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pdf2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
HIQ- HEALTH INSURANCE
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.)
LOADCORR
BOX MC1AA
routing
MC1
yes/no
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).
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?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HIMC1
(02) MC2 - WHATWRNG
(-8) MC11 - REFERMED
(-9) BOX HIMC4
[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) 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
(01) MC2B - YDISNROL
PLAN
(02) MC3 - PRIMPHYS
(03) SP NOW DISENROLLED FROM (CMS MHMO
(03) MC2B - YDISNROL
PLAN NAME), NO LONGER IN ANY MEDICARE
(04) MC4 - SAMEPLAN
ADVANTAGE PLAN
(05) MC11 - REFERMED
(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)
Page 1 of 13
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
HIQ- HEALTH INSURANCE
Question Text/Description
Code List
Routing
What is the most important reason [you/(SP)] stopped the (CMS MEDICARE MANAGED CARE PLAN NAME)
coverage?
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) 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
YDISNROL
MC2B
code 1
YDISNROS
MC2B
verbatim text
BOX MC1A
routing
PRIMPHYS
MC3
yes/no
(01) YES
In many Medicare Advantage Plans, such as HMOs or PPOs, the health plan gives the patient a list of doctors from
(02) NO
which he chooses a primary care physician. This primary care physician provides the patient’s usual medical care
(-8) Don't Know
and can refer the patient to specialists, if necessary. [Do you/Does (SP)] have a primary care physician?
(-9) Refused
BOX HIMC1
SAMEPLAN
MC4
code 1
(01) SAME PLANS
Is it possible that [your/(SP’s)] current insurance plan is just another name for (CMS MEDICARE MANAGED CARE (02) NOT THE SAME PLANS
PLAN NAME), or are they not the same plans?
(-8) Don't Know
(-9) Refused
(01) BOX HIMC1
(02) MC5 - PLAN_MHMOMCA
(-8) MC5 - PLAN_MHMOMCA
(-9) MC5 - PLAN_MHMOMCA
OTHER (SPECIFY)
IF MC2 - WHATWRNG = 1/EnrolledNewPlan, GO TO MC5 - PLAN_MHMOMCA.
ELSE GO TO HIMC16 - MHMOMORE.
BOX MC1A
What is the name of the Medicare Advantage Plan that provides [your/(SP’s)] health care benefits?
PLAN_MHMOMCA MC5
roster
BOX HIMC1
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
Do you refer to [your/(SP’s)] Medicare coverage by any name besides Medicare?
REFERMED
MC11
PLAN_MHMOMCB MC12
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 name (-8) Don't Know
on it?]
(-9) Refused
(01) BOX HIMC4
(02) MC12 - PLAN_MHMOMCB
(-8) BOX HIMC4
(-9) BOX HIMC4
roster
What do you call [your/(SP’s)] coverage?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS ROSTER.
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
YDISNROL
HIMC1B1
code 1
(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
What is the most important reason [you/(SP)] stopped the (MEDICARE MANAGED CARE PLAN NAME) coverage? (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
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) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HIMC1
(02) HIMC1B1 - YDISNROL
(-8) HIMC1C - MHMOOTHR
(-9) BOX HIMC4
(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
HIMC1C - MHMOOTHR
(01) HIMC3 - MHMOCURR
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4
Page 2 of 13
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
MHMOCOV
HIMC1
yes/no
HIQ- HEALTH INSURANCE
Question Text/Description
SHOW CARD HI2
As you (may) know, Medicare beneficiaries can enroll in either Original Medicare or a Medicare Advantage plan,
such as an HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization).
Code List
(01) 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 of (-8) Don't Know
these/any)] Medicare Advantage plans?
(-9) Refused
Routing
(01) HIMC3 - MHMOCURR
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]
MHMOCURR
HIMC3
yes/no
PLAN_MHMO
HIMC5
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
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)?
MHMORXTM
HIMC6A
yes/no
[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.]
BOX HIMC1CC1
routing
IF (THIS MEDICARE MANAGED CARE PLAN IS NEW OR HAS BEEN "RESTARTED"), GO TO HIMC7 MHMODENT.
ELSE GO TO BOX HIMC2.
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 or vision coverage through (CURRENT MEDICARE MANAGED CARE
PLAN NAME), that is, for eye exams, eyeglasses, or contact lenses?
[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
HIMC10
yes/no
(EXPLAIN IF NECESSARY: Under regular fee-for-service, Medicare pays for limited skilled nursing facility (SNF)
care during a benefit period. In [BEGIN_YEAR], the first 20 days are paid in full and the next 80 days 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.
