Attachment 14 – HC Showcards

MEDICAL EXPENDITURE PANEL SURVEY

HOUSEHOLD COMPONENT
MAIN STUDY

BLAISE
SHOW CARDS
Panels 23, 22, and 21
January 2018

TABLE OF CONTENTS
ROUNDS 1-5
Card Number
RE-1
RE-2
PE-1
PE-2
HE-1
PP-1
PP-2
PP-3
PP-4
PP-5
PP-6
PP-7
PP-8
PP-9
PP-10
PP-11
PP-12
PP-13
PP-14
PP-15
EV-1A
EV-1B
HS-1
ER-1
ER-2
OP-1
OP-2
MV-1

Topic
Ethnic Background
Racial Background
Types of Cancer
Frequency Scale
Level of Difficulty Categories
Types of Hospital Visits
Types of Emergency Room Services
Types of Outpatient Care
Types of Primary Care
Types of Medical Specialists
Types of Other Medical Providers
Types of Clinics
Types of Laboratories
Types of Mental Health Professionals
Types of Therapists
Types of Dental Care Providers
Types of Vision Specialists
Types of Alternative Care
Types of Home Care Services
Types of Residential or Long Term Care
Examples of Where Care Received (Event Typing)
Examples of Where Care Received (Event Typing)
Reasons for Entering the Hospital
Care Received During ER Visit
Services Received During ER Visit
Care Received During Outpatient Visit
Services Received During Outpatient Visit
Care Received During Medical Provider Visit

Round(s) Used
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4
1, 2, 3, 4
1, 3
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4 ,5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5
1, 2, 3, 4, 5

MV-2

Services Received During Medical Provider Visit

1, 2, 3, 4, 5

DN-1

Types of Dental Care Providers

1, 2, 3, 4, 5

DN-2

Care Received During Dental Visit

1, 2, 3, 4, 5
Table of Contents Continued on the Following Page

TABLE OF CONTENTS (Cont.)
Card Number
HH-1

Topic
Types of Home Health Care Workers

Round(s) Used
1, 2, 3, 4, 5

HH-2

Types of Home Health Care Workers

1, 2, 3, 4, 5

IC-1

Types of Residential or Long Term Care Facilities

1, 2, 3, 4, 5

OM-1

Types of Disposable Medical Supplies

1, 2, 3, 4, 5

OM-2

Types of Other Medical Equipment

1, 2, 3, 4, 5

CP-1

Reasons for Not Receiving Anything in Writing

1, 2, 3, 4, 5

CP-2

Total Charges for Disposable Supplies

1, 2, 3, 4, 5

CS-1

Scale for Child Health Supplement

2, 4

CS-2

Scale for Child Health Supplement

2, 4

CS-3

Number of Times Went to Doctor’s Office or Clinic

2, 4

CS-4

Scale for Child Health Supplement

2, 4

AC-1

Difficulty Scale

2, 4

AC-2

Provider’s Race

2, 4

AC-3

Frequency Scale

2, 4

HX-1

Sample Medicare Card

1, 2, 3, 4, 5

HX-2

Sample Medicaid Card (for STATE)

1, 2, 3, 4, 5

HX-3

Source of Health Insurance (for STATE)

1, 2, 3, 4, 5

HX-4

Types of Public Insurance

1, 2, 3, 4, 5

HX-5

Medicare HMO Premium Ranges

1, 3

HX-6

Medicare Part D Premium Ranges

1, 3

HX-7

Types of Health Insurance Coverage

1, 2, 3, 4, 5

HX-8

State Sources of Health Insurance for Self-Employed Jobs

1, 2, 3, 4, 5

IN-1

Yearly Income Ranges

3, 5

IN-2

Yearly Income Ranges

3, 5

IN-3

Monthly Income Ranges

3, 5

IN-4

Other Sources of Income Categories

3, 5

AS-1

Asset Ranges

5

AS-2

Asset Ranges

5

CARD RE-1
RE-1

One or more categories may be selected.
--

Mexican

--

Mexican-American/Chicano

--

Puerto Rican

--

Cuban/Cuban American

--

Dominican

--

Central or South American

Spring 2018

CARD RE-2

One or more categories may be selected.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

