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pdf2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
Routing
HEALTH INSURANCE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C003, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If (INTTYPE in(C001, C002, C004, C005, C006) and SEASON=FALL) or (INTTYPE=C003), administer after HAQ.
If (INTTYPE in(C001, C002, C004, C005, C006) and SEASON=WINTER or SUMMER) or (INTTYPE in (C007,
C010)), administer after ENS.
BOX HIBEG
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE), GO TO HIMCINTR - HIINTR1.
ELSE GO TO BOX MC1AA.
SHOW CARD HI1
The next questions are about [your/(SP's)] health insurance benefits. This card outlines the types of health
insurance that I’ll be asking you about. [INTERVIEWER SHOULD POINT TO HEALTH INSURANCE OPTIONS ON
FRONT OF SHOWCARD HI1.] Please refer to this card as we talk about [your/(SP’s)] health insurance coverage.
HIINTR1
HIMCINTR
no entry
BOX MC1AA
It would also be helpful if I could look at a health plan card, insurance statement, or something with the plan name
on it. These materials will ensure that I record the information accurately.
(EXPAIN IF NECESSARY: We ask about health insurance coverage because it is important to understand how
beneficiaries cover the costs of their medical care, such as doctor visits, prescribed medicines, and hospital
stays.)
BOX MC1AA
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (SP HAS A LOADED CMS MEDICARE MANAGED CARE
PLAN), GO TO MC1 - LOADCORR.
ELSE IF (SP IS NOT IN THE SUPPLEMENTAL SAMPLE) AND (SP HAS A MEDICARE MANAGED CARE PLAN
THAT WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW), GO TO HIMC1A MHMOSAME.
ELSE GO TO HIMC1 - MHMOCOV.
As you (may) know, Medicare beneficiaries can enroll in either Original Medicare or a Medicare Advantage plan,
such as an HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization).
LOADCORR
MC1
yes/no
According to Medicare records, [you are/(SP) is] currently enrolled in a Medicare Advantage Plan called (CMS
MEDICARE MANAGED CARE PLAN NAME). Is this information correct?
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HIMC1
(02) MC2 - WHATWRNG
(-8) MC11 - REFERMED
(-9) BOX HIMC4
Page 1 of 26
2024 MCBS Community Questionnaire
Variable Name
WHATWRNG
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
MC2
code 1
Question Text/Description
Code List
Routing
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) MC2B - YDISNROL
(02) MC3 - PRIMPHYS
(03) MC2B - YDISNROL
(04) MC4 - SAMEPLAN
(05) MC11 - REFERMED
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) BOX MC1A
(02) BOX MC1A
(03) BOX MC1A
(04) BOX MC1A
(05) BOX MC1A
(06) BOX MC1A
(07) BOX MC1A
(08) BOX MC1A
(09) BOX MC1A
(10) BOX MC1A
(11) BOX MC1A
(91) MC2B - YDISNROS
(-8) BOX MC1A
(-9) BOX MC1A
YDISNROL
MC2B
code 1
What is the most important reason [you/(SP)] stopped the (CMS MEDICARE MANAGED CARE PLAN NAME)
coverage?
YDISNROS
MC2B
verbatim text
OTHER (SPECIFY)
BOX MC1A
routing
IF MC2 - WHATWRNG = 1/EnrolledNewPlan, GO TO MC5 - PLAN_MHMOMCA.
ELSE GO TO HIMC16 - MHMOMORE.
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
(02) NO
from which he chooses a primary care physician. This primary care physician provides the patient’s usual medical
(-8) Don't Know
care and can refer the patient to specialists, if necessary. [Do you/Does (SP)] have a primary care physician?
(-9) Refused
SAMEPLAN
MC4
code 1
Is it possible that [your/(SP’s)] current insurance plan is just another name for (CMS MEDICARE MANAGED
CARE PLAN NAME), or are they not the same plans?
PLAN_MHMOMCA
MC5
roster
What is the name of the Medicare Advantage Plan that provides [your/(SP’s)] health care benefits?
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
BOX MC1A
(01) SAME PLANS
(02) NOT THE SAME PLANS
(-8) Don't Know
(-9) Refused
BOX HIMC1
(01) BOX HIMC1
(02) MC5 - PLAN_MHMOMCA
(-8) MC5 - PLAN_MHMOMCA
(-9) MC5 - PLAN_MHMOMCA
BOX HIMC1
Page 2 of 26
2024 MCBS Community Questionnaire
HIQ-HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
Question Text/Description
Code List
REFERMED
MC11
code 1
(01) MEDICARE ONLY
(02) OTHER NAME
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-8) Don't Know
on it?]
(-9) Refused
(01) BOX HIMC4
(02) MC12 - PLAN_MHMOMCB
(-8) BOX HIMC4
(-9) BOX HIMC4
PLAN_MHMOMCB
MC12
roster
What do you call [your/(SP’s)] coverage?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS ROSTER.
BOX HIMC1
Do you refer to [your/(SP’s)] Medicare coverage by any name besides Medicare?
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
Routing
(01) BOX HIMC1
(02) HIMC1B - COVENDMM
(-8) HIMC1C - MHMOOTHR
(-9) BOX HIMC4
MHMOSAME
HIMC1A
yes/no
COVENDMM
HIMC1B
date
(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Advantage Plan's coverage [most recently/last] stop?
(-9) Refused
COVENDYY
COVENDYY
HIMC1B
date
(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Advantage Plan's coverage [most recently/last] stop?