MHMOPAY
HIMC11
MHMOAMT
HIMC12
yes/no
[EXPLAIN IF NECESSARY: Some managed care plans may charge a monthly premium to cover the cost of the
deductibles and coinsurance for Medicare-covered services or because they provide services that are not covered
by original Medicare such as prescribed medicines, and dental, vision, or hearing care. 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
quantity unit hybrid
[you/(SP)].)
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HIMC1CC1
HIMC8 - MHMOEYE
HIMC10 - MHMONH
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HIMC11 - MHMOPAY
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(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
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]
MHMOUNIT
HIMC12
Not including the cost of [your/(SP’s)] Medicare Part B premium, what [is/was] the additional amount that [you
pay/(SP) pays/(SP) paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(Please do not include any copayments or any amount that may [be/have been] paid for anyone other than
quantity unit hybrid
[you/(SP)].)
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]
Page 3 of 13
2020 MCBS Community Questionnaire
HIQ- HEALTH INSURANCE
Variable Name
MHMOUNOS
MR Screen Name Question Type
MHMOUNOS
verbatim text
Question Text/Description
OTHER (SPECIFY)
Code List
Routing
HIMC12A - MHMOCOST
MHMOCOST
HIMC12A
yes/no
[Does/Did] anyone else, such as an employer, a union or professional organization pay all or some portion of the
additional cost for [your/(SP’s)] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HIMC12B - MHMOWHO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2
(01) BOX HIMC2
(02) BOX HIMC2
(03) BOX HIMC2
(04) BOX HIMC2
(05) BOX HIMC2
(06) BOX HIMC2
(07) BOX HIMC2
(91) HIMC12B - MHMOWHOS
(-8) BOX HIMC2
(-9) BOX HIMC2
BOX HIMC2
MHMOWHO
HIMC12B
code 1
(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
Who else [pays/paid] all or some portion of the additional cost for [your/(SP’s)] (CURRENT MEDICARE MANAGED (05) SPOUSE'S FORMER EMPLOYER
CARE PLAN NAME) coverage?
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused
MHMOWHOS
HIMC12B
verbatim text
OTHER (SPECIFY)
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 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.
BOX HIMC2
MHMOMORE
HIMC16
yes/no
SHOW CARD HI2
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)] been covered by any other Medicare Advantage Plans
besides (MEDICARE MANAGED CARE PLAN and MEDICARE MANAGED CARE PLAN)?
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]
PLAN_MHMOOTH
HIMC17
ER
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
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
RECMHMO
BOX HI1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HIMC5
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.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
HIMC24 - HMONUM96
numeric
How many years [have you/has (SP)] been enrolled in a managed care plan?
(01) LESS THAN ONE YEAR
(-7) Empty
BOX HI1
routing
IF A MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HI6 COVTIME.
ELSE GO TO HI5INTRO - MCAIDINT.
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.
BOX HI1B
HI5 - AIDCOVER
Page 4 of 13
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
HIQ- HEALTH INSURANCE
Question Text/Description
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?
Code List
AIDCOVER
HI5
yes/no
(01) YES
(02) NO
(-8) Don't Know
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
(-9) Refused
on it?]
COVTIME
HI6
code 1
(01) THE WHOLE TIME
(At the time of the last interview [you were/(SP) was] covered by Medicaid[, also known as (READ FROM ABOVE).]
(02) PART OF THE TIME
[Were you/Was (SP)] covered by Medicaid the whole time between (REFERENCE DATE) and [(today/DATE OF
(-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION)], or only part of the time?
(-9) Refused
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
COVBEGDD
HI8
date
COVBEGYY
HI8
date
COVENDMM
HI9
date
COVENDDD
HI9
date
COVENDYY
HI9
date
MCAIDHMO
HI10A
yes/no
MPDCOVER
BOX HI5D
routing
HI10C1
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
On what date did [your/(SP’s)] Medicaid start between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE
(-8) Don't Know
OF INSTITUTIONALIZATION)]?
(-9) Refused
(01) [Continuous answer.]
On what date did [your/(SP’s)] Medicaid start between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE
(-8) Don't Know
OF INSTITUTIONALIZATION)]?
(-9) Refused
(01) [Continuous answer.]
On what date did [your/(SP’s)] Medicaid start between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE
(-8) Don't Know
OF INSTITUTIONALIZATION)]?
(-9) Refused
(01) [Continuous answer.]
On what date [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid coverage [most recently/last] stop?