RE-2

---------------

Spring 2018

CARD PE-1

Bladder
Blood
Bone
Brain
Breast
Cervical
Colon
Esophagus
Gallbladder
Kidney/Renal
Larynx-Windpipe
Leukemia
Liver
Lung
Lymphoma
(Non-Hodgkin’s)

----------------

Mouth/Tongue/Lip
Ovarian
Pancreas
Prostate
Rectum
Skin – Melanoma
Skin – Non-Melanoma
Skin (unknown type)
Soft tissue muscle or fat
Stomach
Testicular
Throat or Pharynx
Thyroid
Uterine
Other

Spring 2018

PE-1

----------------

CARD PE-2

--

Within the last 7 days

--

More than 7 days ago, but within last 30 days

--

More than 30 days ago

PE-2
Spring 2018

CARD HE-1

--

No Difficulty

--

Some Difficulty

--

A Lot of Difficulty

--

Completely Unable To Do It

HE-1
Spring 2018

CARD PP-1
PP-1

--

Admitted to the hospital for one or more nights

--

Admitted and discharged from the hospital on the
same day

Spring 2018

CARD PP-2

--

Any type of care received in a hospital emergency
room

PP-2
Spring 2018

CARD PP-3

Same-day care received at a hospital outpatient
department such as...
Surgery Centers

--

Cancer Treatment Centers

--

Physical Therapy and Rehabilitation Centers

--

Cardiology Centers

--

Obesity Treatment Centers

--

Radiology and Imaging Centers

PP-3

--

Spring 2018

CARD PP-4

Primary care doctor such as...
--

General Practitioner

--

Internist

--

Pediatrician

--

Family Medicine Provider

--

Medical Doctor

PP-4
Spring 2018

CARD PP-5

Such as...
Orthopedist

--

Cardiologist

--

Dermatologist

--

Oncologist

--

Neurologist

--

Gynecologist

--

Allergist

--

Gastroenterologist

--

Surgeon

--

Kidney specialist (Nephrologist)

--

Radiologist

--

Ear, nose and throat specialist
(Otorhinolaryngologist)

--

Urologist

--

Podiatrist

--

Audiologist

--

Any other type of medical specialist

PP-5

--

Spring 2018

CARD PP-6
PP-6

Such as...
--

Nurse (RN, LPN, PHN, BSN)

--

Nurse practitioner

--

Nurse’s aide

--

Physician’s assistant (PA)

--

Midwife

--

Health aide

Spring 2018

CARD PP-7

Such as...
Walk-in Urgent Care

--

Retail Clinic – in a pharmacy

--

Retail Clinic – in a grocery store

--

Family Planning Center

--

College or University Clinic

--

Employer Clinic

--

Free Clinic

--

Infirmary

--

Other type of Health Clinic

PP-7

--

Spring 2018

CARD PP-8

Such as...
--

Independent Medical Lab

--

Testing Facility Lab

PP-8
Spring 2018

CARD PP-9

Such as...
--

Psychiatrist

--

Psychologist

--

Licensed Clinical Social Worker

--

Mental Health Therapist

--

Counselor

--

Psychiatric Social Worker

--

Other Mental Health Professional
PP-9
Spring 2018

CARD PP-10

Such as...
--

Physical Therapist

--

Occupational Therapist

--

Speech Therapist

--

Chiropractor

--

Physiatrist

--

Behavioral Therapist

--

Other type of Therapist

PP-10
Spring 2018

CARD PP-11
PP-11

Such as...
--

Dentists

--

Oral Surgeons

--

Orthodontists

--

Dental Assistants

--

Dental Hygienists

--

Pediatric Dentists

--

Endodontists

--

Periodontists

--

Dental Technicians

--

Other Type of Dental Care Providers

Spring 2018

CARD PP-12

Such as...
Optometrist

--

Ophthalmologist

--

Vision Technician

--

Optician

--

Orthoptist

--

Other Eye Care Professional

PP-12

--

Spring 2018

CARD PP-13

Such as...
Acupuncture

--

Homeopathic care

--

Massage therapy

--

Hypnosis

--

Naturopathic care

--

Herbalist

--

Other alternative care professional

PP-13

--

Spring 2018

CARD PP-14

Care received at home, such as…
Skilled Medical Care from -- a home care nurse,
-- any type of therapist,
-- a social worker,
-- anyone else providing nursing or medical care
Personal Care Services such as help with -- bathing,
-- dressing,
-- taking medication
Household Chore Services
-- help with cooking
-- help with cleaning
PP-14

