SP)] may (pay/have paid) as a co-payment for an
office visit or a prescribed medicine.
MHMOPAY

MHMOAMT

HIMC11

HIMC12

yes/no

[EXPLAIN IF NECESSARY: Some managed care plans may charge a
monthly premium to cover the cost of the deductibles and
coinsurance for Medicare-covered services or because they
provide services that are not covered by Medicare such as
prescribed medicines, routine exams, and dental, eye, or hearing.
Plans that have premiums typically charge from $50 to $75 per
month.]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Not including the cost of [your/(SP’s)] Medicare Part B premium,
what [is/was] the additional amount that [you pay/(SP) pays/(SP)
paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE
PLAN NAME) coverage? (Please do not include any copayments or (01) [Continuous answer.]
quantity unit hybrid any amount that may [be/have been] paid for anyone other than (-8) Don't Know
[you/(SP)].)
(-9) Refused
[PROBE IF NECESSARY: Is that per year, per month, per week, or
what?]

MHMOUNIT

HIMC12

Not including the cost of [your/(SP’s)] Medicare Part B premium,
what [is/was] the additional amount that [you pay/(SP) pays/(SP)
paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE
PLAN NAME) coverage? (Please do not include any copayments or
quantity unit hybrid any amount that may [be/have been] paid for anyone other than
[you/(SP)].)
[PROBE IF NECESSARY: Is that per year, per month, per week, or
what?]

MHMOUNOS
MHMOCOST

HIMC12
HIMC12A

verbatim text
yes/no

MHMOWHO

HIMC12B

code 1

MHMOWHOS

HIMC12B

verbatim text

BOX HIMC2

routing

OTHER (SPECIFY)
[Does/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)] (CURRENT MEDICARE MANAGED CARE PLAN
NAME) coverage?

Who else [pays/paid] all or some portion of the additional cost for
[your/(SP’s)] (CURRENT MEDICARE MANAGED CARE PLAN NAME)
coverage?

OTHER (SPECIFY)
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO TO BOX CPS29A.
ELSE IF HIMC1A - MHMOSAME = 1/Yes, GO TO BOX HIMC4.
ELSE IF HIMC3 - MHMOCURR = 2/No, DK OR RF, GO TO HIMC17 PLAN_MHMOOTHER.
ELSE GO TO HIMC16 - MHMOMORE.

(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused

[your] respondent is SP
[(SP's)] respondent is proxy
[is] SP alive
[was] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[pay] SP alive
[have paid] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
[is] SP aluve
[was] SP deceased
[you pay] respondent is SP
[(SP) pays] respondent is proxy, SP alive
[(SP) paid] respondent is proxy, SP deceased
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[be] SP alive
[have been paid] SP deceased
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[is] SP aluve
[was] SP deceased
[you pay] respondent is SP
[(SP) pays] respondent is proxy, SP alive
[(SP) paid] respondent is proxy, SP deceased
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[be] SP alive
[have been paid] SP deceased
[you] respondent is SP
[(SP)] respondent is proxy
[Does] SP alive
[Did] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy

[pays] SP alive
[paid] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy

(01) HIMC12 - MHMOAMT
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2

(01) HIMC12 - MHMOUNIT
(-8) HIMC12A - MHMOCOST
(-9) HIMC12A - MHMOCOST

HIMC12A - MHMOCOST

(01) HIMC12B - MHMOWHO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2
(01) BOX HIMC2
(02) BOX HIMC2
(03) BOX HIMC2
(04) BOX HIMC2
(05) BOX HIMC2
(06) BOX HIMC2
(07) BOX HIMC2
(91) HIMC12B - MHMOWHOS
(-8) BOX HIMC2
(-9) BOX HIMC2
BOX HIMC2

MHMOMORE

HIMC16

yes/no

SHOW CARD HI2
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE
OF DEATH/ DATE OF INSTITUTIONALIZATION)], [have you/has
(SP)/had (SP)] been covered by any other Medicare Advantage
Plans besides (MEDICARE MANAGED CARE PLAN and MEDICARE
MANAGED CARE PLAN)?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

PLAN_MHMOOTHER

HIMC17

roster

[Besides (MEDICARE MANAGED CARE PLAN and MEDICARE
MANAGED CARE PLAN), what other/What] Medicare Advantage
Plans provided [your/(SP’s)] health care since (REFERENCE DATE)?
SELECT OR ADD MEDICARE ADVANTAGE PLAN NAMES AT THIS
ROSTER.
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

BOX HIMC4

RECMHMO

HIMC19

BOX HIMC5

routing

yes/no

routing

HMONUMYR

HIMC24

numeric

HMONUM96

HIMC24

numeric

BOX HI1

routing

HI5INTRO

no entry

BOX HI1B

routing

HI5INTRB

no entry

MCAIDINT

MCAIDINTB

AIDCOVER

HI5

yes/no

[Since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased

(01) HIMC17 - PLAN_MHMOOTHER
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4

[Besides (MEDICARE MANAGED CARE PLAN and
MEDICARE MANAGED CARE PLAN) what other] second or
more time through loop
[What] first time through loop
[your] respondent is SP
[(SP's)] respondent is proxy

BOX HIMC4

IF FALL ROUND AND (SP IS ALIVE AND NOT INSTITUTIONALIZED)
AND (SP HAS A MEDICARE MANAGED CARE PLAN THAT IS
"CURRENT"), GO TO HIMC19 - RECMHMO.
ELSE GO TO BOX HI1.
Would you recommend (CURRENT MEDICARE MANAGED CARE
PLAN NAME) to your family or friends?
IF (SP HAS A MEDICARE MANAGED CARE PLAN THAT IS "CURRENT")
AND (THE NUMBER OF YEARS THE SP WAS COVERED BY A
MANAGED CARE PLAN HAS NEVER BEEN COLLECTED), GO TO
HIMC24 - HMONUMYR.
ELSE GO TO BOX HI1.
How many years [have you/has (SP)] been enrolled in a Medicare
Advantage plan?
[IF THE RESPONDENT HAS BEEN ENROLLED IN MORE THAN ONE
MEDICARE ADVANTAGE PLAN, THEN ENTER THE TOTAL NUMBER
OF YEARS THAT HE/SHE HAS BEEN ENROLLED IN ALL MEDICARE
ADVANTAGE PLANS.]
How many years [have you/has (SP)] been enrolled in a managed
care plan?
IF A MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI6 - COVTIME.
ELSE GO TO HI5INTRO - MCAIDINT.
SHOW CARD HI3

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

BOX HIMC5

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused

[have you] respondent is SP
[has (SP)] respondent is proxy

HIMC24 - HMONUM96

(01) LESS THAN ONE YEAR
(-7) Empty

[have you] respondent is SP
[has (SP)] respondent is proxy

BOX HI1

PLEASE READ THIS INTRODUCTION SLOWLY AND CLEARLY:
Medicaid is a state program for low income persons or for persons
on public assistance. Sometimes persons with very large medical
bills are also covered by Medicaid.
IF STATE IN WHICH SP LIVES DOES NOT OFFER A MEDICAID
MANAGED CARE PLAN, GO TO HI5 - AIDCOVER.
ELSE GO TO HI5INTRB - MCAIDINTB.
SHOW CARD HI4
Some people receive their Medicaid benefits from plans that have
names like those listed on this card.

At any time [since (REFERENCE DATE)/between (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have
(01) YES
you/has (SP) been/was (SP)] covered by Medicaid?
(02) NO
(-8) Don't Know
[PROBE IF NECESSARY: Do you have a health plan card or
(-9) Refused
something with the plan name on it?]

BOX HI1B

HI5 - AIDCOVER
[Since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased

(01) HI6 - COVTIME
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1

COVTIME

COVNOW

HI6

HI7

BOX HI4

COVBEGMM

HI8

code 1

(At the time of the last interview [you were/(SP) was] covered by
Medicaid, (also known as [READ FROM ABOVE].) [Were you/Was
(SP)] covered by Medicaid the whole time between (REFERENCE
DATE) and [(today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], or only part of the time?