(-9) Refused
(01) [Continuous answer.]
On what date [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid coverage [most recently/last] stop?
(-9) Refused
(01) [Continuous answer.]
On what date [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid coverage [most recently/last] stop?
(-9) Refused
(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
(01) YES
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 MAY
(-9) Refused
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?]
IF ((ADMINISTERING ST, NS OR CPS) AND SP WAS COVERED BY A MEDICARE PRESCRIPTION DRUG
PLAN ANYTIME DURING THE CURRENT ROUND) OR (ADMINSTERING HI AND THERE WAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW),
GO TO BOX HIT1.
ELSE IF (ADMINISTERING ST, NS OR CPS) AND SP WAS NOT COVERED BY A MEDICARE PRESCRIPTION
DRUG PLAN ANYTIME DURING THE CURRENT ROUND, GO TO HI10D - MCDRXCOV.
ELSE GO TO HI10C1 - MPDCOVER.
(Some people who receive Medicaid benefits are also enrolled in a Medicare Prescription Drug plan, or Medicare
Part D plan, that pays for some or all of their prescribed medicines. The Medicare program automatically enrolls
such beneficiaries into a Medicare Prescription Drug plan, although the beneficiary may choose to switch to a
different prescription plan.)
(01) YES
(02) NO
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 Drug plan
(-9) Refused
that [covers/covered] medicines prescribed by a doctor or other health professional?
Routing
(01) HI6 - COVTIME
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1
(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
BOX HI5D
(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)]?
[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) 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
HI10C4 - PDPMORE
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
Page 5 of 13
2020 MCBS Community Questionnaire
HIQ- HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
Question Text/Description
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/INSTITUTIONALIZATION)],
[have you/has (SP)/had (SP)] been covered by any other Medicare Prescription Drug plans besides (CURRENT
MEDICARE PRESCRIPTION DRUG PLAN)?
PDPMORE
HI10C4
(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.)
Yes/No
Code List
Routing
(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_CAIDMPDP
HI10C5
OTHR
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
TRICOVER
HI10D
yes/no
BOX HIT1
routing
HIT1
yes/no
(Does/Did) [your/(SP’s)] Medicaid plan cover medicines prescribed by a doctor or other health professional?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HIT1
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF A TRICARE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
HIT2 - COVTIME.
ELSE GO TO HIT1 - TRICOVER.
SHOW CARD HIT1
As you (may) know, the Department of Defense sponsors a regionally managed health care program called
TRICARE for active duty and retired members of the uniformed Armed Forces, their families, and survivors.
(01) YES
Please look at this card. At any time [since (REFERENCE DATE)/ between (PREVIOUS ROUND INTERVIEW
(02) NO
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)] enrolled in(-8) Don't Know
or covered by any of these TRICARE plans?
(-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
[At the time of the last interview [you were/(SP) was] covered by TRICARE.] [Were you/Was (SP)] covered by
TRICARE the whole time between [(REFERENCE DATE) and (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], or only part of the time?
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) HIT4 - TRIRXCOV
(02) HIT3 - COVNOW
(-8) HIT3 - COVNOW
(-9) HIT3 - COVNOW
COVNOW
HIT3
yes/no
[[Are you/Is (SP)] now covered by TRICARE?] [Was (SP) covered by TRICARE on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HIT4 - TRIRXCOV
TRIRXCOV
HIT4
yes/no
[Does/Did] [your/(SP’s)] TRICARE plan cover medicines prescribed by a doctor or other health professional?
TRIMEDS
HIT4A1
code 1
TRIMEDOS
TRIMEDOS
verbatim text
MILTHOSP
(01) YES
(02) NO
[PROBE: I am asking about the type of insurance coverage that [you personally have/(SP) personally has], not what(-8) Don't Know
the plan offers everyone.]
(-9) Refused
(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
(02) A TRICARE RETAIL PHARMACY NETWORK
PHARMACY (TRRX)
SHOW CARD HIT2
(03) A MILITARY TREATMENT FACILITY PHARMACY
Where [do you/does (SP)/did you/did (SP)] usually obtain [your/his/her] medicines? [Do you/Does (SP)/Did you/Did
(MTF)
(SP)] usually obtain them at a TRICARE mail order pharmacy (TMOP), a TRICARE retail pharmacy network
(04) A NON-NETWORK RETAIL PHARMACY
pharmacy (TRRx), a military treatment facility pharmacy (MTF), a non-network retail pharmacy, or somewhere else?
