CMS-P-0015A Health Insurance

2021 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

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

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

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

(01) SP DISENROLLED FROM (CMS MHMO PLAN
NAME), ENROLLED IN NEW MEDICARE ADVANTAGE
PLAN
(02) SP HAS PLAN CALLED (CMS MHMO PLAN
NAME), R DOESN'T THINK IT'S A MEDICARE
ADVANTAGE PLAN
(03) SP NOW DISENROLLED FROM (CMS MHMO
PLAN NAME), NO LONGER IN ANY MEDICARE
ADVANTAGE PLAN
(04) SP ENROLLED IN MEDICARE ADVANTAGE PLAN,
BUT NEVER (CMS MHMO PLAN NAME)
(05) SP NEVER COVERED BY OR ENROLLED IN (CMS
MHMO PLAN NAME)

(01)
(02)
(03)
(04)
(05)

(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

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

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)

MC2B - YDISNROL
MC3 - PRIMPHYS
MC2B - YDISNROL
MC4 - SAMEPLAN
MC11 - REFERMED

BOX MC1A

Page 1 of 15

2021 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name

Question Type

Question Text/Description

BOX MC1A

routing

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

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

PLAN_MHMOMCA

MC5

roster

REFERMED

MC11

code 1

PLAN_MHMOMCB

MC12

roster

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

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

HIMC1A

yes/no

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

What do you call [your/(SP’s)] coverage?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS ROSTER.
At the time of the last interview [you were/(SP) was] covered by the Medicare Advantage Plan named (MEDICARE
MANAGED CARE PLAN NAME).
[[Are you/Is (SP)] now covered by (MEDICARE MANAGED CARE PLAN NAME)?] [Was (SP) covered by
(MEDICARE MANAGED CARE PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?]
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE THE PREVIOUS INTERVIEW DATE,
BUT PICKED UP THE COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE NAMED PLAN, SELECT
“YES” FOR THIS QUESTION.]

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

YDISNROL

HIMC1B1

code 1

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)?

HIMC1C

HIMC1

yes/no

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

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

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

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

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

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

(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

MHMOOTHR

Routing

BOX HIMC1

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

MHMOSAME

Code List

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

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

BOX HIMC1

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

Page 2 of 15

2021 MCBS Community Questionnaire

Variable Name

Question Type

Question Text/Description

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

HIMC6A

yes/no

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

MHMOEYE

HIMC8

yes/no

MHMORXTM

MR Screen Name

HIQ-HEALTH INSURANCE

Code List

Routing

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

BOX HIMC1CC1

[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

[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?

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

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

[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.]

[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

MHMOAMT

HIMC11

HIMC12

yes/no

quantity unit hybrid

[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
[you/(SP)].)
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]

MHMOUNIT

HIMC12

quantity unit hybrid

Not including the cost of [your/(SP’s)] Medicare Part B premium, what [is/was] the additional amount that [you
pay/(SP) pays/(SP) paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(Please do not include any copayments or any amount that may [be/have been] paid for anyone other than
[you/(SP)].)
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]

MHMOUNOS

MHMOUNOS

verbatim text

OTHER (SPECIFY)

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?

HIMC12A - MHMOCOST

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

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

Page 3 of 15

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

HIQ-HEALTH INSURANCE

Question Type

Question Text/Description

Code List

(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_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.

Routing

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

BOX HIMC4

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

BOX HIMC4

routing

IF FALL ROUND AND (SP IS ALIVE AND NOT INSTITUTIONALIZED) AND (SP HAS A MEDICARE MANAGED
CARE PLAN THAT IS "CURRENT"), GO TO HIMC19 - RECMHMO.
ELSE GO TO BOX HI1.

HIMC19

yes/no

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

BOX HIMC5

routing

IF (SP HAS A MEDICARE MANAGED CARE PLAN THAT IS "CURRENT") AND (THE NUMBER OF YEARS THE
SP WAS COVERED BY A MANAGED CARE PLAN HAS NEVER BEEN COLLECTED), GO TO HIMC24 HMONUMYR.
ELSE GO TO BOX HI1.