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

yes/no

(01) YES
[[Are you/Is (SP)] now covered by Medicaid?] [Was (SP) covered by (02) NO
Medicaid on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?] (-8) Don't Know
(-9) Refused

routing

IF THIS MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI10A - MCAIDHMO.
ELSE GO TO HI8 - COVBEGMM.

date

On what date did [your/(SP’s)] Medicaid start between (REFERENCE (01) [Continuous answer.]
DATE) and [today/(DATE OF DEATH)/(DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)]?
(-9) Refused

COVBEGDD

HI8

date

On what date did [your/(SP’s)] Medicaid start between (REFERENCE (01) [Continuous answer.]
DATE) and [today/(DATE OF DEATH)/(DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)]?
(-9) Refused

COVBEGYY

HI8

date

On what date did [your/(SP’s)] Medicaid start between (REFERENCE (01) [Continuous answer.]
DATE) and [today/(DATE OF DEATH)/(DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)]?
(-9) Refused

date

On what date [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid
coverage [most recently/last] stop?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

date

On what date [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid
coverage [most recently/last] stop?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

COVENDMM

COVENDDD

HI9

HI9

[you were] respondent is SP
[(SP) was] respondent is proxy
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized

(01) HI10A - MCAIDHMO
(02) HI7 - COVNOW
(-8) HI7 - COVNOW
(-9) HI7 - COVNOW

[Are you] now covered by Medicaid?] respondent is SP
[Is (SP)] now covered by Medicaid?] respondent is proxy,
SP not deceased or institutionalized
[Was (SP) covered by Medicaid on (DATE OF DEATH)?]
respondent is proxy, SP deceased
[Was (SP) covered by Medicaid on (DATE OF
INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized

(01) BOX HI4
(02) HI9 - COVENDMM
(-8) HI10A - MCAIDHMO
(-9) HI10A - MCAIDHMO

[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased
[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased

MM

HI8 - COVBEGDD

DD

HI8 - COVBEGYY

YY

HI10A - MCAIDHMO

MM

HI9 - COVENDDD

DD

HI9 - COVENDYY

COVENDYY

MCAIDHMO

HI9

HI10A

date

yes/no

On what date [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid
coverage [most recently/last] stop?

(Some states now use managed care plans, such as HMOs (Health
Maintenance Organizations), to provide some or all health care for
Medicaid beneficiaries.) [At the time of the last interview [you
were/(SP) was] enrolled in a Medicaid Managed Care Plan.] [Are
you now/Is (SP) now/Were you/Was (SP)] enrolled in a Medicaid
Managed Care Plan [as of (DATE OF DEATH)/(DATE OF
INSTITUTIONALIZATION)/(MEDICAID COVERAGE STOP DATE)/the
date [your/(SP’s)] Medicaid coverage stopped]?
[ONLY SELECT “YES” IF THE RESPONDENT IS ACTUALLY ENROLLED
IN THE PLAN; SOME STATES MAY OFFER MANAGED CARE, BUT
NOT REQUIRE ENROLLMENT.]

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[At the time of the last interview [you were] enrolled in a
Medicaid Managed Care Plan] respondent is SP, second or
more time through loop, indicated plan already existed
[At the time of the last interview [(SP) was] enrolled in a
Medicaid Managed Care Plan] respondent is proxy, second
or more time through loop, indicated plan already existed
[Are you now] enrolled in a Medicaid Managed Care Plan
[as of the date [your] Medicaid coverage stopped]
respondent is SP, plan is beginning
[Is (SP) now] enrolled in a Medicaid Managed Care Plan [as
of the date [(SP's)] Medicaid coverage stopped]
respondent is proxy, SP alive, plan is beginning
[Were you] enrolled in a Medicaid Managed Care Plan [as
of (MEDICAID COVERAGE STOP DATE)] respondent is SP,
indicated that plan ended
[Were you] enrolled in a Medicaid Managed Care Plan [as
of the date [your] Medicaid coverage stopped] respondent
is SP, indicated that plan is beginning
[Was (SP)] enrolled in a Medicaid Managed Care Plan [as
of (DATE OF DEATH)] respondent is proxy, SP deceased
[Was (SP)] enrolled in a Medicaid Managed Care Plan [as
of (DATE OF INSTITUTIONALIZATION)] respondent is
proxy, SP institutionalized
[Was (SP)] enrolled in a Medicaid Managed Care Plan [as
of (MEDICAID COVERAGE STOP DATE)] respondent is
proxy, indicated that plan ended

BOX HI5D

[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you been] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased
[covers] SP alive
[covered] SP deceased

(01) HI10C2 - PDPCURR
(02) HI10D - MCDRXCOV
(-8) HI10D - MCDRXCOV
(-9) HI10D - MCDRXCOV

[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

BOX HI5D

yes/no

IF ((ADMINISTERING ST, NS OR CPS) AND SP WAS COVERED BY A
MEDICARE PRESCRIPTION DRUG PLAN ANYTIME DURING THE
CURRENT ROUND) OR (ADMINSTERING HI AND THERE WAS A
MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT
THE TIME OF THE PREVIOUS ROUND INTERVIEW), GO TO BOX
HIT1.
ELSE IF (ADMINISTERING ST, NS OR CPS) AND SP WAS NOT
COVERED BY A MEDICARE PRESCRIPTION DRUG PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO HI10D - MCDRXCOV.
ELSE GO TO HI10C1 - MPDCOVER.
(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 Medicare
Prescription Drug plan, although the beneficiary may choose to
switch to a different prescription plan.)

MPDCOVER

HI10C1

yes/no

YY

(01) YES
(02) NO
At any time [since (REFERENCE DATE)/between (REFERENCE DATE)
(-8) Don't Know
AND (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have
(-9) Refused
you been/has (SP) been/was (SP)] enrolled in a Medicare
Prescription Drug plan that [covers/covered] medicines prescribed
by a doctor or other health professional?
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

PDPCURR

PLAN_CAIDMPDP

HI10C2

HI10C3

yes/no

roster

[Are you/Is (SP)/Was (SP)] [currently] covered by or enrolled in a
Medicare Prescription Drug plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[What is the name of the Medicare Prescription Drug plan that
(currently covers/covered) [you/(SP)] [on (DATE OF DEATH)/(DATE
OF INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN
AT THIS ROSTER.

[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE
OF DEATH/INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)]
been covered by any other Medicare Prescription Drug plans
besides (CURRENT MEDICARE PRESCRIPTION DRUG PLAN)?
PDPMORE

HI10C4

Yes/No

(PROBE IF NECESSARY: Please include Medicare Prescription Drug
plans [you were/(SP) was] automatically enrolled in through
Medicaid as well as any [you/he/she] enrolled in on [your/his/her]
own.)

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
Please tell me the names of [the other/all] Medicare Prescription
Drug plans that [you have/he has/she has] been enrolled in since
(REFERENCE DATE) [besides (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)].

PLAN_CAIDMPDPOTHR HI10C5

roster

[PROBE IF NECESSARY: Please include Medicare Prescription Drug
plans [you were/(SP) was] automatically enrolled in through
Medicaid as well as any [you/he/she] enrolled in on [your/his/her)
own.]
SELECT OR ADD MEDICARE PRESCRIPTION DRUG PLAN NAMES AT
THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

MCDRXCOV

TRICOVER

HI10D

yes/no

BOX HIT1

routing

HIT1

yes/no

(01) YES
(Does/Did) [your/(SP’s)] Medicaid plan cover medicines prescribed (02) NO
by a doctor or other health professional?
(-8) Don't Know
(-9) Refused
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF A TRICARE PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HIT2 - COVTIME.
ELSE GO TO HIT1 - TRICOVER.
SHOW CARD HIT1
As you (may) know, the Department of Defense sponsors a
regionally managed health care program called TRICARE for active
duty and retired members of the uniformed Armed Forces, their
families, and survivors.
(01) YES
Please look at this card. At any time [since (REFERENCE DATE)/
(02) NO
between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
(-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP)
(-9) Refused
been/was (SP)] enrolled in or covered by any of these TRICARE
plans?
(EXPLAIN IF NECESSARY: You may have received a reference card
that looks like this (BACK OF SHOWCARD HIT1).)

[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondent is proxy, SP deceased
[currently] SP is not deceased or institutionalized
[on (DATE OF DEATH)] SP deceased
[on (DATE OF INSTITUTIONALIZATION)] SP institutionalized

(01) HI10C3 - PLAN_CAIDMPDP
(02) HI10C5 - PLAN_CAIDMPDPOTHR
(-8) HI10C5 - PLAN_CAIDMPDPOTHR
(-9) HI10C5 - PLAN_CAIDMPDPOTHR

[currently covers] SP alive
[covered] SP deceased or institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
[on (DATE OF DEATH)] SP is deceased
[on (DATE OF INSTITUTIONALIZATION)] SP is
institutionalized

HI10C4 - PDPMORE

[Since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[you were] respondent is SP
[(SP) was] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[the other] second or more time through loop
[all] first time through loop
[you have] respondent is SP
[he has] respondent is proxy, SP male
[she has] respondent is proxy, SP female
[you were] respondent is SP
[(SP) was] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Does] SP alive
[Did] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy

[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased,
second or more time through loop
[between (PREVIOUS ROUND INTERVIEW) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, second or more time through loop
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased

(01) HI10C5 - PLAN_CAIDMPDPOTHR
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1

BOX HIT1

BOX HIT1

(01) HIT2 - COVTIME
(02) BOX HIT3
(-8) BOX HIT3
(-9) BOX HIT3

COVTIME

COVNOW

HIT2

HIT3

code1

yes/no

[At the time of the last interview [you were/(SP) was] covered by
TRICARE.] [Were you/Was (SP)] covered by TRICARE the whole
time between [(REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], or only part of the
time?

