CMS-P-0015A Health Insurance

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

HIQ - HEALTH INSURANCE

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.
BOX HIBEG

routing

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.

HIINTR1

HIMCINTR

no entry

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

MC1

yes/no

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

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

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

2019 MCBS Community Questionnaire

HIQ - HEALTH INSURANCE

(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

YDISNROL

MC2B

code 1

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

YDISNROS

MC2B

verbatim text

OTHER (SPECIFY)

BOX MC1A

routing

IF MC2 - WHATWRNG = 1/EnrolledNewPlan, GO TO MC5 - PLAN_MHMOMCA.
ELSE GO TO HIMC16 - MHMOMORE.

yes/no

In many Medicare Advantage Plans, such as HMOs or PPOs, the health plan gives the patient a list of
doctors from which he chooses a primary care physician. This primary care physician provides the patient’s
usual medical care and can refer the patient to specialists, if necessary. [Do you/Does (SP)] have a primary
care physician?

(01) SAME PLANS
Is it possible that [your/(SP’s)] current insurance plan is just another name for (CMS MEDICARE MANAGED (02) NOT THE SAME PLANS
CARE PLAN NAME), or are they not the same plans?
(-8) Don't Know
(-9) Refused

PRIMPHYS

MC3

SAMEPLAN

MC4

code 1

PLAN_MHMOMCA

MC5

roster

BOX MC1A

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

What is the name of the Medicare Advantage Plan that provides [your/(SP’s)] health care benefits?
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

Do you refer to [your/(SP’s)] Medicare coverage by any name besides Medicare?
REFERMED

MC11

code 1

(01) MEDICARE ONLY
(02) OTHER NAME
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan (-8) Don't Know
name on it?]
(-9) Refused

PLAN_MHMOMCB

MC12

roster

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).
MHMOSAME

HIMC1A

yes/no

(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

(01) YES
[[Are you/Is (SP)] now covered by (MEDICARE MANAGED CARE PLAN NAME)?] [Was (SP) covered by
(02) NO
(MEDICARE MANAGED CARE PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?] (-8) Don't Know
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE THE PREVIOUS INTERVIEW
(-9) Refused
DATE, BUT PICKED UP THE COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE NAMED
PLAN, SELECT “YES” FOR THIS QUESTION.]

BOX HIMC1

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

BOX HIMC1

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

BOX HIMC1

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

2019 MCBS Community Questionnaire

HIQ - HEALTH INSURANCE

YDISNROL

HIMC1B1

code 1

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

YDISNROS

HIMC1B1

verbatim text

OTHER (SPECIFY)

yes/no

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

MHMOOTHR

HIMC1C

(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

HIMC1C - MHMOOTHR

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

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

(01) YES
(02) NO
(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 (-8) Don't Know
(-9) Refused
covered by [(one of these/any)] Medicare Advantage plans?

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

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

HIMC1

yes/no

(01) 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

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

MHMOCURR

PLAN_MHMO

HIMC3

HIMC5

yes/no

roster

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

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

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

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

BOX HIMC1

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

BOX HIMC1

MHMORXTM

HIMC6A

BOX HIMC1CC1

routing

yes/no

routing

THIS PLAN IS THE SP'S CURRENT MEDICARE MANAGED CARE PLAN
IF (THIS MEDICARE MANAGED CARE PLAN IS NEW OR HAS BEEN "RESTARTED") OR THIS IS A
FALL ROUND GO TO HIMC6A - MHMORXTM.
ELSE GO TO BOX HIMC1CC1
[Do you/Does (SP)/Did (SP)] have prescribed medicine coverage
through (CURRENT MEDICARE MANAGED CARE PLAN)?
[PROBE: I am asking about the type of insurance coverage that [you personally have/(SP) personally
has/(SP) 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) YES
(02) NO
(-8) Don't Know
(-9) Refused

BOX HIMC1CC1

2019 MCBS Community Questionnaire

MHMODENT

MHMOEYE

HIMC7

HIMC8

HIQ - HEALTH INSURANCE

yes/no

[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

HIMC8 - MHMOEYE

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?

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

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 (-8) Don't Know
(SNF) care during a benefit period. In [BEGIN_YEAR], the first 20 days are paid in full and the next 80 days (-9) Refused
require a copayment of up to [SNF_RATE] 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 (-8) Don't Know
the deductibles and coinsurance for Medicare-covered services or because they provide services that are
(-9) Refused
not covered by Medicare such as prescribed medicines, routine exams, and dental, eye, or hearing. Plans
that have premiums typically charge from $50 to $75 per month.]

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

HIMC11 - MHMOPAY

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

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

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

(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

MHMOUNIT

HIMC12

quantity unit hybrid

(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
Not including the cost of [your/(SP’s)] Medicare Part B premium, what [is/was] the additional amount that
(04) PER MONTH
[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 (05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
other than [you/(SP)].)
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]
(-8) Don't Know
(-9) Refused

MHMOUNOS

MHMOUNOS

verbatim text

OTHER (SPECIFY)

HIMC12A - MHMOCOST

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
the additional cost for [your/(SP’s)] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(-8) Don't Know
(-9) Refused

(01) HIMC12B - MHMOWHO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2

MHMOCOST

HIMC12A

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

2019 MCBS Community Questionnaire

BOX HIMC2

MHMOMORE

HIMC16

HIQ - HEALTH INSURANCE

routing

yes/no

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

PLAN_MHMOOTHER

HIMC17

roster

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

[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.