HMONUMYR

HIMC24

numeric

HMONUM96

HIMC24

numeric

MCAIDINT

HI5INTRO

no entry

BOX HI1B

routing

RECMHMO

(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

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

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

BOX HI1

SHOW CARD HI3
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

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

Page 4 of 15

2021 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name

Question Type

Question Text/Description

MCAIDINTB

HI5INTRB

no entry

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

AIDCOVER

HI5

yes/no

COVTIME

HI6

code 1

COVNOW

HI7

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

Routing

HI5 - AIDCOVER

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

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

(At the time of the last interview [you were/(SP) was] covered by Medicaid[, also known as (READ FROM
ABOVE).] [Were you/Was (SP)] covered by Medicaid the whole time between (REFERENCE DATE) and
[(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], or only part of the time?

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

(01) HI10A - MCAIDHMO
(02) HI7 - COVNOW
(-8) HI7 - COVNOW
(-9) HI7 - COVNOW

yes/no

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

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

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.

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

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

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?

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

HI9 - COVENDDD

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

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

BOX HI5D

MCAIDHMO

HI10A

yes/no

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

(Some states now use managed care plans, such as HMOs (Health Maintenance Organizations), to provide some
or all health care for Medicaid beneficiaries.) [At the time of the last interview [you were/(SP) was] enrolled in a
Medicaid Managed Care Plan.] [Are you now/Is (SP) now/Were you/Was (SP)] enrolled in a Medicaid Managed
Care Plan [as of (DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)/(MEDICAID COVERAGE STOP
DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
[ONLY SELECT “YES” IF THE RESPONDENT IS ACTUALLY ENROLLED IN THE PLAN; SOME STATES 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?]

Page 5 of 15

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

BOX HI5D

HIQ-HEALTH INSURANCE

Question Type

Question Text/Description

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.

Code List

(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 Drug plan
(-9) Refused
that [covers/covered] medicines prescribed by a doctor or other health professional?

Routing

(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

BOX HIT1

yes/no

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

routing

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF A TRICARE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
HIT2 - COVTIME.
ELSE GO TO HIT1 - TRICOVER.

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

BOX HIT1

Page 6 of 15

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

HIQ-HEALTH INSURANCE

Question Type

Question Text/Description

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?

Code List

Routing

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

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

(EXPLAIN IF NECESSARY: You may have received a reference card that looks like this (BACK OF SHOWCARD
HIT1).)

COVTIME

HIT2

code1

[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

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

(01) HIT4A1 - TRIMEDS
(02) BOX HIT3
(-8) BOX HIT3
(-9) BOX HIT3

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

(01) 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

[Does/Did] [your/(SP’s)] TRICARE plan cover medicines prescribed by a doctor or other health professional?
[PROBE: I am asking about the type of insurance coverage that [you personally have/(SP) personally has], not
what the plan offers everyone.]

TRIMEDS

HIT4A1

code 1

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

TRIMEDOS

TRIMEDOS

verbatim text

SOMEWHERE ELSE (SPECIFY)

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.]

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.

MILTHOSP

VACOVER

BOX HI20

BOX HI7

Page 7 of 15

2021 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

PUBINTRO

HI11PREV

no entry

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

(01) CONTINUE
(-7) Empty

BOX HI7A

BOX HI7A

routing

CREATE CURRENT ROUND PLRO FOR PUBLIC PLAN
GO TO HI13 - COVTIME.

PUBCOVER

HI11

yes/no

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

PLAN_PUBLIC

HI12

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

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?

(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

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)?

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

HI15 - COVBEGDD

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)?

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

HI15 - COVBEGYY

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)?

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

HI16A - PUBRXCOV

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

HI16 - COVENDDD

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?

COVENDDD

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

HI16 - COVENDYY

COVENDYY

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

HI16A - PUBRXCOV

PUBRXCOV

HI16A

yes/no

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

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

BOX HI12

routing

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF REVIEWING PUBLIC PLANS THAT WERE "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO BOX HI7A.
ELSE GO TO HI12-PLAN_PUBLIC.