Companionship Services such as -- reading,
-- talking,
-- going for a walk or drive
Any Other Type of Home Care

Spring 2018

CARD PP-15

Residential or long-term care received at places such
as...
--

Nursing Home for Rehabilitation Services

--

Inpatient Rehabilitation Facility or Convalescent
Home

--

Hospice Care

--

Respite Care

--

Mental Health Treatment Center

--

Drug and Alcohol Treatment Center

--

Addiction Treatment Center

--

Eating Disorder Treatment Center

--

Other Treatment Center
PP-15
Spring 2018

--

Hospital – Inpatient Stay

--

Hospital Emergency Room

--

Hospital Outpatient Department

--

Dental Office

--

Medical Provider Office or Clinic

--

Care Received at Home

--

Residential or Long Term Care Facility
•

EV-1A

CARD EV-1A

e.g., Nursing Home, Rehabilitation Facility, Drug
Treatment, Psychiatric Facility

Spring 2018

CARD EV-1B

Hospital – Inpatient Stay

--

Hospital Emergency Room

--

Hospital Outpatient Department

--

Dental Office

--

Medical Provider Office or Clinic

--

Care Received at Home

--

Residential or Long Term Care Facility
•

EV-1B

--

e.g., Nursing Home, Rehabilitation Facility, Drug
Treatment, Psychiatric Facility

--

Glasses/Contact Lenses

--

Other Medical Expenses

Spring 2018

CARD HS-1

Operation or Surgical Procedure

--

Treatment or Therapy, Not Including Surgery

--

Diagnostic Tests Only

--

Give Birth to a Baby - Normal or
Caesarean Section (Mother)

--

To Be Born (Baby)

--

Pregnancy-Related Complications

HS-1

--

Spring 2018

CARD ER-1

--

Diagnosis or Treatment

--

Emergency (e.g., Accident or Injury)

--

Psychotherapy or Mental Health Counseling

--

Follow-up or Post-Operative Visit

--

Immunization or Shots

--

Pregnancy-Related
(Including Prenatal Care and Delivery)

ER-1
Spring 2018

CARD ER-2

--

Laboratory Tests

--

Sonogram or Ultrasound

--

X-Rays

--

Mammogram

--

MRI or CAT Scan

--

EKG, ECG, or EEG

--

Vaccination

ER-2
Spring 2018

CARD OP-1
OP-1

--

General Checkup

--

Diagnosis or Treatment

--

Emergency (e.g., Accident or Injury)

--

Psychotherapy or Mental Health Counseling

--

Follow-up or Post-Operative Visit

--

Immunizations or Shots

--

Vision Exam

--

Pregnancy-Related
(Including Prenatal Care and Delivery)

--

Well Child Exam

--

Laser Eye Surgery

Spring 2018

CARD OP-2

Laboratory Tests

--

Sonogram or Ultrasound

--

X-Rays

--

Mammogram

--

MRI or CAT Scan

--

EKG, ECG, or EEG

--

Vaccination

OP-2

--

Spring 2018

CARD MV-1

General Checkup

--

Diagnosis or Treatment

--

Emergency (e.g., Accident or Injury)

--

Psychotherapy or Mental Health Counseling

--

Follow-up or Post-Operative Visit

--

Immunizations or Shots

--

Vision Exam

--

Pregnancy-Related
(Including Prenatal Care and Delivery)