(-9) Refused
HIMC1B1 - YDISNROL
YDISNROL
HIMC1B1
code 1
What is the most important reason [you/(SP)] stopped the (MEDICARE MANAGED CARE PLAN NAME)
coverage?
YDISNROS
HIMC1B1
verbatim text
OTHER (SPECIFY)
MHMOOTHR
HIMC1C
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)?
(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) 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) HIMC5-PLAN_MHMO
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4
Page 3 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
SHOW CARD HI2
As you (may) know, Medicare beneficiaries can enroll in either Original Medicare or a Medicare Advantage plan,
such as an HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization).
MHMOCOV
HIMC1
yes/no
(01) 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
Routing
(01) HIMC5-PLAN_MHMO
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]
PLAN_MHMO
HIMC5
roster
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.
COVTIME
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) BOX HIMC1
(02) BOX HID
(-8) BOX HID
(-9) BOX HID
HIMC3
code 1
Were you covered by (MEDICARE ADVANTAGE PLAN NAME) the whole time between [(REFERENCE DATE)
and (today], or only part of the time?
BOX HID
routing
IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HI3.
ELSE GO TO HI2-CURRCOV.
HI2
yes/no
(01) YES
[[Are you/Is (SP)] now covered by (MEDICARE ADVANTAGE PLAN NAME)? [Was (SP) covered by (MEDICARE (02) NO
ADVANTAGE PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?]
(-8) Don't Know
(-9) Refused
BOX HI3
routing
IF THIS MEDICARE ADVANTAGE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO BOX HIMC1.
ELSE GO TO HI3 - COVBEGMM.
COVBEGMM
HI3
date
When did [your/(SP’s)] (MEDICARE ADVANTAGE PLAN NAME) start between (REFERENCE DATE) and
[today/(DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HI3-COVBEGYY
COVBEGYY
HI3
date
When did [your/(SP’s)] (MEDICARE ADVANTAGE PLAN NAME) start between (REFERENCE DATE) and
[today/(DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
BOX HIMC1
COVENDMM
HI3A
date
(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Advantage Plan's coverage [most recently/last] stop?
(-9) Refused
COVENDYY
COVTIME
CURRCOV
(01) BOX HI3
(02) HI3A - COVENDMM
(-8) BOX HIMC1
(-9) BOX HIMC1
Page 4 of 26
2024 MCBS Community Questionnaire
HIQ-HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
Question Text/Description
COVENDYY
HI3A
date
(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Advantage Plan's coverage [most recently/last] stop?
(-9) Refused
BOX HIMC1
routing
IF (THIS MEDICARE MANAGED CARE PLAN IS NEW) OR THIS IS A FALL ROUND GO TO MHMOCVR.
ELSE GO TO BOX HIMC2
SHOWCARD HI6
I'd like to know what [your/SP's] [CURRENT MEDICARE MANAGED CARE PLAN] coverage [includes/included].
(Please look at this card). Which services [are/were] covered through [CURRENT MEDICARE MANAGED CARE
PLAN)]?
MHMOCVR
MHMOCVR
mark all
[PROBE: I am asking about the type of insurance coverage that [you personally have/(SP) personally has/(SP)
personally had], not what the plan offers everyone.]
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]
CHECK ALL THAT APPLY
MHMOCVOS
MHMOCVOS
verbatim text
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]
Code List
Routing
BOX HIMC1
(01) Prescribed medicines
(02) Visits to a doctor or other health professional
(03) Lab work
(04) Inpatient hospital care
(05) Nursing home or long term care
(06) Dental care
(07) Optical or vision care
(08) Hearing care
(09) Behavioral health care (e.g., counseling,
psychotherapy, mental health and substance use
disorder services)
(91) Other services
(-8) Don't Know
(-9) Refused
(01)-(08) HIMC11 - MHMOPAY
(91) MHMOCVOS
(-8) HIMC11 - MHMOPAY
(-9) HIMC11 - MHMOPAY
(01) [Continuous Answer]
HIMC11 - MHMOPAY
OTHER (SPECIFY)
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
(01) YES
(02) NO
(-8) Don't Know
[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 (-9) Refused
by Original Medicare such as prescribed medicines, and dental, vision, or hearing care. Plans that have premiums
typically charge from $50 to $75 per month.]
Not including the cost of [your/(SP’s)] Medicare Part B premium, what [is/was] the additional amount that [you
pay/(SP) pays/(SP) paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(Please do not include any copayments or any amount that may [be/have been] paid for anyone other than
quantity unit hybrid
[you/(SP)].)
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) HIMC12 - MHMOAMT
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2
(01) HIMC12 - MHMOUNIT
(-8) HIMC12 - MHMOUNIT
(-9) HIMC12 - MHMOUNIT
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]
Page 5 of 26
2024 MCBS Community Questionnaire
Variable Name
MHMOUNIT
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
HIMC12
Question Text/Description
Not including the cost of [your/(SP’s)] Medicare Part B premium, what [is/was] the additional amount that [you
pay/(SP) pays/(SP) paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(Please do not include any copayments or any amount that may [be/have been] paid for anyone other than
quantity unit hybrid
[you/(SP)].)
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]
MHMOUNOS
MHMOUNOS
BOX MHMOCAT
verbatim text
OTHER (SPECIFY)
routing
IF MHMOAMT=DK AND MHMOUNIT=1/PER YEAR, GO TO MHMOPYR.
ELSE IF MHMOAMT=DK AND MHMOUNIT=2/QUARTERLY, GO TO MHMOQR.
