CMS-P-0015A Comm2019R83HIQ

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

HEALTH INSURANCE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C003, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If (INTTYPE in(C001, C002, C004, C005, C006) and SEASON=FALL) or (INTTYPE=C003), administer after HAQ.
If (INTTYPE in(C001, C002, C004, C005, C006) and SEASON=WINTER or SUMMER) or (INTTYPE in (C007,
C010)), administer after ENS.

HIINTR1

BOX HIBEG

routing

HIMCINTR

no entry

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 HI1.] Please refer to this card as we talk about [your/(SP’s)] health insurance
coverage.
BOX MC1AA

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

WHATWRNG

MC1

MC2

yes/no

code 1

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

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)

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

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

Variable Name

MR Screen Name

Question type

YDISNROL

MC2B

code 1

YDISNROS

MC2B

verbatim text

BOX MC1A

routing

PRIMPHYS

SAMEPLAN

MC3

MC4

yes/no

code 1

Question text/description

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

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?

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

Routing
(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
BOX MC1A

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

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

What is the name of the Medicare Advantage Plan that provides [your/(SP’s)] health care benefits?
PLAN_MHMOMCA MC5

BOX HIMC1

roster
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
Do you refer to [your/(SP’s)] Medicare coverage by any name besides Medicare?

REFERMED

MC11

code 1

PLAN_MHMOMCB MC12

roster

[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, 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.

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

(01) BOX HIMC4
(02) MC12 - PLAN_MHMOMCB
(-8) BOX HIMC4
(-9) BOX HIMC4
BOX HIMC1

At the time of the last interview [you were/(SP) was] covered by the Medicare Advantage Plan named
(MEDICARE MANAGED CARE PLAN NAME).
MHMOSAME

HIMC1A

yes/no

[[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.]

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

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

Variable Name

MR Screen Name

Question type

YDISNROL

HIMC1B1

code 1

YDISNROS

HIMC1B1

verbatim text

MHMOOTHR

HIMC1C

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)?

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

Routing
(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

HIMC1C - MHMOOTHR
(01) HIMC3 - MHMOCURR
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4

(01) YES
(Please look at this card.) At any time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF (02) NO
DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been enrolled in or covered by [(one (-8) Don't Know
of these/any)] Medicare Advantage plans?
(-9) Refused

(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

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

MHMOCURR

PLAN_MHMO

MHMORXTM

HIMC3

HIMC5

yes/no

roster

BOX HIMC1

routing

HIMC6A

yes/no

BOX HIMC1CC1

routing

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

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

BOX HIMC1

BOX HIMC1CC1

Variable Name

MR Screen Name

Question type

Question text/description

MHMODENT

HIMC7

yes/no

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

MHMOEYE

HIMC8

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?

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

Routing
HIMC8 - MHMOEYE

HIMC10 - MHMONH

[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?
MHMONH

MHMOPAY

MHMOAMT

HIMC10

HIMC11

HIMC12

yes/no

yes/no

quantity unit
hybrid

(01) YES
(02) NO
(EXPLAIN IF NECESSARY: Under regular fee-for-service, Medicare pays for limited skilled nursing facility (SNF) (-8) Don't Know
care during a benefit period. In 2017, the first 20 days are paid in full and the next 80 days require a
(-9) Refused
copayment of up to $164.50 per day.)
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.
(01) YES
(02) NO
[EXPLAIN IF NECESSARY: Some managed care plans may charge a monthly premium to cover the cost of the (-8) Don't Know
deductibles and coinsurance for Medicare-covered services or because they provide services that are not
(-9) Refused
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 [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)].)

HIMC11 - MHMOPAY

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

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

(01) HIMC12 - MHMOUNIT
(-8) HIMC12A - MHMOCOST
(-9) HIMC12A - 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) HIMC12A - MHMOCOST
(02) HIMC12A - MHMOCOST
(03) HIMC12A - MHMOCOST
(04) HIMC12A - MHMOCOST
(05) HIMC12A - MHMOCOST
(06) HIMC12A - MHMOCOST
(07) HIMC12A - MHMOCOST
(91) MHMOUNOS-MHMOUNOS
(-8) HIMC12A - MHMOCOST
(-9) HIMC12A - MHMOCOST
HIMC12A - MHMOCOST
(01) HIMC12B - MHMOWHO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2

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

MHMOUNIT

HIMC12

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

MHMOUNOS
HIMC12A

verbatim text

OTHER (SPECIFY)

yes/no

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

MHMOWHO

HIMC12B

code 1

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

MHMOWHOS

HIMC12B

verbatim text

OTHER (SPECIFY)

(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) 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

Variable Name

MHMOMORE

MR Screen Name

Question type

BOX HIMC2

routing

HIMC16

PLAN_MHMOOTHE
HIMC17
R

yes/no

roster

Question text/description
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.