(91) SOMEWHERE ELSE
(-8) Don't Know
(-9) Refused
SOMEWHERE ELSE (SPECIFY)
(01) [Continuous Answer]
BOX HIT3
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 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 - MILTHOSP.
ELSE GO TO BOX HI20.
HIT11
yes/no
[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since (REFERENCE DATE), [have
(01) YES
you/has (SP) received/did (SP) receive] health care or health services or prescribed medicines at a Military
(02) NO
Treatment Facility or MTF?
(-8) Don't Know
(-9) Refused
[EXPLAIN IF NECESSARY: A Military Treatment Facility is any military hospital, clinic, or NAVCARE clinic.]
(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
BOX HI20
Page 6 of 13
2020 MCBS Community Questionnaire
Variable Name
HIQ- HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
BOX HI20
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
(01) YES
[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since (REFERENCE DATE), [have
(02) NO
you/has (SP) received/did (SP) receive] health care or health services or prescribed medicines through the
(-8) Don't Know
Department of Veterans Affairs or V.A.?
(-9) Refused
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
CREATE CURRENT ROUND PLRO FOR PUBLIC PLAN
GO TO HI13 - COVTIME.
PUBCOVER
HI11
yes/no
PLAN_PUBLIC
HI12
COVTIME
COVNOW
VACOVER
Code List
Routing
BOX HI7
(01) CONTINUE
(-7) Empty
BOX HI7A
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?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI12 - PLAN_PUBLIC
(02) BOX HI12AA
(-8) BOX HI12AA
(-9) BOX HI12AA
roster
What is the name of each of the public programs other than Medicaid that covered [you/(SP)]?
SELECT OR ADD ALL PUBLIC PROGRAM NAMES AT THIS ROSTER.
[WHEN YOU ENTER A PLAN, VERIFY WITH THE RESPONDENT THAT IT IS A PUBLIC PLAN.]
(01) ADD NEW PLAN
(02) CONTINUE THE INTERVIEW
(01) HI13 - COVTIME
(02) BOX HI12AA
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?
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) HI16A - PUBRXCOV
(02) HI14 - COVNOW
(-8) HI14 - COVNOW
(-9) HI14 - 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)?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HI10
(02) HI16 - COVENDMM
(-8) HI16A - PUBRXCOV
(-9) HI16A - PUBRXCOV
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
COVBEGYY
HI15
date
COVENDMM
HI16
date
COVENDDD
HI16
date
COVENDYY
HI16
date
PUBRXCOV
HI16A
yes/no
PUBINTRO
BOX HI12
routing
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start between (REFERENCE DATE) and
(-8) Don't Know
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?
(-9) Refused
(01) [Continuous answer.]
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start between (REFERENCE DATE) and
(-8) Don't Know
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?
(-9) Refused
On what date [since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
(01) [Continuous answer.]
DEATH/DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC PLAN NAME) coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused
On what date [since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
(01) [Continuous answer.]
DEATH/DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC PLAN NAME) coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused
On what date [since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
(01) [Continuous answer.]
DEATH/DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC PLAN NAME) coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused
(01) YES
(Does/Did) [your/(SP’s)] (PUBLIC PLAN NAME) plan cover medicines prescribed by a doctor or other health
(02) NO
professional?
(-8) Don't Know
(-9) Refused
HI15 - COVBEGDD
HI15 - COVBEGYY
HI16A - PUBRXCOV
HI16 - COVENDDD
HI16 - COVENDYY
HI16A - PUBRXCOV
BOX HI12
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.
Page 7 of 13
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
BOX HI12AA
routing
HIQ- HEALTH INSURANCE
Question Text/Description
IF (SP HAS A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW), GO TO HI16AB - PDPSAME.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW) AND (SP DOES NOT HAVE A "CURRENT" MEDICARE
MANAGED CARE PLAN WITH RX COVERAGE) AND (HI10C1 - MPDCOVER = empty)), GO TO HI16B PDPCOVER.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW) AND (SP DOES NOT HAVE A "CURRENT" MEDICARE
MANAGED CARE PLAN WITH RX COVERAGE) AND (HI10C1 - MPDCOVER = 2/No)), GO TO HI16B1 PDPCOVER.
ELSE GO TO BOX HI12A.