ELSE IF MHMOAMT=DK AND MHMOUNIT=3/BIMONTHLY, GO TO MHMOBI.
ELSE IF MHMOAMT=DK AND MHMOUNIT=4/PER MONTH, GO TO MHMOMO.
ELSE IF MHMOAMT=DK AND MHMOUNIT=5/PER WEEK, GO TO MHMOWE.
ELSE IF MHMOAMT=DK AND MHMOUNIT=6/SEMI-ANNUALLY/2 TIMES PER YEAR, GO TO MHMOSA.
ELSE IF MHMOAMT=DK AND MHMOUNIT=7/SEMI-MONTHLY/2 TIMES PER MONTH, GO TO MHMOSM.
ELSE GO TO HI33A-MHMOCOST.
Code List
Routing
(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)-(07) BOX MHMOCAT
(91) MHMOUNOS-MHMOUNOS
(-8) BOX MHMOCAT
(-9) BOX MHMOCAT
BOX MHMOCAT
MHMOPYR
MHMOPYR
code 1
PER YEAR: Please tell me which is the closest…
(01) <250
(02) 250-749
(03) 750-1499
(04) 1500-3999
(05) 4000+
MHMOQR
MHMOQR
code 1
PER QUARTER: Please tell me which is the closest…
(01) <200
(02) 200-399
(03) 400-599
(04) 600-899
(05) 900+
HI33A-MHMOCOST
BIMONTHLY: Please tell me which is the closest…
(01) <150
(02) 150-299
(03) 300-449
(04) 450-599
(05) 600+
HI33A-MHMOCOST
HI33A-MHMOCOST
HI33A-MHMOCOST
MHMOBI
MHMOBI
code 1
MHMOMO
MHMOMO
code 1
PER MONTH: Please tell me which is the closest…
(01) <50
(02) 50-99
(03) 100-199
(04) 200-399
(05) 400+
MHMOWE
MHMOWE
code 1
PER WEEK: Please tell me which is the closest…
(01) <10
(02) 10-24
(03) 25-74
(04) 75-149
(05) 150+
HI33A-MHMOCOST
Page 6 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
Routing
HI33A-MHMOCOST
MHMOSA
MHMOSA
code 1
2 TIMES/YEAR: Please tell me which is the closest…
(01) <100
(02) 100-299
(03) 300-999
(04) 1000-1999
(05) 2000+
MHMOSM
MHMOSM
code 1
2 TIMES/MONTH: Please tell me which is the closest…
(01) <10
(02) 10-34
(03) 35-99
(04) 100-199
(05) 200+
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)] (PLAN NAME) coverage?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HIMC12B - MHMOWHO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2
(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) BOX HIMC2
(02) BOX HIMC2
(03) BOX HIMC2
(04) BOX HIMC2
(05) BOX HIMC2
(06) BOX HIMC2
(07) BOX HIMC2
(91) HIMC12B - MHMOWHOS
(-8) BOX HIMC2
(-9) BOX HIMC2
MHMOWHO
HI33B
code 1
Who else [pays/paid] all or some portion of the cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
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 HI2-CURRCOV = 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?]
BOX HIMC2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HIMC17 - PLAN_MHMOOTHER
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4
Page 7 of 26
2024 MCBS Community Questionnaire
HIQ-HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
Question Text/Description
PLAN_MHMOOTHER
HIMC17
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.
roster
Code List
Routing
BOX HIMC4
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]
BOX HIMC4
routing
IF FALL ROUND AND (SP IS ALIVE AND NOT INSTITUTIONALIZED) AND (SP HAS A MEDICARE MANAGED
CARE PLAN THAT IS "CURRENT"), GO TO HIMC19 - RECMHMO.
ELSE GO TO BOX HI1.
HIMC19
yes/no
Would you recommend (CURRENT MEDICARE MANAGED CARE PLAN NAME) to your family or friends?
BOX HIMC5
routing
IF (SP HAS A MEDICARE MANAGED CARE PLAN THAT IS "CURRENT") AND (THE NUMBER OF YEARS THE
SP WAS COVERED BY A MANAGED CARE PLAN HAS NEVER BEEN COLLECTED), GO TO HIMC24 HMONUMYR.
ELSE GO TO BOX HI1.
HMONUMYR
HIMC24
numeric
HMONUM96
HIMC24
RECMHMO
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HIMC5
How many years [have you/has (SP)] been enrolled in a Medicare Advantage plan?
[IF THE RESPONDENT HAS BEEN ENROLLED IN MORE THAN ONE MEDICARE ADVANTAGE PLAN, THEN
ENTER THE TOTAL NUMBER OF YEARS THAT HE/SHE HAS BEEN ENROLLED IN ALL MEDICARE
ADVANTAGE PLANS.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
HIMC24 - HMONUM96
numeric
How many years [have you/has (SP)] been enrolled in a managed care plan?
(01) LESS THAN ONE YEAR
(-7) Empty
BOX HI1
BOX HI1
routing
IF A MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HI6 COVTIME.
ELSE GO TO HI5INTRO - MCAIDINT.
HI5INTRO
no entry
BOX HI1B
routing
SHOW CARD HI3
MCAIDINT
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 8 of 26
2024 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 List
Routing
HI5 - AIDCOVER
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?
(01) YES
(02) NO
(-8) Don't Know
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
(-9) Refused
on it?]
(01) HI6 - COVTIME
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1
code 1
(01) THE WHOLE TIME
(At the time of the last interview [you were/(SP) was] covered by Medicaid[, also known as (READ FROM ABOVE).]