Code list

SHOW CARD HI2
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/ DATE OF
(01) YES
INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)] been covered by any other Medicare Advantage Plans
(02) NO
besides (MEDICARE MANAGED CARE PLAN and MEDICARE MANAGED CARE PLAN)?
(-8) Don't Know
(-9) Refused
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, 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.

Routing

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

BOX HIMC4

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
BOX HIMC4

RECMHMO

routing

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.

HIMC19

yes/no

Would you recommend (CURRENT MEDICARE MANAGED CARE PLAN NAME) to your family or friends?

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

HMONUM96

HIMC24

numeric

BOX HI1

routing

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

(01) [Continuous answer.]
How many years [have you/has (SP)] been enrolled in a Medicare Advantage plan?
(-7) Empty
[IF THE RESPONDENT HAS BEEN ENROLLED IN MORE THAN ONE MEDICARE ADVANTAGE PLAN, THEN ENTER
(-8) Don't Know
THE TOTAL NUMBER OF YEARS THAT HE/SHE HAS BEEN ENROLLED IN ALL MEDICARE ADVANTAGE PLANS.]
(-9) Refused
(01) LESS THAN ONE YEAR
How many years [have you/has (SP)] been enrolled in a managed care plan?
(-7) Empty
IF A MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HI6 COVTIME.
ELSE GO TO HI5INTRO - MCAIDINT.

BOX HIMC5

HIMC24 - HMONUM96

BOX HI1

SHOW CARD HI3
MCAIDINT

MCAIDINTB

HI5INTRO

no entry

PLEASE READ THIS INTRODUCTION SLOWLY AND CLEARLY:
Medicaid[, also known as (MEDICAID STATE PLAN NAME),] 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.

BOX HI1B

routing

IF STATE IN WHICH SP LIVES DOES NOT OFFER A MEDICAID MANAGED CARE PLAN, GO TO HI5 - AIDCOVER.
ELSE GO TO HI5INTRB - MCAIDINTB.

HI5INTRB

no entry

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?

AIDCOVER

HI5

yes/no
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan
name on it?]

BOX HI1B

HI5 - AIDCOVER

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

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

Variable Name

MR Screen Name

Question type

Question text/description

COVTIME

HI6

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?

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

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

COVBEGMM

HI8

date

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

COVBEGDD

HI8

date

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

COVBEGYY

HI8

date

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

COVENDMM

HI9

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?

COVENDDD

HI9

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?

COVENDYY

HI9

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?
(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]?

MCAIDHMO

HI10A

yes/no
[ONLY SELECT “YES” IF THE RESPONDENT IS ACTUALLY ENROLLED IN THE PLAN; SOME STATES MAY OFFER
MANAGED CARE, BUT NOT REQUIRE ENROLLMENT.]

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

Routing
(01) HI10A - MCAIDHMO
(02) HI7 - COVNOW
(-8) HI7 - COVNOW
(-9) HI7 - COVNOW
(01) BOX HI4
(02) HI9 - COVENDMM
(-8) HI10A - MCAIDHMO
(-9) HI10A - MCAIDHMO

HI8 - COVBEGDD

HI8 - COVBEGYY

HI10A - MCAIDHMO

HI9 - COVENDDD

HI9 - COVENDYY

HI10A- MCAIDHMO

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

BOX HI5D

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

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

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

BOX HI5D

routing

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

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

Variable Name

PDPCURR

PLAN_MPDP

MR Screen Name

HI10C2

HI10C3

Question type

Question text/description

Code list

Routing

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

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

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.

HI10C4 - PDPMORE

[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

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

[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, 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_CAIDMPDPO
HI10C5
THR

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.

BOX HIT1

[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

MCDRXCOV

HI10D

yes/no

BOX HIT1

routing

(01) YES
(02) NO
(Does/Did) [your/(SP’s)] Medicaid plan cover medicines 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 A TRICARE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HIT2 COVTIME.
ELSE GO TO HIT1 - TRICOVER.

BOX HIT1

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.
TRICOVER

HIT1

yes/no

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?