BOX HI12

Page 8 of 15

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

BOX HI12AA

HIQ-HEALTH INSURANCE

Question Type

Question Text/Description

routing

IF (SP HAS A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW), GO TO HI16AB - PDPSAME.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW) AND (SP DOES NOT HAVE A "CURRENT" MEDICARE
MANAGED CARE PLAN WITH RX COVERAGE) AND (HI10C1 - MPDCOVER = empty)), GO TO HI16B PDPCOVER.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW) AND (SP DOES NOT HAVE A "CURRENT" MEDICARE
MANAGED CARE PLAN WITH RX COVERAGE) AND (HI10C1 - MPDCOVER = 2/No)), GO TO HI16B1 PDPCOVER.
ELSE GO TO BOX HI12A.
At the time of the last interview [you were/(SP) was] covered by a Medicare Prescription Drug Plan named
(MEDICARE PRESCRIPTION DRUG PLAN NAME).

PDPSAME

HI16AB

yes/no

[[Are you/Is (SP)] now covered by (MEDICARE PRESCRIPTION DRUG PLAN NAME)?] [Was (SP) covered by
(MEDICARE PRESCRIPTION DRUG PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?]
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE THE PREVIOUS INTERVIEW DATE,
BUT PICKED UP THE COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE NAMED PLAN, SELECT
“YES” FOR THIS QUESTION.]

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

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

Code List

Routing

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

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

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

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

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

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

(Medicare beneficiaries can receive insurance coverage for prescription drugs through Medicare Prescription Drug
plans. These plans are also called "Medicare Part D" plans.)
At any time since (REFERENCE DATE), [have you/has (SP)/had (SP)] been enrolled in a Medicare Prescription
Drug plan that [covers/covered] medicines prescribed by a doctor or other health professional?
PDPCOVER

HI16B

yes/no

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

Page 9 of 15

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

HIQ-HEALTH INSURANCE

Question Type

Question Text/Description
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)]?

Code List

Routing

(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

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

HI16F - PDPMORE

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

PDPMORE

HI16F

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 Drug plans besides (CURRENT
MEDICARE PRESCRIPTION DRUG PLAN)?
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

PLAN_MPDPOTHR

HI16G

roster

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

[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)?

(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).

BOX HI12B

routing

CREATE A CURRENT ROUND PLRO FOR PRIVATE PLAN
GO TO HI21 - COVTIME.

(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

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 (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.

Page 10 of 15

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

HIQ-HEALTH INSURANCE

Question Type

Question Text/Description

Code List

Routing

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

HI20 - PLAN_PRIVATE

SHOW CARD HI5
As you may know, every state now offers a health insurance marketplace, also referred to as an exchange.
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.
EXCHGCOV

HI18A

yes/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 covered by one of
these exchange plans?
[MEDICARE BENEFICIARIES ARE NOT ELIGIBLE TO OBTAIN INSURANCE THROUGH THESE PLANS. THE
RESPONSE TO THIS QUESTION SHOULD ALMOST ALWAYS BE “NO”. HOWEVER, SOME RESPONDENTS
MAY SIGN UP FOR THESE PLANS DUE TO CONFUSION ABOUT THE PROGRAM.]

BOX HI13A

routing

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

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

GAPCOVER

HI19

yes/no

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?]

PLAN_PRIVATE

HI20

roster

What is the name of each of the [other] private plans that [provide/provided] [your/(SP’s)] medical insurance
coverage?
SELECT OR ADD ALL PRIVATE PLAN NAMES AT THIS ROSTER.

(01) continuous answer
(996) PLAN ENTERED IN ERROR

HI21-COVTIME

COVTIME

HI21

code 1

[At the time of the last interview [you were/(SP) was] covered by a private plan named (PRIVATE PLAN NAME).]
[Were you/Was (SP)] covered by (PRIVATE 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) BOX HI17
(02) HI22 - COVNOW
(-8) HI22 - COVNOW
(-9) HI22 - COVNOW

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)?]