(02) PART OF THE TIME
[Were you/Was (SP)] covered by Medicaid the whole time between (REFERENCE DATE) and [(today/DATE OF
(-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION)], or only part of the time?
(-9) Refused
(01) BOX HI1C
(02) BOX HI1C
(-8) BOX HI1C
(-9) BOX HI1C
BOX HI1C
routing
IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HI4.
ELSE IF COVTIME = THE WHOLE TIME, GO TO HI10A-MCAIDHMO,
ELSE GO TO HI7-CURRCOV.
HI7
yes/no
[[Are you/Is (SP)] now covered by Medicaid?] [Was (SP) covered by Medicaid on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)?]
BOX HI4
routing
IF COVTIME=PART OF THE TIME, GO TO COVENDMM,
ELSE IF COVTIME=THE WHOLE TIME AND [(IT'S A NEW PLAN) OR (IT'S A FALL ROUND)], GO TO HI10A MCAIDHMO,
ELSE GO TO BOX HIT1.
COVBEGMM
HI8
date
COVBEGYY
HI8
COVENDMM
COVENDYY
CURRCOV
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI8-COVBEGMM
(02) HI9 - COVENDMM
(-8) HI10A - MCAIDHMO
(-9) HI10A - MCAIDHMO
Between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)], when did
[your (SP's) Medicaid coverage start?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HI8-COVBEGYY
date
Between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)], when did
[your (SP's) Medicaid coverage start?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HI10A - MCAIDHMO
HI9
date
[since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicaid coverage [most recently/last] stop?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HI9 - COVENDYY
HI9
date
[since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicaid coverage [most recently/last] stop?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
BOX HI4A
Page 9 of 26
2024 MCBS Community Questionnaire
Variable Name
MCAIDHMO
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
BOX HI4A
IF THIS MEDICAID PLAN IS NEW, GO TO HI10A-MCAIDHMO,
ELSE GO TO BOX HIT1.
HI10A
routing
yes/no
Code List
(Some states now use managed care plans, such as HMOs (Health Maintenance Organizations), to provide some
or all health care for Medicaid beneficiaries.) [At the time of the last interview [you were/(SP) was] enrolled in a
Medicaid Managed Care Plan.] [Are you now/Is (SP) now/Were you/Was (SP)] enrolled in a Medicaid Managed
Care Plan [as of (DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)/(MEDICAID COVERAGE STOP
(01) YES
DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
(02) NO
(-8) Don't Know
[ONLY SELECT “YES” IF THE RESPONDENT IS ACTUALLY ENROLLED IN THE PLAN; SOME STATES MAY
(-9) Refused
OFFER MANAGED CARE, BUT NOT REQUIRE ENROLLMENT.]
Routing
BOX HI5D
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]
BOX HI5D
routing
IF ((ADMINISTERING ST, NS OR CPS) AND SP WAS COVERED BY A MEDICARE PRESCRIPTION DRUG
PLAN ANYTIME DURING THE CURRENT ROUND) OR (ADMINSTERING HI AND THERE WAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW), GO TO BOX HIT1.
ELSE IF (ADMINISTERING ST, NS OR CPS) AND SP WAS NOT COVERED BY A MEDICARE PRESCRIPTION
DRUG PLAN ANYTIME DURING THE CURRENT ROUND, GO TO HI10D - MCDRXCOV.
ELSE GO TO HI10C1 - MPDCOVER.
(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
At any time [since (REFERENCE DATE)/between (REFERENCE DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you been/has (SP) been/was (SP)] enrolled in a Medicare Prescription Drug
plan that [covers/covered] medicines prescribed by a doctor or other health professional?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI10C2 - PDPCURR
(02) HI10D - MCDRXCOV
(-8) HI10D - MCDRXCOV
(-9) HI10D - MCDRXCOV
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI10C3 - PLAN_CAIDMPDP
(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_CAIDMPDP
HI10C2
HI10C3
yes/no
roster
[Are you/Is (SP)/Was (SP)] [currently] covered by or enrolled in a Medicare Prescription Drug plan [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
[What is the name of the Medicare Prescription Drug plan that (currently covers/covered) [you/(SP)] [on (DATE OF
DEATH)/(DATE OF INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN AT THIS ROSTER.
HI10C4 - PDPMORE
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
Page 10 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/INSTITUTIONALIZATION)],
[have you/has (SP)/had (SP)] been covered by any other Medicare Prescription Drug plans besides (CURRENT
MEDICARE PRESCRIPTION DRUG PLAN)?
PDPMORE
HI10C4
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.)
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI10C5 - PLAN_CAIDMPDPOTHR
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]
Please tell me the names of [the other/all] Medicare Prescription Drug plans that [you have/he has/she has] been
enrolled in since (REFERENCE DATE) [besides (CURRENT MEDICARE PRESCRIPTION DRUG PLAN)].
PLAN_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
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
(01) YES
Please look at this card. At any time [since (REFERENCE DATE)/ between (PREVIOUS ROUND INTERVIEW
(02) NO
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)] enrolled (-8) Don't Know
in or covered by any of these TRICARE plans?
(-9) Refused
BOX HIT1
(01) HIT2 - COVTIME
(02) BOX HIT3
(-8) BOX HIT3
(-9) BOX HIT3
(EXPLAIN IF NECESSARY: You may have received a reference card that looks like this (BACK OF SHOWCARD
HIT1).)
