Cms-p-0015a Mcbs

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
BOX HIBEG
routing
HIINTR1

HIMCINTR

no entry

Question text/description
IF (SP IS IN THE SUPPLEMENTAL SAMPLE), GO TO HIMCINTR - 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.

Code list

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.

LOADCORR

BOX MC1AA

routing

MC1

yes/no

(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.)
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).

(01) YES
(02) NO
(-8) Don't Know
According to Medicare records, [you are/(SP) is] currently enrolled in a Medicare Advantage Plan called (CMS (-9) Refused
MEDICARE MANAGED 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

MC2

code 1

How is this information incorrect?
SELECT ONLY ONE. IF MORE THAN ONE RESPONSE IS APPLICABLE, SELECT THE RESPONSE THAT IS CLOSEST
TO THE TOP OF THE LIST.

(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
(03) SP NOW DISENROLLED FROM (CMS MHMO PLAN
NAME), NO LONGER IN ANY MEDICARE ADVANTAGE
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)

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
YDISNROL
MC2B
code 1

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

YDISNROS

MC2B
BOX MC1A

verbatim text
routing

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?
Is it possible that [your/(SP’s)] current insurance plan is just another name for (CMS MEDICARE MANAGED
CARE PLAN NAME), or are they not the same plans?

PRIMPHYS

MC3

yes/no

SAMEPLAN

MC4

code 1

PLAN_MHMOMCA

MC5

roster

What is the name of the Medicare Advantage Plan that provides [your/(SP’s)] health care benefits?

REFERMED

MC11

code 1

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
Do you refer to [your/(SP’s)] Medicare coverage by any name besides Medicare?
[PROBE IF NECESSARY: Do you have a health plan card or something with the plan name on it?]

PLAN_MHMOMCB

MC12

roster

MHMOSAME

HIMC1A

yes/no

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.]

Code list
(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) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) SAME PLANS
(02) NOT THE SAME PLANS
(-8) Don't Know
(-9) Refused

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

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

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
YDISNROL
HIMC1B1
code 1

YDISNROS
MHMOOTHR

HIMC1B1
HIMC1C

verbatim text
yes/no

MHMOCOV

HIMC1

yes/no

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

OTHER (SPECIFY)
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)?
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).

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

(Please look at this card.) At any time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been 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

HIMC3

yes/no

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

PLAN_MHMO

HIMC5

roster

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.

BOX HIMC1

routing

HIMC6A

yes/no

MHMORXTM

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

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
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
(01) YES
through (CURRENT MEDICARE MANAGED CARE PLAN)?
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that [you personally have/(SP) personally has/(SP) (-9) Refused
personally had], not what the plan offers everyone.]

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
BOX HIMC1CC1
routing

MHMODENT

HIMC7

MHMOEYE

HIMC8

MHMONH

HIMC10

MHMOPAY

HIMC11

MHMOAMT

HIMC12

MHMOUNIT

HIMC12

yes/no

Question text/description
Code list
IF (THIS MEDICARE MANAGED CARE PLAN IS NEW OR HAS BEEN "RESTARTED"), GO TO HIMC7 - MHMODENT.
ELSE GO TO BOX HIMC2.
[Do you/Does (SP)/Did (SP)] have dental coverage through (CURRENT MEDICARE MANAGED CARE PLAN
NAME)?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
[Do you/Does (SP)/Did (SP)] have optical coverage through (CURRENT MEDICARE MANAGED CARE PLAN
(01) YES
NAME), that is, for eyeglasses or contact lenses?
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
[Does your/Does (SP’s)/Did (SP’s)] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage include
(01) YES
nursing home care above and 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 (SNF) (-9) Refused
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.)
yes/no
Besides the cost of [your/(SP’s)] Medicare Part B premium, [is/was] there an additional cost for [your/(SP’s)] (01) YES
(CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage? Please do not include any amount that
(02) NO
[you/(SP)] may (pay/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.]
quantity unit hybrid Not including the cost of [your/(SP’s)] Medicare Part B premium, what [is/was] the additional amount that
(01) [Continuous answer.]
[you pay/(SP) pays/(SP) paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE PLAN NAME)
(-8) Don't Know
coverage? (Please do not include any copayments or any amount that may [be/have been] paid for anyone (-9) Refused
other than [you/(SP)].)
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]
quantity unit hybrid 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 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

(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

OTHER (SPECIFY)
[Does/Did] anyone else, such as an employer, a union or professional organization pay all or some portion of (01) YES
the additional cost for [your/(SP’s)] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(02) NO
(-8) Don't Know
(-9) Refused

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
MHMOWHO
HIMC12B
code 1

MHMOWHOS

HIMC12B
BOX HIMC2

verbatim text
routing

MHMOMORE

HIMC16

yes/no

PLAN_MHMOOTHER

HIMC17

roster

Question text/description
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.
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?]
[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]
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?