[[Are you/Is (SP)] now covered by TRICARE?] [Was (SP) covered by
TRICARE on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION?]

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

[At the time of the last interview [you were] covered by
TRICARE] respondent is SP, second or more time through
loop
[At the time of the last interview [(SP)] was covered by
TRICARE] respondent is proxy, second or more time
through loop
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[(REFERENCE DATE) and today] respondent is SP or proxy,
SP not institutionalized or deceased
[(REFERENCE DATE) and (DATE OF DEATH)] respondent is
proxy, SP deceased
[(REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized

(01) HIT4 - TRIRXCOV
(02) HIT3 - COVNOW
(-8) HIT3 - COVNOW
(-9) HIT3 - COVNOW

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[[Are you] now covered by TRICARE?] respondent is SP
[[Is (SP)] now covered by TRICARE?] respondent is proxy,
SP not deceased or institutionalized
[Was (SP) covered by TRICARE on (DATE OF DEATH)?]
respondent is proxy, SP deceased
[Was (SP) covered by TRICARE on (DATE OF
INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized

HIT4 - TRIRXCOV

[Does] SP alive
[Did] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
[you personally have] respondent is SP
[(SP) personally has] respondent is proxy, SP alive

(01) HIT4A1 - TRIMEDS
(02) BOX HIT3
(-8) BOX HIT3
(-9) BOX HIT3

[Does/Did] [your/(SP’s)] TRICARE plan cover medicines prescribed
by a doctor or other health professional?
TRIRXCOV

HIT4

yes/no

(01) YES
(02) NO
[PROBE: I am asking about the type of insurance coverage that
(-8) Don't Know
[you personally have/(SP) personally has], not what the plan offers (-9) Refused
everyone.]

TRIMEDS

HIT4A1

code 1

(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
SHOW CARD HIT2
(02) A TRICARE RETAIL PHARMACY NETWORK
Where [do you/does (SP)/did you/did (SP)] usually obtain
PHARMACY (TRRX)
[your/his/her] medicines? [Do you/Does (SP)/Did you/Did (SP)]
(03) A MILITARY TREATMENT FACILITY PHARMACY
usually obtain them at a TRICARE mail order pharmacy (TMOP), a (MTF)
TRICARE retail pharmacy network pharmacy (TRRx), a military
(04) A NON-NETWORK RETAIL PHARMACY
treatment facility pharmacy (MTF), a non-network retail pharmacy, (91) SOMEWHERE ELSE
or somewhere else?
(-8) Don't Know
(-9) Refused

TRIMEDOS

HIT4A1

verbatim text

SOMEWHERE ELSE (SPECIFY)

routing

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO BOX CPS29A.
ELSE IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO BOX HI7.
ELSE IF ((SP DID NOT REPORT RECEIVING HEALTH CARE SERVICES
FROM M.T.F IN THE PREVIOUS ROUND) AND ((SP WAS COVERED
BY TRICARE IN THE CURRENT OR PREVIOUS ROUND) OR (SP
SERVED IN THE ARMED FORCES)), GO TO HIT11 - MTFCOVER.
ELSE GO TO BOX HI20.

BOX HIT3

MTFCOVER

HIT11

BOX HI20

VACOVER

HI36

yes/no

routing

yes/no

[We recorded that [you/(SP)] served in the Armed Forces of the
United States.] Since (REFERENCE DATE), [have you/has (SP)
received/did (SP) receive] health care or health services or
prescribed medicines at a Military Treatment Facility or MTF?
[EXPLAIN IF NECESSARY: A Military Treatment Facility is any
military hospital, clinic, or NAVCARE clinic.]
IF (SP DID NOT REPORT RECEIVING HEALTH CARE SERVICES
THROUGH V.A. IN THE PREVIOUS ROUND) AND (SP SERVED IN THE
ARMED FORCES), GO TO HI36 - VACOVER.
ELSE GO TO BOX HI7.
[We recorded that [you/(SP)] served in the Armed Forces of the
United States.] Since (REFERENCE DATE), [have you/has (SP)
received/did (SP) receive] health care or health services or
prescribed medicines through the Department of Veterans Affairs
or V.A.?

[do you] respondent is SP, SP still obtains medicines
[does (SP)] respondent is proxy, SP alive
[did you] respondent is SP, SP no longer obtains medicines
[did (SP)] respondent is proxy, SP deceased
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP, SP still obtains medicines
[Does (SP)] respondent is proxy, SP alive
[Did you] respondent is SP, SP no longer obtains medicines
[Did (SP)] respondent is proxy, SP deceased

(01) [Continuous Answer]

BOX HIT3

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[you] respondent is SP
[(SP)] respondent is proxy
[have you] respondent is SP
[has (SP) received] respondent is proxy, SP alive
[did (SP) receive] respondent is proxy, SP deceased

BOX HI20

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[you] respondent is SP
[(SP)] respondent is proxy
[have you] respondent is SP
[has (SP) received] respondent is proxy, SP alive
[did (SP) receive] respondent is proxy, SP deceased

BOX HI7

BOX HI7

routing

IF AT LEAST ONE PUBLIC PLAN WAS "CURRENT" AT THE TIME OF
THE PREVIOUS ROUND INTERVIEW, GO TO HI11PREV - PUBINTRO.
ELSE GO TO HI11 - PUBCOVER.

PUBINTRO

HI11PREV

no entry

The next questions are about public plans [you were/(SP) was]
covered by as of (REFERENCE DATE).

NAVIGATOR

HI11PREV_IN

instance navigator

BOX HI7A

routing

CREATE CURRENT ROUND PLRO FOR PUBLIC PLAN
GO TO HI13 - COVTIME.

yes/no

SHOW CARD HI6
At any time [since (REFERENCE DATE)/between (PREVIOUS ROUND
INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)], [have you/has (SP) been/was
(SP)] covered by any public program other than Medicaid that pays
for medical care [for example, a public program that pays for
prescribed medicines?

What is the name of each of the public programs other than
Medicaid that covered [you/(SP)]?
SELECT OR ADD ALL PUBLIC PROGRAM NAMES AT THIS ROSTER.
(01) [Continuous answer.]
[WHEN YOU ENTER A PLAN, VERIFY WITH THE RESPONDENT THAT
IT IS A PUBLIC PLAN.]

PUBCOVER

HI11

PLAN_PUBLIC

HI12

roster

NAVIGATOR

HI12_IN

instance navigator

COVTIME

COVNOW

HI13

HI14

BOX HI10

COVBEGMM

COVBEGDD

HI15

HI15

code 1

(01) CONTINUE
(-7) Empty
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[you were] respondent is SP
[(SP) was] respondent is proxy

(01) BOX HI7A
(02) HI11 - PUBCOVER

[since (REFERENCE DATE)] SP not deceased or
institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[have you] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP institutionalized

(01) HI12 - PLAN_PUBLIC
(02) BOX HI12AA
(-8) BOX HI12AA
(-9) BOX HI12AA

[you] respondent is SP
[(SP)] respondent is proxy

HI12_IN - NAVIGATOR

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

[At the time of the last interview [you were/(SP) was] covered by
(PUBLIC PLAN NAME).] [Were you/Was (SP)] covered by (PUBLIC
PLAN NAME) the whole time between [(REFERENCE DATE) and
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], or only
part of the time?

yes/no

[[Are you/Is (SP)] now covered by (PUBLIC PLAN NAME)?] [Was
(SP) covered by (PUBLIC PLAN NAME) on (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)?]

routing

IF THIS PUBLIC PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI16A - PUBRXCOV.
ELSE GO TO HI15 - COVBEGMM.