--

Well Child Exam

--

Laser Eye Surgery

MV-1

--

Spring 2018

CARD MV-2

--

Laboratory Tests

--

Sonogram or Ultrasound

--

X-Rays

--

Mammogram

--

MRI or CAT Scan

--

EKG, ECG, or EEG

--

Vaccination

MV-2
Spring 2018

CARD DN-1

--

General Dentist

--

Pediatric Dentist

--

Dental Specialist
(e.g., Orthodontist, Endodontist, Periodontist)

--

Dental Hygienist

DN-1
Spring 2018

CARD DN-2
DN-2

Diagnostic or Preventive
-- General Exam, Check-up, or Consultation
-- Cleaning, Prophylaxis, Polishing, or
Periodontal Recall Visit (Periodic or Regular)
-- X-Rays, Radiographs, or Bitewings
-- Fluoride Treatment
-- Sealant (Plastic Coatings on Back Teeth)
Restorative or Endodontic
-- Fillings, Inlays, Crowns or Caps
-- Root Canal
Periodontic (Gum Treatment)
-- Periodontal Scaling, Root Planing, or Gum Surgery
Oral Surgery
-- Extraction, Tooth Pulled, or Other Oral Surgery
-- Implants
Prosthetics
-- Fixed Bridges, Dentures or Removable Partial Dentures,
Relining or Repair of Bridges or Dentures
Orthodontics
-- Orthodontia, Braces, or Retainers
Additional Procedures

Spring 2018

CARD HH-1

Certified Nursing Assistant (CNA)

--

Dietitian/Nutritionist

--

I.V. or Infusion Therapist

--

Medical Doctor

--

Nurse/Nurse Practitioner

--

Occupational Therapist

--

Physical Therapist

--

Respiratory Therapist

--

Social Worker

--

Speech Therapist

HH-1

--

Spring 2018

CARD HH-2

Companion

--

Homemaker or House Cleaner

--

Home Health or Home Care Aide

--

Hospice Worker

--

Nurse’s Aide

--

Personal Care Attendant

HH-2

--

Spring 2018

CARD IC-1

--

Inpatient Rehabilitation Facility or
Convalescent Home

--

Nursing Home

--

Residential Mental Health Treatment Center

--

Residential Eating Disorder Treatment Center

--

Residential Drug and Alcohol or
Addiction Treatment Center

--

Residential Hospice Care

--

Residential Respite Care
IC-1
Spring 2018

CARD OM-1

Disposable Supplies such as...
--

Ostomy supplies

--

Bandages and dressings

--

Tape

--

Adult disposable diapers

--

Catheters

--

Syringes not prescribed by a physician

--

IV supplies

OM-1
Spring 2018

CARD OM-2
OM-2

Medical Equipment such as...
Mobility aids
- Walker
- Scooter

- Wheelchair
- Braces

Equipment used in the home
- Hospital bed - Lift
- Monitor
- Special chair
- Bed pan
- Adaptive feeding equipment
Home and automobile modifications
- Ramp
- Handrails
- Elevator
- Automobile modifications
Hearing and speech assistance
- Hearing aid
- Amplifier for a telephone
- Adaptive speech equipment
Other
- Blood pressure monitor
- Oxygen
- Vaporizer or nebulizer

Spring 2018

CARD CP-1

Paid at Time of Visit

--

Made a Co-payment

--

Bill Sent Directly to Other Source

--

Bill Has Not Arrived

CP-1

--

No Bill Sent:
-- HMO Plan
-- VA (Veterans Administration)/CHAMPVA
-- Military Facility
-- Public Assistance/Medicaid/SCHIP
-- Indian Health Service (IHS)
-- Worker’s Compensation
-- Private Health Center/Clinic
-- Public Clinic/Health Center or Private Charity
--