BOX HIMC4

routing

HIMC19

yes/no

BOX HIMC5

routing

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.

HMONUMYR

HIMC24

numeric

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.]

HMONUM96

HIMC24

numeric

How many years [have you/has (SP)] been enrolled in a managed care plan?

BOX HI1

routing

IF A MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HI6 COVTIME.
ELSE GO TO HI5INTRO - MCAIDINT.

RECMHMO

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

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

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
MCAIDINT
HI5INTRO
no entry

Question text/description
SHOW CARD HI3

Code list

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.

BOX HI1B

routing

MCAIDINTB

HI5INTRB

no entry

AIDCOVER

HI5

yes/no

COVTIME

HI6

code 1

COVNOW

HI7

yes/no

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

BOX HI4

routing

COVBEGMM

HI8

date

COVBEGDD

HI8

date

COVBEGYY

HI8

date

COVENDMM

HI9

date

COVENDDD

HI9

date

COVENDYY

HI9

date

IF THIS MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HI10A MCAIDHMO.
ELSE GO TO HI8 - COVBEGMM.
On what date did [your/(SP’s)] Medicaid start between (REFERENCE DATE) and [today/(DATE OF
(01) [Continuous answer.]
DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] Medicaid start between (REFERENCE DATE) and [today/(DATE OF
(01) [Continuous answer.]
DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] Medicaid start between (REFERENCE DATE) and [today/(DATE OF
(01) [Continuous answer.]
DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(-8) Don't Know
(-9) Refused
On what date [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/
(01) [Continuous answer.]
DATE OF INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid coverage [most recently/last] stop?
(-8) Don't Know
(-9) Refused
On what date [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid coverage [most recently/last] stop?
(-8) Don't Know
(-9) Refused
On what date [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid coverage [most recently/last] stop?
(-8) Don't Know
(-9) Refused

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 you/has (SP) been/was (SP)] covered by Medicaid?
[PROBE IF NECESSARY: Do you have a health plan card or something with the plan name on it?]
(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) YES
(02) NO
(-8) Don't Know
(-9) Refused
(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

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
MCAIDHMO
HI10A
yes/no

Question text/description
(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]?

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

[ONLY SELECT “YES” IF THE RESPONDENT IS ACTUALLY ENROLLED IN THE PLAN; SOME STATES MAY OFFER
MANAGED CARE, BUT NOT REQUIRE ENROLLMENT.]

MPDCOVER

BOX HI5D

routing

HI10C1

yes/no

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

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

At any time [since (REFERENCE DATE)/between (REFERENCE DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have 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?

PDPCURR

HI10C2

yes/no

PLAN_CAIDMPDP

HI10C3

roster

PDPMORE

HI10C4

Yes/No

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

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
PLAN_CAIDMPDPOTHR HI10C5
roster

Question text/description
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)].

Code list

[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

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

BOX HIT1

routing

HIT1

yes/no

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

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

Please look at this card. 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)] 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).)
COVTIME

HIT2

code1

COVNOW

HIT3

yes/no

TRIRXCOV

HIT4

yes/no

[At the time of the last interview [you were/(SP) was] covered by TRICARE.] [Were you/Was (SP)] covered by (01) THE WHOLE TIME
TRICARE the whole time between [(REFERENCE DATE) and (today/DATE OF DEATH/DATE OF
(02) PART OF THE TIME
INSTITUTIONALIZATION)], or only part of the time?
(-8) Don't Know
(-9) Refused
[[Are you/Is (SP)] now covered by TRICARE?] [Was (SP) covered by TRICARE on (DATE OF DEATH/DATE OF
(01) YES
INSTITUTIONALIZATION?]
(02) NO
(-8) Don't Know
(-9) Refused
[Does/Did] [your/(SP’s)] TRICARE plan cover medicines prescribed by a doctor or other health professional? (01) YES
(02) NO
[PROBE: I am asking about the type of insurance coverage that [you personally have/(SP) personally has], not (-8) Don't Know
what the plan offers everyone.]
(-9) Refused