HI11PREV_IN - NAVIGATOR

(01) HI13 - COVTIME
(02) BOX HI12AA

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

[you were] respondent is SP
[(SP) was] respondent is proxy
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[between (REFERENCE DATE) and today] respondent is SP
or proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized

(01) HI16A - PUBRXCOV
(02) HI14 - COVNOW
(-8) HI14 - COVNOW
(-9) HI14 - COVNOW

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[[Are you] now covered by (PUBLIC PLAN NAME)?]
respondent is SP
[[Is (SP)] now covered by (PUBLIC PLAN NAME)?]
respondent is proxy, SP not deceased or institutionalized
[Was (SP) covered by (PUBLIC PLAN NAME) on (DATE OF
DEATH)?] respondent is proxy, SP deceased
[Was (SP) covered by (PUBLIC PLAN NAME) on (DATE OF
INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized

(01) BOX HI10
(02) HI16 - COVENDMM
(-8) HI16A - PUBRXCOV
(-9) HI16A - PUBRXCOV

date

On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start (01) [Continuous answer.]
[between (REFERENCE DATE) and (today/DATE OF DEATH/DATE OF (-8) Don't Know
INSTITUTIONALIZATION)?
(-9) Refused

date

On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start (01) [Continuous answer.]
between (REFERENCE DATE) and (today/DATE OF DEATH/DATE OF (-8) Don't Know
INSTITUTIONALIZATION)?
(-9) Refused

[your] respondent is SP
[(SP's)] respondent is proxy
[between (REFERENCE DATE) and today] respondent is SP
or proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
MM
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[between (REFERENCE DATE) and today] respondent is SP
or proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
DD
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized

HI15 - COVBEGDD

HI15 - COVBEGYY

COVBEGYY

COVENDMM

COVENDDD

COVENDYY

PUBRXCOV

HI15

HI16

HI16

HI16

date

date

date

date

HI16A

yes/no

BOX HI12

routing

BOX HI12AA

routing

On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start (01) [Continuous answer.]
between (REFERENCE DATE) and (today/DATE OF DEATH/DATE OF (-8) Don't Know
INSTITUTIONALIZATION)?
(-9) Refused

[your] respondent is SP
[(SP's)] respondent is proxy
[between (REFERENCE DATE) and today] respondent is SP
or proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
YY
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized

HI16A - PUBRXCOV

On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC PLAN
NAME) coverage [most recently/last] stop?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

[since (REFERENCE DATE)] SP not deceased or
institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased

MM

HI16 - COVENDDD

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

[since (REFERENCE DATE)] SP not deceased or
institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased

DD

HI16 - COVENDYY

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

[since (REFERENCE DATE)] SP not deceased or
institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased

YY

HI16A - PUBRXCOV

On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC PLAN
NAME) coverage [most recently/last] stop?

On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC PLAN
NAME) coverage [most recently/last] stop?

(01) YES
(Does/Did) [your/(SP’s)] (PUBLIC PLAN NAME) plan cover medicines (02) NO
prescribed by a doctor or other health professional?
(-8) Don't Know
(-9) Refused
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF REVIEWING PUBLIC PLANS THAT WERE "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HI11PREV_IN NAVIGATOR.
ELSE GO TO HI12_IN - NAVIGATOR.
IF (SP HAS A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS
"CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW),
GO TO HI16AB - PDPSAME.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG
PLAN THAT WAS "CURRENT" AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW) AND (SP DOES NOT HAVE A "CURRENT"
MEDICARE MANAGED CARE PLAN WITH RX COVERAGE) AND
(HI10C1 - MPDCOVER = empty)), GO TO HI16B - PDPCOVER.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG
PLAN THAT WAS "CURRENT" AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW) AND (SP DOES NOT HAVE A "CURRENT"
MEDICARE MANAGED CARE PLAN WITH RX COVERAGE) AND
(HI10C1 - MPDCOVER = 2/No)), GO TO HI16B1 - PDPCOVER.
ELSE GO TO BOX HI12A.

[Does] SP alive
[Did] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy

BOX HI12

At the time of the last interview [you were/(SP) was] covered by a
Medicare Prescription Drug Plan named (MEDICARE PRESCRIPTION
DRUG PLAN NAME).

PDPSAME

HI16AB

yes/no

[[Are you/Is (SP)] now covered by (MEDICARE PRESCRIPTION DRUG
PLAN NAME)?] [Was (SP) covered by (MEDICARE PRESCRIPTION
DRUG PLAN NAME) on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)?]
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE
THE PREVIOUS INTERVIEW DATE, BUT PICKED UP THE COVERAGE
AGAIN AND CURRENTLY IS COVERED BY THE NAMED PLAN, SELECT
“YES” FOR THIS QUESTION.]

PDPYSTOP

HI16AC

code 1

What is the most important reason [you/(SP)] stopped the
(MEDICARE PRESCRIPTION DRUG PLAN NAME) coverage?

PDPYSTOS

HI16AC

verbatim text

OTHER (SPECIFY)

PDPOTHER

HI16AD

yes/no

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE
OF DEATH/INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)]
been covered by any other Medicare Prescription Drug plans
besides (MEDICARE PRESCRIPTION DRUG PLAN CURRENT LAST
ROUND)?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[you were] respondent is SP
[(SP) was] respondent is proxy
[[Are you] now covered by (MEDICARE PRESCRIPTION
DRUG PLAN NAME)?] respondent is SP
[[Is (SP)] now covered by (MEDICARE PRESCRIPTION DRUG
PLAN NAME)?] respondent is proxy, SP not deceased or
institutionalized
[Was (SP) covered by (MEDICARE PRESCRIPTION DRUG
PLAN NAME) on (DATE OF DEATH)?] respondent is proxy,
SP deceased
[Was (SP) covered by (MEDICARE PRESCRIPTION DRUG
PLAN NAME) on (DATE OF INSTITUTIONALIZATION)?]
respondent is proxy, SP institutionalized

(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH PLAN'S COVERAGE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET DIFFERENT HEALTH CARE COVERAGE
(05) PLAN NO LONGER CONTRACTS FOR MEDICARE RX
COVERAGE
[you] respondent is SP
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
[(SP)] respondent is proxy
BY/MERGED WITH ANOTHER PLAN
(07) SP MOVED OUT OF PLAN AREA
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX HI12A
(02) HI16AC - PDPYSTOP
(-8) BOX HI12A
(-9) HI16AD - PDPOTHER

(01) HI16AD - PDPOTHER
(02) HI16AD - PDPOTHER
(03) HI16AD - PDPOTHER
(04) HI16AD - PDPOTHER
(05) HI16AD - PDPOTHER
(06) HI16C - PDPCURR
(07) HI16AD - PDPOTHER
(91) HI16AC - PDPYSTOS
(-8) HI16AD - PDPOTHER
(-9) HI16AD - PDPOTHER
HI16AD - PDPOTHER

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

[Since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)], respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased

(01) HI16C - PDPCURR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A

[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[covers] SP alive
[covered] SP deceased

(01) HI16C - PDPCURR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A

[you have] respondent is SP
[(SP) has] respondent is proxy, SP alive
[(SP) had] respondent is proxy, SP deceased
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased

(01) HI16C - PDPCURR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A

[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondent is proxy, SP deceased or
institutionalized
[currently] SP is alive
[on (DATE OF DEATH)] SP deceased
[on (DATE OF INSTITUTIONALIZATION)] SP institutionalized

(01) HI16E - PLAN_MPDP
(02) HI16G - PLAN_MPDPOTHR
(-8) HI16G - PLAN_MPDPOTHR
(-9) HI16G - PLAN_MPDPOTHR

(Medicare beneficiaries can receive insurance coverage for
prescription drugs through Medicare Prescription Drug plans.
These plans are also called "Medicare Part D" plans.)

PDPCOVER

HI16B

yes/no

(01) YES
At any time since (REFERENCE DATE), [have you/has (SP)/had (SP)]
(02) NO
been enrolled in a Medicare Prescription Drug plan that
(-8) Don't Know
[covers/covered] medicines prescribed by a doctor or other health
(-9) Refused
professional?
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
You mentioned that [you have/(SP) has/(SP) had] not been enrolled
in a Medicare Prescription Drug plan associated with [your/his/her]
Medicaid coverage.

PDPCOVER

HI16B1

yes/no

(01) YES
At any time since (REFERENCE DATE), [have you/has (SP)/had (SP)] (02) NO
been enrolled in a Medicare Prescription Drug plan in any way
(-8) Don't Know
other than through Medicaid?
(-9) Refused
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

PDPCURR

HI16C

yes/no

[Are you/Is (SP)/Was (SP)] [currently] covered by or enrolled in a
Medicare Prescription Drug plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

PLAN_MPDP

HI16E

roster

What is the name of the Medicare Prescription Drug plan that
[currently covers/covered] [you/(SP)] [on (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN
AT THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

PDPMORE

PLAN_MPDPOTHR

HI16F

HI16G

yes/no

roster

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE
OF DEATH/ INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)]
(01) YES
been covered by any other Medicare Prescription Drug plans
(02) NO
besides (CURRENT MEDICARE PRESCRIPTION DRUG PLAN)?
(-8) Don't Know
(-9) Refused
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

[Besides (CURRENT PRESCRIPTION DRUG PLAN), what
other/Besides (PREVIOUS ROUND PRESCRIPTION DRUG PLAN),
what other/What] Medicare Prescription Drug plans covered
[your/(SP’s)] medicines since (REFERENCE DATE)?
SELECT OR ADD MEDICARE PRESCRIPTION DRUG PLAN NAMES AT
THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

BOX HI12A

routing

IF AT LEAST ONE PRIVATE PLAN WAS "CURRENT" AT THE TIME OF
THE PREVIOUS ROUND INTERVIEW, GO TO HI17PREV - PRIVINTRO.
ELSE GO TO HI17 - PRVCOVER

PRIVINTRO

HI17PREV

no entry

The next questions are about private plans [you were/(SP) was]
covered by as of (REFERENCE DATE).