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

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

(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

(01) THE WHOLE TIME
[At the time of the last interview [you were/(SP) was] covered by TRICARE.] [Were you/Was (SP)] covered by
(02) PART OF THE TIME
TRICARE the whole time between [(REFERENCE DATE) and (today/DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], or only part of the time?
(-9) Refused
(01) YES
(02) NO
[[Are you/Is (SP)] now covered by TRICARE?] [Was (SP) covered by TRICARE on (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION?]
(-9) Refused

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

Variable Name

MR Screen Name

Question type

Question text/description

Code list

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

HIT4

yes/no

TRIMEDS

HIT4A1

code 1

TRIMEDOS

TRIMEDOS

verbatim text

BOX HIT3

routing

MTFCOVER

HIT11

yes/no

(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

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?

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),
[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.]

routing

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.

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 through
the Department of Veterans Affairs or V.A.?

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

BOX HI20

VACOVER

HI36

PUBCOVER

HI11

yes/no

PLAN_PUBLIC

HI12

roster

NAVIGATOR

HI12_IN

instance navigator

COVTIME

HI13

code 1

CREATE CURRENT ROUND PLRO FOR PUBLIC PLAN
GO TO HI13 - COVTIME.
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.
[WHEN YOU ENTER A PLAN, VERIFY WITH THE RESPONDENT THAT IT IS A PUBLIC PLAN.]

[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?

(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]

Routing
(01) HIT4A1 - TRIMEDS
(02) BOX HIT3
(-8) BOX HIT3
(-9) BOX HIT3
(01) BOX HIT3
(02) BOX HIT3
(03) BOX HIT3
(04) BOX HIT3
(91) TRIMEDOS-TRIMEDOS
(-8) BOX HIT3
(-9) BOX HIT3
BOX HIT3

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

BOX HI20

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

BOX HI7

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

HI11PREV_IN - NAVIGATOR
(01) BOX HI7A
(02) HI11 - PUBCOVER

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

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

(01) [Continuous answer.]
(996) PLAN ENTERED IN ERROR

HI12_IN - NAVIGATOR

(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) HI13 - COVTIME
(02) BOX HI12AA
(01) HI16A - PUBRXCOV
(02) HI14 - COVNOW
(-8) HI14 - COVNOW
(-9) HI14 - COVNOW

Variable Name

MR Screen Name

Question type

Question text/description

COVNOW

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)?]

routing

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

BOX HI10

COVBEGMM

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)?

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)?
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?

COVENDMM

HI16

date

COVENDDD

HI16

date

COVENDYY

HI16

date

PUBRXCOV

HI16A

yes/no

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

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.

routing

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.

BOX HI12

BOX HI12AA

Code list
(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

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

HI15 - COVBEGDD

HI15 - COVBEGYY

HI16A - PUBRXCOV

HI16 - COVENDDD

HI16 - COVENDYY

HI16A - PUBRXCOV

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.]

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

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

Variable Name

MR Screen Name

Question type

Question text/description

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)

Code list
(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

Routing
(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

[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)?
PDPOTHER

HI16AD

yes/no

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

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

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

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

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

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

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

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

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

ONLY ENTER STAND-ALONE PRESCRIPTION DRUG PLANS AT THIS QUESTION. IF THE R HAS RX COVERAGE
THROUGH ANOTHER INSURANCE PLAN, SUCH AS A MEDICARE ADVANTAGE PLAN, DO NOT ENTER A
SEPARATE PRESCRIPTION DRUG PLAN.
(Medicare beneficiaries can receive insurance coverage for prescription drugs through Medicare Prescription
Drug plans. These plans are also called "Medicare Part D" plans.)
At any time since (REFERENCE DATE), [have you/has (SP)/had (SP)] been enrolled in a Medicare Prescription
Drug plan that [covers/covered] medicines prescribed by a doctor or other health professional?
PDPCOVER

HI16B

yes/no

[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan
name on it?]
ONLY ENTER STAND-ALONE PRESCRIPTION DRUG PLANS AT THIS QUESTION. IF THE R HAS RX COVERAGE
THROUGH ANOTHER INSURANCE PLAN, SUCH AS A MEDICARE ADVANTAGE PLAN, DO NOT ENTER A
SEPARATE PRESCRIPTION DRUG PLAN.
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

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?
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, 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)]?
What is the name of the Medicare Prescription Drug plan that [currently covers/covered] [you/(SP)] [on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?]

PLAN_MPDP

HI16E

roster

SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN AT THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

HI16F - PDPMORE

Variable Name

MR Screen Name

Question type

PDPMORE

HI16F

yes/no

PLAN_MPDPOTHR

HI16G

roster

Question text/description
Code list
[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 (01) YES
MEDICARE PRESCRIPTION DRUG PLAN)?
(02) NO
(-8) Don't Know
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan
(-9) Refused
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)?

