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pdfHealth Insurance Summary (HIS)
Variable Name
HISINT
MR Screen Name
HISINTRO
Question type
no entry
HISCORRB
HIS1
code one
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].
PLAN_DELETION
HIS2
roster
PLANDVB
HIS2A
verbatim text
PLAN_CORRECT
HIS2B
code one
PLAN_CORRECT_NAME
PLAN_STOPPED
HIS2B
HIS2C
verbatim text
roster
HISSTPMM
HIS2D
date
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
ADDHITYPE
HIS3
code one
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.
What type of insurance plan needs to be added?
PLAN_HISMHMO
HISMC1
roster
HISMHMOCURR
HISMC2
yes/no
BOX HISMC1
routing
HISMC3
yes/no
HISMHMOCHNG
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.
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage
stop?
What is the name of the Medicare Advantage Plan that covered [you/(SP)]?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS ROSTER.
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
[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?
Code list
(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
(01) continuous answer
(01) continuous answer
(01) continuous answer
(01) continuous answer
(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
(01) continuous answer
(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) continuous answer
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Health Insurance Summary (HIS)
Variable Name
MR Screen Name
BOX HISMC2
Question type
routing
Question text/description
Code list
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.
BOX HISMC2A
routing
MHMORX
HISMC4
yes/no
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 MANAGED CARE PLAN NAME)?
MHMODENT
HISMC5
yes/no
MHMOEYE
HISMC6
yes/no
MHMONH
HISMC8
yes/no
MHMOPAY
HISMC9
yes/no
MHMOAMT
HISMC10
numeric
(01) YES
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan (-9) Refused
offers everyone.]
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did [you/(SP)] have dental coverage
(01) YES
through (MEDICARE MANAGED CARE PLAN NAME)?
(02) NO
(-8) Don't Know
(-9) Refused
Did [you/(SP)] have optical coverage through (MEDICARE MANAGED CARE PLAN NAME), that is, for
(01) YES
eyeglasses or contact lenses?
(02) NO
(-8) Don't Know
(-9) Refused
Did [your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME) coverage include nursing home care above and (01) YES
beyond what Medicare normally covers?
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: Under regular fee-for-service, Medicare pays for limited skilled nursing facility
(-9) Refused
(SNF) care during a benefit period. In 2016, the first 20 days are paid in full and the next 80 days require a
copayment of up to $161 per day.)
Besides the cost of [your/(SP’s)] Medicare Part B premium, was there an additional cost for [your/(SP’s)]
(01) YES
(MEDICARE MANAGED CARE PLAN NAME) coverage? Please do not include any amount that [you/(SP)] may (02) NO
have paid as a co-payment for an office visit or a prescribed medicine.
(-8) Don't Know
(-9) Refused
[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.]
Not including the cost of [your/(SP’s)] Medicare Part B premium, what was the additional amount that
(01) continuous answer
[you/(SP)] paid for (your/his/her) (MEDICARE MANAGED CARE PLAN NAME) coverage? [Please do not
(-8) Don't Know
include any copayments or any amount that may be 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
MHMOCOST
HISMC10
HISMC11
verbatim text
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.]
(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
Health Insurance Summary (HIS)
Variable Name
MHMOWHO
MR Screen Name
HISMC12
Question type
code one
Question text/description
Who else paid all or some portion of the additional cost for [your/(SP’s)] (MEDICARE MANAGED CARE PLAN
NAME) coverage?
MHMOWHOS
HISMC12
BOX HIS2AA
verbatim text
routing
COVTIME
HIS6
code one
OTHER (SPECIFY)
CREATE MEDICAID PLAN IN THE PREVIOUS ROUND
GO TO HIS6 - COVTIME.
[Were you/Was (SP)] covered by Medicaid the whole time between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE), or only part of the time?
COVNOW
HIS7
yes/no
[Were you/Was (SP)] covered by Medicaid on (REFERENCE DATE)?
COVBEGMM
HIS8
date
On what date did [your/(SP’s)] Medicaid start between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE)?
COVBEGDD
HIS8
date
On what date did [your/(SP’s)] Medicaid start between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE)?
COVBEGYY
HIS8
date
On what date did [your/(SP’s)] Medicaid start between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE)?
COVENDMM
HIS9
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] Medicaid
coverage stop?
COVENDDD
HIS9
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] Medicaid
coverage stop?
COVENDYY
HIS9
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] Medicaid
coverage stop?
MCAIDHMO
HIS10A
yes/no
BOX HIS2C
routing
HIS10B1
yes/no
Some states now use managed care plans, such as HMOs (Health Maintenance Organizations), to provide
some or all health care for Medicaid beneficiaries. [Were you/Was (SP)] enrolled in a Medicaid Managed
Care Plan on [(REFERENCE DATE)/(PLAN COVERAGE STOP DATE)/the date [your/(SP’s)] Medicaid coverage
stopped]?
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.
Some people who receive Medicaid benefits are also enrolled in a Medicare Prescription Drug plan, or
Medicare Part D plan, that pays for some or all of their prescribed medicines. The Medicare program
automatically enrolls such beneficiaries into a Prescription Drug plan, although the beneficiary may choose
to switch to a different plan.