NAVIGATOR

HI17PREV_IN

instance navigator

BOX HI12B

routing

(01) CONTINUE
(-7) Empty
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

HI17

yes/no

HI16F - PDPMORE

(01) HI16G - PLAN_MPDPOTHR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A

BOX HI12A

[you were] respondent is SP
[(SP) was] respondent is proxy
(01) BOX HI12B
(02) HI17 - PRVCOVER

CREATE A CURRENT ROUND PLRO FOR PRIVATE PLAN
GO TO HI21 - COVTIME.
You reported being covered by [READ PLAN NAME(S) AND PLAN
TYPE(S) LISTED ABOVE].

PRVCOVER

[currently covers] SP alive
[covered] SP deceased or institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
[on (DATE OF DEATH)] SP is deceased
[on (DATE OF INSTITUTIONALIZATION)] SP is
institutionalized
[Since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[Besides (CURRENT PRESCRIPTION DRUG PLAN), what
other] second or more time through the loop, SP enrolled
in prescription drug plan
[Besides (PREVIOUS ROUND PRESCRIPTION DRUG PLAN),
what other] second or more time through loop, SP
previously enrolled in prescription drug plan
[What] first time through loop
[your] respondent is SP
[(SP's)] respondent is proxy

(Now, I would like to ask about another type of health insurance.)
At any time [since (REFERENCE DATE)/between (PREVIOUS ROUND
INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(01) YES
INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)]
(02) NO
covered by (any other) private health insurance plans?
(-8) Don't Know
(-9) Refused
Private plans include supplemental or Medigap plans, plans that
are provided by a former or current employer., and plans that you
have directly purchased. Such plans cover the cost of hospital or
doctor visits, prescribed medicines, or dental care.

[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[have you] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased
[any other] SP already covered by private health insurance
or private managed care plan
[plan] SP already covered by private health insurance or
private managed care plan
[plan] SP not already covered by private health insurance
or private managed care plan

(01) HI18A - EXCHGCOV
(02) BOX HI13A
(-8) BOX HI13A
(-9) BOX HI13A

SHOW CARD MA PLANS
As you may know, every state now offers a health insurance
marketplace, also referred to as an exchange.
[STATE MARKETPLACE NAME] fill with name from table
here: "\\norc.org\Projects\7649\Common\NORC-SM\Data
Quality\Plan Name Lookup\State Marketplace
Names.xlsx"

The marketplace allows residents to compare and purchase
available health insurance options that meet their needs. While
most Medicare beneficiaries are not eligible for insurance from a
health insurance marketplace, there are some special
circumstances that allow enrollment.
EXCHGCOV

HI18A

BOX HI13A

GAPCOVER

HI19

yes/no

routing

(01) YES
(02) NO
Please look at this card. At any time [since (REFERENCE
(-8) Don't Know
DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF (-9) Refused
INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been
enrolled in or covered by one of these exchange plans?
[MEDICARE BENEFICIARIES ARE NOT ELIGIBLE TO OBTAIN
INSURANCE THROUGH THESE PLANS. THE RESPONSE TO THIS
QUESTION SHOULD ALMOST ALWAYS BE “NO”. HOWEVER, SOME
RESPONDENTS MAY SIGN UP FOR THESE PLANS DUE TO
CONFUSION ABOUT THE PROGRAM.]
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM
FACILITY), GO TO HI19 - GAPCOVER.
ELSE GO TO HI35 - PRVOCOV.
Some people who are eligible for Medicare have additional
coverage through a private insurance carrier referred to as
Medigap or Medicare Supplement -insurance. These plans help
pay some of the health care costs that Original Medicare doesn't
cover, like copayments, coinsurance and deductibles.

yes/no
At any time since (REFERENCE DATE) did [you/(SP)] have this type
of health insurance coverage?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[since (REFERENCE DATE)] SP alive and not
institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)] SP
deceased
[(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased

HI20 - PLAN_PRIVATE

[you] respondent is SP
[(SP)] respondent is proxy

(01) HI20 - PLAN_PRIVATE
(02) HI35 - PRVOCOV
(-8) HI35 - PRVOCOV
(-9) HI35 - PRVOCOV

[other] SP already covered by private plan
[provide] SP alive
[provided] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy

HI20_IN - NAVIGATOR

[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]

PLAN_PRIVATE

HI20

roster

NAVIGATOR

HI20_IN

instance navigator

COVTIME

COVNOW

HI21

HI22

BOX HI16

code 1

What is the name of each of the [other] private plans that
[provide/provided] [your/(SP’s)] medical insurance coverage?
SELECT OR ADD ALL PRIVATE PLAN NAMES AT THIS ROSTER.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

[At the time of the last interview [you were/(SP) was] covered by a
private plan named (PRIVATE PLAN NAME).] [Were you/Was (SP)]
covered by (PRIVATE PLAN NAME) the whole time between
(REFERENCE DATE) and [today/ DATE OF DEATH/DATE OF
INSTITUTIONALIZATION], or only part of the time?

yes/no

[[Are you/Is (SP)] now covered by (PRIVATE PLAN NAME)?] [Was
(SP) covered by (PRIVATE PLAN NAME) on (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)?]

routing

IF THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO BOX HI17.
ELSE GO TO HI23 - COVBEGMM.

(01) HI21 - COVTIME
(02) HI35 - PRVOCOV

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

[At the time of the last interview [you were] covered by
(PRIVATE PLAN NAME).] respondent is SP, second or more
time through loop
[At the time of the last interview [(SP) was] covered by
(PRIVATE PLAN NAME).] respondent is proxy, second or
more time through loop
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[today] SP not deceased or institutionalized
[(DATE OF DEATH)] SP deceased
[(DATE OF INSTITUTIONALIZATION)] SP institutionalized

(01) BOX HI17
(02) HI22 - COVNOW
(-8) HI22 - COVNOW
(-9) HI22 - COVNOW

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[[Are you] now covered by (PRIVATE PLAN NAME)?]
respondent is SP
[[Is (SP)] now covered by (PRIVATE PLAN NAME)?]
respondent is proxy, SP not deceased or institutionalized
[Was (SP) covered by (PRIVATE PLAN NAME) on (DATE OF
DEATH)?] respondent is proxy, SP deceased
[Was (SP) covered by (PRIVATE PLAN NAME) on (DATE OF
INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized

(01) BOX HI16
(02) HI24 - COVENDMM
(-8) BOX HI17
(-9) BOX HI17

COVBEGMM

HI23

date

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

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

COVBEGDD

HI23

date

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

COVBEGYY

HI23

date

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

date

On what date [since (REFERENCE DATE)/between (PREVIOUS
(01) [Continuous answer.]
ROUND INTERVIEW DATE) and (DATE OF DEATH/
(-8) Don't Know
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage under
(-9) Refused
(PRIVATE PLAN NAME) stop?

date

On what date [since (REFERENCE DATE)/between (PREVIOUS
(01) [Continuous answer.]
ROUND INTERVIEW DATE) and (DATE OF DEATH/
(-8) Don't Know
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage under
(-9) Refused
(PRIVATE PLAN NAME) stop?

date

On what date [since (REFERENCE DATE)/between (PREVIOUS
(01) [Continuous answer.]
ROUND INTERVIEW DATE) and (DATE OF DEATH/
(-8) Don't Know
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage under
(-9) Refused
(PRIVATE PLAN NAME) stop?

COVENDMM

COVENDDD

COVENDYY

HI24

HI24

HI24

BOX HI17

routing

PPRVHMO

HI25

yes/no

PERS_MIPNUM

HI26

roster

IF THIS PRIVATE PLAN IS NEW OR HAS BEEN "RESTARTED", GO TO
HI25 - PPRVHMO
ELSE IF THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW AND IS STILL "CURRENT", AND IT IS
A FALL ROUND, GO TO HI26 - PERS_MIPNUM.
ELSE GO TO HI30 - PRVRXCOV.
CODE WITHOUT ASKING IF VOLUNTEERED.
[Is/Was] this a managed care plan, such as an HMO (Health
Maintenance Organization) or PPO (Preferred Provider
(01) YES
Organization)?
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: Managed care plans generally provide a
(-9) Refused
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.]
Who [is/was] listed as the main insured person on the (PRIVATE
PLAN NAME) policy or contract?
SELECT OR ADD ONLY ONE PERSON.