COVTIME
HIT2
code1
[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) BOX HIT2A
(02) BOX HIT2
(-8) BOX HIT2
(-9) BOX HIT2
Page 11 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
Routing
BOX HIT2
routing
IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HIT2A,
ELSE GO TO HIT3-CURRCOV.
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
(01) HIT5-COVBEGMM
(02) HIT4-COVENDMM
(-8) TRICOV
(-9) TRICOV
BOX HIT2A
routing
IF COVTIME=PART OF THE TIME, GO TO HIT4-COVENDMM,
ELSE IF COVTIME=THE WHOLE TIME AND [(IT'S A NEW PLAN) OR (IT'S A FALL ROUND)], GO TO TRICOV.
ELSE GO TO BOX HIT3.
COVENDMM
HIT4
date
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], when did [your/(SP’s)] TRICARE coverage [most recently/last] stop?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HIT4 - COVENDYY
COVENDYY
HIT4
date
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], when did [your/(SP’s)] TRICARE coverage [most recently/last] stop?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
BOX HIT2AA
BOX HI2AA
routing
IF THIS TRICARE PLAN IS NEW, GO TO HI10A-TRICOV,
ELSE GO TO BOX HIT3.
COVBEGMM
HIT5
date
When did [your/(SP’s)] TRICARE plan start between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE
OF INSTITUTIONALIZATION)]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HIT5-COVBEGYY
COVBEGYY
HIT5
date
When did [your/(SP’s)] TRICARE plan start between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE
OF INSTITUTIONALIZATION)]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
TRICOV
CURRCOV
Page 12 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
Routing
SHOWCARD HI6
(01) Prescribed medicines
(02) Visits to a doctor or other health professional
(03) Lab work
(04) Inpatient hospital care
(05) Nursing home or long term care
(06) Dental care
(Please look at this card). Which services are covered through TRICARE?
(07) Optical or vision care
(08) Hearing care
[PROBE: I am asking about the type of insurance coverage that you personally [have/have had], not what the plan
(09) Behavioral health care (e.g., counseling,
offers everyone.]
psychotherapy, mental health and substance use
disorder services)
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
(91) Other services
education, or gym membership.]
(-8) Don't Know
(-9) Refused
CHECK ALL THAT APPLY
TRICARE 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)] TRICARE coverage
[includes/included].
TRICOV
TRICOV
mark all
TRICOVOS
TRICOVOS
verbatim text
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]
BOX HIT2B
(91) TRICOVOS
(01) [Continuous Answer]
BOX HIT2B
OTHER (SPECIFY)
BOX HIT2B
routing
If TRICOV includes 01/Prescribed medicines, GO TO TRIMEDS;
ELSE GO TO 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
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)
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.
BOX HIT3
MILTHOSP
HIT11
yes/no
[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since (REFERENCE DATE),
[have you/has (SP) received/did (SP) receive] health care or health services or prescribed medicines at a
TRICARE Military Treatment Facility or MTF?
(01) YES
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: A TRICARE Military Treatment Facility is any military hospital, or clinic, or NAVCARE (-9) Refused
clinic located on a military base or post around the world. MTFs are different from VA facilities.]
BOX HI20
Page 13 of 26
2024 MCBS Community Questionnaire
Variable Name
VACOVER
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
BOX HI20
routing
IF (SP DID NOT REPORT RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE PREVIOUS ROUND)
FALL ROUND AND (SP SERVED IN THE ARMED FORCES, P_SPAFEVER =1), GO TO HI36 - VACOVER
VACARCOV-VACARCOV.
ELSE GO TO BOX HI7.
HI36
yes/no
[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since (REFERENCE DATE),
[have you/has (SP) received/did (SP) receive] health care or health services or prescribed medicines through the
Department of Veterans Affairs or V.A.?
Since (TODAY'S DATE - 12 MONTHS, MONTH AND YEAR), did [you/(SP)] receive any care at a Veteran's Health
Administration facility or receive any other health care paid for by the VA?
VACARCOV
VACARCOV
yes/no
[IF NEEDED: Veteran's Health Administration facilities include VA hospitals, VA medical centers, VA outpatient
clinics, and VA nursing homes.]
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HI7
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HI17
(02) VAENROLL- VAENROLL
(-8) VAENROLL- VAENROLL
(-9) VAENROLL- VAENROLL
INCLUDE PRESCRIBED MEDICINES THROUCH THE DEPARTMENT OF VETERANS AFFAIRS OR VA.
VAENROLL
yes/no
(01) YES
Since (TODAY'S DATE - 12 MONTHS, MONTH AND YEAR), [have you been/has (SP) been/was (SP)] enrolled in (02) NO
VA health care?
(-8) Don't Know
(-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.
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
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
(01) HI13 - COVTIME
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) BOX HI10
(02) BOX HI8
(-8) BOX HI8
(-9) BOX HI8
VAENROLL
BOX HI17
Page 14 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
BOX HI8
routing
IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HI10,
ELSE GO TO HI14-CURRCOV.
HI14
yes/no
[[Are you/Is (SP)] now covered by (PUBLIC PLAN NAME)?] [Was (SP) covered by (PUBLIC PLAN NAME) on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?]
BOX HI10
routing
IF COVTIME=PART OF THE TIME, GO TO HI16-COVENDMM,
ELSE IF COVTIME=THE WHOLE TIME AND [(IT'S A NEW PLAN) OR (IT'S A FALL ROUND)], GO TO PUBCOV.
ELSE GO TO BOX HI12.