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

BOX HI12A
SELECT OR ADD MEDICARE PRESCRIPTION DRUG PLAN NAMES AT THIS ROSTER.

BOX HI12A

routing

PRIVINTRO

HI17PREV

no entry

NAVIGATOR

HI17PREV_IN

instance navigator

BOX HI12B

routing

PRVCOVER
PRIVCOV

HI17

yes/no

[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

(01) BOX HI12B
(02) HI17 - PRVCOVER

CREATE A CURRENT ROUND PLRO FOR PRIVATE PLAN
GO TO HI21 - COVTIME.
You reported that [you are/(SP) is/(SP) was] covered by [READ PLAN NAME(S) AND PLAN TYPE(S) LISTED
ABOVE].
(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)] covered by [any other] private health insurance (02) NO
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, vision care, or hearing care.

(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.

EXCHGCOV

HI18A

yes/no

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
(01) YES
enrollment.
(02) NO
(-8) Don't Know
Please look at this card. At any time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF
(-9) Refused
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.

HI20 - PLAN_PRIVATE

Variable Name

MR Screen Name

Question type

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.

GAPCOVER

HI19

yes/no

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

Code list

Routing

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

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

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

HI20

NAVIGATOR

HI20_IN

COVTIME

HI21

COVNOW

HI22

What is the name of each of the [other] private plans that [provide/provided] [your/(SP’s)] medical insurance
(01) continuous answer
coverage?
roster
(996) PLAN ENTERED IN ERROR
SELECT OR ADD ALL PRIVATE PLAN NAMES AT THIS ROSTER.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
instance navigator
(02) CONTINUE INTERVIEW SELECTED
(01) THE WHOLE TIME
[At the time of the last interview [you were/(SP) was] covered by a private plan named (PRIVATE PLAN
(02) PART OF THE TIME
code 1
NAME).] [Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole time between (REFERENCE DATE)
(-8) Don't Know
and [today/ DATE OF DEATH/DATE OF INSTITUTIONALIZATION], or only part of the time?
(-9) Refused
(01) YES
[[Are you/Is (SP)] now covered by (PRIVATE PLAN NAME)?] [Was (SP) covered by (PRIVATE PLAN NAME) on
(02) NO
yes/no
(DATE OF DEATH/
(-8) Don't Know
DATE OF INSTITUTIONALIZATION)?]
(-9) Refused

BOX HI16

routing

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

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]?

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]?

COVENDMM

HI24

date

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

COVENDDD

HI24

date

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

COVENDYY

HI24

date

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

PPRVHMO

BOX HI17

routing

HI25

yes/no

(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

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
(01) YES
Provider Organization)?
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: Managed care plans generally provide a full range of health care services for a
(-9) Refused
prepaid fee. Health care is generally provided by primary care doctors, specialists, or hospitals on the plan’s
list (network) except in an emergency.]

HI20_IN - NAVIGATOR
(01) HI21 - COVTIME
(02) HI35 - PRVOCOV
(01) BOX HI17
(02) HI22 - COVNOW
(-8) HI22 - COVNOW
(-9) HI22 - COVNOW
(01) BOX HI16
(02) HI24 - COVENDMM
(-8) BOX HI17
(-9) BOX HI17

HI23 - COVBEGDD

HI23 - COVBEGYY

BOX HI17

HI24 - COVENDDD

HI24 - COVENDYY

BOX HI17

HI26 - PERS_MIPNUM

Variable Name

PERS_MIPNUM

ROSTFNAM
ROSTLNAM

MR Screen Name

HI26

HI26_NEW
HI26_NEW

Question type

roster

text
text

Question text/description

Who [is/was] listed as the main insured person on the (PRIVATE PLAN NAME) policy or contract?
SELECT OR ADD ONLY ONE PERSON.

[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]

Code list

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/OtherRelative or 92/OtherNonRelative, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

(01-N) HI27 - PPRVGET
(N+1) HI26_NEW-ROSTFNAM
IF EXISTING PERSON SELECTED, GO TO
HI27 - PPRVGET
ELSE IF "ADD ANOTHER" SELECTED, GO
TO HI26_NEW-ROSTFNAM

ROSTREL

HI26_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HI26_NEW

verbatim text

[What is the name of the person and relationship to (SP)?]