[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP
not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy

MM

HI23 - COVBEGDD

DD

HI23 - COVBEGYY

YY

BOX HI17

MM

HI24 - COVENDDD

DD

HI24 - COVENDYY

YY

BOX HI17

[Is] plan still current
[Was] plan no longer current

HI26 - PERS_MIPNUM

[is] plan still current
[was] plan no longer current

HI27 - PPRVGET

PPRVGET

HI27

code 1

PPRVGTOS

HI27

verbatim text

PRVNMCOV

PRVRXCOV

HI29

HI30

BOX HI17AB

numeric

yes/no

routing

(01) DIRECTLY
(02) (MIP'S) CURRENT EMPLOYER
(03) (MIP'S) FORMER EMPLOYER
(04) (MIP'S) UNION
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up
(05) (MIP'S) FAMILY BUSINESS
directly, or did [you/(MIP)] get this insurance through a current
(06) AARP
employer, a former employer, a union, a family business, AARP, or (07) DECEASED SPOUSE'S EMPLOYER
some other way?
(08) DECEASED SPOUSE'S UNION
(09) PROFESSIONAL/FRATERNAL ORGANIZATION
(91) SOME OTHER WAY
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
How many family members, including [yourself/(SP)], [are/were]
covered by [your/(MIP’s)] (PRIVATE PLAN NAME)?
(01) [Continuous answer.]
[INCLUDE ALL FAMILY MEMBERS COVERED BY THE PLAN
(-8) Don't Know
REGARDLESS OF WHETHER OR NOT THEY LIVE WITH THE
(-9) Refused
RESPONDENT. MAKE SURE THE RESPONDENT INCLUDES
HIM/HERSELF IN THE COUNT.]
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)]
(PLAN NAME) coverage [includes/included].
[PROBE: I am asking about the type of insurance coverage that
[you/(SP)] personally [have/has/had], not what the plan offers
everyone.]
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) plan cover
prescribed medicines?
[IF THE RESPONDENT IS COVERED BY A DELTA DENTAL PLAN THAT
PROVIDES ONLY DENTAL COVERAGE, THE INTERVIEWER SHOULD
VERIFY AND SELECT “NO” THAT THE PLAN DOES NOT COVER
OTHER TYPES PRESCRIBED MEDICINES.]
IF (THIS PRIVATE PLAN IS NEW OR HAS BEEN "RESTARTED") OR
(THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW AND IS STILL "CURRENT", AND IT IS
A FALL ROUND), GO TO HI31A - PRVMSCOV.
ELSE GO TO BOX HI19.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
doctor visits to a doctor or other health professional or lab work?
PRVMSCOV

HI31A

list

[PROBE IF NECESSARY: I am asking about the type of insurance
coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
inpatient hospital care?
PRVIPCOV

HI31A

list
[PROBE IF NECESSARY: I am asking about the type of insurance
coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…

nursing home or long term care?
PRVNHCOV

HI31A

list
[PROBE IF NECESSARY: I am asking about the type of insurance
coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[your] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[your] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP

(01) HI29 - PRVNMCOV
(02) HI29 - PRVNMCOV
(03) HI29 - PRVNMCOV
(04) HI29 - PRVNMCOV
(05) HI29 - PRVNMCOV
(06) HI29 - PRVNMCOV
(07) HI29 - PRVNMCOV
(08) HI29 - PRVNMCOV
(09) HI29 - PRVNMCOV
(91) HI27 - PPRVGTOS
(-8) HI29 - PRVNMCOV
(-9) HI29 - PRVNMCOV
HI29 - PRVNMCOV

[yourself] respondent is SP
[(SP)] respondent is proxy
[are] SP alive
[were] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP is not MIP

HI30 - PRVRXCOV

[your] respondent is SP
[(SP's)] respondent is proxy
[includes] SP alive
[included] SP deceased
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP

BOX HI17AB

[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased

HI31A - PRVIPCOV

HI31A - PRVNHCOV

HI31A - MHMODENT

[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
dental care?
MHMODENT

MIPPINS

MIPPAMT

HI31A

HI32

HI33

list

yes/no

[PROBE IF NECESSARY: I am asking about the type of insurance
coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Do/Does/Did] [you/(MIP)] pay any or all of the premium or cost for
(01) YES
the (PRIVATE PLAN NAME) coverage?
(02) NO
(-8) Don't Know
[Do not include the cost of any deductibles [you/(SP)] or
(-9) Refused
[your/(SP’s)] family may [have/have had] to pay.]

How much [do/does/did] [you/(MIP)] pay for the (PRIVATE PLAN
NAME) coverage?
[Please do not include any amount that may be paid for anyone
quantity unit hybrid other than [you/(SP)].]

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

[PROBE IF NECESSARY: [Is/Was] that per year, per month, per
week, or what?]

MIPPUNIT

HI33

How much [do/does/did] [you/(MIP)] pay for the (PRIVATE PLAN
NAME) coverage?
[Please do not include any amount that may be paid for anyone
quantity unit hybrid other than [you/(SP)].]
[PROBE IF NECESSARY: [Is/Was] that per year, per month, per
week, or what?]

MIPPUNOS
MHMOCOST

HI33
HI33A

verbatim text

OTHER (SPECIFY)

yes/no

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

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

MHMOWHO

HI33B

code 1

MHMOWHOS

HI33B

verbatim text

BOX HI17B

routing

OTHER (SPECIFY)
IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO HI33C MHMOPOS.
ELSE GO TO BOX HI19.

(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused

[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Do] respondent is SP, SP is MIP; or respondent is proxy,
proxy is MIP
[Does] respondent is SP, SP is not MIP; ot respondent is
proxy, SP is MIP
[Did] respondent is proxy, SP deceased; or plan is no
longer current
[you] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[have] SP alive
[have had] SP deceased
[Do] respondent is SP, SP is MIP; or respondent is proxy,
proxy is MIP
[Does] respondent is SP, SP is not MIP; ot respondent is
proxy, SP is MIP
[Did] respondent is proxy, SP deceased; or plan is no
longer current
[you] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[Is] SP alive
[Was] SP deceased
[do] respondent is SP, SP is MIP
[does] respondent is SP or proxy, SP is not MIP
[did] respondent is proxy, SP deceased
[you] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[Is] SP alive
[Was] SP deceased
[Does] SP still has private plan
[Did] SP no longer has private plan
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP

[pays] SP still has private plan
[paid] SP no longer has private plan
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP

HI32 - MIPPINS

(01) HI33 - MIPPAMT
(02) HI33A - MHMOCOST
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST

(01) HI33 - MIPPUNIT
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST

(01) HI33A - MHMOCOST
(02) HI33A - MHMOCOST
(03) HI33A - MHMOCOST
(04) HI33A - MHMOCOST
(05) HI33A - MHMOCOST
(06) HI33A - MHMOCOST
(07) HI33A - MHMOCOST
(91) HI33 - MIPPUNOS
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST
HI33A - MHMOCOST
(01) HI33B - MHMOWHO
(02) BOX HI17B
(-8) BOX HI17B
(-9) BOX HI17B
(01) BOX HI17B
(02) BOX HI17B
(03) BOX HI17B
(04) BOX HI17B
(05) BOX HI17B
(06) BOX HI17B
(07) BOX HI17B
(91) HI33B - MHMOWHOS
(-8) BOX HI17B
(-9) BOX HI17B
BOX HI17B

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. [Are/Were/Is/Was] [you/(SP)]
enrolled in a point-of-service option offered by (PRIVATE PLAN
NAME)?
MHMOPOS

PRVOCOV

OTHNHCOV

HI33C

yes/no

BOX HI19

routing

HI35

yes/no

BOX HI19B

routing

HI34

BOX HI21A

(01) YES
(02) NO
[EXPLAIN IF NECESSARY: In a point-of-service option, the member
(-8) Don't Know
typically pays a higher copayment when seeing an out-of-plan
(-9) Refused
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.]
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO TO BOX CPS29A.
ELSE IF REVIEWING PRIVATE PLANS THAT WERE "CURRENT" AT
THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
HI17PREV_IN - NAVIGATOR.
ELSE GO TO HI20_IN - NAVIGATOR.
(01) YES
We’ve talked about [READ PLAN(S) LISTED ABOVE]. [Do you/Does
(02) NO
(SP)/Did (SP)] have medical coverage under any (other) private
(-8) Don't Know
insurance plans we haven’t talked about?
(-9) Refused
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM
FACILITY), GO TO HI34 - OTHNHCOV.
ELSE GO TO BOX HI21A.

yes/no

[Other than the plans you have already told me about, [do
you/does (SP)/did (SP)]/[Do you/Does (SP)/Did (SP)]] have any
insurance that [pays/paid] just for nursing home care or other long
term care?