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
TRIMEDS
HIT4A1
code 1

TRIMEDOS

HIT4A1
BOX HIT3

verbatim text
routing

MTFCOVER

HIT11

yes/no

BOX HI20

routing

HI36

yes/no

BOX HI7

routing

PUBINTRO

HI11PREV

no entry

NAVIGATOR

HI11PREV_IN

instance navigator

BOX HI7A

routing

PUBCOVER

HI11

yes/no

PLAN_PUBLIC

HI12

roster

NAVIGATOR

HI12_IN

instance navigator

VACOVER

Question text/description
SHOW CARD HIT2
Where [do you/does (SP)/did you/did (SP)] usually obtain [your/his/her] medicines? [Do you/Does (SP)/Did
you/Did (SP)] usually obtain them at a TRICARE mail order pharmacy (TMOP), a TRICARE retail pharmacy
network pharmacy (TRRx), a military treatment facility pharmacy (MTF), a non-network retail pharmacy, or
somewhere else?

Code list
(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
(02) A TRICARE RETAIL PHARMACY NETWORK
PHARMACY (TRRX)
(03) A MILITARY TREATMENT FACILITY PHARMACY
(MTF)
(04) A NON-NETWORK RETAIL PHARMACY
(91) SOMEWHERE ELSE
(-8) Don't Know
(-9) Refused
(01) [Continuous Answer]

SOMEWHERE ELSE (SPECIFY)
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.
[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since (REFERENCE DATE),
(01) YES
[have you/has (SP) received/did (SP) receive] health care or health services or prescribed medicines at a
(02) NO
Military Treatment Facility or MTF?
(-8) Don't Know
(-9) Refused
[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),
(01) YES
[have you/has (SP) received/did (SP) receive] health care or health services or prescribed medicines through (02) NO
the Department of Veterans Affairs or V.A.?
(-8) Don't Know
(-9) Refused
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.
The next questions are about public plans [you were/(SP) was] covered by as of (REFERENCE DATE).
(01) CONTINUE
(-7) Empty
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
CREATE CURRENT ROUND PLRO FOR PUBLIC PLAN
GO TO HI13 - COVTIME.
SHOW CARD HI6
(01) YES
At any time [since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/ (02) NO
DATE OF INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)] covered by any public program other (-8) Don't Know
than Medicaid that pays for medical care [for example, a public program that pays for prescribed medicines? (-9) Refused

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.
[WHEN YOU ENTER A PLAN, VERIFY WITH THE RESPONDENT THAT IT IS A PUBLIC PLAN.]

(01) [Continuous answer.]

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

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
COVTIME
HI13
code 1

COVNOW

Question text/description
[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?

HI14

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)?]

BOX HI10

routing

COVBEGMM

HI15

date

IF THIS PUBLIC PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HI16A PUBRXCOV.
ELSE GO TO HI15 - COVBEGMM.
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start [between (REFERENCE DATE) and
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?

COVBEGDD

HI15

date

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

COVBEGYY

HI15

date

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

COVENDMM

HI16

date

COVENDDD

HI16

date

COVENDYY

HI16

date

PUBRXCOV

HI16A

yes/no

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

BOX HI12

routing

BOX HI12AA

routing

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.

Code list
(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

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
PDPSAME
HI16AB
yes/no

PDPYSTOP

HI16AC

code 1

PDPYSTOS
PDPOTHER

HI16AC
HI16AD

verbatim text
yes/no

PDPCOVER

HI16B

yes/no

Question text/description
At the time of the last interview [you were/(SP) was] covered by a Medicare Prescription Drug Plan named
(MEDICARE PRESCRIPTION DRUG PLAN NAME).
[[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.]
What is the most important reason [you/(SP)] stopped the (MEDICARE PRESCRIPTION DRUG PLAN NAME)
coverage?