COVBEGMM
HI15
date
COVBEGYY
HI15
COVENDMM
COVENDYY
CURRCOV
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI15 - COVBEGMM
(02) HI16 - COVENDMM
(-8) PUBCOV
(-9) PUBCOV
When 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
date
When 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
PUBCOV
HI16
date
(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] (PUBLIC PLAN NAME) coverage [most recently/last] stop?
(-9) Refused
HI16 - COVENDYY
HI16
date
(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] (PUBLIC PLAN NAME) coverage [most recently/last] stop?
(-9) Refused
BOX HI11
BOX HI11
routing
IF THIS PUBLIC PLAN IS NEW, GO TO PUBCOV.
ELSE GO TO BOX HI12.
(01) Prescribed medicines
(02) Visits to a doctor or other health professional
(03) Lab work
I'd like to know what your PUBLIC PLAN coverage [includes/included].
(04) Inpatient hospital care
(05) Nursing home or long term care
(Please look at this card). Which services [are/were] covered through [your/(SP's)] PUBLIC PLAN?
(06) Dental care
(07) Optical or vision care
[PROBE: I am asking about the type of insurance coverage that you personally [have/had], not what the plan offers
(08) Hearing care
everyone.]
(09) Behavioral health care (e.g., counseling,
psychotherapy, mental health and substance use
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
disorder services)
education, or gym membership.]
(91) Other services
(-8) Don't Know
CHECK ALL THAT APPLY
(-9) Refused
SHOWCARD HI6
PUBCOV
PUBCOV
mark all
(01)-(08), (-8), (-9) BOX HI12
(91) PUBCOVOS
Page 15 of 26
2024 MCBS Community Questionnaire
HIQ-HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
PUBCOVOS
PUBCOVOS
verbatim text
Question Text/Description
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]
Code List
Routing
(01) [Continuous Answer]
BOX HI12
OTHER (SPECIFY)
BOX HI12
PUBMORE
PUBMORE
BOX HI12AA
routing
code one
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 ADDITIONAL PUBLIC PLANS THAT WERE "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI13-COVTIME.
ELSE GO TO PUBMORE.
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)] been covered by any other 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
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-9) Refused
on it?]
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
COVENDMM
HI16ABB
date
(01) HI12-PLAN_PUBLIC
(02) BOX HI12AA
(-8) BOX HI12AA
(-9) BOX HI12AA
(01) YES
[[Are you/Is (SP)] now covered by (MEDICARE PRESCRIPTION DRUG PLAN NAME)?] [Was (SP) covered by
(02) NO
(MEDICARE PRESCRIPTION DRUG PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?] (-8) Don't Know
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE THE PREVIOUS INTERVIEW DATE, (-9) Refused
BUT PICKED UP THE COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE NAMED PLAN, SELECT
“YES” FOR THIS QUESTION.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Prescription Drug Plan's coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused
(01) BOX HI12A
(02) HI16ABB - COVENDMM
(-8) BOX HI12A
(-9) HI16AD - PDPOTHER
COVENDYY
Page 16 of 26
2024 MCBS Community Questionnaire
HIQ-HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
Question Text/Description
COVENDYY
HI16ABB
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Prescription Drug Plan's coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused
date
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)
Code List
(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
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/INSTITUTIONALIZATION)],
[have you/has (SP)/had (SP)] been covered by any other Medicare Prescription Drug plans besides (MEDICARE
PRESCRIPTION DRUG PLAN CURRENT LAST ROUND)?
PDPOTHER
HI16AD
yes/no
(01) YES
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (02) NO
on it?]
(-8) Don't Know
(-9) Refused
ONLY ENTER STAND-ALONE PRESCRIPTION DRUG PLANS AT THIS QUESTION. IF THE R HAS RX
COVERAGE THROUGH ANOTHER INSURANCE PLAN, SUCH AS A MEDICARE ADVANTAGE PLAN, DO NOT
ENTER A SEPARATE PRESCRIPTION DRUG PLAN.
Routing
HI16AC - PDPYSTOP
(01) HI16AD - PDPOTHER
(02) HI16AD - PDPOTHER
(03) HI16AD - PDPOTHER
(04) HI16AD - PDPOTHER
(05) HI16AD - PDPOTHER
(06) HI16AD - PDPOTHER
(07) HI16AD - PDPOTHER
(91) HI16AC - PDPYSTOS
(-8) HI16AD - PDPOTHER
(-9) HI16AD - PDPOTHER
HI16AD - PDPOTHER
(01) HI16E-PLAN_MPDP
(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
(01) YES
(02) NO
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-8) Don't Know
on it?]
(-9) Refused
(01) HI16E-PLAN_MPDP
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A
ONLY ENTER STAND-ALONE PRESCRIPTION DRUG PLANS AT THIS QUESTION. IF THE R HAS RX
COVERAGE THROUGH ANOTHER INSURANCE PLAN, SUCH AS A MEDICARE ADVANTAGE PLAN, DO NOT
ENTER A SEPARATE PRESCRIPTION DRUG PLAN.
Page 17 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
You mentioned that [you are not currently/(SP) is not currently/(SP) had not been] enrolled in a Medicare
Prescription Drug plan that is 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?]
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI16E-PLAN_MPDP
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A
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
COVTIME
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN AT THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) BOX HIEA
(02) BOX HIE
(-8) BOX HIE
(-9) BOX HIE
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI16D-COVBEGMM
(02) HI16H-COVENDMM
(-8) BOX HI12A
(-9) BOX HI12A
HIMPDP
code 1
Were you covered by (Medicare Prescription Drug PLAN NAME) the whole time between [(REFERENCE DATE)
and (today], or only part of the time?