Code List
Routing
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
PDPYSTOP
HI16AC
code 1
PDPYSTOS
HI16AC
verbatim text
PDPOTHER
HI16AD
yes/no
(01) YES
[[Are you/Is (SP)] now covered by (MEDICARE PRESCRIPTION DRUG PLAN NAME)?] [Was (SP) covered by
(02) NO
(MEDICARE PRESCRIPTION DRUG PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?] (-8) Don't Know
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE THE PREVIOUS INTERVIEW DATE,
(-9) Refused
BUT PICKED UP THE COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE NAMED PLAN, SELECT
“YES” FOR THIS QUESTION.]
What is the most important reason [you/(SP)] stopped the (MEDICARE PRESCRIPTION DRUG PLAN NAME)
coverage?
(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
HI16B
yes/no
(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
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)?
HI16AD - PDPOTHER
(01) YES
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (02) NO
on it?]
(-8) Don't Know
(-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.
(Medicare beneficiaries can receive insurance coverage for prescription drugs through Medicare Prescription Drug
plans. These plans are also called "Medicare Part D" plans.)
(01) HI16C - PDPCURR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A
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
(01) BOX HI12A
(02) HI16AC - PDPYSTOP
(-8) BOX HI12A
(-9) HI16AD - PDPOTHER
(01) YES
(02) NO
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-8) Don't Know
on it?]
(-9) Refused
(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?
(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
[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.
HI16F - PDPMORE
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
Page 8 of 13
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
PDPMORE
HI16F
PLAN_MPDPOTH
HI16G
R
yes/no
HIQ- HEALTH INSURANCE
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 name (-9) Refused
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)?
roster
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.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
PRIVINTRO
BOX HI12A
routing
IF AT LEAST ONE PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW,
GO TO HI17PREV - PRIVINTRO.
ELSE GO TO HI17 - PRVCOVER
HI17PREV
no entry
The next questions are about private plans [you were/(SP) was] covered by as of (REFERENCE DATE).
routing
CREATE A CURRENT ROUND PLRO FOR PRIVATE PLAN
GO TO HI21 - COVTIME.
BOX HI12B
(01) CONTINUE
(-7) Empty
BOX HI12B
You reported that [you are/(SP) is/(SP) was] covered by [READ PLAN NAME(S) AND PLAN TYPE(S) LISTED
ABOVE].
PRIVCOV
HI17
yes/no
(Now, I would like to ask about another type of health insurance.) At any time [since (REFERENCE DATE)/between
(01) YES
(PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have
(02) NO
you/has (SP) been/was (SP)] covered by [any other] private health insurance plans?
(-8) Don't Know
(-9) Refused
Private plans include supplemental or Medigap plans, plans that are provided by a former or current employer, and
plans that you have directly purchased. Such plans cover the cost of hospital or doctor visits, prescribed medicines,
dental care, vision care, or hearing care.
(01) HI18A - EXCHGCOV
(02) BOX HI13A
(-8) BOX HI13A
(-9) BOX HI13A
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 enrollment.
(01) YES
(02) NO
Please look at this card. At any time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF
(-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been enrolled in or covered by one of (-9) Refused
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.
(01) YES
(02) NO
At any time since (REFERENCE DATE) did [you/(SP)] have this type of health insurance coverage?
(-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?]
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 NAME).]
(02) PART OF THE TIME
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole time between (REFERENCE DATE) and
(-8) Don't Know
[today/ DATE OF DEATH/DATE OF INSTITUTIONALIZATION], or only part of the time?
(-9) Refused
GAPCOVER
HI19
yes/no
PLAN_PRIVATE
HI20
roster
COVTIME
HI21
code 1
COVNOW
HI22
yes/no
[[Are you/Is (SP)] now covered by (PRIVATE PLAN NAME)?] [Was (SP) covered by (PRIVATE PLAN NAME) on
(DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)?]
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.
(01) YES
(02) NO
(-8) Don't Know
(-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
Page 9 of 13
2020 MCBS Community Questionnaire
Variable Name
HIQ- HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
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?
BOX HI17
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.
yes/no
CODE WITHOUT ASKING IF VOLUNTEERED.
[Is/Was] this a managed care plan, such as an HMO (Health Maintenance Organization) or PPO (Preferred Provider
(01) YES
Organization)?
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: Managed care plans generally provide a full range of health care services for a prepaid
(-9) Refused
fee. Health care is generally provided by primary care doctors, specialists, or hospitals on the plan’s list (network)
except in an emergency.]