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

(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

OTHER (SPECIFY)
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/INSTITUTIONALIZATION)], [have (01) YES
you/has (SP)/had (SP)] been covered by any other Medicare Prescription Drug plans besides (MEDICARE
(02) NO
PRESCRIPTION DRUG PLAN CURRENT LAST ROUND)?
(-8) Don't Know
(-9) Refused
[PROBE IF NECESSARY: Do you have a health plan card or something with the plan name on it?]
(Medicare beneficiaries can receive insurance coverage for prescription drugs through Medicare Prescription (01) YES
Drug plans. These plans are also called "Medicare Part D" plans.)
(02) NO
(-8) Don't Know
At any time since (REFERENCE DATE), [have you/has (SP)/had (SP)] been enrolled in a Medicare Prescription (-9) Refused
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?]

PDPCOVER

HI16B1

yes/no

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.
At any time since (REFERENCE DATE), [have you/has (SP)/had (SP)] been enrolled in a Medicare Prescription
Drug plan in any way other than through Medicaid?

PDPCURR

HI16C

yes/no

PLAN_MPDP

HI16E

roster

[PROBE IF NECESSARY: Do you have a health plan card or something with the plan name on it?]
[Are you/Is (SP)/Was (SP)] [currently] covered by or enrolled in a Medicare Prescription Drug plan [on (DATE
OF DEATH/DATE OF INSTITUTIONALIZATION)]?

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]

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

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

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
PDPMORE
HI16F
yes/no

PLAN_MPDPOTHR

HI16G

roster

BOX HI12A

routing

PRIVINTRO

HI17PREV

no entry

NAVIGATOR

HI17PREV_IN

instance navigator

BOX HI12B

routing

HI17

yes/no

PRVCOVER

Question text/description
[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)?

Code list
(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?]
[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]
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
The next questions are about private plans [you were/(SP) was] covered by as of (REFERENCE DATE).
(01) CONTINUE
(-7) Empty
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
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].
(01) YES
(02) NO
(Now, I would like to ask about another type of health insurance.) At any time [since (REFERENCE
(-8) Don't Know
DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-9) Refused
INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)] covered by (any other) private health insurance
plans?
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.

EXCHGCOV

HI18A

yes/no

SHOW CARD MA PLANS
As you may know, every state now offers a health insurance marketplace, also referred to as an exchange.

(01) YES
(02) NO
(-8) Don't Know
The marketplace allows residents to compare and purchase available health insurance options that meet their (-9) Refused
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 [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF 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.]

BOX HI13A

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO HI19 - GAPCOVER.
ELSE GO TO HI35 - PRVOCOV.

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
GAPCOVER
HI19
yes/no

Question text/description
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.

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

At any time since (REFERENCE DATE) did [you/(SP)] have this type of health insurance coverage?

PLAN_PRIVATE

HI20

roster

NAVIGATOR

HI20_IN

instance navigator

COVTIME

HI21

code 1

COVNOW

HI22

yes/no

BOX HI16

routing

COVBEGMM

HI23

date

COVBEGDD

HI23

date

COVBEGYY

HI23

date

COVENDMM

HI24

date

COVENDDD

HI24

date

COVENDYY

HI24

date

BOX HI17

routing

[PROBE IF NECESSARY: Do you have a health plan card or something with the plan name on it?]
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
(01) THE WHOLE TIME
NAME).] [Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole time between (REFERENCE DATE) (02) PART OF THE TIME
and [today/ DATE OF DEATH/DATE OF INSTITUTIONALIZATION], or only part of the time?
(-8) Don't Know
(-9) Refused
[[Are you/Is (SP)] now covered by (PRIVATE PLAN NAME)?] [Was (SP) covered by (PRIVATE PLAN NAME) on (01) YES
(DATE OF DEATH/
(02) NO
DATE OF INSTITUTIONALIZATION)?]
(-8) Don't Know
(-9) Refused
IF THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HI17.
ELSE GO TO HI23 - COVBEGMM.
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (REFERENCE DATE) and (01) [Continuous answer.]
[today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION]?
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (REFERENCE DATE) and (01) [Continuous answer.]
[today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION]?
(-8) Don't Know
(-9) Refused
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (REFERENCE DATE) and (01) [Continuous answer.]
[today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION]?
(-8) Don't Know
(-9) Refused
On what date [since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
(01) [Continuous answer.]
DEATH/DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
(-8) Don't Know
(-9) Refused
On what date [since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
(01) [Continuous answer.]
DEATH/DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
(-8) Don't Know
(-9) Refused
On what date [since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
(01) [Continuous answer.]
DEATH/DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
(-8) Don't Know
(-9) Refused
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.