(01) BOX HI16
(02) HI24 - COVENDMM
(-8) BOX HI17
(-9) BOX HI17

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

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]?

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

HI23 - COVBEGDD

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]?

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

HI23 - COVBEGYY

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]?

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

BOX HI17

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?

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

HI24 - COVENDDD

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?

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

HI24 - COVENDYY

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?

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

BOX HI17

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.

Page 11 of 15

2021 MCBS Community Questionnaire

Variable Name

PPRVHMO

PERS_MIPNUM

MR Screen Name

HI25

HI26

HIQ-HEALTH INSURANCE

Question Type

yes/no

roster

Question Text/Description
CODE WITHOUT ASKING IF VOLUNTEERED.
[Is/Was] this a managed care plan, such as an HMO (Health Maintenance Organization) or PPO (Preferred
Provider Organization)?
[EXPLAIN IF NECESSARY: Managed care plans generally provide a full range of health care services for a
prepaid fee. Health care is generally provided by primary care doctors, specialists, or hospitals on the plan’s list
(network) except in an emergency.]

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

Code List

Routing

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

HI26 - PERS_MIPNUM

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

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

ROSTFNAM

HI26_NEW

text

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

(01) continuous answer

HI26_NEW - ROSTLNAM

ROSTLNAM

HI26_NEW

text

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

(01) continuous answer

HI26_NEW - ROSTREL

(02) SPOUSE
(56) PARTNER
(58) CHILD
(59) GRANDCHILD
(60) PARENT
(61) SIBLING
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) HI27 - PPRVGET
(56) HI27 - PPRVGET
(58) HI27 - PPRVGET
(59) HI27 - PPRVGET
(60) HI27 - PPRVGET
(61) 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 (06) AARP
a 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)

PRVNMCOV

HI29

numeric

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

Page 12 of 15

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

HIQ-HEALTH INSURANCE

Question Type

Question Text/Description

Code List

Routing

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

BOX HI17AB

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

HI31A - PRVIPCOV

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

HI31A - PRVNHCOV

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

HI31A - MHMODENT

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

PRVOPEYE-PRVOPEYE

(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

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].
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]
PRVRXCOV

HI30

yes/no

[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) plan cover prescribed medicines?
[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.]
[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.
[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

HI31A

list

PRVOPEYE

PRVOPEYE

yes/no

MIPPINS

HI32

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 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.]

Page 13 of 15

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

HIQ-HEALTH INSURANCE

Question Type

Question Text/Description

Code List

Routing

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

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

(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) HI33A - MHMOCOST
(02) HI33A - MHMOCOST
(03) HI33A - MHMOCOST
(04) HI33A - MHMOCOST
(05) HI33A - MHMOCOST
(06) HI33A - MHMOCOST
(07) HI33A - MHMOCOST
(91) HI33 - MIPPUNOS
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST

How much [do/does/did] [you/(MIP)] pay for the (PRIVATE PLAN NAME) coverage?

MIPPAMT

HI33

quantity unit hybrid

[Please include the full amount paid for the coverage, including 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?]
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.

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

HI33

verbatim text

OTHER (SPECIFY)

HI33A - MHMOCOST

MHMOCOST

HI33A

yes/no

[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?

(01) YES
(02) NO
(-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

(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

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-ofplan providers even in non-emergency situations. [Are/Were/Is/Was] [you/(SP)] enrolled in a point-of-service 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 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

MHMOPOS

PRVOCOV

HI33C

BOX HI17B

BOX HI19

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

Page 14 of 15

2021 MCBS Community Questionnaire

Variable Name

OTHNHCOV

HIQ-HEALTH INSURANCE

MR Screen Name

Question Type

Question Text/Description

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 ROUND = FALL 2021 ROUND 91, GO TO MBQ.
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.

Code List

Routing

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

BOX HI21A

Page 15 of 15