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pdf2021 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
File Type | application/pdf |
File Title | Medicare Current Beneficiary Survey Section Specifications for HIQ |
Subject | Medicare beneficiaries, MCBS community questionnaire, 2021, Health insurance, HIQ |
Author | NORC |
File Modified | 2021-08-13 |
File Created | 2021-08-03 |