HISMPDCOVER
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), [were you/was (SP)] enrolled in a Medicare
Prescription Drug plan that covered medicines prescribed by a doctor or other health professional?
Code list
(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
(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
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Health Insurance Summary (HIS)
Variable Name
MCDRXCOV
MR Screen Name
HIS10C
Question type
yes/no
Question text/description
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
COVTIME
HIST1
code one
CREATE TRICARE PLAN IN THE PREVIOUS ROUND
GO TO HIST1 - COVTIME.
[Were you/Was (SP)] covered by TRICARE the whole time between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE), or only part of the time?
COVNOW
HIST2
yes/no
TRIRXCOV
HIST3
yes/no
TRIMEDS
HIST3AA
code one
TRIMEDOS
PLAN_HISPUBLIC
HIST3AA
HIS12
verebatim text
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
Code list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
[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
(01) YES
medicines prescribed by a doctor or other health professional?
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan (-9) Refused
offers everyone.]
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), where did [you/(SP)] usually obtain
(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
(your/his/her) medicines? Did [you/(SP)] usually obtain them at a TRICARE mail order pharmacy (TMOP), a (02) A TRICARE RETAIL PHARMACY NETWORK
TRICARE retail pharmacy network pharmacy (TRRx), a military treatment facility pharmacy (MTF), a nonPHARMACY (TRRX)
network retail pharmacy, or somewhere else?
(03) A MILITARY TREATMENT FACILITY PHARMACY
(MTF)
(04) A NON-NETWORK RETAIL PHARMACY
(91) 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
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) the whole time between (SUMMARY REFERENCE
(01) THE WHOLE TIME
DATE) and (REFERENCE DATE), or only part of the time?
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) on (REFERENCE DATE)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start between (SUMMARY REFERENCE DATE) (01) continuous answer
and (REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start between (SUMMARY REFERENCE DATE) (01) continuous answer
and (REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start between (SUMMARY REFERENCE DATE) (01) continuous answer
and (REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] (PUBLIC
(01) continuous answer
PLAN NAME) coverage stop?
(-8) Don't Know
(-9) Refused
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] (PUBLIC
(01) continuous answer
PLAN NAME) coverage stop?
(-8) Don't Know
(-9) Refused
Health Insurance Summary (HIS)
Variable Name
COVENDYY
MR Screen Name
HIS16
Question type
date
Question text/description
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] (PUBLIC
PLAN NAME) coverage stop?
PUBRXCOV
BOX HIS2B1
HIS16A
routing
yes/no
EXCHGCOV
BOX HIS3
HIS18A
routing
yes/no
GO TO HIS16A - PUBRXCOV.
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did [your/(SP’s)] (PUBLIC PLAN NAME) plan (01) YES
cover medicines prescribed by a doctor or other health professional?
(02) NO
(-8) Don't Know
(-9) Refused
GO TO HIS12_IN - NAVIGATOR.
SHOW CARD HI5
(01) YES
As you may know, every state now offers a health insurance marketplace, also referred to as an exchange. (02) NO
(-8) Don't Know
The marketplace, known as (STATE MARKETPLACE NAME), allows residents to compare and purchase
(-9) Refused
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.
Code list
(01) continuous answer
(-8) Don't Know
(-9) Refused
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?
PLAN_HISPRIVATE
HIS20
roster
NAVIGATOR
HIS20_IN
instance navigator
COVTIME
HIS21
code one
COVNOW
HIS22
yes/no
COVBEGMM
HIS23
date
COVBEGDD
HIS23
date
COVBEGYY
HIS23
date
COVENDMM
HIS24
date
COVENDDD
HIS24
date
COVENDYY
HIS24
date
BOX HIS3A1
routing
What is the name of each of the (other) private plans that provided [your/(SP’s)] medical insurance coverage (01) continuous answer
between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
SELECT OR ADD ONE PRIVATE PLAN NAME AT THIS ROSTER.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole time between (SUMMARY REFERENCE
(01) THE WHOLE TIME
DATE) and (REFERENCE DATE), or only part of the time?
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) on (REFERENCE DATE)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (SUMMARY
(01) continuous answer
REFERENCE DATE) and (REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (SUMMARY
(01) continuous answer
REFERENCE DATE) and (REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (SUMMARY
(01) continuous answer
REFERENCE DATE) and (REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage
(01) continuous answer
under (PRIVATE PLAN NAME) stop?
(-8) Don't Know
(-9) Refused
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage
(01) continuous answer
under (PRIVATE PLAN NAME) stop?
(-8) Don't Know
(-9) Refused
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage
(01) continuous answer
under (PRIVATE PLAN NAME) stop?
(-8) Don't Know
(-9) Refused
GO TO HIS25 - PPRVHMO.
Health Insurance Summary (HIS)
Variable Name
PPRVHMO
MR Screen Name
HIS25
Question type
yes/no
PERS_HISMIPNUM
HIS26
roster
PPRVGET
HIS27
code one
PPRVGTOS
PRVNMCOV
HIS27
HIS29
verbatim text
numeric
PRVRXCOV
HIS31A
list
PRVMSCOV
HIS31A
list
Question text/description
CODE WITHOUT ASKING IF VOLUNTEERED.