(01) continuous reponse

HI26_NEW - ROSTLNAM
HI26_NEW - ROSTREL
(01) DO NOT DISPLAY
(02) HI27 - PPRVGET
(03) HI27 - PPRVGET
(04) HI27 - PPRVGET
(05) HI27 - PPRVGET
(06) HI27 - PPRVGET
(07) HI27 - PPRVGET
(08) HI27 - PPRVGET
(09) HI27 - PPRVGET
(10) HI27 - PPRVGET
(11) HI27 - PPRVGET
(12) HI27 - PPRVGET
(13) HI27 - PPRVGET
(14) HI27 - PPRVGET
(50) DO NOT DISPLAY
(51) HI27 - PPRVGET
(52) HI27 - PPRVGET
(53) HI27 - PPRVGET
(54) HI27 - PPRVGET
(55) HI27 - PPRVGET
(56) HI27 - PPRVGET
(57) HI27 - PPRVGET
(91) HI26_NEW - ROSTREOS
(-8) HI27 - PPRVGET
(-9) HI27 - PPRVGET
HI27 - PPRVGET

(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) 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

PPRVGET

HI27

code 1

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?

PPRVGTOS

HI27

verbatim text

OTHER (SPECIFY)

(01) continuous answer
(01) continuous answer

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

HI29 - PRVNMCOV

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

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

HI29

numeric

(01) [Continuous answer.]
(-8) Don't Know
[INCLUDE ALL FAMILY MEMBERS COVERED BY THE PLAN REGARDLESS OF WHETHER OR NOT THEY LIVE WITH (-9) Refused
THE RESPONDENT. MAKE SURE THE RESPONDENT INCLUDES HIM/HERSELF IN THE COUNT.]

HI30 - PRVRXCOV

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].

PRVRXCOV

HI30

yes/no

[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?

BOX HI17AB

routing

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

BOX HI17AB

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

HI31A - PRVIPCOV

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

HI31A - PRVNHCOV

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

HI31A - MHMODENT

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

HI32 - MIPPINS

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

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

[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…
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.]
DO NOT INCLUDE DENTISTS AS DOCTORS AT THIS QUESTION. DENTAL VISITS WILL BE ASKED ABOUT
SEPARATELY
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…

PRVIPCOV

HI31A

list

inpatient hospital care?
[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?

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…
dental care?

MHMODENT

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.]

[Do/Does/Did] [you/(MIP)] pay any or all of the premium or cost for the (PRIVATE PLAN NAME) coverage?
MIPPINS

HI32

yes/no
[Do not include the cost of any deductibles [you/(SP)] or [your/(SP’s)] family may [have/have had] to pay.]

Variable Name

MR Screen Name

Question type

Question text/description
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)].]

MIPPAMT

HI33

quantity unit
hybrid

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

Code list

Routing

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

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

ONLY ENTER THE AMOUNT FOR THE R'S COVERAGE ON THIS PLAN. IF THE R DOESN'T KNOW, ANSWER DK

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?]

MIPPUNOS
MHMOCOST

HI33
HI33A

verbatim text

OTHER (SPECIFY)

yes/no

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

MHMOWHO

HI33B

code 1

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

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.

MHMOPOS

yes/no

Some managed care plans offer a point-of-service option which allows members to receive services from outof-plan providers even in non-emergency situations. [Are/Were/Is/Was] [you/(SP)] enrolled in a point-of(01) YES
service option offered by (PRIVATE PLAN NAME)?
(02) NO
[EXPLAIN IF NECESSARY: In a point-of-service option, the member typically pays a higher copayment when
(-8) Don't Know
seeing an out-of-plan provider. For example, if a member sees an in-plan provider, there may only be a $10 (-9) Refused
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.]

routing

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.

HI35

yes/no

(01) YES
We’ve talked about [READ PLAN(S) LISTED ABOVE]. [Do you/Does (SP)/Did (SP)] have medical coverage under (02) NO
(-8) Don't Know
any (other) private insurance plans we haven’t talked about?
(-9) Refused

BOX HI19B

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO HI34 - OTHNHCOV.
ELSE GO TO BOX HI21A.

HI33C

BOX HI19

PRVOCOV

(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) 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

BOX HI19

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

Variable Name

MR Screen Name

Question type

Question text/description

OTHNHCOV

HI34

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

IF 11TH ROUND INTERVIEW AND (INTTYPE IN C001) AND (MREFDATE) IS AFTER (JANUARY 1 (CURRENT YEAR))
GO TO ACQ.
ELSE IF INTTYPE in (C001, C002, C004, C005, C006, C007, C010), GO TO DUQ.
ELSE IF INTTYPE in (C003), GO TO MBQ.

BOX HI21A

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

Routing
BOX HI21A