routing

GO TO NEXT SECTION
IF SAMPLE TYPE IS SUPPLEMENTAL (C003) NEXT SECTION IS MBQ.
ELSE IF SAMPLE TYPE IS CONTINUING, NEXT SECTION IS DUQ.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Are] respondent is SP, SP currently enrolled in private
plan
[Were] respondent is SP, SP not currently enrolled in
private plan
[Is] respondent is proxy, SP alive, SP currently enrolled in
private plan
[Was] respondent is proxy, SP deceased or SP not
currently enrolled in private plan
[you] respondent is SP
[(SP)] respondent is proxy

BOX HI19

[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased

(01) HI20 - PLAN_PRIVATE
(02) BOX HI19B
(-8) BOX HI19B
(-9) BOX HI19B

[Other than the plans you have already told me about, [do
you]] respondent is SP, SP has plans
[Other than the plans you have already told me about,
[does (SP)]] respondent is proxy, SP alive, SP has other
plans
[Other than the plans you have already told me abouy,
[did (SP)]] respondent is proxy, SP deceased, SP had other
plans
[Do you] respondent is SP, SP has no other plans
[Does (SP)] respondent is proxy, SP alive, SP has no other
plans
[Did (SP)] respondent is proxy, SP deceased, SP had no
other plans
[pays] SP alive
[paid] SP deceased

BOX HI21A

Beneficiary Knowledge and Information Needs (KNQ): Updated medical provider terminology highlighted in green
Variable Name
MR Screen Name
Question type
Question text/description
Now I have some questions that ask how you get information
about the Medicare program [for (SP)]. Your answers will help
Medicare provide the information that people need.
KNINTR
KNINTRO
no entry
Keep in mind that, generally, there are no right or wrong answers
to these questions. Your opinions and experiences are important
to us.
SHOW CARD KN1
Overall, how easy or difficult do you think the Medicare program
is to understand?
KNOWMC
KN1
code 1
[PROBE IF NECESSARY: Would you say it is very easy to
understand, somewhat easy to understand, somewhat difficult to
understand, or very difficult to understand?]

KCARKNOW

KNINFMCR

KNINTMCR

KNCOVOPT

KN2

KN25B1

KN25C

KN25D

code 1

In the past year, have you tried to find any information [for (SP)]
about Medicare?

code 1

SHOW CARD KN7
How interested are you in getting (more) information [for (SP)]
about Medicare?

How easy or difficult would you say it is for [you/(SP)] to review
and compare [your/his/her] Medicare coverage options? Would
you say it is …

SHOW CARD KNX
KNCOVREV

KN25E

code 1

Text Fill Logic

(01) CONTINUE
(-7) Empty

[for(SP)] respondent is proxy

(01) VERY EASY
(02) SOMEWHAT EASY
(03) SOMEWHAT DIFFICULT
(04) VERY DIFFICULT
(-8) Don't Know
(-9) Refused

How often [do you/does (SP)] review or compare [your/his/her]
Medicare coverage options? Would that be at least once every
year, once every few years, rarely, or never?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VERY INTERESTED
(02) SOMEWHAT INTERESTED
(03) NOT VERY INTERESTED
(04) NOT AT ALL INTERESTED
(-8) Don't Know
(-9) Refused
(01) Very easy
(02) Somewhat easy
(03) Somewhat difficult
(04) Very difficult
(05) DOES NOT MAKE DECISIONS ON HEALTH INSURANCE
(-8) Don't Know
(-9) Refused
(01) AT LEAST ONCE EVERY YEAR
(02) ONCE EVERY FEW YEARS
(03) RARELY
(04) NEVER
(05) ONLY ONCE WHEN FIRST SIGNED UP FOR DRUG PLAN
(06) ONLY ONCE WHEN FIRST SIGNED UP FOR MEDICARE
(07) JUST SIGNED UP FOR MEDICARE
(-8) DON'T KNOW
(-9) REFUSED

Input mask

Routing

KN1 - KNOWMC

KN2 - KCARKNOW

SHOW CARD KN2
(01) JUST ABOUT EVERYTHING YOU NEED TO KNOW
How much do you think you know about the Medicare program? (02) MOST OF WHAT YOU NEED TO KNOW
(03) SOME OF WHAT YOU NEED TO KNOW
Do you know just about everything you need to know, most of
(04) A LITTLE OF WHAT YOU NEED TO KNOW
what you need to know, some of what you need to know, a little (05) ALMOST NONE OF WHAT YOU NEED TO KNOW
of what you need to know or almost none of what you need to
(-8) Don't Know
know about the Medicare program?
(-9) Refused

yes/no

code 1

Code list

BOX KN1 KN25B1 - KNINFMCR.

[for(SP)] respondent is proxy

KN25C - KNINTMCR

[for(SP)] respondent is proxy

KN26 - KNFOSATI KN25D-KNCOVOPT

[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female

KN25E-KNCOVREV

[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female

KN35F-KNCOVINF

SHOW CARD KNX

KNCOVINF

KN25F

code 1

KNFOSATI

KN26

code 1

KN27IN

KN27INT

no entry

KBOKRECD

KBOKREAD

KN27

KN28

yes/no

code 1

(01) Completely agree
(02) Somewhat agree
To what extent do you agree or disagree with the following
(03) Somewhat disagree
statement:
(04) Completely disagree
[I have/(SP) has] the information [I need/he needs/she needs] to
(05) DOES NOT MAKE DECISIONS ON HEALTH INSURANCE
make an informed comparison among different health insurance
(-8) Don't Know
choices.
(-9) Refused
Would you say you …
(01) VERY SATISFIED
(02) SATISFIED
SHOW CARD KN4
(03) DISSATISFIED
How satisfied are you in general with the availability of
(04) VERY DISSATISFIED
information about the Medicare program when you need it [for
(05) NOT APPLICABLE
(SP)]?
(-8) Don't Know
(-9) Refused
Now I would like to ask you about publications that are available (01) CONTINUE
to you [and (SP)] about the Medicare program.
(-7) Empty
SHOW CARD KN5
Did [you/(SP)] receive in the mail or view on the Medicare website (01) YES
a book called "Medicare and You
(02) NO
2015[CURRENT YEAR]?” This book gives an overview of the
(-8) Don't Know
Medicare program and is sent to Medicare beneficiaries every fall. (-9) Refused
The cover looks like this.
(01) READ IT THOROUGHLY
(02) READ PARTS OF IT
Would you say you have read this book thoroughly, that you have
(03) HAVEN'T READ IT AT ALL
read parts of it, or that you haven't read it at all?
(-8) Don't Know
(-9) Refused

[I have] respondent is SP
[(SP) has] respondent is proxy
[I need] respondent is SP
[he needs] respondent is proxy, SP is male
[she needs] respondent is proxy, SP is female

KN26 - KNFOSATI

[for(SP)] respondent is proxy

KN27INT - KN27IN

[and (SP)] respondent is proxy

KN27 - KBOKRECD

[you] respondent is SP
[(SP)] respondent is proxy

(01) KN28 - KBOKREAD
(02) BOX KN1A
(-8) BOX KN1A
(-9) BOX KN1A
(01) KN29 - KBOKUNDR
(02) KN29 - KBOKUNDR
(03) BOX KN1A
(-8) BOX KN1A
(-9) BOX KN1A

SHOW CARD KN1
How easy or difficult did you find (the parts you read/this book)
to understand?
KBOKUNDR

KN29

code 1
[PROBE IF NECESSARY: Would you say (they were/it was) very
easy to understand, somewhat easy to understand, somewhat
difficult to understand, or very difficult to understand?]
Next, I'd like to ask about [your/(SP's)] use of computers.

KNHAVCOM

KN50

yes/no

[Do you/Does (SP)] have a personal computer in (your/his/her)
home?
Some people use the Internet to get different kinds of
information. The next questions ask about the Internet.

KN51IN

KN51INT

KNETFRND

KNETOFTN

KVSITWEB

KN51A

KN51B

code 1

yes/no

KN51C

code 1

BOX KN7

routing

KN53

yes/no

[the parts you read] respondent only read parts
of book
[this book] respondent read entire book
[they were] respondent only read parts of book
[it was] respondent read entire book

BOX KN1A KN50 - KNHAVCOM

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[your] respondent is SP
[(SP's)] respondent is proxy
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female

KN51INT - KN51IN

(01) CONTINUE
(-7) Empty

KN51A - KNETPERS

[Do you/Does (SP)] personally ever use the Internet to get
information of any kind?

(01) YES
(02) NO
(03) NEVER HEARD OF THE INTERNET
(-8) Don't Know
(-9) Refused

[Do you] respondent is SP
[Does (SP)] respondent is proxy

(01) KN51C - KNETOFTN
(02) KN51B - KNETFRND
(03) BOX KN8
(-8) BOX KN8
(-9) BOX KN8

[Do you/Does(SP)] have someone else, such as a friend, relative,
or anyone else, get information for (you/him/her) on the
Internet?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female

(01) KN51C - KNETOFTN
(02) BOX KN8
(-8) BOX KN8
(-9) BOX KN8

[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female

BOX KN7

[Has anyone] respondent is SP or proxy, used if
(for [you/SP]) used
If KN51B - KNETFRND = 1/YES, display "Has
anyone". Else display {Have you/Has (SP)] where
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[for you] respondent is SP, used if [Has anyone]
used
[for (SP)] respondent is proxy, used if [Has
anyone] used
If KN51B - KNETFRND = 1/YES, display " - for
[you/{SP}], else do not display.