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
PPRVHMO
HI25
yes/no

PERS_MIPNUM

HI26

roster

PPRVGET

HI27

code 1

PPRVGTOS
PRVNMCOV

HI27
HI29

verbatim text
numeric

PRVRXCOV

HI30

yes/no

Question text/description
CODE WITHOUT ASKING IF VOLUNTEERED.
[Is/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 [is/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, or did [you/(MIP)] get this insurance
through a current employer, a former employer, a union, a family business, AARP, or some other way?

OTHER (SPECIFY)
How many family members, including [yourself/(SP)], [are/were] covered by [your/(MIP’s)] (PRIVATE PLAN
NAME)?

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

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

[INCLUDE ALL FAMILY MEMBERS COVERED BY THE PLAN REGARDLESS OF WHETHER OR NOT THEY LIVE WITH
THE 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 (01) YES
as prescribed medicines or dental coverage. I’d like to know what [your/(SP’s)] (PLAN NAME) coverage
(02) NO
[includes/included].
(-8) Don't Know
(-9) Refused
[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?

PRVMSCOV

BOX HI17AB

routing

HI31A

list

[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.
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
(01) YES
(02) NO
visits to a doctor or other health professional or lab work?
(-8) Don't Know
(-9) Refused
[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.]

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
PRVIPCOV
HI31A
list

Question text/description
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
inpatient hospital 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.]
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
nursing home or long term care?

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

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

[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.]
MHMODENT

HI31A

list

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

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

[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.]
MIPPINS

HI32

yes/no

[Do/Does/Did] [you/(MIP)] pay any or all of the 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/have had] to pay.]

MIPPAMT

HI33

MIPPUNIT

HI33

quantity unit hybrid 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 other than [you/(SP)].]
[PROBE IF NECESSARY: [Is/Was] that per year, per month, per week, or what?]
quantity unit hybrid 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 other than [you/(SP)].]
[PROBE IF NECESSARY: [Is/Was] that per year, per month, per week, or what?]

MIPPUNOS
MHMOCOST

HI33
HI33A

verbatim text
yes/no

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(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

OTHER (SPECIFY)
[Does/Did] anyone else, such as an employer, a union or professional organization pay all or some portion of (01) YES
the premium or cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
(02) NO
(-8) Don't Know
(-9) Refused

Health Insurance (HIQ)
Variable Name
MR Screen Name Question type
MHMOWHO
HI33B
code 1

MHMOWHOS

HI33B
BOX HI17B

verbatim text
routing

MHMOPOS

HI33C

yes/no

BOX HI19

routing

HI35

yes/no

BOX HI19B

routing

HI34

yes/no

BOX HI21A

routing

PRVOCOV

OTHNHCOV

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

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

OTHER (SPECIFY)
IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO HI33C - MHMOPOS.
ELSE GO TO BOX HI19.
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. [Are/Were/Is/Was] [you/(SP)] enrolled in a point-of(02) NO
service option offered by (PRIVATE PLAN NAME)?
(-8) Don't Know
(-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.]
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.
We’ve talked about [READ PLAN(S) LISTED ABOVE]. [Do you/Does (SP)/Did (SP)] have medical coverage
(01) YES
under any (other) private insurance plans we haven’t talked about?
(02) NO
(-8) Don't Know
(-9) Refused
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO HI34 - OTHNHCOV.
ELSE GO TO BOX HI21A.
[Other than the plans you have already told me about, [do you/does (SP)/did (SP)]/[Do you/Does (SP)/Did
(01) YES
(SP)]] have any insurance that [pays/paid] just for nursing home care or other long term care?
(02) NO
(-8) Don't Know
(-9) Refused
GO TO NEXT SECTION
IF SAMPLE TYPE IS SUPPLEMENTAL (C003) NEXT SECTION IS MBQ.
ELSE IF SAMPLE TYPE IS CONTINUING, NEXT SECTION IS DUQ.