(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

HIMC19

BOX HIMC5

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.

yes/no

(01) YES
(02) NO
Would you recommend (CURRENT MEDICARE MANAGED CARE PLAN NAME) to your family or friends?
(-8) Don't Know
(-9) Refused

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.

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

HIMC24 - HMONUM96

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

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?

routing

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

BOX HI1

BOX HIMC5

SHOW CARD HI3
MCAIDINT

HI5INTRO

no entry

BOX HI1B

routing

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.

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

2019 MCBS Community Questionnaire

MCAIDINTB

AIDCOVER

HI5INTRB

HI5

HIQ - HEALTH INSURANCE

no entry

SHOW CARD HI4
Some people receive their Medicaid benefits from plans that have names like those listed on this card.

HI5 - AIDCOVER

yes/no

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

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

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

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)]?

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

HI8 - COVBEGDD

COVBEGDD

HI8

date

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

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

HI8 - COVBEGYY

COVBEGYY

HI8

date

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

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

HI10A - MCAIDHMO

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

HI9 - COVENDDD

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?

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

HI9 - COVENDYY

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?

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

HI10A- MCAIDHMO

MCAIDHMO

HI10A

yes/no

(Some states now use managed care plans, such as HMOs (Health Maintenance Organizations), to provide
some or all health care for Medicaid beneficiaries.) [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
(01) YES
COVERAGE STOP DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
(02) NO
(-8) Don't Know
[ONLY SELECT “YES” IF THE RESPONDENT IS ACTUALLY ENROLLED IN THE PLAN; SOME STATES
(-9) Refused
MAY OFFER MANAGED CARE, BUT NOT REQUIRE ENROLLMENT.]
[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.

BOX HI5D

2019 MCBS Community Questionnaire

HIQ - HEALTH INSURANCE

(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

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

(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?]

PDPCURR

PLAN_MPDP

HI10C2

HI10C3

yes/no

roster

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

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

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

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

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_CAIDMPDPOTHR HI10C5

roster

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

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.
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

BOX HIT1

(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
(02) PART OF THE TIME
by 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
(-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION?]
(-9) Refused

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

2019 MCBS Community Questionnaire

TRIRXCOV

HIT4

HIQ - HEALTH INSURANCE

yes/no

[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], (-8) Don't Know
not what the plan offers everyone.]
(-9) Refused

(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

(01) [Continuous Answer]

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

BOX HI7A

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

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

(01) ADD NEW PLAN
(02) CONTINUE THE INTERVIEW

(01) HI13 - COVTIME
(02) BOX HI12AA

(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) HI16A - PUBRXCOV
(02) HI14 - COVNOW
(-8) HI14 - COVNOW
(-9) HI14 - COVNOW
(01) BOX HI10
(02) HI16 - COVENDMM
(-8) HI16A - PUBRXCOV
(-9) HI16A - PUBRXCOV

TRIMEDS

HIT4A1

code 1

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

TRIMEDOS

TRIMEDOS

verbatim text

SOMEWHERE ELSE (SPECIFY)

routing

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

BOX HIT3

MTFCOVER

HIT11

yes/no

[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since (REFERENCE
DATE), [have you/has (SP) received/did (SP) receive] health care or health services or prescribed
medicines at a Military Treatment Facility or MTF?
[EXPLAIN IF NECESSARY: A Military Treatment Facility is any military hospital, clinic, or NAVCARE clinic.]

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.

HI36

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.

HI11PREV

no entry

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

BOX HI7A

routing

BOX HI20

VACOVER

PUBINTRO

PUBCOVER

HI11

yes/no

PLAN_PUBLIC

HI12

roster

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.]

COVTIME

HI13

code 1

[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?

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)?]

BOX HI10

routing

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

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)?

COVENDMM

HI16

date

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

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

HI15 - COVBEGDD
HI15 - COVBEGYY
HI16A - PUBRXCOV
HI16 - COVENDDD

2019 MCBS Community Questionnaire

HIQ - HEALTH INSURANCE

COVENDDD

HI16

date

COVENDYY

HI16

date

PUBRXCOV

HI16A

yes/no

BOX HI12

routing

BOX HI12AA

routing

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

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) YES
(Does/Did) [your/(SP’s)] (PUBLIC PLAN NAME) plan cover medicines prescribed by a doctor or other health (02) NO
(-8) Don't Know
professional?
(-9) Refused
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF REVIEWING PUBLIC PLANS THAT WERE "CURRENT" AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO BOX HI7A.
ELSE GO TO HI12-PLAN_PUBLIC.
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.