BOX KN7A KN53D - KNDOCREC

[you] respondent is SP
[(SP)] respondent is proxy
[visit] respondent is SP
[visits] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[(SP's)] respondent is proxy
[you are] respondent is SP
[he is] respondent is proxy, SP male
[she is] respondent is proxy, SP female

BOX KN8

no entry
[EXPLAIN IF NECESSARY: The Internet includes web sites, e-mail,
newsgroups, and other forums.]

KNETPERS

(01) VERY EASY
(02) SOMEWHAT EASY
(03) SOMEWHAT DIFFICULT
(04) VERY DIFFICULT
(-8) Don't Know
(-9) Refused

(01) EVERY DAY
How often [do you/does (SP)] access the Internet to seek
(02) A FEW TIMES A WEEK
information, either on (your/his/her) own or with someone else's
(03) A FEW TIMES PER MONTH
help?
(04) A FEW TIMES PER YEAR OR LESS
(-8) Don't Know
Please do not include any time spent reading or sending e-mail.
(-9) Refused
IF SP DID NOT REPORT VISITING OR ACCESSING THE OFFICAL
WEBSITE FOR MEDICARE INFORMATION IN ANY PREVIOUS
ROUND (SAMPLE_PERSON.P_KVISITWEB ^=1) GO TO KN53 KVSITWEB.
ELSE GO TO BOX KN7A.

(01) YES
(Has anyone/[Have you/Has (SP)]) ever visited or ever accessed
(02) NO
the official website for Medicare information - www.medicare.gov
(-8) Don't Know
(- for [you/(SP)])?
(-9) Refused

Many health care providers are beginning to use electronic or
computer-based medical records instead of using paper-based
records.

KNDOCREC

KN53D

yes/no

(01) YES
When [you/(SP)] (visit/visits) (your/his/her) usual doctor, does the
(02) NO
doctor generally enter [your/(SP's)] health information into a
(-8) Don't Know
computer while (you are/he is/she is) present?
(-9) Refused
[EXPLAIN IF NECESSARY: "Health Information" includes
information such as symptoms, vital signs, test results, or
prescribed medicines.]

BOX KN8

KCHIHELP

routing

KN54

code 1

BOX KN9

routing

IF PROXY IS RESPONDENT, GO TO BOX KN9.
ELSE GO TO KN54 - KCHIHELP.
(01) MAKES DECISIONS ON OWN
Most of the time, do you make decisions about Medicare health
(02) GETS HELP ON DECISIONS
insurance on your own, do you get help from someone in making
(03) SOMEONE ELSE MAKES DECISIONS
these decisions, or do you rely on someone else to make decisions
(-8) Don't Know
about health insurance for you?
(-9) Refused
IF IT IS UNKNOWN WHETHER OR NOT THIS SP IS AWARE OF THE 1800 MEDICARE LINE (SAMPLE_PERSON.P_KREELINE = .), GO TO
KN56 - KREELINE.
ELSE GO TO BOX KN10.

BOX KN9

KREELINE

KN56

BOX KN10

KCPHINFO

KCSUGGST

KN57

yes/no

Before today, were you aware of the 1-800-MEDICARE toll-free
line?

routing

IF SP DID NOT REPORT CALLING 1-800-MEDICARE TO GET
INFORMATION ABOUT MEDICARE IN ANY PREVIOUS ROUND
(SAMPLE_PERSON.P_KREELINE ^= 1) GO TO KN57 - KCPHINFO.
ELSE GO TO KN58 - KCSUGGST.

yes/no

Have you ever called 1-800-MEDICARE to get information about
Medicare?

KN58

verbatim text

BOX KNEND

routing

As you know, this survey is sponsored by the Centers for
Medicare and Medicaid Services, which is the government agency
that runs Medicare. What are your suggestions or concerns about
Medicare?
RECORD VERBATIM.
GO TO NEXT SECTION

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) KN57 - KCPHINFO
(02) KN58 - KCSUGGST
(-8) KN58 - KCSUGGST
(-9) KN58 - KCSUGGST

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

KN58 - KCSUGGST

(01) R DOES NOT HAVE SUGGESTIONS OR CONCERNS
(02) RECORD ALL OTHER RESPONSES VERBATIM
(-8) Don't Know
(-9) Refused

(01) BOX KNEND KNEND - KNENDSCR
(02) KN58 - KCSUGGVB
(-8) BOX KNEND KNEND - KNENDSCR
(-9) BOX KNEND KNEND - KNENDSCR

Prescription Medicine (PMQ): Updated medical provider terminology highlighted in green
Variable Name

MR Screen
Name

Question type

Question text/description

Code list

Text Fill Logic

Input mask

Routing

If UTILDATE^=MREFDATE and OPTION64_FLAG^=1, fill [UTILDATE].
Else fill [REFERENCE DATE].
[Now let’s talk about prescribed medicines [you have/(SP) has] obtained since (REFERENCE DATE).]
SP reported PM purchases in the previous round
[] SP did not report PM purchases in the second round
[you have] respondent is SP
[(SP) has] respondent is proxy

[Now let’s talk about prescribed medicines [you have/(SP) has] obtained since (REFERENCE DATE/UTILDATE).]
[While talking about medical visits, you mentioned some medicine(s): [READ MEDICINE NAME(S) BELOW.]]
PMINTA

PMINTROA

[While talking about medical visits, you mentioned some medicine(s): [READ MEDICINE NAME(S)
BELOW.]] SP reported PM's in the current round utilization
[] SP did not report PM's in the current round utilization

no entry
[Now I’d like to talk about prescribed medicines.]

PM1 - PMFILLED

[Now I’d like to talk about prescribed medicines.] (SP did not report PM purchases in the previous
round) and (SP
did not report PM's in the current round utilization)
[] (SP reported PM purchases in the previous round) or (SP reported PM's in the current round
utilization)
Else do not display.

If only one PM reported during current round utilization, fill “[Besides that medicine, ]”
Else if more than one PM reported during the current round utilization fill, “[Besides those
medicines, ]”
Else fill nothing.
If SP is deceased, fill "[(Between/between) (REFERENCE DATE) and (DATE OF DEATH)]",
Else if SP is institutionalized “[(Between/between) (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)]",
Else if ENDUTILD 0 OR EQUAL
TO DK OR RF, GO TO RXNOFILL
ELSE GO TO PM17 - PMMORE.

BOX PM1

IF NO EXISTING MEDICINES DISPLAY "NO MEDICINES
LISTED"]

What is the name of the medicine?
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.

PMEDNAME

GETNUM

[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR EACH.

PM6-PMSTRUNI

(01) ADD ANOTHER
(02) ALL DONE
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

PM6B-ADDP
(01)PM6- PMEDNAME
(02) BOX PM1

BOX PM1A

RXNOFILL

PM6AB

list

SHOW CARD PM1
Please think about the medicines you have obtained [since (REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE) and (ENDUTILD)], including [READ MEDICINE NAME(S) BELOW.] [Since (REFERENCE
DATE/UTILDATE)/Between (REFERENCE DATE) and ENDUTILD], how often did [you/(SP)] do any of the
following things for these medicines. Did [you/(SP)] often, sometimes, or never…

(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED

decide not to fill or refill a prescription because the medicine cost too much?

RXDELAY

PM6AB

list

([Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and ENDUTILD], how often did [you/(SP)]
do any of the following things for these medicines. Did [you/(SP)] often, sometimes, or never…)
delay getting a prescription filled or refilled because the medicine cost too much?

RXSKIP

PM6AB

list

([Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and ENDUTILD], how often did [you/(SP)]
do any of the following things for these medicines. Did [you/(SP)] often, sometimes, or never…)
skip doses to make the medicine last longer?

RXDOSE

PM6AB

list

([Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and ENDUTILD], how often did [you/(SP)]
do any of the following things for these medicines. Did [you/(SP)] often, sometimes, or never…)
take smaller doses to make the medicine last longer?

(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED

(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED

(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED

If SP is deceased, fill "[between (REFERENCE DATE) and (DATE OF DEATH)]",
Else if SP is institutionalized, fill "[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)]",
Else if ENDUTILDFile Type application/pdf
Author NORC
File Modified 2015-09-08
File Created 2015-09-08
File Type	application/pdf
Author	NORC
File Modified	2015-09-08
File Created	2015-09-08