Telephone Call – No Charge

--

Free From Provider

--

Government-Financed Research and Clinical Trials

Spring 2018

CARD CP-2

--

0

--

1 - 10

--

11 - 30

--

31 - 100

--

101 or More
CP-2
Spring 2018

CARD CS-1

0

No Problem

1
2

Some Problem

3
4

A Very Big Problem

CS-1
Spring 2018

CARD CS-2

--

Never

--

Sometimes

--

Usually

--

Always

CS-2
Spring 2018

CARD CS-3
CS-3

None
1 time
2 times
3 times
4 times
5 to 9 times
10 or more times

Spring 2018

CARD CS-4

CS-4

0 Worst Health Care Possible
1
2
3
4
5
6
7
8
9
10 Best Health Care Possible

Spring 2018

CARD AC-1

White

--

Black/African American

--

Asian

--

Indian/Native American Alaska Native

--

Other Pacific Islander

--

Some Other Race

AC-1

--

Spring 2018

CARD AC-2

--

Very Difficult

--

Somewhat Difficult

--

Not Too Difficult

--

Not At All Difficult

AC-2
Spring 2018

CARD AC-3

--

Never

--

Sometimes

--

Usually

--

Always

AC-3
Spring 2018

CARD HX-1
HX-1

Sample Medicare Card

Spring 2018

CARD HX-2

Sample Medicaid Card
[State Name Here]
(One for Each State)
HX-2
Spring 2018

CARD HX-3

From a Group or Association

--

Directly Through a School

--

Directly From an Insurance Agent

--

Directly From Insurance Company

--

Directly From an HMO

--

From a Union

--

From Anyone’s Previous Employer

--

From Spouse’s/Deceased Spouse’s Previous
Employer

--

From Some Other Employer

--

Under Plan of Someone Not Living Here

--

Directly From the Health Insurance Marketplace

HX-3

--

Spring 2018

CARD HX-4

--

Medicare

--

Medicaid

--

SCHIP

--

TRICARE

--

CHAMPVA

--

VA

--

Other Government Program Providing Hospital and
Physician Benefits

HX-4
Spring 2018

CARD HX-5

--

1 - 50

--

51 - 100

--

101 - 200

--

201 - 300

--

301 or more

HX-5
Spring 2018

CARD HX-6
HX-6

--

1 - 30

--

31 - 60

--

61 - 90

--

91 - 120

--

121 or more

Spring 2018

CARD HX-7

Hospital and Physician Benefits, Including Coverage
Through an HMO

--

Dental

--

Prescription Drugs

--

Vision

--

Medicare Supplement/Medigap

--

Long-Term Care in a Nursing Home

--

Extra Cash for Hospital Stays

--

Serious Disease or Dread Disease

HX-7

--

Spring 2018

CARD HX-8

From a Professional Association

--

From a Small Business Group

--

From a Union

--

Directly From an Insurance Agent

--

Directly From an Insurance Company

--

Directly From an HMO

--

From a Previous Employer

--

Directly From the Health Insurance Marketplace

HX-8

--

Spring 2018

CARD IN-1

--

1 - 5,000

--

5,001 - 10,000

--

10,001 - 15,000

--

15,001 - 25,000

--

25,001 - 50,000

--

50,001 - 100,000

--

100,001 or more

IN-1
Spring 2018

CARD IN-2

--

1 - 100

--

101 - 500

--

501 - 1,000

--

1,001 - 5,000

--

5,001 - 15,000

--

15,001 or more

IN-2
Spring 2018

CARD IN-3
IN-3

--

1 - 250

--

251 - 500

--

501 - 750

--

751 - 1,000

--

1,001 or more

Spring 2018

CARD IN-4

Wages and salary

--

Farm income (or loss)

--

Business income (or loss)

--

Social Security/Railroad Retirement

--

Private, military, or government pensions

--

Interest

--

Dividends

--

Rental income (or loss)

--

Other source

IN-4

--

Spring 2018

CARD AS-1

0 - 10,000

--

10,001 - 25,000

--

25,001 - 50,000

--

50,001 - 100,000

--

100,001 - 250,000

--

250,001 - 500,000

--

500,001 - 1,000,000

--

1,000,001 or more

AS-1

--

Spring 2018

CARD AS-2

--

0 - 1,000

--

1,001 - 5,000

--

5,001 - 10,000

--

10,001 - 25,000

--

25,001 - 50,000

--

50,001 - 100,000

--

100,001 - 250,000

--

250,001 - 500,000

--

500,001 or more
AS-2
Spring 2018