Was this a managed care plan, such as an HMO (Health Maintenance Organization) or PPO (Preferred
Provider Organization)?
[EXPLAIN IF NECESSARY: Managed care plans generally provide a full range of health care services for a
prepaid fee. Health care is generally provided by primary care doctors, specialists, or hospitals on the plan’s
list (network) except in an emergency.]
Who was listed as the main insured person on the (PRIVATE PLAN NAME) policy or contract?
SELECT OR ADD ONLY ONE PERSON.
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up directly with the (insurance company/managed
care plan), or did [you/(MIP)] get this insurance through a current employer, a former employer, a union, a
family business, AARP, or some other way?
Code list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) DIRECTLY
(02) (MIP'S) CURRENT EMPLOYER
(03) (MIP'S) FORMER EMPLOYER
(04) (MIP'S) UNION
(05) (MIP'S) FAMILY BUSINESS
(06) AARP
(07) DECEASED SPOUSE'S EMPLOYER
(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) (01) continuous answer
between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
(-8) Don't Know
(-9) Refused
Supplemental insurance plans may cover a variety of services or may be specific to only certain services,
(01) YES
such as prescribed medicines or dental coverage. I’d like to know what [your/(SP’s)] (PRIVATE PLAN NAME) (02) NO
coverage included between (SUMMARY REFERENCE DATE) and (REFERENCE DATE).
(-8) Don't Know
(-9) Refused
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan
offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
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) and (REFERENCE DATE).
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan
offered everyone.]
PRVIPCOV
HIS31A
list
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) and (REFERENCE DATE).
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan
offered everyone.]
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
inpatient hospital care?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Health Insurance Summary (HIS)
Variable Name
PRVNHCOV
MR Screen Name
HIS31A
Question type
list
Question text/description
Supplemental insurance plans may cover a variety of services or may be specific to only certain services,
such as prescribed medicines or dental coverage. I’d like to know what [your/(SP’s)] (PRIVATE PLAN NAME)
coverage included between (SUMMARY REFERENCE DATE) and (REFERENCE DATE).
Code list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan
offered everyone.]
MHMODENT
HIS31A
list
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) and (REFERENCE DATE).
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan
offered everyone.]
MIPPINS
HIS32
yes/no
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
dental care?
Was there a premium or cost for the (PRIVATE PLAN NAME) coverage?
[Do not include the cost of any deductibles [you/(SP)] or [your/(SP’s)] family may have had to pay.]
MIPPAMT
HIS33
numeric
How much did [you/(MIP)] pay for the (PRIVATE PLAN NAME) coverage?
[Please do not include any amount that may be paid for anyone other than [you/(SP)].]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
[PROBE IF NECESSARY: Was that per year, per month, per week, or what?]
MIPPUNIT
HIS33
code one
MIPPUNOS
MHMOCOST
HIS33
HIS33A
verbatim text
yes/no
MHMOWHO
HIS33B
code one
MHMOWHOS
HIS33B
BOX HIS3B
verbatim text
routing
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?
[DO NOT INCLUDE AMOUNTS PAID BY FAMILY MEMBERS.]
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.
(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) [(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
Health Insurance Summary (HIS)
Variable Name
MHMOPOS
MR Screen Name
HIS33C
Question type
yes/no
PLAN_HISMPDP
BOX HIS4
HIS34
routing
roster
HISMPDPCURR
HIS35
yes/no
BOX HIS5A
routing
HIS36
yes/no
BOX HIS6
routing
BOX HIS6A
routing
PDPYSTOP
HIS37
code one
PDPYSTOS
ENDHIS
HIS37
HISCLOSE
verbatim text
no entry
BOX HIS5
routing
HISMPDPCHNG
Question text/description
Code list
Some managed care plans offer a point-of-service option which allows members to receive services from out- (01) YES
of-plan providers even in non-emergency situations. Between (SUMMARY REFERENCE DATE) and
(02) NO
(REFERENCE DATE), [were you/was (SP)] enrolled in a point-of-service option offered by (PRIVATE PLAN
(-8) Don't Know
NAME)?
(-9) Refused
[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)]?
(01) continuous answer
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN AT THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
[Were you/Was (SP)] covered by or enrolled in (MEDICARE PRESCRIPTION DRUG PLAN NAME) on
(REFERENCE DATE)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
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.
I recorded previously that (PREVIOUS ROUND CURRENT MEDICARE PRESCRIPTION DRUG PLAN NAME) was (01) YES
[your/(SP’s)] current Medicare Prescription Drug Plan on (REFERENCE DATE). Has this information changed? (02) NO
(-8) Don't Know
(-9) Refused
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)
(01) TOO EXPENSIVE OR COULDN'T AFFORD
coverage?
(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
OTHER (SPECIFY)
(01) continuous answer
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)
| File Type | application/pdf |
| Author | NORC |
| File Modified | 2016-03-17 |
| File Created | 2016-03-17 |