BOX HIE
routing
GO TO HI16C-CURRCOV.
CURRCOV
HI16C
yes/no
[Are you/Is (SP)/Was (SP)] [currently] covered by or enrolled in (Medicare Prescription Drug PLAN NAME) [on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
COVBEGMM
HI16D
date
(01) [Continuous answer.]
When did [your/(SP’s)] Medicare Prescription Drug Plan start between (REFERENCE DATE) and [today/(DATE OF
(-8) Don't Know
DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(-9) Refused
COVBEGYY
HI16D
date
(01) [Continuous answer.]
When did [your/(SP’s)] Medicare Prescription Drug Plan start between (REFERENCE DATE) and [today/(DATE OF
(-8) Don't Know
DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(-9) Refused
BOX HIEA
COVENDMM
HI6H
date
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Prescription Drug Plan's coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused
COVENDYY
COVENDYY
HI16H
date
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Prescription Drug Plan's coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused
BOX HIEA
COVTIME
HI8-COVBEGYY
Page 18 of 26
2024 MCBS Community Questionnaire
Variable Name
PDPMORE
PLAN_MPDPOTHR
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
BOX HIEA
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 GO TO HI16F - PDPMORE.
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/ INSTITUTIONALIZATION)],
(01) YES
[have you/has (SP)/had (SP)] been covered by any other Medicare Prescription Drug plans besides (CURRENT
(02) NO
MEDICARE PRESCRIPTION DRUG PLAN)?
(-8) Don't Know
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-9) Refused
on it?]
HI16F
HI16G
roster
Code List
[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)?
Routing
(01) HI16G - PLAN_MPDPOTHR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A
BOX HI12A
SELECT OR ADD MEDICARE PRESCRIPTION DRUG PLAN NAMES AT THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]
PRIVINTRO
BOX HI12A
routing
IF AT LEAST ONE PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW,
GO TO HI17PREV - PRIVINTRO.
ELSE GO TO HI17 - PRIVCOV
HI17PREV
no entry
The next questions are about private plans [you were/(SP) was] covered by as of (REFERENCE DATE).
(01) CONTINUE
(-7) Empty
HI21 - COVTIME
(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 19 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HI20 - PLAN_PRIVATE
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
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 BOX HI19B.
(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) BOX HI14
(-8) BOX HI14
(-9) BOX HI14
BOX HI14
routing
IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW AND COVTIME=PART
OF THE TIME, GO TO COVENDMM,
ELSE GO TO HI22-CURRCOV.
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) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI23-COVBEGMM
(02) HI24 - COVENDMM
(-8) BOX HI17
(-9) BOX HI17
CURRCOV
Page 20 of 26
2024 MCBS Community Questionnaire
HIQ-HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
Question Text/Description
Code List
Routing
COVBEGMM
HI23
date
When 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
When 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
(01) [Continuous answer.]
[since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
(-9) Refused
HI24 - COVENDYY
COVENDYY
HI24
date
(01) [Continuous answer.]
[since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
(-9) Refused
BOX HI17
BOX HI17
routing
IF THIS PRIVATE PLAN IS NEW, 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 BOX HI19.
PPRVHMO
PERS_MIPNUM
HI25
HI26
yes/no
roster
CODE WITHOUT ASKING IF VOLUNTEERED.
[Is/Was] this a managed care plan, such as an HMO (Health Maintenance Organization) or PPO (Preferred
Provider Organization)?
[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.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
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.
HI26 - PERS_MIPNUM
(01-N) BOX HI15
(N+1) HI26_NEW-ROSTFNAM
IF EXISTING PERSON SELECTED, GO TO BOX HI15
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
Page 21 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
Routing
(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) BOX HI15
(56) BOX HI15
(58) BOX HI15
(59) BOX HI15
(60) BOX HI15
(61) BOX HI15
(91) HI26_NEW - ROSTREOS
(-8) BOX HI15
(-9) BOX HI15
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)?]
BOX HI15
routing
IF PRIVOBTN HAS NEVER BEEN ASKED FOR THIS PLAN (PLAN.PRIVOBTN=.), GO TO PRIVOBTN,
ELSE GO TO PRVNMCOV.
(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 - PRIVOBOS
(-8) HI29 - PRVNMCOV
(-9) HI29 - PRVNMCOV
HI29 - PRVNMCOV
(01) continuous reponse
(-8) Don't Know
(-9) Refused
PRIVOBTN
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
PRIVOBOS
HI27
verbatim text
OTHER (SPECIFY)
PRVNMCOV
HI29
numeric
BOX HI17AB
routing
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
BOX HI15
BOX HI17AB
IF (THIS PRIVATE PLAN IS NEW) 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 PRIVSERV.
ELSE GO TO BOX HI19.
Page 22 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
Routing
SHOWCARD HI6
(01) Prescribed medicines
(02) Visits to a doctor or other health professional
(03) Lab work
(04) Inpatient hospital care
(05) Nursing home or long term care
(06) Dental care
(Please look at this card). Which services [are/were] covered through [PLAN NAME]?
(07) Optical or vision care
(08) Hearing care
[PROBE: I am asking about the type of insurance coverage that [you/(SP) personally [have/has/had], not what the
(09) Behavioral health care (e.g., counseling,
plan offers everyone.]
psychotherapy, mental health and substance use
disorder services)
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
(91) Other services
education, or gym membership.]
(-8) Don't Know
(-9) Refused
CHECK ALL THAT APPLY
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].