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

(01) YES
[[Are you/Is (SP)] now covered by (MEDICARE PRESCRIPTION DRUG PLAN NAME)?] [Was (SP) covered
(02) NO
by (MEDICARE PRESCRIPTION DRUG PLAN NAME) on (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)?]
(-9) Refused
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE THE PREVIOUS INTERVIEW
DATE, BUT PICKED UP THE COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE NAMED
PLAN, SELECT “YES” FOR THIS QUESTION.]

PDPYSTOP

HI16AC

code 1

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

PDPYSTOS

HI16AC

verbatim text

OTHER (SPECIFY)
[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

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

(01) YES
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan (02) NO
(-8) Don't Know
name on it?]
(-9) Refused
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.

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

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

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

2019 MCBS Community Questionnaire

HIQ - HEALTH INSURANCE

(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

(01) YES
(02) NO
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan (-8) Don't Know
(-9) Refused
name on it?]

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

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

(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

HI16F - PDPMORE

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

PDPMORE

PLAN_MPDPOTHR

PRIVINTRO

PRIVCOV

HI16F

HI16G

yes/no

roster

BOX HI12A

routing

HI17PREV

no entry

BOX HI12B

routing

HI17

yes/no

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/
INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)] been covered by any other Medicare Prescription (01) YES
Drug plans besides (CURRENT 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)?

BOX HI12A

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).
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
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, dental care, vision care, or hearing care.

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

(01) CONTINUE
(-7) Empty

BOX HI12B

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

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

2019 MCBS Community Questionnaire

HIQ - HEALTH INSURANCE

SHOW CARD HI5
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
(-9) Refused
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been enrolled in or
covered by one of these exchange plans?

HI20 - PLAN_PRIVATE

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

PLAN_PRIVATE

HI20

roster

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

What is the name of each of the [other] private plans that [provide/provided] [your/(SP’s)] medical insurance
(01) continuous answer
coverage?
(996) PLAN ENTERED IN ERROR
SELECT OR ADD ALL PRIVATE PLAN NAMES AT THIS ROSTER.
(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
NAME).] [Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole time between (REFERENCE
(-8) Don't Know
DATE) 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
(02) NO
NAME) on (DATE OF DEATH/
(-8) Don't Know
DATE OF INSTITUTIONALIZATION)?]
(-9) Refused

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

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

COVTIME

HI21

code 1

COVNOW

HI22

yes/no

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

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

HI23 - COVBEGDD

COVBEGDD

HI23

date

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

HI23 - COVBEGYY

COVBEGYY

HI23

date

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

BOX HI17

COVENDMM

HI24

date

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

HI24 - COVENDDD

HI24 - COVENDYY

BOX HI17

COVENDDD

HI24

date

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

COVENDYY

HI24

date

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

routing

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.

BOX HI17

2019 MCBS Community Questionnaire

PPRVHMO

PERS_MIPNUM

HI25

HI26

HIQ - HEALTH INSURANCE

yes/no

roster

CODE WITHOUT ASKING IF VOLUNTEERED.
[Is/Was] this a managed care plan, such as an HMO (Health Maintenance Organization) or PPO (Preferred
Provider Organization)?

(01) YES
(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.]

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

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/OtherNon-Relative, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

ROSTFNAM
ROSTLNAM

HI26_NEW
HI26_NEW

text
text

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

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)?]

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

(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
(01) continuous reponse
(-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

HI26 - PERS_MIPNUM

(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_NEWROSTFNAM

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

2019 MCBS Community Questionnaire

HIQ - HEALTH INSURANCE

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

HI29

numeric

[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.]

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

HI30 - PRVRXCOV

(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

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

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

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?
[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.]

BOX HI17AB

routing

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…

PRVNHCOV

HI31A

list

nursing home or long term 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…

MHMODENT

MIPPINS

HI31A

HI32

list

yes/no

dental 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.]
[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.]
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)].]
[Please include the full amount paid for the coverage, including 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?]
ONLY ENTER THE AMOUNT FOR THE R'S COVERAGE ON THIS PLAN. IF THE R DOESN'T KNOW,
ANSWER DK.
IF MORE THAN ONE PERSON (EX: SPOUSE, FAMILY MEMBER) IS COVERED BY THIS PLAN, THEN
ENTER THE TOTAL AMOUNT PAID, INCLUDING THE COST FOR THESE OTHER MEMBERS.

2019 MCBS Community Questionnaire

MIPPUNIT

HI33

HIQ - HEALTH INSURANCE

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

(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

verbatim text

OTHER (SPECIFY)

HI33A - MHMOCOST

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
the premium or cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
(-8) Don't Know
(-9) Refused

(01) HI33B - MHMOWHO
(02) BOX HI17B
(-8) BOX HI17B
(-9) BOX HI17B

(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

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

OTHER (SPECIFY)

BOX HI17B

routing

IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO HI33C - MHMOPOS.
ELSE GO TO BOX HI19.

yes/no

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

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 BOX HI12B.
ELSE GO TO HI35-PRVOCOV.

HI35

yes/no

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

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?

MHMOPOS

HI33C

BOX HI19

PRVOCOV

OTHNHCOV

HI34

(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

(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

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

BOX HI19

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

BOX HI21A

2019 MCBS Community Questionnaire

BOX HI21A

HIQ - HEALTH INSURANCE

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.