PPRVHMO
PERS_MIPNUM
ROSTFNAM
ROSTLNAM
HI25
HI26
HI26_NEW
HI26_NEW
roster
text
text
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
(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
HI23 - COVBEGDD
HI23 - COVBEGYY
BOX HI17
HI24 - COVENDDD
HI24 - COVENDYY
BOX HI17
HI26 - PERS_MIPNUM
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) HI27 - PPRVGET
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) HI26_NEW-ROSTFNAM
(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) continuous answer
(01) continuous answer
IF EXISTING PERSON SELECTED, GO TO HI27 PPRVGET
ELSE IF "ADD ANOTHER" SELECTED, GO TO
HI26_NEW-ROSTFNAM
HI26_NEW - ROSTLNAM
HI26_NEW - ROSTREL
Page 10 of 13
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
HIQ- HEALTH INSURANCE
Question Text/Description
Code List
(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
Routing
(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
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) 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
(01) continuous reponse
(-8) Don't Know
(-9) Refused
PPRVGET
HI27
code 1
(01) DIRECTLY
(02) (MIP'S) CURRENT EMPLOYER
(03) (MIP'S) FORMER EMPLOYER
(04) (MIP'S) UNION
(05) (MIP'S) FAMILY BUSINESS
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up directly, or did [you/(MIP)] get this insurance through a (06) AARP
current employer, a former employer, a union, a family business, AARP, or some other way?
(07) DECEASED SPOUSE'S EMPLOYER
(08) DECEASED SPOUSE'S UNION
(09) PROFESSIONAL/FRATERNAL ORGANIZATION
(91) SOME OTHER WAY
(-8) Don't Know
(-9) Refused
PPRVGTOS
HI27
verbatim text
OTHER (SPECIFY)
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
HI27 - PPRVGET
HI30 - PRVRXCOV
Private 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.]
(01) YES
(02) NO
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) plan cover prescribed medicines?
(-8) Don't Know
(-9) Refused
[IF THE RESPONDENT IS COVERED BY A PRIVATE PLAN THAT PROVIDES ONLY DENTAL COVERAGE (E.G.
DELTA DENTAL), VERIFY AND SELECT “NO” THAT THE PLAN DOES NOT COVER PRESCRIBED MEDICINES.]
BOX HI17AB
[IF THE PRIVATE PLAN MENTIONED IS A MEDICARE SUPPLEMENTAL INSURANCE PLAN (MEDIGAP),
SELECT “NO” AS THIS PLAN DOES NOT COVER 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.
Page 11 of 13
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
HIQ- HEALTH INSURANCE
Question Text/Description
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
Code List
Routing
(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 PRVOPEYE-PRVOPEYE
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.]
PRVOPEYE
PRVOPEYE
yes/no
MIPPINS
HI32
yes/no
[Do you/Does (SP)/Did (SP)] have optical or vision coverage through (PRIVATE PLAN NAME), that is, for eye
exams, eyeglasses or contact lenses?
[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.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HI32 - MIPPINS
(01) HI33 - MIPPAMT
(02) HI33A - MHMOCOST
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST
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?]
MIPPAMT
HI33
quantity unit hybrid IF MORE THAN ONE PERSON (EX: SPOUSE, FAMILY MEMBER) IS COVERED BY THIS PLAN, THEN ONLY
ENTER THE AMOUNT FOR THE R'S COVERAGE. DO NOT ENTER THE TOTAL AMOUNT FOR ALL
INDIVIDUALS COVERED.
(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
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI33B - MHMOWHO
(02) BOX HI17B
(-8) BOX HI17B
(-9) BOX HI17B
IF R DOES NOT KNOW THE AMOUNT FOR JUST THE R’s COVERAGE, 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
yes/no
OTHER (SPECIFY)
[Does/Did] anyone else, such as an employer, a union or professional organization pay all or some portion of the
premium or cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
HI33A - MHMOCOST
Page 12 of 13
2020 MCBS Community Questionnaire
Variable Name
MHMOWHO
MHMOWHOS
MHMOPOS
PRVOCOV
OTHNHCOV
MR Screen Name Question Type
HIQ- HEALTH INSURANCE
Question Text/Description
Code List
Routing
(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
HI33B
code 1
Who else [pays/paid] all or some portion of the cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
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-ofplan providers even in non-emergency situations. [Are/Were/Is/Was] [you/(SP)] enrolled in a point-of-service option
(01) YES
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.]
BOX HI19
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 under (02) NO
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.
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?
BOX HI21A
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 DVH.
ELSE IF INTTYPE in (C003), GO TO MBQ.
HI33C
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
Page 13 of 13
| File Type | application/pdf |
| File Title | HIQ.xlsx |
| Author | Wishart-Marisa |
| File Modified | 2020-03-27 |
| File Created | 2020-03-27 |