PRIVSERV
HI31A
mark all
PRIVSVOS
PRIVSVOS
text
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]
HI32 - MIPPINS
(91) PRIVSVOS
(01) [Continuous answer]
HI32 - MIPPINS
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI33 - MIPPAMT
(02) HI33A - MHMOCOST
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST
OTHER (SPECIFY)
MIPPINS
HI32
yes/no
[Do/Does/Did] [you/(MIP)] pay any or all of the premium or cost for the (PRIVATE PLAN NAME) coverage?
[Do not include the cost of any deductibles [you/(SP)] or [your/(SP’s)] family may [have/have had] to pay.]
How much [do/does/did] [you/(MIP)] pay for the (PRIVATE PLAN NAME) coverage?
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?]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) HI33 - MIPPUNIT
(-8) HI33-MIPPUNIT
(-9) HI33-MIPPUNIT
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)
(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)-(07) BOX PRIVCAT
(91) HI33 - MIPPUNOS
(-8) BOX PRIVCAT
(-9) BOX PRIVCAT
BOX PRIVCAT
Page 23 of 26
2024 MCBS Community Questionnaire
Variable Name
HIQ-HEALTH INSURANCE
MR Screen Name Question Type
Question Text/Description
Code List
Routing
BOX PRIVCAT
routing
IF MIPPAMT=DK AND MIPPUNIT=1/PER YEAR, GO TO MIPPYR.
ELSE IF MIPPAMT=DK AND MIPPUNIT=2/QUARTERLY, GO TO MIPPQR.
ELSE IF MIPPAMT=DK AND MIPPUNIT=3/BIMONTHLY, GO TO MIPPBI.
ELSE IF MIPPAMT=DK AND MIPPUNIT=4/PER MONTH, GO TO MIPPMO.
ELSE IF MIPPAMT=DK AND MIPPUNIT=5/PER WEEK, GO TO MIPPWE.
ELSE IF MIPPAMT=DK AND MIPPUNIT=6/SEMI-ANNUALLY/2 TIMES PER YEAR, GO TO MIPPSA.
ELSE IF MIPPAMT=DK AND MIPPUNIT=7/SEMI-MONTHLY/2 TIMES PER MONTH, GO TO MIPPSM.
ELSE GO TO HI33A-MHMOCOST.
MIPPYR
MIPPYR
code 1
PER YEAR: Please tell me which is the closest…
(01) <250
(02) 250-749
(03) 750-1499
(04) 1500-3999
(05) 4000+
HI33A-MHMOCOST
MIPPQR
MIPPQR
code 1
PER QUARTER: Please tell me which is the closest…
(01) <200
(02) 200-399
(03) 400-599
(04) 600-899
(05) 900+
HI33A-MHMOCOST
MIPPBI
MIPPBI
code 1
BIMONTHLY: Please tell me which is the closest…
(01) <150
(02) 150-299
(03) 300-449
(04) 450-599
(05) 600+
HI33A-MHMOCOST
HI33A-MHMOCOST
MIPPMO
MIPPMO
code 1
PER MONTH: Please tell me which is the closest…
(01) <50
(02) 50-99
(03) 100-199
(04) 200-399
(05) 400+
MIPPWE
MIPPWE
code 1
PER WEEK: Please tell me which is the closest…
(01) <10
(02) 10-24
(03) 25-74
(04) 75-149
(05) 150+
HI33A-MHMOCOST
MIPPSA
MIPPSA
code 1
2 TIMES/YEAR: Please tell me which is the closest…
(01) <100
(02) 100-299
(03) 300-999
(04) 1000-1999
(05) 2000+
HI33A-MHMOCOST
Page 24 of 26
2024 MCBS Community Questionnaire
HIQ-HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
Question Text/Description
Code List
Routing
MIPPSM
MIPPSM
code 1
2 TIMES/MONTH: Please tell me which is the closest…
(01) <10
(02) 10-34
(03) 35-99
(04) 100-199
(05) 200+
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.
BOX HI17B
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)?
MHMOPOS
HI33C
BOX HI19
yes/no
routing
(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
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 ADDITIONAL PRIVATE PLANS THAT WERE "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI21-COVTIME.
ELSE GO TO HI35-PRVOCOV.
Page 25 of 26
2024 MCBS Community Questionnaire
HIQ-HEALTH INSURANCE
Variable Name
MR Screen Name Question Type
Question Text/Description
PRVOCOV
HI35
yes/no
(01) YES
We’ve talked about [READ PLAN(S) LISTED ABOVE]. [Do you/Does (SP)/Did (SP)] have medical coverage under (02) NO
any (other) private insurance plans we haven’t talked about?
(-8) Don't Know
(-9) Refused
BOX HI19B
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO HI34 - OTHNHCOV.
ELSE GO TO BOX HI21A.
HI34
yes/no
[Other than the plans you have already told me about, [do you/does (SP)/did (SP)]/[Do you/Does (SP)/Did (SP)]]
have any insurance that [pays/paid] just for nursing home care or other long term care?
BOX HI21A
routing
IF SEASON=FALL, GO TO MBQ.
IF SEASON= WINTER OR SUMMER, GO TO PVQ.
OTHNHCOV
Code List
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Routing
(01) HI20 - PLAN_PRIVATE
(02) BOX HI19B
(-8) BOX HI19B
(-9) BOX HI19B
BOX HI21A
Page 26 of 26
| File Type | application/pdf |
| Author | Theresa Juliano |
| File Modified | 2023-05-17 |
| File Created | 2023-05-17 |